Surgical Management of Dysphagia Due to Anterior Cervical Osteophytes.

PURPOSE: The present study was performed to share personal experiences and to discuss the advantages and disadvantages of anterior cervical osteophytes surgical procedures. METHODS: The operative records of anterior cervical osteophytes patients who did not benefit from conventional treatments and underwent osteophytectomy were analyzed retrospectively. Transoral and transcervical anterolateral methods were applied, considering both the localization of the osteophyte and the patient's preference. RESULTS: Five patients were operated with the transcervical anterolateral method, and 3 patients were operated with the transoral procedure. Those using the transcervical method were likely to encounter complications, however, being comfortable for patients. Although the transoral procedure is much safer, the patients may face postoperative pain, long healing time, and morbidities as hematoma, cervical instability, and infection after surgery. CONCLUSIONS: Both transcervical and transoral methods will improve the functional swallowing pathologies and decrease aspiration-penetration. Transoral approach is not recommended due to slow healing times and postoperative pain, although it creates easier access to the spine.

Effects of Nasal Obstruction due to Nasal Polyposis on Nasal Resonance and Voice Perception.

OBJECTIVE: The aim of this study was to use subjective and objective methods to investigate the effects of total or nearly total nasal obstruction due to nasal polyposis on nasal resonance and voice perception. PATIENTS AND METHODS: A total of 63 nasal polyposis patients (53 men and 10 women), aged between 19 and 72 years (mean age 37.01 ± 13.70), were included in the study. The severity of the nasal obstruction was assessed using a visual analog scale. Nasal resonance and voice perception were evaluated subjectively by the voice handicap index (VHI)-10 questionnaire and objectively by computerized analysis (nasometry) before and after treatment of patients with nasal polyposis. RESULTS: Significant improvement was seen in the nasal obstruction values in all patients (100%; p < 0.001) and in the VHI-10 scores in 62 patients (98%; p < 0.001). Nasalance scores increased in all patients following treatment (100%; p < 0.001). CONCLUSION: Voice perception is negatively affected by nasal obstruction due to nasal polyposis, and changes in voice perception may arise after the surgery. Before the surgery, informing the patient about potential voice perception changes may be useful for the prevention of legal disputes.

Airway and Respiration Parameters Improve Following Vocal Fold Medialization: A Prospective Study.

OBJECTIVES/HYPOTHESIS: Laryngeal medialization procedures such as injection laryngoplasty (IL) and thyroplasty type 1 (TT1) are standard techniques for the treatment of glottic insufficiency related to unilateral vocal fold paralysis (UVFP). These procedures reliably improve the voice and may also improve swallowing function. Despite the association of laryngeal paralysis with airway regulation, there is little published on the effect of UVFP and its surgical treatment on respiration. The aim of this prospective study was to evaluate the aerodynamic outcomes of UVFP patients before and after vocal fold medialization, either by IL or TT1. METHODS: Consecutive patients with dysphonia due to UVFP were included in this prospective study between 2012 and 2014. Nineteen patients were investigated (5 females, 14 males) with a mean age of 37.05 ± 17.8 years. Eight patients were treated by IL while 11 patients received TT1. The patients were subjected to Modified Medical Research Council (MMRC) and Borg dyspnea scales, maximum phonation time (MPT) measurement, spirometry, and cycle ergometry, pre- and postoperatively at 2 months. RESULTS: There was a statistically significant increase in MPT from 5.5 ± 3 seconds to 11.2 ± 4.9 seconds postoperatively (P < .001). The MMRC and Borg dyspnea scales also showed significant improvement postoperatively (P < .001, P = .006, respectively). The change in spirometric parameters (peak expiratory flow, forced expiratory volume in 1 second, forced vital capacity, and peak inspiratory flow) were nonsignificant, while there was a significant improvement in cycle ergometry test postoperatively (P = .018). CONCLUSION: Laryngeal medialization procedures such as IL and TT1 improve UVFP patients' respiration-related quality of life and aerodynamic performance with no significant changes in spirometry.

Do Pharyngeal Surgeries for Snoring and Obstructive Sleep Apnea Have an Impact on Nasalance Scores?

