Formal psychological testing in patients with paradoxical vocal fold dysfunction.

OBJECTIVE: The etiology of paradoxical vocal fold dysfunction (PVFD) has been unclear, but it has long been hypothesized that there is a significant psychological component. The purpose of this study was to elucidate the psychological profiles of patients newly diagnosed with PVFD using psychometrically-sound psychological assessment instruments. STUDY DESIGN: Prospective cohort study of 45 adults newly diagnosed with PVFD at a tertiary university referral center. METHODS: The Minnesota Multiphasic Personality Inventory (MMPI-2) was administered to test for psychopathology. The Life Experiences Survey (LES) was administered to investigate levels of stress. Demographic, medical, and social histories were reviewed. MMPI-2 and LES scores for the PVFD cohort were compared with scores previously established for normative populations. RESULTS: The study population included 81% female and 60% who were age 50 or older. Compared to the normative population for the MMPI-2, significant differences were noted for both male and female PVFD patients; on average, scores were highly elevated on the hypochondriasis scale and hysteria scale and less elevated on the depression scale. This pattern was consistent with conversion disorder (P < .01). In MMPI-2 subset analysis, 18 patients had a classic conversion profile while 13 others had elevated scores in the three scales of interest, but not in the classic conversion disorder pattern. Also, 11 patients had normal scores, suggesting no psychopathology. PVFD patients with a psychological history scored significantly higher on the depression and anxiety scales than PVFD patients without a psychological history. Patients with a history of asthma or gastroesophageal reflux disease (GERD) achieved significantly higher scores on the hypochondriasis scale than those without that medical history. On the LES assessment, female PVFD patients had significantly lower levels of positive stress and higher levels of negative stress than the general population; total levels of stress were not significantly different, however. Male PVFD patients had significantly lower levels of positive, negative, and total stress. For the entire cohort, asthma (65%), GERD (51%), and a history of abuse (38%) were common comorbidities. CONCLUSIONS: On average, in both male and female adults, PVFD is associated with conversion disorder, representing a physical manifestation of underlying psychological difficulty. There also appears to be a subset of PVFD that is not associated with psychopathology. PVFD patients with a previous psychological history are prone to more depressive and anxious symptomatology. Patients with PVFD and a history of asthma or GERD are more likely to excessively complain about physical symptoms. Overall levels of stress are not higher in PVFD patients compared to a general population. However, females report more negative stress, and both males and females may have trouble coping with the amount of stress that they do have. PVFD is more common among women, more prevalent among older individuals, and can be comorbid with asthma, GERD, and previous abuse. These results have implications for treatment- psychotherapy directed for somatoform and conversion disorders may be added to traditional speech therapy for increased efficacy.

Neuroglial heterotopia causing neonatal airway obstruction: presentation, management, and literature review.

Neuroglial heterotopias are rare congenital masses that are thought to represent encephaloceles that become sequestered on the extracranial side of the skull base. Although most often adjacent to bony skull base defects, they lack communication to the subarachnoid space. They contain mature neuroglial tissue and specialized central nervous system elements, such as a functioning choroid plexus. A case is presented of neonatal airway obstruction due to neuroglial heterotopia in the nasopharynx. The patient's clinical course and treatment are discussed, along with their radiology and histology. The relevant scientific literature is reviewed.

Recurrence of isolated multiple myeloma in the skull base: a case report and review of the literature.

Extramedullary plasmacytoma involving the skull base is rare. We describe what we believe is the first reported case of recurrent multiple myeloma presenting as an isolated lesion in the central skull base in a patient with no evidence of systemic involvement. We discuss the patient's presentation, clinical course, and treatment, and we review the relevant scientific literature.

Hedonic and motivational responses to food reward are unchanged in rats with neuropathic pain.

Rewards influence responses to acute painful stimuli, but the relationship of chronic pain to hedonic or motivational aspects of reward is not well understood. We independently evaluated hedonic qualities of sweet or bitter tastants and motivation to seek food reward in rats with experimental neuropathic pain induced by L5/6 spinal nerve ligation. Hedonic response was measured by implantation of intraoral catheters to allow passive delivery of liquid solutions, and "liking/disliking" responses were scored according to a facial reactivity scale. Spinal nerve ligation rats did not differ from controls in either "liking" or "disliking" reactions to intraoral sucrose or quinine, respectively, at postsurgery day 21, suggesting no differences in perceived hedonic value of sweet or bitter tastants. To assess possible motivational deficits during acute and chronic pain, we used fixed- and progressive-ratio response paradigms of sucrose pellet presentation in rats with transient inflammatory or chronic neuropathic pain. Assessment of response acquisition and break points under the progressive ratio schedule revealed no differences between sham and spinal nerve ligation rats for up to 120 days after injury. However, rats with inflammation showed decrements in lever pressing and break points on days 1 and 2 after complete Freund adjuvant injection that normalized by day 4, consistent with transient ongoing pain. Thus, although acute ongoing inflammatory pain may transiently reduce reward motivation, we did not detect influences of chronic neuropathic pain on hedonic or motivational responses to food rewards. Adaptations that allow normal reward responding to food regardless of chronic pain may be of evolutionary benefit to promote survival.

