Long-term voice evaluation after arytenoid adduction surgery in patients with unilateral vocal fold paralysis.

PURPOSE: Laryngeal framework surgery, including medialization laryngoplasty and arytenoid adduction (AA), is expected to have a lasting or permanent effect in patients with unilateral vocal fold paralysis (UVFP); however, there are few reports about the long-term outcomes of AA. This study aimed to evaluate the long-term postoperative effects of AA surgery and examine its stability and reliability. METHODS: This study collected the voice handicap index (VHI) questionnaire from patients with UVFP who underwent AA more than 2 years previously. The VHI values preoperatively and 3 months postoperatively (early postoperative evaluation) were retrospectively calculated, and VHI values more than 2 years after surgery (late postoperative evaluation) were collected by mailing a sheet to the patients and asking to fill and return it. Possible influenced subscales such as age, sex, causes of UVFP, affected side, and surgeons were also analyzed. RESULTS: A total of 77 patients with UVFP who underwent AA had significantly lower early and late postoperative evaluations than preoperative evaluations. In 38 patients with no missing values, there were no significant differences between early and late postoperative evaluations, measured at a median of approximately 5 years. There were also no significant differences between early and late postoperative evaluations in any of the subscale groups. CONCLUSION: Patients with UVFP who underwent AA surgery achieved stable voice improvement in the long term after surgery.

Long-term outcomes after surgery to prevent aspiration for patients with amyotrophic lateral sclerosis.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that affects motor neurons selectively. In particular, weakness in respiratory and swallowing muscles occasionally causes aspiration pneumonia and choking, which can be lethal. Surgery to prevent aspiration, which separates the trachea and esophagus, can reduce the associated risks. Central-part laryngectomy (CPL) is a relatively minimally invasive surgery to prevent aspiration. No studies have been conducted on the long-term outcomes of surgery to prevent aspiration in patients with ALS. This case series aimed to determine the long-term outcomes of surgery to prevent aspiration and the use of a continuous low-pressure aspirator in patients with ALS by evaluating the frequency of intratracheal sputum suctions performed per day, intra- and postoperative complications, oral intake data, and satisfaction of patients and their primary caregiver to predict improvement in patients' quality of life (QOL). METHODS: We report a case series of six patients with ALS who underwent CPL along with tracheostomy to prevent aspiration between January 2015 and November 2018. We evaluated their pre- and postoperative status and administered questionnaires at the time of last admission to the patients and their primary caregivers. RESULTS: The mean follow-up period after CPL was 33.5 months. Aerophagia was a common postoperative complication. The use of a continuous low-pressure aspirator resulted in reduced frequency of intratracheal sputum suctions. All cases avoided aspiration pneumonia. Oral intake was continued for 2-4 years after the tracheostomy and CPL. The satisfaction levels of the patient and primary caregiver were high. CONCLUSION: Our case series suggests that the use of a continuous low-pressure aspirator in patients undergoing CPL improves oral intake and reduces the frequency of intratracheal sputum suctions, which improves the QOL of patients with ALS and their families and caregivers. CPL and continuous low-pressure aspiration should be considered as a management option for ALS with significant bulbar and respiratory muscle weakness/dysfunction.

Simultaneous evaluation of symptoms, swallowing functions, and patient-reported swallowing difficulties and their correlations with ingestion status during definitive chemoradiotherapy for oropharyngeal and hypopharyngeal cancer.