OBJECTIVE: Most of the surgeries which are used in the treatment of habitual snoring and obstructive sleep apnea (OSA) mainly target velopharyngeal structures, which play an important role in voice characteristics such as nasalance. The aim of this study is to assess the effect of different types of such surgical procedures including expansion sphincter pharyngoplasty (ESP), lateral pharyngoplasty (LP), and anterior palatoplasty (AP) on nasalance scores. SUBJECTS AND METHODS: Forty-nine consecutive patients with primary snoring or OSA who underwent AP, LP, and ESP procedures were included in this study. All patients underwent a fully attended overnight polysomnography and detailed otolaryngologic examination. Nasalance studies were performed with Nasometer II instrument (model 6400; Kay Elemetrics, Lincoln Park, NJ) by reading 3 passages that were categorized according to the amount of nasal consonants (oral, oro-nasal, and nasal passages), preoperatively, and 3 months after surgery. RESULTS: There was no statistically significant difference in either group between preoperative and postoperative assessments of nasalance scores for all 3 passages. Seven patients experienced nasal regurgitation symptoms for fluids for a short time after LP, 2 patients after AP, and 7 patients after ESP. None of these symptoms showed persistence and diminished approximately at 1-month follow-up. CONCLUSION: Anterior palatoplasty, LP, and ESP seem not to have any impact on nasalance scores of males.

Nasalance scores for normal-speaking Turkish population.

OBJECTIVE: The aim of this study was to obtain normative nasalance scores for adult and children subjects speaking Turkish language and obtain a reference for normality when nasality is evaluated. METHODS: Mean nasalance scores were obtained from 35 normal-speaking children aged 7 to 13 years, and 125 adults aged 18 to 69 years during the repetition of 3 nasalance passages that were categorized according to the amount of nasal consonants (oral, oronasal, and nasal passages). The Nasometer (model 6400) was used to obtain nasalance scores for the 3 reading passages. RESULTS: Group mean ± SD nasalance scores of children for oral passage, oronasal passage, and nasal passage were 15.14 ± 4.81, 37.76 ± 4.42, and 49.23 ± 6.95, respectively. Nasalance scores for the adult group were 13.46 ± 6.26, 37.84 ± 6.13, and 50.28 ± 7.77, respectively. There were significant differences in mean nasalance scores for oral versus nasal materials both for children and adult groups. CONCLUSIONS: The present study provides normative nasalance scores for Turkish-speaking children and adults. The results indicated acceptable differentiation between oral and nasal materials.

Submandibular triangle masses.

OBJECTIVE: The study aims to analyze the demographic data of a large case series operated on because of submandibular triangle mass for more than 10 years and presents a review of the literature. MATERIALS AND METHODS: The charts of patients who underwent surgical intervention for submandibular triangle mass between January 2000 and November 2010 were reviewed. The medical history, age, sex, duration of symptoms, clinical presentation, preoperative investigations, and histopathologic diagnosis were reviewed. RESULTS: The study included 66 subjects; 12 patients (18.2%) with submandibular sialolithiasis, 18 patients (27.2%) with sialadenitis, 10 patients with lymphadenitis (15.1%), and 26 patients (39.3%) with tumors. Of the tumors, 23% was malignant and 77% was benign. Benign tumors of submandibular gland comprised 22.7% and malign tumors of submandibular gland comprised 3% of all submandibular mass. The most common benign tumor was pleomorphic adenoma. The most frequent histopathologic diagnoses of submandibular masses originated from the submandibular gland, and these comprised 71.2% of all submandibular mass pathologies. The main symptom was a painless mass. Ultrasonography was the most common preoperative diagnostic procedure. Fine-needle aspiration biopsy was performed in 26 patients. A clear diagnosis could not be provided in 3 (12%) patients. CONCLUSION: Infectious conditions and benign tumors are more frequent than malign tumors in the submandibular region. The histopathologic diagnoses mainly consisted of submandibular sialadenitis, sialolithiasis, pleomorphic adenoma, and lymphadenitis. Ultrasonography is the first option of radiologic evaluation. Fine-needle aspiration biopsy is a very useful and usually sufficient diagnostic procedure for histopathologic diagnosis. Excisional biopsy can be performed when the fine-needle aspiration biopsy failed.

