Stefano Bondi

Oropharyngeal pH Monitoring for Laryngopharyngeal Reflux: Is It a Reliable Test Before Therapy?

OBJECTIVE Current methods of measuring pharyngeal pH are problematic. The aim of the study was to assess the ability of the oropharyngeal pH monitoring (Restech) in predicting the response to proton pump inhibitor (PPI) therapy in patients with gastroesophageal reflux disease-related laryngopharyngeal symptoms. STUDY DESIGN The study design is prospective and uncontrolled. METHODS Twenty-two consecutive naive patients with chronic laryngeal symptoms were enrolled. Reflux symptom index, fibrolaryngoscopy, and 24-hour oropharyngeal pH monitoring were performed. Both patients and laryngoscopist were blinded by the results of Restech. All the patients were given a 3-month therapy with pantoprazole of 40mg twice a day and then repeated both the reflux symptom index and fibrolaryngoscopic evaluation. Patients were considered as responders if a five-point decrease in symptom score was recorded. RESULTS Thirteen of the 22 patients (59.1%) responded to therapy. Laryngoscopic findings did not correlate with the clinical improvement after the 3 months of PPI. Nine patients (40.9%) had a pathologic Restech study, and all resulted responsive to PPI; nine patients (40.9%) with a negative Restech were nonresponsive to PPI, and four patients (18.2%) despite a negative Restech resulted responsive to therapy. Responsive patients showed both a higher oropharyngeal acid exposure in orthostatic position and a higher Ryan score, compared with nonresponders (49.74±58.11 vs 2.12±0.0, P=0.002). Considering responsiveness to medical therapy as the gold standard of laryngopharyngeal reflux (LPR) for the diagnosis of LPR, Restech showed a sensitivity of 69% and a specificity of 100%. CONCLUSIONS The high specificity and reasonable sensitivity of this technique make the Restech an interesting tool before therapy of patients with pharyngoesophageal reflux.

Role of Montgomery salivary stent placement during pharyngolaryngectomy, to prevent pharyngocutaneous fistula in high-risk patients.

OBJECTIVE To evaluate the incidence of pharyngocutaneous fistula after pharyngolaryngectomy with and without a Montgomery salivary stent. DESIGN Retrospective analysis of patients with factors that predispose to the development of pharyngocutaneous fistula (i.e. disease extending to the supraglottic region, base of the tongue or pyriform sinuses, and/or radiochemotherapy). SUBJECTS Between 2002 and 2008, 85 pharyngolaryngectomies were performed in our clinic. Of these patients, 31 were at increased risk of fistula development, of whom 45 per cent developed fistulas post-operatively. This subgroup of 31 patients was compared with a second subgroup of 22 patients at high risk of fistula development, treated between 2009 and 2011 with pharyngolaryngectomy and with a Montgomery salivary stent placed in advance during closure of the neopharynx. RESULTS Statistical analysis showed a significant reduction in the rate of fistula development, from 45 to 9 per cent (p < 0.01), with application of the salivary stent. CONCLUSION These data confirm the preventive effect of a salivary stent placed during pharyngolaryngectomy, for patients at high risk of fistula development.

Satisfaction and Quality of Life in Laryngectomees after Voice Prosthesis Rehabilitation

Objective/Hypothesis: The purpose of the study was to assess the satisfaction and quality of life in laryngectomees after vocal rehabilitation using voice prostheses. We evaluated the impact on quality of life between laryngectomees with voice prostheses, laryngectomees without them and healthy controls. Methods: This was a prospective study on a sample of laryngectomees in an Italian university hospital. Our study population was composed of 42 patients who had previously undergone a total laryngectomy; in 24 of them, voice rehabilitation was obtained with a voice prosthesis device (group A), while 18 of them learned oesophageal voice (group B). The results were compared with a group of 25 healthy controls (group C). In order to investigate the quality of life, we administered the Short Form 36-Item Health Survey (SF-36) to the 3 groups. Moreover, self-satisfaction of the subjects in group A was assessed by single questions regarding their use of the voice prosthesis. Results: A statistical difference in the SF-36 was detected for social functioning (SF) between groups A and B. Role physical, SF and role emotional were significantly better in group C than in group A. Group A stated they were very satisfied with voice quality while there were still some problems regarding prosthesis lifetime and communication at the telephone or in noisy environments. Conclusions: Voice prosthesis implantation in laryngectomees showed positive effects on patients’ quality of life; however, there are still some negative aspects. At present, an early diagnosis of larynx cancer with a partial laryngectomy in order to preserve phonatory function is the gold standard.