PURPOSE: To clarify the correlations among symptoms, swallowing functions, and ingestion status and to validate a method of swallowing evaluation during chemoradiotherapy (CRT) for head and neck cancer. METHODS: Oropharyngeal and hypopharyngeal cancer patients who were to receive definitive CRT as initial treatment were included in this prospective, single-center, observational study. The Functional Oral Intake Scale (FOIS) for ingestion status and grades of symptoms (dryness, dysgeusia, mucositis, and the analgesic ladder); the Yale Pharyngeal Residue Severity Rating Scale on fiberoptic endoscopic evaluation of swallowing (FEES) and the Penetration-Aspiration Scale (PAS) on videofluoroscopic (VF) evaluation for swallowing functions; and the 10-item Eating Assessment Tool (EAT-10) questionnaire were assessed at 5 time points unless the participant refused. The FEES and VF evaluation findings at each point were also compared. RESULTS: There were 38 participants. Dysgeusia, mucositis, and pain grade, as well as the FOIS score, were the worst at 70 Gy and then improved after treatment. The improvements of pharyngeal residue and the PAS after treatment were limited. The EAT-10 and the pain ladder were highly correlated with the FOIS changes at many time points. The VF evaluation rate dropped after 40 Gy, whereas the FEES rate remained high. There were good correlations between pharyngeal residue and the PAS at 0 Gy, 70 Gy, and 3 months. CONCLUSION: The EAT-10 and pain reflected the FOIS score changes well, while two swallowing evaluations did not. To avoid aspiration, VF evaluation may not be necessary during CRT because of high correlations with pharyngeal residue on FEES.

Complications of using Gore-Tex in medialization laryngoplasty: case series and literature review.

PURPOSE: This study was performed to evaluate the incidence and contributing factors of complications associated with medialization laryngoplasty using Gore-Tex in patients with unilateral vocal fold paralysis. METHODS: A retrospective chart review was conducted for all patients who underwent medialization laryngoplasty using Gore-Tex at Tohoku University Hospital between January 2014 and April 2018. A search of series and case reports in PubMed was performed to determine the incidence of complications following medialization laryngoplasty using Gore-Tex. RESULTS: Sixty-eight patient charts were reviewed. Two patients (2.9%) had complications (infection and extrusion into the airway) related to the Gore-Tex implant after surgery. In the 555 medialization laryngoplasty cases reported in both our current data and eight additional articles, there were 11 complications related to the Gore-Tex implant (2.0%). The most common event was extrusion into the lumen, which occurred in six cases (1.1%), followed by persistent inflammation with the granulation formation (0.5%). There were 12 cases of Gore-Tex extrusion (one male, six female, and five of unknown gender). The interval to onset ranged from 1 month to 10 years (median, 49 months). CONCLUSIONS: Our findings serve as a reminder that complications can occur with Gore-Tex implants following medialization laryngoplasty in patients with unilateral vocal fold paralysis, even in the long-term. We suggest that the use of excessively large implants in women and occurrence of postoperative hematoma followed by infection are factors that may cause complications. Nevertheless, Gore-Tex has been proven to be a relatively safe and reliable material for medialization laryngoplasty.

Poor oral intake causes enteral nutrition dependency after concomitant chemoradiotherapy for pharyngeal cancers.

PURPOSE: To identify precipitating factors responsible for enteral nutrition (EN) dependency after concomitant chemoradiotherapy (CCRT) of head and neck cancers and to examine their statistical correlations. METHODS: Factors related to feeding condition, nutritional status, disease, and treatment of 26 oropharyngeal and hypopharyngeal cancer patients who received definitive CCRT were retrospectively investigated by examining their medical records. The days of no oral intake (NOI) during hospitalization and the months using enteral nutrition after CCRT were counted as representing the feeding condition, and the changes in body weight (BW) were examined as reflecting nutritional status. The factors related to EN dependency after CCRT were analyzed. RESULTS: Long duration of total NOI (≥ 30 days) and maximum NOI ≥ 14 days were significant predictors of EN dependency. Decreased BW (≥ 7.5 kg) was the next predictor identified, but it was not significant. Multivariate analysis showed that the total duration of NOI was more correlated with EN dependency than changes in BW. CONCLUSIONS: A long duration of NOI was more strongly related to EN dependency than nutritional factors.

Cricoarytenoid Articulation in Elderly Japanese With Special Reference to Morphology of the Synovial Tissue.