An unusual case of anterior and posterior laryngeal cleft together: combined cleft of larynx.

Congenital clefts of the larynx are rare and usually found dorsally. An anterior or ventral cleft of the larynx is extremely rare. Only a few patients with this defect have been reported in the literature. The purpose of this paper is to present a patient having an anterior and posterior laryngeal cleft together. A 20-year-old man presented with a history of dysphonia since childhood. He did not report symptoms of swallowing or respiration, and had no history of neck trauma. Findings of videolaryngoscopy showed a grossly abnormal larynx. The anterior commissure was wider than normal, and the vocal folds did not show a fusion anteriorly. There was an interarytenoid cleft posteriorly. A neck CT with 3D reconstruction demonstrated a ventral cleft or nonfusion of the thyroid cartilage with a posterior cricoid cleft. Barium swallow study was in normal limits. Since the patient did not have any problem with swallowing or respiration, no surgical intervention was planned, and the patient was put on speech therapy, which revealed improvement in voice. To our knowledge, this is the first case of a combined laryngeal cleft. The diagnosis is established by the clinical symptoms, endoscopic evaluation, and radiographic examinations including 3D and barium studies.

Principles of Subglottic and Tracheal Visualization with Transnasal Flexible Laryngoscopy.

OBJECTIVE: The subglottic area and trachea are important parts of the upper airway, and can be visualized easily using transnasal flexible laryngoscopy (TFL). The aim of this study was to develop a clinical grading system to assist in documentation of the subglottic area and trachea with TFL, and to demonstrate the basic principles of visualization of these anatomic areas as a laryngology practice. METHODS: The TFL videos of 100 randomized patients were evaluated by three laryngologists. The simple head extension (SHE) position and flexion position (FP) were applied to the patients during the visualization of the subglottic area and trachea. A paired t test was used to compare the grades of the subglottic and tracheal view according to the SHE and FP scores. RESULTS: This study examined 50 male and 50 female patients ranging in age from 28 to 83 years (mean age: 50.09 ± 13.05 years). For the SHE and FP, the numbers of patients constituting grade 1 were 2 and 35, grade 2 were 2 and 37, grade 3 were 30 and 19, and grade 4 were 41 and 9, respectively. There was a statistically significant difference between SHE and FP (P  <  0.05). The k score was 0.785 between the ratings of observer 1 and observer 2; 0.771 between observer 1 and observer 3; and 0.757 between observer 2 and observer 3 (P  <  0.001). CONCLUSION: This new grading system for the visualization of the subglottis and trachea can help physicians assess and identify the upper airways, and FP provides a better subglottic and tracheal view than SHE.

The Effect of Obesity on Transnasal Flexible Laryngoscopy.

OBJECTIVE: Transnasal flexible laryngoscopy (TFL) is a practical and cost-effective procedure, allowing excellent evaluation of the upper airway with minimal risk of complications. The effect of obesity on endoscopic examination still remains unclear. The aim of this study was to determine if obesity has an effect on TFL. METHODS: Demographic data including age and gender, and physical and endoscopic examinations including body mass index (BMI), neck circumference, and grade of the laryngeal view according to Tasli classification (TC), Mallampati classification (MC), Friedman classification, and Moore tongue base classification (MTC) scores of 200 patients were evaluated. The patients were divided into two categories as obese and nonobese, and the scores of patients were compared. RESULTS: Evaluation was made of 99 (50.5%) obese and 97 (49.5%) nonobese patients ranging in age from 18 to 65 years (mean age: 37.89 ± 13.55 years). Of the 196 patients in this study, 101 (51.5%) were male, and 95 (48.5%) were female. The mean BMI of the obese and nonobese patients was 33.18 ± 5.18 (min: 25, max: 45) and 22.48 ± 1.5 (min: 19, max: 24), respectively. According to cutoff points, 27 patients (27.3%) were classified as overweight, 30 (30.3%) as obese, and 42 (42.4%) as morbidly obese. According to TC, there was no statistically significant difference between the obese and nonobese groups (mean difference 0.12, P: 0.39). In Pearson correlation analysis, the scores for a correlation between TC, and MC and MTC were 0.206 (very weak) and 0.653 (strong), respectively, which were statistically significant (P < 0.05). There was no correlation between TC and BMI values (r = -0.051; P: 0.48). CONCLUSION: The results of this study demonstrated that obesity influences the scores of MC, Friedman classification, and MTC, but does not affect the laryngeal view on TFL.