A review of recent literature on functional MRI and personal experience in two cases of definite vestibular migraine

The pathophysiology of vestibular migraine (VM) is at present poorly understood. Functional magnetic resonance imaging (fMRI), a technique that measures brain activity by detecting changes associated with blood flow oxygenation, has been used to study neural pathways involved in VM pathophysiology. In this study, we summarize results of previous fMRI studies in VM patients, both during and between vertigo attacks. Moreover, we report our experience in two patients with definite VM, who underwent fMRI during a visual stimulation in a vertigo-free period. Compared with 15 matched healthy controls, fMRI demonstrated activation of brain areas related to integration of visual and vestibular cues (increased activation of the paracentral lobule and bilateral inferior parietal lobule and decreased activation of the left superior frontal gyrus, head of the caudate nucleus, left superior temporal gyrus, left parahippocampal gyrus, and right lingual gyrus). Our results partially confirm those of other authors, reporting increased activation of multimodal association brain areas (BA 40, BA 31/5) and decreased activation of occipital regions In addition, we also found a decreased activation of fronto-temporal areas, such as the parahippocampal region, functionally involved in space memory and navigation.

Therapeutic modalities and oncologic outcomes in the treatment of T1b glottic squamous cell carcinoma: a systematic review

T1a and T1b glottic squamous cell carcinoma (SCC) are often analyzed together by authors who investigate the oncologic outcomes achieved after different therapeutic options. Nevertheless, T1b definitely represents a more advanced tumor stage compared to T1a glottic SCC. The objective of this review was first to analyze the overall success rates in the treatment of patients affected by T1b glottic SCC. Moreover, a subgroup analysis was planned to specifically compare the outcomes obtained with radiotherapy (RT), transoral laser microsurgery (TLM) and open partial laryngectomies (OPL). An electronic library search of the relevant English literature was performed. Potentially eligible articles were reviewed. Qualified articles were selected and evaluated. Fifty-two studies comprising 2360 patients were included. The overall rate of disease-free survival (DFS) was 85% (95% CI 83–87). The overall rate of overall survival was 85% (95% CI 80–88) while the rate of disease-specific survival (DSS) was found to be 96% (95% CI 90–98). Statistical data concerning outcomes for each therapeutic modality showed an higher DFS rate for subjects treated with RT and OPL, respectively, 87% (95% CI 0.85–0.89) and 83% (95% CI 0.78–0.89), when compared to those who underwent TLM 77% (95% CI 0.69–0.83). In conclusion, our results showed a high level of overall DSS (96%) for patients affected by T1b glottic SCC. Regarding the specific therapeutic options, our subgroup analysis showed as patients treated with TLM present a higher rate of oncological recurrence in comparison to those who underwent RT or OPL. Nevertheless, on the basis of our data it was also noted that no significant differences subsist in terms of survival rates among the three different treatments. Moreover, the absence of a comparative analysis useful to confirm these conclusions must be considered.

Diagnosis and Treatment of Laryngeal Schwannoma: A Systematic Review:

Objective This review summarizes the clinical features, diagnostic workup, and surgical treatment of laryngeal schwannoma with the aim of providing guidance for the management of this rare disease. The collated data allowed the statistical testing of several hypotheses, including the efficacy of endoscopic vs open surgical intervention and the usefulness of preoperative biopsy. Data Sources PubMed, Google Scholar, Cochrane, and SCOPUS. Review Methods Basic epidemiological and clinical presentation data were collated together with details of diagnostic image modality, lesion attributes, and the use of preoperative biopsy. Surgical approach to intervention and outcome was also collated and simple statistical analyses applied. Results The 60 original articles selected provided a combined cohort of 74 patients for review. The combined data revealed that schwannoma with pedunculated morphology were always safely removed by endoscopic resection regardless of size and should be treated as a separate entity. Of the nonpedunculated schwannoma, larger tumors were more likely to undergo an open approach, which in turn was associated with higher rates of tracheotomy and postoperative vocal fold paralysis. The small cohort did not reveal a significant association between surgery type and persistent disease. Interestingly, the data revealed a significant association between the use of incisional biopsy and persistent disease. Cases exhibiting extralaryngeal extension of the lesion were shown to exclusively belong to patients with neurofibromatosis/schwannomatosis syndromes. Conclusions Taken together, these findings suggest that incisional biopsy should be avoided, and given the benign nature of the pathology, the least invasive radical approach should be employed.