Cricoid palpability as a selection criterion for bedside tracheostomy.

OBJECTIVE: To prospectively evaluate the significance of cricoid cartilage palpability as a selection criterion for bedside tracheostomy and to prospectively compare a cohort of patients undergoing bedside tracheostomy with another cohort receiving operating room tracheostomy. STUDY DESIGN/SETTING: Prospective trial comparing 2 cohorts of patients receiving tracheostomies at a tertiary care center (university hospital). In all, 220 consecutive intubated patients selected for elective tracheostomy were enrolled. Of them, 134 patients had palpable cricoid cartilage and underwent open surgical tracheostomy at the bedside. The remaining 68 patients received open surgical tracheostomies in the operating room. Demographic data, patient anatomic features, and perioperative complications were prospectively recorded. There were no statistically significant differences in age, gender, reason for admission, indication for tracheostomy, Acute Physiology and Chronic Health Evaluation II score, number of days intubated, or time required to perform the procedure for those patients whose tracheostomies were performed in the operating room versus the intensive care unit. RESULTS: Patients with a palpable cricoid cartilage had a significantly reduced perioperative complication rate compared with those without a palpable cricoid cartilage (2% vs 22%, P < 0.001). Comparison of cervical girth, mental-to-sternum distance, and thyroid-notch-to-sternum distance showed no significant difference between the 2 groups and did not further define selection criteria. CONCLUSION: This investigation prospectively confirms the safety of bedside tracheostomy placement in properly selected patients. Complication incidences are defined for open surgical tracheostomy at the bedside and in the operating room. Palpability of the cricoid cartilage has significant value as a selection criterion for bedside tracheostomy. SIGNIFICANCE: These findings will aid in the development of protocols and pathways for surgical airway management in critically ill patients to maximize cost-effective, high-quality care.

Paradoxical vocal cord motion: classification and treatment.

Paradoxical vocal cord motion (PVCM), or vocal cord dysfunction, is a descriptive term for inappropriate adduction of the vocal folds during respiration. The laryngeal mistiming leads to breathing difficulty and is often misdiagnosed as refractory asthma. The etiology of PVCM has been unclear but has long been hypothesized to be psychological. The present thesis is a prospective study of 170 patients older than 18 years being evaluated for PVCM, with 117 of the 170 (68.8%) identified as having PVCM by video laryngoscopy. Laryngeal edema (P = .021) and reflux (P = .026) were increased in patients with PVCM. A flat inspiratory arm of the flow volume loop during spirometry testing was a predictor of PVCM (P = .034). A subgroup of 47 newly diagnosed patients with PVCM underwent psychological analysis. The psychological profiles were elucidated using the Minnesota Multiphasic Personality Inventory and the Life Experiences Survey to evaluate stress. Compared to established normative data, PVCM demonstrated a conversion disorder pattern (P < .01) but not an anxiety disorder or a correlation with stress. A subgroup, 11 of the 47 (23.4%), had normal psychological outcomes, and two of the 47 (4.3%) were identified as malingering. Previous studies have suggested that PVCM is strictly a psychological disorder. It is proposed that PVCM is a descriptive term that is multifactorial and the etiology should direct treatment. A classification scheme divides PVCM into primary, or psychological, and secondary. The secondary form consists of medical disorders divided into irritable larynx syndrome and neurologic disorders.

Anthropometric and aesthetic analysis of the Indian American woman's face.

BACKGROUND: This is the first study defining the facial anthropometric and aesthetic measurements in Indian American women (IAW). METHODS: This is a prospective cohort study involving evaluation of facial photographs. Frontal, lateral and basal photographs were taken of IAW (n=102), and 30 anthropometric measurements were determined. Proportions were compared with published North American white women (NAWW) norms. Judges (n=6) evaluated the photographs for aesthetics using a visual analogue scale. Attractive IAW (top 15%) were compared with average IAW (remaining 85%) and average NAWW. All completed a facial self-esteem survey. RESULTS: There were significant differences between IAW and NAWW in 25 of 30 facial measurements. Six measurements correlated with aesthetic scores: intercanthal distance, mouth width, nasolabial angle, midface height 2, ear length and nasal height. Attractive IAW had nine measurements approximating NAWW features, 15 measurements similar to average IAW values and two measurements distinct from both average IAW and average NAWW. Attractive IAW had higher facial self-esteem scores than average IAW. CONCLUSIONS: Facial measurements in IAW are much different from NAWW, and these results will assist in preoperative planning. Several features are correlated with attractiveness in IAW: larger and wider-set eyes, a smaller midface, a smaller nose with greater tip rotation, smaller ears and a larger mouth. Attractive IAW display many measurements typical of average IAW and several measurements that reflect average NAWW values. These results contribute to concepts of transcultural aesthetics--for a minority ethnic group, facial beauty appears to be an assimilation of deep-rooted ethnic features with prevailing cultural traits and aesthetic standards.

