Sanjay Morzaria

A Comparison of the VHI, VHI-10, and V-RQOL for Measuring the Effect of Botox Therapy in Adductor Spasmodic Dysphonia

BACKGROUND Although disease-specific quality-of-life (QOL) instruments are an invaluable outcome measure in spasmodic dysphonia, there is no consensus on which QOL instrument should be used. OBJECTIVE To determine the responsiveness of the Voice Handicap Index (VHI), Voice Handicap Index-10 (VHI-10), and Voice-Related Quality of Life (V-RQOL) to the treatment effect of botulinum toxin (Botox) in adductor spasmodic dysphonia (ADSD). SETTING Stanford University Voice and Swallowing Center. DESIGN Prospective case series (level of evidence=4). METHODS Consecutive ADSD patients with a stable Botox dose-response relationship were recruited prospectively. VHI, VHI-10, and V-RQOL scores were obtained pretreatment and during the middle third of the posttreatment injection cycle. RESULTS Thrity-seven patients completed the follow-up. The average total Botox dose was 0.88 units. The average follow-up time after injection was 7.84 weeks. The pretreatment QOL scores reflected the burden of the disease. All the three instruments were highly correlated in subscale and total scores. After treatment, all three instruments showed significant improvement. CONCLUSION The VHI, VHI-10, and V-RQOL all reflected the morbidity associated with ADSD and were significantly responsive to the effect of Botox therapy. The choice of instrument should be based on physician preference.

A Meta-analysis of Voice Outcome Comparing Calcium Hydroxylapatite Injection Laryngoplasty to Silicone Thyroplasty

Objectives To compare the voice outcome of calcium hydroxylapatite (CaHA) injection laryngoplasty (IL) vs silicone medialization thyroplasty (MT) in the treatment of unilateral vocal fold paralysis (UVFP). Data Sources Systematic review of English literature from MEDLINE, Google Scholar, Web of Science, Scopus, and the Cochrane library from January 1, 1980, to December 31, 2010. Review Methods Included studies reporting voice-related quality of life (Voice Handicap Inventory [VHI]) following IL with CaHA or MT with silicone. The primary outcome measure was the improvement in VHI. The secondary outcome was improvement in maximum phonatory time (MPT). Results Of the 742 abstracts screened for relevancy, 24 studies qualified for analysis. The mean (SD) VHI scores were 72.22 (11.06) before MT and 34.02 (6.48) after MT. The mean (SD) VHI scores were 68.36 (6.88) before IL and 32.24 (7.33) after IL. The paired difference mean of VHI improvement was 38.20 (95% confidence interval [CI], 17.05-59.32; P = .007) for MT and 36.11 (95% CI, 29.65-42.57; P = .001) for IL. The mean (SD) MPT scores were 7.40 (3.14) before IL and 13.00 (1.75) after IL. The mean (SD) MPT scores were 6.16 (1.90) before MT and 12.40 (2.72) after MT. The paired difference mean of MPT improvement was 6.23 (95% CI, 4.74-7.73; P < .001) for MT and 5.60 (95% CI, 2.95-8.25; P = .006) for IL. Conclusion Injection laryngoplasty with CaHA and MT with silicone appear to achieve comparable voice improvement within 1 year, but a definitive conclusion is limited by a lack of standardized outcome measures.

Carbon Dioxide Laser-Assisted Endoscopic Cricopharyngeal Myotomy With Primary Mucosal Closure

Objectives: Carbon dioxide laser–assisted endoscopic cricopharyngeal myotomy (ECPM) has emerged as a viable therapy for dysphagia. The risks of the procedure include pharyngoesophageal perforation and mediastinitis, which may discourage adoption of this technique. To address these complications, we examined outcomes of ECPM with primary mucosal closure. Methods: A case series of 7 patients who underwent ECPM between 2006 and 2008 were reviewed for length of operation, length of hospitalization, postoperative complications, and outcomes by use of the M. D. Anderson Dysphagia Index (MDADI) and the Functional Outcome Swallowing Scale (FOSS). The results were compared to those of a control group of 7 patients treated during the same period via open cricopharyngeal myotomy. Results: All patients who had ECPM were treated successfully without complications. The operative times averaged 128 minutes. The hospitalization averaged 2.1 days. Statistically significant improvements in swallowing were seen (MDADI score from 51.3 to 77.7, p < 0.0006; FOSS score from 3.7 to 1.3, p < 0.0005), and were similar to those in the patients who had the open procedure (FOSS score from 3.0 to 1.0, p < 0.006). Trends toward decreased blood loss, a shorter hospital stay, and a lower complication rate were observed in the patients who had ECPM. Conclusions: ECPM is beneficial as a primary treatment for cricopharyngeal dysfunction. Closure of the mucosal defect may help reduce the incidence of postoperative cervical emphysema and mediastinitis, and does not appear to compromise functional outcome.

