The ancient practice of sutra neti leading to velopharyngeal stenosis: case report.

BACKGROUND: An ancient yoga technique called sutra neti, which is extensively used in India to keep the sinuses healthy, led to complete velopharyngeal stenosis in a 67-year-old male patient who presented with bilateral nasal obstruction, mouth breathing, anosmia and a change in voice. METHOD: The patient was diagnosed by nasal endoscopy using a zero-degree Hopkins rod endoscope, and adhesions were released using coblation. RESULTS: The patient had post-operative alleviation of symptoms and a patent velopharyngeal inlet on examination. CONCLUSION: Vigorous sutra neti can lead to velopharyngeal stenosis. Release of the stenosis is then required to cure the nasal blockade.

Feasibility of transnasal flexible carbon dioxide laser surgery for laryngopharyngeal lesions.

OBJECTIVE: The fiber-guided carbon dioxide (CO2) laser is a useful device for laryngopharyngeal surgery. The flexible CO2 wave-guide laser has been developed and commercially available for several years. However, the transnasal use of CO2 flexible wave-guided laser surgery through the instrument channel of a flexible endoscope (CO2 TNFLS) is not permitted in Japan. This feasibility study aimed to assess the value and the safety of an in-office CO2 TNFLS procedure. METHODS: Patients with small laryngopharyngeal diseases were enrolled from June 2015. Eligible patients had indications with lesions generally localized superficial lesions such as the benign tumor, leukoplakia, and premalignant lesion-like carcinoma in situ (CIS). Patients were locally well anesthetized using xylocaine. After removing as much of the lesion(s) as possible with flexible forceps, the remainder of the lesions were evaporated using CO2 TNFLS through the instrument channel of a flexible endoscope under local anesthesia. RESULTS: Eighteen surgeries involving 13 patients, including 9 papilloma (7 recurrent respiratory papilloma [RRP]), 2 carcinoma in situ, 1 leukoplakia, and 1 large epiglottic cyst), were performed. Four patients with RRP required multiple surgeries. Except for 3 patients with RRP, all patients achieved disease control without additional intervention. All procedures were completed with no severe adverse events. CONCLUSION: Office-based CO2 TNFLS is safe and feasible for patients with laryngopharyngeal pathologies. It is especially valuable for RRP patients with small lesions to avoid surgery under general anesthesia.

Crude tonsillectomy and local concepts of illness in Kisoro, Uganda: community perception of gapfura and its treatment.

The practice of crude tonsillectomy (CT), performed by traditional healers for a locally defined illness known as gapfura, has become increasingly common in south-western Uganda. This study describes perceptions of gapfura and examines the intersection of locally defined and biomedical illness. Kisoro District Hospital (KDH) staff (n=55) were surveyed, with 95% reporting that CT caused death, and 60% estimating that recipients died as a result of the procedure. Surveys of community members (n=737) revealed that 95% were familiar with gapfura as a common illness with variable symptoms; syndrome classification categorised 58% of descriptive responses as 'upper respiratory infection', while 42% suggested more severe diseases. Although only 26% of community respondents told the interviewer that CT was the best treatment, 47% believed the majority of community members use CT and 43% of those treated for gapfura within the past year received CT. The divergent perceptions of community members and allopathic health providers may be rooted in the use of gapfura as an idiom reflecting larger social stressors and CT as a response to this distress. Interventions to curb the practice of CT need to be multifaceted and will involve further anthropologic investigation, public health involvement, and education that encompasses the social context of disease.

Total laryngectomy for a dysfunctional larynx after (chemo)radiotherapy.

OBJECTIVE: To evaluate the functional outcomes after total laryngectomy (TLE) for a dysfunctional larynx in patients with head and neck cancer that is in complete remission after (chemo)radiotherapy. DESIGN: Retrospective cohort study. SETTING: Tertiary comprehensive cancer center. PATIENTS: The study included 25 patients from a cohort of 217 consecutive patients with TLE who were treated between January 2000 and July 2010. The inclusion criteria for this subgroup analysis were complete remission and functional problems for which TLE was considered to be the only resolution. Quality of life assessment was carried out using the European Organization for Research and Treatment of Cancer Quality of Life C30 and Head and Neck Module 35 questionnaires and an additional study-specific questionnaire covering functional aspects, such as swallowing and dyspnea, in more detail. INTERVENTION: Total laryngectomy. MAIN OUTCOME MEASURES: Morbidity, mortality, and functional outcomes. RESULTS The indication for TLE was chronic aspiration with or without recurrent pneumonia (n = 15 [60%]), debilitating dyspnea (n = 8 [32%]), and persistent profuse hemorrhage (radiation ulcer) (n = 2 [8%]). After TLE, 14 of the 25 patients (56%) had 20 major postoperative complications, including 11 pharyngocutaneous fistulas, requiring additional treatment. Tube feeding and recurrent pneumonia incidence had decreased from 80% and 28% to 29% and 0%, respectively, 2 years after surgery. Prosthetic voice rehabilitation was possible in 19 patients (76%). Two years after surgery, 10 of 14 patients (71%) still reported TLE-related pulmonary problems despite the consistent use of a heat and moisture exchanger. The 5-year overall survival rate was 35%. CONCLUSIONS: Total laryngectomy for a dysfunctional larynx tends to have a high complication rate. However, in this study, the initial functional problems (aspiration, recurrent pneumonia, and dyspnea) did not recur. Tube feeding was significantly reduced, and the quality of life of the surviving patients appeared to be reasonable.