Optimal Position for Transnasal Flexible Laryngoscopy.

OBJECTIVE: Transnasal flexible laryngoscopy (TFL) is a simple, safe, and cost-effective procedure. TFL is routinely performed to awake patients in a sitting position but there is no a definite data about ideal head and neck position to be applied. The aim of this study is to determine which position is most appropriate to obtain the best laryngeal view during the TFL. METHODS: The TFL videos of 132 randomized patients were evaluated by three blind observers experienced with laryngology. Three basic head positions; simple head extension (SHE), sniffing position (SP), and neutral position (NP) were performed during the TFL-Interobserver agreements for the grading system scores were assessed by using the kappa (k) statistic. RESULTS: For the SHE and SP, the numbers of patients constituting grade 1 were 127 (96.2%) and 126 (95.5%), respectively, while grade 2a were 5 (3.8%) and 6 (4.5%), respectively. In NP, the number of patients constituting grade 1 was 5 (3.8%), while grade 2a was 83 (62.9%), grade 2b was 37 (28%), and grade 3 was 7 (5.3%). The k score of the SHE was 0.826 (P < 0.001) between the ratings of observer 1 and observer 2, 0.905 (P < 0.001) between observer 1 and observer 3, and 0.919 (P < 0.001) between observer 2 and observer 3. These values denote nearly perfect agreement. A complete agreement was seen in 130 of the 132 (98.48%) videos. CONCLUSION: SHE and SP both provide a better glottic view than the NP and demonstrate the same success.

Laryngoscopic Examination During the COVID-19 Pandemic: Turkish Voice Speech and Swallowing Disorders Society and Turkish Professional Voice Society Recommendations.

COVID-19 is highly transmissible and spreads rapidly in the population. This increases the occupational risk for health care workers. In otolaryngology clinic practice, patients with upper respiratory tract infection symptoms are common. Also, routine head and neck examinations such as oral cavity examination, nasal/nasopharyngeal examination, or video laryngostroboscopic evaluation are highly risky because of the aerosol formation. To emphasize this issue, two leading otolaryngology organizations in Turkey; 'Voice Speech and Swallowing Disorders Society', and 'Professional Voice Society' gathered a task force. This task force aimed to prepare a consensus report that would provide practical recommendations of the safety measurements during routine clinical care of laryngology patients. To fulfill this, universal aim, on the 2nd and 9th of May 2020, two web-based meetings were conducted by 20 expert physicians. This eighteen items list was prepared as an output.

Dosage changes in patients with long-term botulinum toxin use for laryngeal dystonia.

OBJECTIVE: To investigate the dosage consistency of botulinum toxin injections in patients with long-term treatment for laryngeal dystonia. STUDY DESIGN: Chart review. SUBJECTS AND METHODS: Patients with laryngeal dystonia who had received at least 20 injections to the thyroarytenoid muscle were selected. Change of botulinum toxin dose, patient-reported effective weeks, and intervals between injections were investigated; data from the first five injections were excluded to eliminate initial dose titration. RESULTS: Fifty-five patients with an average follow-up of 12.5 years were identified. Mean dose of botulinum toxin was 2.37 +/- 1.6 U at the sixth injection; there was a decrease in mean dose over time, which became statistically significant at the 13th injection with a mean dose of 2.02 +/- 1.16 U. Mean duration of good effect and treatment intervals showed no significant change over time. CONCLUSION: Botulinum toxin dose needed for a constant response in treatment of laryngeal dystonia decreases over time, without any accompanying change in effective weeks and intervals.

Choanal polyp originating from the nasal septum: septochoanal polyp.

Most of the nasal polyps arise from the lateral walls of the nasal cavity. Nasal polyps originating from the nasal septum with choanal extension are extremely rare. We report a case of large choanal polyp that arised from the posterosuperior aspect of the nasal septum, and extended down to the oropharynx. A 52-year-old woman presented with a two-year history of progressive nasal obstruction and snoring. Findings of anterior rhinoscopy were in normal limits. We think that the term "septochoanal polyp" which, as far as we know, has not been mentioned in the literature before, can be used for this rare lesion.