Evidence-based algorithm for the evaluation of a child with bilateral sensorineural hearing loss

OBJECTIVE To develop an evidence-based algorithm for determining the etiology of bilateral sensorineural hearing loss (SNHL) in a child. METHODS The frequency of different etiologies was previously determined. A systematic review of the literature for articles published between 1940 and January 2003 was performed for studies providing information on the diagnosis of each etiology relevant to their clinical presentation. RESULTS Connexin mutation testing is highly sensitive and specific. CT scanning of the temporal bones is frequently valuable in detecting inner ear malformations. Routine laboratory studies are rarely helpful. ECG is particularly valuable when a history of syncope or arrhythmias or a family history of sudden death in a young child is elicited. There is no literature to support routine urinalysis for the diagnosis of Alport syndrome and thyroid studies lack specificity in the absence of physical findings (goiter). CONCLUSIONS An evidence-based algorithm was developed that included: history, physical and audiological evaluation, and ophthalmological evaluation. Further directed investigations may include genetic testing for the Cx26 mutation, CT scan of the temporal bones, ECG and urinalysis.

Quality of life following ear surgery measured by the 36-item Short Form Health Survey and the Glasgow Benefit Inventory.

BACKGROUND Quality of life (QOL) following ear surgery is an important outcome measure. Most QOL studies are retrospective and therefore biased by uncertainties about preoperative QOL. OBJECTIVES The primary objective was to prospectively assess change in QOL following ear surgery. The secondary objective was to determine if QOL was associated with audiometric change. METHODS Twenty-six patients undergoing ear surgery were studied prospectively between 1999 and 2000. Before and after surgery, patients received a detailed audiometric evaluation and completed a generic (36-Item Short Form Health Survey [SF-36]) and a disease-specific (Glasgow Benefit Inventory [GBI]) QOL instrument. RESULTS Significant audiometric improvement was noted following surgery. For six of the eight subsections of the SF-36, there was significant improvement following surgery. Three subsections correlated with the reduction in air-bone gap. GBI scores indicated that 50% of patients experienced an increase in QOL. The GBI correlated with one subsection of the SF-36. Higher GBI scores were associated with a reduction in the air-bone gap, but there was no significant correlation. CONCLUSIONS QOL improved following ear surgery. QOL can be effectively assessed using both generic and disease-specific instruments. Improvement in the SF-36 score was correlated with reduction of the air-bone gap, suggesting that improved hearing was a determinant of improved QOL.

Management of intraoral needle migration into the posterior cervical space

Foreign bodies within the deep spaces of the neck pose infrequent but substantial risks involving migration, including infection, pseudoaneurysm formation, pneumothorax, hemopericardium, and embolization to the central circulation. A rare case of foreign body migration through the parapharyngeal space into the posterior cervical space is described from an intraoral needle shard. A 48-year-old male presented with a right neck tenderness, referred otalgia, and intermittent neck twitching after a needle fragment was lost during an inferior alveolar nerve block. A CT scan six months after the incident revealed migration of the 2.5 cm needle posterolateral to the great vessels into the posterior cervical space. A transcervical approach led to identification and extraction of the foreign body, with resolution of symptoms. Sharp foreign bodies in the head and neck introduce an uncommon but high-impact risk of complications. Migration is often unpredictable in trajectory and time course. Early surgical removal is recommended for persistent symptoms, sustained migration, and localization to sites with critical structures.

A Meta-analysis of Injection Laryngoplasty vs Thyroplasty

Objective: Compare the long-term voice outcome following calcium hydroxylapatite injection laryngoplasty (IL) vs silicone medialization laryngoplasty (ML) as the long-term treatment modalities for the treatment of unilateral vocal fold paralysis (UVFP) through a meta-analysis study. Method: A systematic literature review was performed from MEDLINE, Google Scholar, Web of Science, Scopus, and Cochrane between January 1, 1980, and December 31, 2010. Studies reporting voice outcome after IL with calcium hydroxylappatite and/or ML with silicone for the treatment for UVFP were included. The primary outcome measure was change in Voice Handicap Index (VHI). Results: Seven hundred and forty-two abstracts were screened for relevancy. Seventy-one articles were reviewed in detail. Twelve studies satisfied the inclusion criteria. The mean VHI score, following IL (n = 209), improved from 68.36 (±6.88) to 32.24 (±7.33). The mean VHI score, following ML (n = 110), improved from 72.22 (±11.06) to 34.02 (±6.48). The improvement in VHI following both techniques was statistically significant. Conclusion: Injection laryngoplasty with calcium hydroxylapatite and medialization laryngoplasty with silicone offer comparable voice improvement as long-term treatment modalities for UVFP. The choice of procedure should be based on planned duration of medialization, patient’s preference, and physician’s preference.