Functional outcomes after supracricoid laryngectomy.

OBJECTIVES: Local control and 5-year survival rates are similar for patients undergoing total laryngectomy and supracricoid laryngectomy for the treatment of advanced-stage laryngeal carcinoma. However, comprehensive studies of functional outcomes after supracricoid laryngectomy are lacking. STUDY DESIGN: Cohort study. METHODS: This investigation provides objective voice laboratory data, skilled listener impressions of voice samples, swallowing evaluations, and patient self-perceptions of speech ability obtained from 10 supracricoid laryngectomees. RESULTS: Results demonstrated variable acoustic and speech aerodynamic disturbances, hoarse-breathy vocal quality, and speech dysfluency. Patients' self-perceptions of voice revealed severe dysphonia that induced certain emotional, physical, and functional setbacks. However, blinded judges rated these individuals as possessing intelligible speech and communication skills. All patients demonstrated premature spillage of the bolus and varying degrees of laryngeal penetration, aspiration, and retention during swallowing studies. However, each patient used a compensatory strategy to protect the airway. Voice and swallowing abilities appeared to depend on the mobility of the arytenoid cartilages, base of tongue action, and residual supraglottic tissue for the creation of a competent neoglottal sphincter complex that vibrated during phonation efforts and protected the airway during deglutition. CONCLUSIONS: Supracricoid laryngectomy avoids the potential complications, limitations, and emotional problems associated with a permanent tracheostoma. All patients demonstrated intelligible voice and effective swallowing function postoperatively, supporting supracricoid laryngectomy as a suitable alternative surgical approach to the total laryngectomy in select patients.

Craniocervical necrotizing fasciitis: an 11-year experience.

OBJECTIVE: We review our experience and present our approach to treating craniocervical necrotizing fasciitis (CCNF). STUDY DESIGN: All cases of CCNF treated at Wayne State University/Detroit Receiving Hospital from January 1989 to April 2000 were reviewed. Patients were analyzed for source and extent of infection, microbiology, co-morbidities, antimicrobial therapy, hospital days, surgical interventions, complications, and outcomes. RESULTS: A review of 250 charts identified 10 cases that met the study criteria. Five cases (50%) had spread of infection into the thorax, with only 1 (10%) fatality. An average of 24 hospital days (7 to 45), 14 ICU days (6 to 21), and 3 surgical procedures (1 to 6) per patient was required. CONCLUSION: Aggressive wound care, broad-spectrum antibiotics, and multiple surgical interventions resulted in a 90% (9/10) overall survival and 80% (4/5) survival for those with thoracic extension. SIGNIFICANCE: This is the largest single institution report of CCNF with thoracic extension identified to date.

Use of topical lidocaine in the treatment of muscle tension dysphonia.

This investigation explored the potential usefulness of topical lidocaine in the treatment of muscle tension dysphonia. Three patients with this disorder, who were previously unresponsive to standard voice therapy, were treated with lidocaine. In each case, the outcome was prompt, clinically significant, and sustained. Persistently high-pitched and shrill vocal quality was converted to near normal voice patterns within 15 minutes after transcricothyroid membrane lidocaine injection. We suggest that this temporary and simple laryngeal and tracheal anesthetic technique may have helped to break the perverse cycle of hyperactive glottal and supraglottal muscle contractions evident in each of these patients during phonation efforts. We discuss the possible sensorimotor mechanism of action of this therapeutic technique.

Videostroboscopy of the pharyngoesophageal segment in laryngectomy patients treated with botulinum toxin.

OBJECTIVES: The purpose of this investigation was to use videostroboscopy to study the physiologic and biomechanical effects of botulinum toxin (Botox) injection on the pharyngoesophageal segment (PES) in total laryngectomy patients with poor-quality tracheoesophageal puncture (TEP) voice caused by PES spasm. METHODS: The following was a prospective study. Videostroboscopy of the PES and videotaped recordings of patients performing TEP voice tasks were conducted before and after Botox injection of the PES. Ratings of videostroboscopic and speech samples were performed by 3 blinded judges with extensive experience with this patient population. RESULTS: Perceptually, TEP voice was more fluent and less strained after injection. Videostroboscopically, patients demonstrated improved PES volitional control and mucosal wave characteristics after Botox injection. CONCLUSION: Botox injection in total laryngectomy patients with poor-quality TEP voice caused by PES spasm provides improved physiologic and biomechanical function of the PES, as demonstrated for the first time videostroboscopically. These findings help explain the perceptual ratings of TEP voice improvement noted after Botox injection. Videostroboscopy can be used to provide diagnostic information to help confirm the clinical impression of PES spasm, as well as to document the effects of Botox injection on PES function.