Analysis of Age-Related Differences of Risk Factors and Comorbidities in Laryngotracheal Stenosis Patients.

Laryngotracheal stenosis (LTS) is a life threatening airway problem that is mainly caused by prolonged intubation. The authors intend to assess whether there was variability in the risk factors depending on age, and to determine which risk factors and comorbidities were more important in the development of LTS at older or younger ages. Fifty-two LTS patients were evaluated for comorbidities and risk factors retrospectively. The LTS etiologies, demographics, and medical and surgical histories of the patients were determined by the medical records. The patients under 40 years old were defined as group 1, and the patients 40 years of age or older were defined as group 2. Our study revealed that with regard to GERD, hypertension, DM2, and pulmonary infection, there was a statistically significant difference between group 1 and group 2 (p = 0.025, p = 0.0005, p = 0.002, and p = 0.000, respectively). Those patients ≥ 40 years old exhibited higher rates of GERD, hypertension, DM2, and pulmonary infection. However, there were no statistically significant differences between the groups with regard to smoking, alcohol consumption, COPD/asthma, immunological disease, and obesity (BMI > 30). There was a statistically significant difference between the groups for all the risk factors except a previous tracheotomy (p = 0.115). The risk factors and comorbidities thought to be involved in the development of LTS could show age-related variability. Therefore, in patients over 40 years of age with comorbidities (GERD, hypertension, DM2, and pulmonary infection), it is necessary to take precautions before the development of LTS. Prolonged intubation and tracheotomy history are the main risk factors for all patients, regardless of age.

A Grading System for Transnasal Flexible Laryngoscopy.

OBJECTIVE: Transnasal flexible laryngoscopy (TFL) is becoming more popular in laryngology clinical practice. There has not been any grading system for TFL to help the physician document and communicate the laryngeal view yet. In this study, we aimed to classify the laryngeal view based on the visualization of the glottic aperture with TFL performed on conscious patients. METHODS: The TFL videos of 920 randomized patients were evaluated by three blind observers experienced with laryngology. The laryngeal view, consisting of the basic anatomic landmarks of the glottis, arytenoids, and epiglottis, was examined, and the glottic aperture was classified with a five-point grading system. Interobserver agreements for the grading system scores were assessed by using the kappa (k) statistic. RESULTS: Nine hundred and twenty subjects were enrolled in the study. Six hundred and thirty-eight (69.3%) were men, and 282 (30.6%) were women, and the mean age was 40.13 ± 15.08 (18-89 years). The number of patients constituting grade 1 was 737 (80.1%), while grade 2a was 122 (13.2%), grade 2b was 32 (3.4%), grade 3 was 24 (2.6%), and finally, grade 4 was only 5 (0.5%). The k score was 0.945 (P < 0.001) between the ratings of observer 1 and observer 2, 0.933 (P < 0.001) between observer 1 and observer 3, and 0.91 (P < 0.001) between observer 2 and observer 3. CONCLUSION: This new grading system for the laryngeal view can help physicians assess the upper airways, and it can also help visualize how much of a glottic opening there is.

Does Pepsin Play a Role in Etiology of Laryngeal Nodules?

OBJECTIVES: Vocal fold nodules (VFNs) are benign disorders affecting the superficial lamina propria of the true vocal folds. The etiology of VFNs still remains unclear but laryngeal trauma caused by vocal abuse, tobacco, alcohol, and laryngopharyngeal reflux (LPR) plays a crucial role on the pathogenesis. The aim of this study was to assess the presence of pepsin in formalin-fixed, paraffin-embedded (FEPE) specimens of VFNs to evaluate the role of LPR as a risk factor for VFNs. MATERIALS AND METHODS: A total of 28 pathology specimens of patients suffering from VFNs who had undergone laser microsurgery under general anesthesia were evaluated. The specimens were maintained in paraffin blocks in the pathology department. Western blot (WB) and enzyme-linked immunosorbent assay (ELISA) analyses were used to measure pepsin enzyme levels in the VFNs tissue specimens. Signs of LPR were assessed according to the reflux finding score. RESULTS: The mean reflux finding score of the patients was 13.6 ± 2.89 (8-21). According to WB and ELISA analyses, pepsin was detected with both the WB the ELISA tests in positive controls, but there was no pepsin enzyme in any of the 28 laryngeal FEPE VFNs specimens. CONCLUSION: The pepsin enzyme was not detected in any of the FEPE VFNs specimens, and it is concluded that further studies are needed to reveal the role of pepsin in the etiology of VFNs.