OBJECTIVE: To clarify composite fibers and cells in the synovial tissues of the cricoarytenoid joint (CA joint). METHODS: Routine histology and immunohistrochemistry using sagittal or nearly sagittal sections obtained from 18 elderly cadaveric specimens. RESULTS: The CA joint capsule was thin and contained few elastic fibers. A limited supportive ligament, namely, a thickened fascia of the posterior cricoarytenoid muscles, was sometimes evident on the lateral aspect of the CA joint. However, even in the weaker medial aspect of the joint, no marked destruction of the synovial tissues was found. The CA joint always contained synovial folds--a short medial fold and long lateral folds--but these contained no or few macrophages, lymphocytes, and blood capillaries. In 2 exceptional specimens showing inflammatory cell infiltration in the submucosal tissue of the larynx, the macrophage-rich area extended toward the capsule and medial synovial fold. CONCLUSIONS: The lateral aspect of the CA joint was likely to be supported mechanically by the muscle-associated tissues. Strong support of the arytenoid by muscles might reduce the degree of CA joint injury with age. However, some patients with hoarseness due to mucosal inflammation of the larynx might have accompanying synovitis and subsequent cartilage injury in the CA joint.

Submucosal Elastic Laminae of the Middle and Lower Pharynx: A Histological Study Using Elderly Cadaveric Specimens.

Although the pharyngeal wall is well known to have high elasticity, the distribution of submucosal elastic fibers has not been described. Observations of histological sections of the mid and lower pharyngeal walls from 15 elderly donated cadavers were made. We found two distinct submucosal tissue layers with a high content of elastic fibers (tentatively termed the "submucosal elastic laminae"). The inferolateral elastic lamina was restricted to the level from the upper part of the arytenoid to the lower end of the inferior cornu of the thyroid cartilage. It originated from the pharyngeal submucosa, extended laterally along the inner aspect of the thyropharyngeal muscle, and inserted into the posterior margin of the thyroid cartilage including the cornu. The posteromedial lamina extended along the supero-inferior axis from a level above the greater horn of the hyoid bone to reach the muscularis mucosae of the cervical esophagus. The inferolateral and posteromedial laminae were connected at levels below the cricoarytenoid joint. Individual variations were evident in their thicknesses (ranging from almost absent to 0.3 mm) as well as the extent of connection between them. In association with striated muscle function, the inferolateral lamina seemed to suspend the lower pharyngeal mucosa, while the posteromedial lamina seemed to provide mucosal fold forcing smoothly peristaltic conveyance of a bolus during swallowing.

Guidance of clinical management for patients with tonsillar focal disease.

Tonsillar focal diseases (TFDs) are defined as "diseases caused by organic and/or functional damage in organs distant from tonsil, and the disease outcome is improved by tonsillectomy." Although several reports and reviews have shown the efficacy of tonsillectomy for TFDs, no guidelines for the clinical management of the diagnosis and treatment of TFDs have been reported. Therefore, the Society of Stomato-pharyngology established a committee to guide the clinical management of patients with TFDs, and the original guide was published in May 2023. This article summarizes the English version of the manuscript. We hope that the concept of TFDs will spread worldwide, and that one as many patients with TFDs will benefit from tonsillectomy.

Bedside evaluation of swallowing function to predict aspiration pneumonia in Duchenne muscular dystrophy.