Ectopic molar in the maxillary sinus precipitating a mucocele: a case report and literature review.

Ectopic teeth are rarely found in the maxillary sinus. When they are, they represent an anomaly of odontogenic development that is generally associated with odontogenic cysts, trauma, or idiopathic etiology. Although affected patients are often asymptomatic, documented morbidities include sinus disease that is often refractory to treatment. The diagnosis is usually made by plain-film radiography. Computed tomography is indicated when an ectopic tooth is associated with an antral mass and prior to surgery. Treatment of symptomatic patients and those with an antral mass is surgical, with either a Caldwell-Luc operation or an endoscopic procedure. We describe what we believe is the first reported case of a third molar in the roof of the maxillary sinus associated with a mucocele, and we review the literature.

Esophageal reconstruction with larynx preservation using forearm-free flap.

Surgery for cervical esophageal malignancy frequently involves comcomitant total laryngectomy carried out because of either oncologic or functional concerns. Though uncommon, preservation of the larynx has, in recent years, been described in patients undergoing cervical esophagectomy with reconstruction of the resulting circumferential esophageal defect achieved using either free jejunal flaps or gastric pullup procedures. The use of tubed-free cutaneous flaps for circumferential cervical esophageal reconstruction, however, has been rarely described in situations where the larynx has been preserved. We describe successful use of a tubed radial forearm-free flap for reconstruction of a circumferential cervical esophageal defect with preservation of the larynx. Use of the radial forearm flap in this situation resulted in minimal donor site-related morbidity, avoided the need for laparotomy and excellent voice and swallowing function were maintained. As such, use of tubed cutaneous free flaps can be considered an option for cervical esophageal reconstruction when the larynx has been preserved.

Hierarchical cluster analysis of myoepithelial/basal cell markers in adenoid cystic carcinoma and polymorphous low-grade adenocarcinoma.

Distinguishing adenoid cystic carcinoma from polymorphous low-grade adenocarcinoma of the salivary glands is important for their management. We studied the expression of several myoepithelial and basal/stem cell markers (smooth muscle actin, calponin, smooth muscle myosin heavy chain, metallothionein, maspin, and p63) by immunohistochemistry in 23 adenoid cystic carcinoma and 24 polymorphous low-grade adenocarcinoma, to identify the most useful marker or combination of markers that may help their diagnoses. The results were analyzed using hierarchical cluster analysis and chi(2) test for trend. We noted diffuse expression of smooth muscle actin in 20 adenoid cystic carcinoma vs one polymorphous low-grade adenocarcinoma (P<0.0001), calponin in 15 adenoid cystic carcinoma vs one polymorphous low-grade adenocarcinoma (P<0.0001), smooth muscle myosin heavy chain in 15 adenoid cystic carcinoma vs one polymorphous low-grade adenocarcinoma (P=0.001), metallothionein in 22 adenoid cystic carcinoma vs eight polymorphous low-grade adenocarcinoma (P<0.001), maspin in 22 adenoid cystic carcinoma vs 14 polymorphous low-grade adenocarcinoma, and p63 in 21 adenoid cystic carcinoma vs 14 polymorphous low-grade adenocarcinoma. Hierarchical clustering of smooth muscle actin, calponin, smooth muscle myosin heavy chain, and metallothionein was virtually identical (kappa< or =0.0035), suggesting no significant advantage to their use in combination than individually. Diffuse smooth muscle actin expression showed the highest accuracy (91.5%) and positive predictive value (95.2%) for adenoid cystic carcinoma. Thus, diffuse expression of smooth muscle actin, calponin, smooth muscle myosin heavy chain, and metallothionein was highly predictive of adenoid cystic carcinoma, whereas maspin and p63 were frequently expressed in both tumors. In differentiating adenoid cystic carcinoma from polymorphous low-grade adenocarcinoma, smooth muscle actin as a single ancillary test in support of the histological findings, appears to be as efficient as multiple immunohistochemical tests.