Botulinum toxin injection of the cricopharyngeus muscle for the treatment of dysphagia.

OBJECTIVE: This study was conducted to evaluate, subjectively and objectively, the diagnostic and therapeutic effects of botulinum toxin (Botox) in patients with dysphagia caused by cricopharyngeus (CP) muscle spasm and/or hypertonicity. METHODS: A retrospective chart review was done of 5 patients with normally functioning larynges treated with CP Botox injection for dysphagia caused by perceived spasm. Subjective measures of swallowing function after injection were obtained with a patient questionnaire. Objective data were obtained both before and after surgery by one or more of the following tests: modified barium swallow study, manometry, videostroboscopy, and fiberoptic endoscopic evaluation of swallowing. Quality-of-life measures were obtained with a swallowing rating scale. RESULTS: Overall, all patients had initial improvement in swallowing after Botox injection. The duration of benefit was from 2 to 14 months. There were no complications. Four of 5 patients had long-term benefits, as evidenced by decreased or eliminated aspiration symptoms, removal of tracheotomy, ability to eat solid foods, and weight gain. One patient continues to have poor swallowing function. CONCLUSION: Botox injection of the CP muscle to treat dysphagia is effective in patients with underlying muscle spasm or hypertonicity. A positive response to Botox can also help confirm the diagnosis of CP muscle spasm.

Anti-CD3/anti-CD28 bead stimulation overcomes CD3 unresponsiveness in patients with head and neck squamous cell carcinoma.

OBJECTIVES: To test whether T-cell CD3 responses are altered in patients with advanced-stage head and neck squamous cell carcinoma (HNSCC) and whether anti-CD3/anti-CD28 (alphaCD3/alphaCD28) bead stimulation could reverse CD3 unresponsiveness. DESIGN: Anti-CD3 (alphaCD3) monoclonal antibody immobilized on tissue culture plastic was used to stimulate lymph node mononuclear cells (LNMCs) and peripheral blood mononuclear cells (PBMCs) from patients with advanced-stage HNSCC. Proliferation, T-cell phenotype, and cytokines were measured during 8-day in vitro stimulation. Immune-enhancing properties of alphaCD3/ alphaCD28 beads were also tested on LNMCs and PBMCs. Cytotoxicity of bead-activated T cells (ATCs) was measured against autologous and allogeneic HNSCC. RESULTS: Six patients were nonresponders to alphaCD3 stimulation defined by tritium (3H) incorporation of less than 3500 cpm, whereas 11 patients were responders with 3H incorporation of 3500 cpm or more. Responders produced higher levels of interleukin (IL)-12 and interferon gamma (IFN-gamma) after alphaCD3 stimulation than nonresponders. No phenotypic or clinical differences were identified between groups. Stimulation with alphaCD3/alphaCD28 beads enhanced IFN-gamma and IL-2 produced by both groups. Bead ATCs were generated from PBMCs of patient 11 in the responder group and lysed (+/- SD) 100% +/-1% of autologous tumor and 49% +/-1% of allogeneic tumor. Bead ATCs from LNMCs of this patient lysed 58%+/-1% of autologous tumor and 63%+/-1% of allogeneic tumor. CONCLUSIONS: A subpopulation of patients with HNSCC who are nonresponders to alphaCD3 stimulation has been identified, showing reduced proliferation and IL-12 and IFN-gamma secretion. Nonresponders stimulated with alphaCD3/alphaCD28 beads reversed immune unresponsiveness and induced a type 1 cytokine response. Bead-generated ATCs from patient 11 in the responder group lysed autologous and allogeneic HNSCC in vitro, suggesting a possible effective immunotherapeutic modality in the treatment of HNSCC.