Prospective study of the impact of thyroid hormone replacement on objective voice parameters.

OBJECTIVES: Hypothyroidism has long been considered to have an impact on phonation. In this study, objective evaluation of vocal function in women with hypothyroidism was performed in order to characterize potential dysphonia; their subsequent response to thyroid hormone replacement was prospectively studied. It was hypothesized that thyroid hormone replacement therapy in this cohort would have an objectively measurable impact on vocal function. METHODS: Prospectiv evaluation of objective voice parameters and concurrent determination of serum thyroid status was executed both before and after thyroid hormone replacement in a cohort of patients who had had total thyroidectomy. Objective voice parameters before and after treatment were compared. RESULTS: Twenty-four female subjects were recruited over an 18-month period. After surgery, all subjects were hypothyroid (mean thyroid-stimulating hormone level, 81.38 mIU/L; range, 25.26 to 100.00 mIU/L) before replacement. After hormone therapy, their mean thyroid-stimulating hormone level dropped to 1.20 mIU/L (range, 0.28 to 3.83 mIU/L). The mean fundamental frequency significantly increased from a pretreatment average of 223.48 +/- 36.10 Hz to 237.64 +/- 38.81 Hz. Other measured voice parameters (jitter, shimmer, amplitude perturbation quotient, pitch perturbation quotient, noise-to-harmonics ratio, and maximum phonation time) were not affected. CONCLUSIONS: Thyroid hormone replacement therapy following total thyroidectomy has a measurable impact on mean fundamental frequency in female patients. The mechanism of this effect is not known.

Spindle cell carcinoma of the larynx with a verrucous carcinoma component: combined carcinoma of larynx.

Squamous cell carcinoma (SCC) is the most common neoplasm of the larynx. There are three variants of SCC. Each variant presents distinctive biologic behaviors and clinical courses. Therefore reaching the exact diagnosis and distinguishing the variants is fateful. We describe a case of spindle cell carcinoma of the larynx with a verrucous carcinoma component. To our knowledge, this entity has never been documented before.

Intraventricular traumatic tension pneumocephalus: a case report.

Traumatic tension pneumocephalus with intraventricular extension is an extremely rare, potentially lethal condition that requires prompt diagnosis and treatment. A 27-year-old man was admitted with blunt head injury and rhinorrhea. There was no pathological finding on plain X-ray and axial computed tomography (CT) images. He had nothing remarkable but persistent nasal discharge. Biochemical and histological examination showed that the rhinorrhea material was cerebrospinal fluid (CSF). Lumbar spinal drainage was performed for the treatment of rhinorrhea. On the third day of drainage, he had headache, nausea and vomiting. A skull X-ray and CT scan revealed a large volume of intraventricular and subdural air in the frontotemporoparietal region, suggesting tension pneumocephalus. The CSF drainage was removed and medical treatment with mannitol (1 g/kg) was initiated, after which CSF rhinorrhea ceased and a gradual decrease in intracranial air volume was observed on follow-up CT scans. Improvement in his condition continued and the final CT scan demonstrated resolution of the pneumocephalus. The patient was discharged without any deficit.

Three Cases of Relapsing Polycondritis with Isolated Laryngotracheal Stenosis.

Relapsing polychondritis (RP) is a rare autoimmune and inflammatory disease, particularly characterized by recurrent inflammation of the hyaline cartilage. Laryngotracheal involvement in RP is the most serious complication that is observed in 50% of the patients and may lead to a life-threatening condition. The most common cause of death is laryngotracheal stenosis associated with lung infections or severe respiratory insufficiency that may be observed in 10%-50% of the patients. In this study, three RP patients comprising a child with isolated laryngotracheal stenosis have been presented.