OBJECTIVE: Aspiration pneumonia is one of the leading causes of death in patients with muscular dystrophy; therefore, it is important to predict its occurrence in the clincal setting. We aimed to examine the usefulness of repeated saliva swallowing test (RSST), modified water swallowing test (MWST), and flexible endoscopic evaluation of swallowing (FEES) for evaluating the Hyodo score at the bedside, to predict the risk of aspiration pneumonia in patients with Duchenne muscular dystrophy (DMD). METHODS: In this retrospective cohort study involving 43 patients, we evaluated the swallowing function using the RSST, MWST, and FEES, and predicted the likelihood of aspiration pneumonia within 2 years after the assessment. The Hyodo score, a scoring system for evaluating the swallowing function determined by the FEES, was used. RESULTS: Pneumonia was observed in 14 patients (32.6%). The RSST was not significantly useful for predicting the onset of pneumonia. The MWST was reported to have a cutoff value of < 4 points. Significantly more patients in the pneumonia group had an MWST score of < 4 points. The results revealed that the occurrence of pneumonia could be predicted based on a Hyodo cutoff score of ≥ 6. Significantly more patients in the pneumonia group had an MWST score of < 4 or a Hyodo score of ≥ 6. CONCLUSIONS: Combining MWST and FEES is useful for evaluating the bedside swallowing function and predicting the onset of pneumonia.

Outcome of the 'waiting until spontaneous extrusion' strategy for long-term tympanostomy tube placement in children with cleft palate.

BACKGROUND: Otitis media with effusion (OME) in children with cleft palate (CP) is known to be refractory to treatment and most of these patients undergo surgery for ventilation tube (VT) placement. OBJECTIVES: To identify the outcomes of children with CP using long-term VT with a 'waiting until spontaneous extrusion' strategy. MATERIAL AND METHODS: We retrospectively reviewed the medical records of all children with CP who visited our department from December 2016 to November 2017 and who received long-term VT placement in our department. Risk factors related to residual perforation and recurrence of OME were analyzed. RESULTS: A total of 106 children were included in this study. Our statistical analysis of 94 ears followed for more than three months after VT loss revealed that longer VT placement was associated with residual perforation, and shorter VT placement was associated with OME recurrence. Although a longer duration of VT placement was associated with an increased rate, extremely long-term VT placement was not associated with residual perforation, as expected. Half of the VTs were spontaneously extruded at 40 months after insertion. CONCLUSIONS AND SIGNIFICANCE: Long-term VT insertion using a waiting until spontaneous extrusion strategy is a potential option for children with CP.

Characteristics of the Voice Handicap Index for Patients With Unilateral Vocal Fold Paralysis Who Underwent Arytenoid Adduction.

PURPOSE: This study was performed to evaluate the characteristics of the Voice Handicap Index (VHI), a self-assessment measure, for patients with unilateral vocal fold paralysis (UVFP) who underwent arytenoid adduction (AA), in comparison with postoperative vocal function examinations. METHODS: A retrospective chart review was conducted for patients who underwent AA at Tohoku University Hospital during the period between 2014 and 2017. VHI was compared before and after surgery; moreover, correlations were assessed between the VHI and other voice measurements, including perceptual assessment of voice, as well as aerodynamic and acoustic measures. Factors involved in the VHI score were explored by multivariate analysis. RESULTS: Forty-three UVFP patients (28 males, age 32-81 years; 15 females, age 34-80 years) were enrolled in the study; the average age of all patients was 61.5 years (32-81 years). Among the enrolled patients, 33 (76.7%) left and 10 (23.3%) right vocal folds were impaired. After surgery, nearly all of the patients exhibited significantly improved VHI score; each of the three subscales (functional, physical, and emotional) was also improved. The postoperative VHI correlated mildly with several values of the other voice measurements, with the exception of the mean flow rate. Multivariate analysis showed that the sole variable associated with postoperative VHI score was preoperative VHI. CONCLUSIONS: The postoperative VHI likely reflects improvement in the voices of the patients with UVFP. Although there were weak correlations with other voice measures, postoperative VHI is a relatively independent measurement parameter for patients with UVFP who underwent AA.

Assessment of the Physical Properties of Inclusion Complexes of Forchlorfenuron and γ-Cyclodextrin Derivatives and Their Promotion of Plant Growth.