Magnetic resonance imaging of the facial nerve in children with idiopathic facial paralysis.

The role of gadolinium-enhanced MRI (Gd-MRI) in the diagnosis of idiopathic facial paralysis (IFP) in children is not well defined. Fourteen children with IFP were evaluated to assess the use of Gd-MRI for the presence and pattern of enhancement and its usefulness in predicting the recovery of facial function. Six of 14 children had enhancement of the facial nerve on Gd-MRI, whereas 8 had none. Enhancement was noted in the tympanic, mastoid, and most commonly in the distal intracanalicular and labyrinthine segments. The average time from onset of paresis to recovery in patients with enhancement was 19.3 weeks, whereas in those with no enhancement, mean recovery time was 9.5 weeks (P = 0.003, t test). All 14 patients eventually had recovery to House-Brackmann grade I or II. Gd-MRI is not required for all children with IFP but may yield information about the time course of recovery of facial function.

Functional outcomes of the retromaxillary-infratemporal fossa dissection for advanced head and neck/skull base lesions.

The retromaxillary-infratemporal fossa (RM-ITF) dissection, using a preauricular incision, was initially popularized for the treatment of temporomandibular joint disorders, facial fractures, and orbital tumors. This approach has been expanded for the treatment of advanced head and neck and skull base tumors extending into the infratemporal fossa. We studied prospectively eight consecutive patients requiring a RM-ITF dissection. Pre- and postoperative functional outcomes measured were mastication, speech, swallowing, cranial nerve function, pain, and cosmesis. A significant reduction in pain was noted postoperatively in all patients studied. Limited changes were identified in mastication, speech, swallowing, vision, hearing, or cosmesis postoperatively. The RM-ITF dissection should be considered when resecting advanced head and neck/skull base lesions that extend into this region. We have found minimal morbidity associated with this dissection. This procedure may have a useful place in palliation of patients with incurable pain caused by tumor invasion into the infratemporal fossa.

Anti-CD3/anti-CD28 monoclonal antibody-coated suture enhances the immune response of patients with head and neck squamous cell carcinoma.

OBJECTIVE: To test whether anti-CD3/anti-CD28 (alphaCD3/alphaCD28) monoclonal antibodies could be coated on surgical suture and used to enhance T-cell immune function in patients with advanced-stage head and neck squamous cell carcinoma (HNSCC). DESIGN: AlphaCD3/alphaCD28 monoclonal antibodies at varying concentrations and ratios were coated on surgical sutures and tested on peripheral blood mononuclear cells from normal donors to identify the optimal stimulating condition. Immune-enhancing properties of alphaCD3/alphaCD28 monoclonal antibody suture were tested on peripheral blood mononuclear cells and regional lymph node mononuclear cells isolated from patients with advanced HNSCC and on normal donor peripheral blood mononuclear cells. Proliferation, T-cell phenotype, and cytokines were measured during 8-day in vitro stimulation with alphaCD3/alphaCD28 suture and compared with alphaCD3/alphaCD28-coated tissue culture plastic, a previously recognized carrier. RESULTS: Optimal stimulation was observed with monofilament nylon incubated with alphaCD3/alphaCD28, 2 microg/mL, at a 1:1 ratio for 18 hours at 37 degrees C. Strong proliferation of peripheral blood mononuclear cells and lymph node mononuclear cells in patients with HNSCC was induced by alphaCD3/alphaCD28 suture. There was no difference in maximal proliferation between alphaCD3/alphaCD28 plastic and suture. On day 6 after alphaCD3/alphaCD28 suture stimulation, T-cell subpopulations expressing CD3, CD4, CD8, CD28, and CD45RO were enhanced. Suture stimulation significantly enhanced interleukin 2 secretion when compared with plastic stimulation (P = .01). Both alphaCD3/alphaCD28 suture and plastic stimulated interferon gamma secretion. CONCLUSIONS: To our knowledge, this study is the first to report the modification of surgical suture to create an immunomodulant. AlphaCD3/alphaCD28-coated suture expanded T cells from patients with HNSCC and induced a T(H)1 immune response, which may be a useful therapeutic tool in the treatment of HNSCC and other diseases.

Nasal alar reconstruction: a critical analysis using melolabial island and paramedian forehead flaps.

OBJECTIVES: To qualitatively and quantitatively describe aesthetic and functional outcomes following Mohs ablative surgery involving the alar subunit, using a paramedian or subcutaneous melolabial island flap. STUDY DESIGN: Retrospective review. METHODS: A single surgeon's results in 38 consecutive patients were analyzed. Objective measures (alar rim thickness, donor scar width and length), subjective assessment (seven aesthetic parameters) by three academic otolaryngologists, and patient satisfaction questionnaires were evaluated. Student t test was used to ascertain statistically significant differences between reconstructive groups. RESULTS: Questionnaire results demonstrate a significant (P = .026) difference in donor site rating favoring melolabial group responses. Objective scar measurements and subjective ratings of textural quality and alar notching also favored melolabial reconstructions. CONCLUSIONS: More favorable aesthetic and functional outcomes are seen with single subunit cutaneous alar defects reconstructed with the melolabial island flap than with deep composite or extensive unilateral nasal defects reconstructed with the paramedian forehead flap.

Botulinum toxin injection to improve tracheoesophageal speech after total laryngectomy.

Total laryngectomy patients, after undergoing a tracheoesophageal puncture (TEP), may have poor TEP speech because of hypertonicity or spasm of the pharyngoesophageal segment (PES). Conventional treatment options include speech therapy, PES dilation, pharyngeal neurectomy, and myotomy. Botulinum toxin injection into the PES has recently been reported to be effective for this disorder. However, data accumulated were based primarily on subjective analyses. This prospective investigation used both qualitative and quantitative measures to assess the effects of videofluoroscopy-guided botulinum toxin injection on TEP voice quality in laryngectomees with PES dysfunction. Patients underwent voice analyses, tracheal air pressure measures, and barium swallows before and after botulinum toxin injection. Seven of 8 patients had significant voice quality improvement, and tracheal air pressures normalized in 6 of 8 patients after injection. Videofluoroscopic botulinum toxin injection into the PES is efficacious, safe, and cost-effective and should be considered as a first-line therapy for the treatment of laryngectomees with poor quality TEP speech caused by PES dysfunction.

Videostroboscopy of the pharyngoesophageal segment in total laryngectomees.

OBJECTIVES: The reconstructed pharyngoesophageal segment (PES) serves as the neoglottis following total laryngectomy, as it provides the source of vibration for production of tracheoesophageal puncture (TEP) voice. To date, little information exists regarding the vibratory characteristics of the PES. The purpose of this investigation was to study the anatomy and physiology of the PES using videostroboscopy. STUDY DESIGN: Prospective study investigating the anatomy and physiology of the PES in 34 laryngectomees who used TEP speech as their primary form of communication. MATERIALS AND METHODS: Videostroboscopy and voice recordings were graded by three trained, blinded judges using a seven-point scale. RESULTS: The patients demonstrated differences that allowed for separation of patients into two main groups: "poor" and "effective" TEP speakers. The voice quality differences were explained by anatomic and physiologic characteristics of the PES. Redundant, thick, and dyssynchronous PES features were observed in patients with poor TEP speech skills; the effective speakers exhibited less redundant, thinner mucosa and more synchronous vibratory patterns. Moreover, the latter subgroup consistently demonstrated a greater degree of volitional PES control and less spasmodic activity than their poorly speaking counterparts. Length of the PES opening (measured in the horizontal plane) as well as amount and consistency of secretions did not appear to influence TEP speech or voice proficiency. CONCLUSION: Videostroboscopy in laryngectomees is a noninvasive, inexpensive, easily performed procedure that may contribute valuable information regarding the anatomy and physiology of the PES, especially in patients who experience difficulties achieving satisfactory TEP voice and speech production.

Laryngeal obstructing saccular cysts: a review of this disease and treatment approach emphasizing complete endoscopic carbon dioxide laser excision.

Airway-obstructing saccular cysts in adults are rare laryngeal anomalies. Treatment with tracheotomy may be needed for control of the airway, often followed by marsupialization of the cyst wall. Unfortunately, recurrence rates are high following marsupialization. We describe 2 patients with saccular cysts obstructing the airway and discuss airway management and the results following complete endoscopic carbon dioxide laser excision. Both patients had normal voice and swallowing function postoperatively and are disease free.