The current study prepared solid dispersions of forchlorfenuron (CPPU) and γ-cyclodextrin (γCD) or CPPU and 2-hydroxypropyl-γ-cyclodextrin (HPγCD) via cogrinding and coprecipitation to assess their physicochemical properties and their effect on plant growth. According to phase solubility diagrams, both CPPU/γCD and CPPU/HPγCD formed an inclusion complex at a molar ratio of 1/1. According to differential scanning calorimetry and powder X-ray diffraction, a ground mixture (GM) of CPPU and γCD (molar ratio = 1/1), a GM of CPPU and HPγCD (molar ratio = 1/1), and a coprecipitate (CP) of CPPU and γCD (molar ratio = 1/1) formed an inclusion complex. According to 1H-1H nuclear Overhauser effect spectroscopy NMR spectroscopy of the GMs and CP, the aromatic rings of the CPPU molecule are presumably included in CD from the wider to the narrower rim of its ring. Cultivation of broccoli sprouts with the GMs and CP resulted in no differences in the length of sprouts in comparison to a commercial preparation (Fulmet).

Nasolacrimal duct opening to the inferior nasal meatus in human fetuses.

The purpose of this study is to describe the Hasner's membrane which is the main factor of congenital nasolacrimal duct obstruction. Hasner's membrane at the nasal end of the fetal nasolacrimal duct (NLD) is considered to rupture at and after birth. However, topographical anatomy around the membrane as well as a mechanism of rupture seems to be still obscure. We observed frontal or sagittal sections of 20 late-stage fetuses (28-33 weeks) and found the on-going rupture in 2 specimens. The present sections demonstrated that 1) the nasal dilation was not a simple ball-like structure but extended posteriorly and laterally; 2) dilation of the NLD consistently involved the lacrimal sac; 3) Hasner's membrane and ductal mucosal layer contained no macrophages and no or few arteries and nerves. The posterior extension of the NLD end ranged from 1-2 mm, while the lateral extension 3-5 mm although a site of the thinnest membrane varied in location between specimens. Moreover, the thickest NLD due to dilation was in the slightly orbital or upper side of the nasal end. Therefore, before surgical treatment of Hasner's membrane, evaluation using medical images seems to be necessary. Since the nasal epithelium on Hasner's membrane was most likely to destroy earlier than the NLD mucosal lining, observations of the membrane from the nasal cavity seemed helpful for diagnosis at which site would be broken and when.

Anticancer drugs up-regulate HspBP1 and thereby antagonize the prosurvival function of Hsp70 in tumor cells.

The 70-kDa heat shock protein (Hsp70) is up-regulated in a wide variety of tumor cell types and contributes to the resistance of these cells to the induction of cell death by anticancer drugs. Hsp70 binding protein 1 (HspBP1) modulates the activity of Hsp70 but its biological significance has remained unclear. We have now examined whether HspBP1 might interfere with the prosurvival function of Hsp70, which is mediated, at least in part, by inhibition of the death-associated permeabilization of lysosomal membranes. HspBP1 was found to be expressed at a higher level than Hsp70 in all normal and tumor cell types examined. Tumor cells with a high HspBP1/Hsp70 molar ratio were more susceptible to anticancer drugs than were those with a low ratio. Ectopic expression of HspBP1 enhanced this effect of anticancer drugs in a manner that was both dependent on the ability of HspBP1 to bind to Hsp70 and sensitive to the induction of Hsp70 by mild heat shock. Furthermore, anticancer drugs up-regulated HspBP1 expression, whereas prevention of such up-regulation by RNA interference reduced the susceptibility of tumor cells to anticancer drugs. Overexpression of HspBP1 promoted the permeabilization of lysosomal membranes, the release of cathepsins from lysosomes into the cytosol, and the activation of caspase-3 induced by anticancer drugs. These results suggest that HspBP1, by antagonizing the prosurvival activity of Hsp70, sensitizes tumor cells to cathepsin-mediated cell death.