A comparison of methods of botulinum toxin injection for abductory spasmodic dysphonia.

Treatment of abductory spasmodic dysphonia with botulinum toxin injection into the posterior cricoarytenoid muscles often results in only partial symptom relief. In contrast, excellent results can be achieved after thyroarytenoid injection for the adductory type of spasmodic dysphonia. One reason for disappointing results may be inaccurate placement of the botulinum toxin into the posterior cricoarytenoid muscles. We describe a new approach to posterior cricoarytenoid injection used in 18 patients for treatment of abductory spasmodic dysphonia. Of the 30 patients treated for abductory spasmodic dysphonia at Loyola University-Chicago, 6 underwent both a retrocricoid approach and the newer transcricoid method, thus allowing patient and clinician comparison of techniques. We and all six of our patients preferred the transcricoid approach because of less discomfort, equivalent or better voice results, and fewer side effects.

Mucosal injuries of the upper aerodigestive tract after smoking crack or freebase cocaine.

The introduction of "crack" and 'freebase" cocaine to the United States has resulted in an increased number of patients presenting to emergency rooms with cocaine-related burns of the upper aerodigestive tract. Because symptoms are nonspecific and histories often unreliable, the emergency room physician must keep a high index of suspicion for cocaine use when confronted with these types of patients. We present seven patients who had burns to the upper aerodigestive tract as a result of smoking crack or freebase cocaine. Two of seven patients underwent an emergency tracheotomy, probably because of delayed diagnosis and inadequate early medical intervention. This article reviews the history behind cocaine use, its different modes of administration, potential complications associated with smoking cocaine, diagnostic workup, and treatment options.

Changes in the tonotopic map of the dorsal cochlear nucleus in hamsters with hair cell loss and radial nerve bundle degeneration.

Hamsters were exposed to an intense tone (10 kHz) at levels and durations sufficient to cause hair cell loss and radial nerve bundle degeneration. A previous study reported changes in the tonotopic map of the dorsal cochlear nucleus (DCN) in hamsters with tone-induced stereocilia loss. Such changes appear similar to those observed by others in the auditory nerve following acoustic trauma, and suggest that the map alterations have a peripheral origin. However, the potential for tonotopic map reorganization after more severe lesions involving cellular degeneration in the cochlea has not yet been determined. The purpose of the present study was to determine how the tonotopic map of the DCN appears in animals with severe cochlear injury involving hair cell loss and radial nerve bundle degeneration. Neural population thresholds and tonotopic organization were mapped over the surface of the DCN in normal unexposed animals and those showing tone-induced lesions. The results indicate that cochlear lesions characterized mainly by radial bundle degeneration in a restricted portion of the organ of Corti cause changes in a corresponding region of the tonotopic map which reflect primarily changes in the shape and thresholds of neural tuning curves. In many cases the center of the lesion was represented in the DCN as a distinct characteristic frequency (CF) gap in the tonotopic map in which responses were either extremely weak or absent. In almost all cases the map area representing the center of the lesion was bordered by an expanded region of near-constant CF, a feature superficially suggestive of map reorganization (i.e., plasticity). However, these expanded map areas had abnormal tip thresholds and showed other features suggesting that their CFs had been shifted downward by distortion and deterioration of their original tips. Such changes in neural tuning following tone-induced loss of anatomical input to the central auditory pathway are similar to those observed in our previous study and by others in the auditory nerve following less severe acoustic trauma, and thus would seem to have a peripheral origin. Thus, changes in the DCN tonotopic map can be explained by peripheral modifications and do not seem to involve plastic changes (i.e., reorganization).

Dorsal cochlear nucleus blood flow during acoustic stimulation.

Dynamic in vivo changes in dorsal cochlear nucleus blood flow during pure-tone stimulation were assessed with intravital microscopy. Subjects were stimulated with 5-, 10-, or 15-kHz pure tones at 70, 80, and 90 dB sound pressure level. Measurements in red blood cell velocity and vessel diameter were made in capillaries overlying the 10-kHz isofrequency band of the dorsal cochlear nucleus. Stimulation with 10 kHz induced intensity-dependent increases in local blood flow in the 10-kHz isofrequency band of the dorsal cochlear nucleus. Stimulation with 5 kHz and 15 kHz, frequencies represented in remote locations on the dorsal cochlear nucleus surface, did not significantly alter blood flow in the defined 10-kHz isofrequency band. These data demonstrate a direct relationship between spectral and intensity-dependent pure-tone stimulation of the dorsal cochlear nucleus and increases in local blood flow. These findings suggest that tonal stimulation of the dorsal cochlear nucleus induces an increase in local metabolic demands with resultant rapid blood flow increases.

Carotid artery resection for cancer of the head and neck.

OBJECTIVE: To compare the morbidity and mortality associated with ligation and reconstruction of the carotid artery after resection. DESIGN: Cohort study. SETTING: Tertiary referral center and Veterans Affairs medical center. PATIENTS: Twenty consecutive patients who underwent carotid artery resection for metastatic squamous cell carcinoma between January 1985 and June 1992. RESULTS: Seven (58%) of 12 patients with ligation suffered neurological sequelae compared with one (13%) of eight patients with interposition grafts (P < .05). Six of eight patients with neurological sequelae had delayed onset of complications. Local control of tumor was achieved in 14 (74%) of 19 patients overall. Median survival was 6.3 months, and the 1-year disease-free survival rate was 16% (three patients). CONCLUSION: Carotid artery replacement is superior to ligation in avoiding the neurological complications of carotid artery resection. Carotid artery resection can provide local control of tumor but fails to achieve a high rate of disease-free survival.

Bone graft implantation for correction of the anophthalmic orbit.

Prosthetic rehabilitation of the anophthalmic orbit may result in a syndrome characterized by retrodisplacement and tilt of the prosthesis, deepening of the upper eyelid sulcus, retraction of the upper eyelid, and stretching of the lower eyelid. Patients requiring enucleation of the orbit following trauma can also have accentuation of the enophthalmos, with hypophthalmos and displacement of the malar eminence. These cosmetic defect are difficult to manage, and a number of corrective surgical techniques have been described. In this study we review the pathophysiology of the anophthalmic orbit and present our recent experience utilizing the strategic placement of iliac crest bone grafts to compensate for the bony and soft-tissue injuries associated with traumatic loss of the globe. All six patients experienced subjective and objective improvement postoperatively. Results are presented as case presentations with accompanying photographs and follow-up data.

Forward masking properties of neurons in the dorsal cochlear nucleus: possible role in the process of echo suppression.

The majority of single unit studies in the auditory system have been carried out using stimuli whose temporal and spectral contexts are held constant. Relatively little attention has been given to the influence of context on unit response properties. Indeed, auditory nerve fiber responses are known to be context-dependent due to the property of forward masking, a phenomenon by which the response to one sound results in a reduction in the response to a subsequent sound. Forward masking might be expected to be even more influential at central levels of the auditory pathway where the responses are reshaped by additional synaptic interactions. The purpose of the present study was to characterize the forward masking properties of neurons in the dorsal cochlear nucleus (DCN). A tool was developed for measuring the response to a probe tone as a function of delay following a previous tone-burst. The frequency of the probe was held constant at the unit's characteristic frequency while the frequency of the leading tone (masker) was varied. These measures provided a description of neural masking effects in different temporal and spectral contexts. The data yielded two patterns of suppression. In the first pattern (Type A), the suppression of the probe response became evident immediately following offset of the masker; the suppression bandwidth showed a gradual narrowing as the delay between masker and probe was increased. In the second class (Type B), the suppression of the probe response did not become evident until well after offset of the masker; this pattern appeared more circumscribed in that the suppression bandwidth gradually increased as a function of delay up to a maximum then decreased with further increases in delay. The results imply that mechanisms intrinsic to the DCN contribute to further modification and reshaping of the spectral and temporal context of masking effects beyond those seen in the auditory nerve. It is hypothesized that such properties may be specialized for suppressing the response to echoes thus facilitating communication and localization of sound in enclosed spaces.