Pharyngoesophageal junction neoplasia--therapeutic management.

Not only the anatomy but the treatment and the prognosis of these tumors are intermediate between hypopharyngeal and esophageal tumors. After a portion of the esophagus is removed or complete esophagectomy, a conduit must be established. The authors reviewed the experience of Prof. Cristian Popescu in total pharyngo-laryngectomy and his technique of pharyngoesophageal reconstruction with synthetic esophageal prosthesis. We have some 21 patients who underwent an esophageal reconstruction with Montgomery esophageal tube. This is a very important new, modem, interdisciplinary approach bewteen the head and neck surgeon and the general/thoracic surgeon to treat the pharyngo-laryngo-esofageal neoplasia with one stage reconstruction. The follow up for these patients shows that this reconstruction method is a good, reliable choice with low costs and considerable advantages for the quality of life. Surgery for these patients should be considered primarily palliative and the optimal reconstruction should preserve the quality of life for the duration of survival.

Tracheotomy in the unprotected airway.

PURPOSE: Although rare, there are many circumstances in which a secure airway is needed urgently. A newly developed technique is presented for quick and efficient performance of this procedure. PATIENTS AND METHODS: All patients who had tracheotomies performed at a tertiary referral center from January 1, 2004, through December 31, 2008, were found by querying the admission database. Three hundred twenty-seven separate procedures performed in 325 patients were identified. Urgent tracheotomies were distinguished from elective and emergent tracheotomies by reading operative reports and excluding elective and emergent procedures. Elective procedures were defined as performed in patients with a secure airway (with an endotracheal tube or laryngeal mask airway). Urgent tracheotomies were defined as having an intact, unprotected airway. Emergent procedures were performed in a patient with complete airway obstruction. RESULTS: Twenty instances of urgent, awake tracheotomies were found in 19 patients, resulting in an incidence of 20 of 327 tracheotomies (6.1%) in 19 of 325 patients (5.8%). CONCLUSIONS: Tracheotomy is an alternative to cricothyroidotomy as a surgical airway in patients with deteriorating respiratory status who cannot be safely intubated by nonsurgical means.

Surgical treatment of pharyngostomes in irradiated patients. Our experience with musculocutaneous pectoralis major flap and hyperbaric oxygen therapy.

CONCLUSION: Our experience confirms that pectoralis major flap is the first-choice technique for repairing recurrent hypopharyngeal fistulae in previously irradiated patients in whom microsurgical techniques are not indicated, and that hyperbaric oxygen therapy helps to solve this complex pathology. OBJECTIVES: A pharyngostome is a complication encountered when performing surgical operations on pharyngolaryngeal structures. The authors present their experience of treating recurrent complex pharyngostomes in previously irradiated patients in poor physical health. These patients need a simple, safe reconstruction with a low incidence of postoperative complications. MATERIAL AND METHODS: A pedicled pectoralis major flap was used for reconstruction: the skin side of the flap was used to restore the continuity of the pharyngeal mucosa, while the muscle was used to reconstruct the intermediate layer. The skin layer was completed by means of a free skin graft. In all cases, surgical treatment was combined with hyperbaric oxygen therapy before and after the operation. RESULTS: A total of 10 patients, all of whom had previously undergone surgery and radiotherapy, had recurring or pluri-recurring pharyngostomes. All patients (8 males, 2 females; age range 52-80 years) had previously been affected by carcinoma of the pharyngolaryngeal region. All underwent major local Ablation together with radical neck dissection and radiotherapy. In all cases there was mucosa on the posterior wall; a musculocutaneous pectoralis major flap was used in all cases for reconstruction.

Telescopic laryngeal and pharyngeal surgery.

Surgery of the hypopharynx and larynx has traditionally been performed with either direct, unaided vision or the operating microscope. We proposed to extend the surgical capability provided by angled Hopkins telescopes to the larynx and hypopharynx. Forty-eight cases in which rigid telescopes were employed primarily for intervention were reviewed. We found significant advantages of the telescopic system when performing procedures on surfaces that were not 90 degrees from the observer, such as the walls of the hypopharynx, the petiole of the epiglottis, the ventricle, and the posterior commissure. Both 30 degree and 70 degree telescopes were found useful, but required complementary instruments. The potassium titanyl phosphate laser's flexible fiber provided a distinct advantage in resecting lesions that presented on vertical surfaces. Telescopes also permitted the use of large instruments designed for intraperitoneal and intrathoracic surgery that blocked the view of the operating microscope. Telescopic pharyngeal and laryngeal visualization allowed surgical procedures complementary to more traditional forms of endoscopic surgery.

Meditation on the pathogenesis of hypopharyngeal (Zenker's) diverticulum and a report of endoscopic treatment in 545 patients.

Much discussion in the literature concerning Zenker's diverticulum is related to etiology. Various theories have been propounded, but no single conclusion is generally accepted. We believe that an anatomic predisposition plays a prominent role. Considerations for this conclusion will be discussed. In the otorhinolaryngology departments of University Hospital and Martini Hospital (Groningen, the Netherlands) 545 patients with a diverticulum were treated endoscopically since 1964. Initially we used the procedure described by Dohlman. With the increase in the number of patients, the technique and instruments used have improved. In 1981 we started to apply a microendoscopic procedure with a special double-lipped scope and the carbon dioxide laser. The rate of complications was very low, and 91% of the patients are highly satisfied. In view of our results, we feel justified in maintaining that endoscopic treatment is a relatively safe and effective method.

Uvulectomy in Nigeria.

The removal of the uvula for minor pharyngeal lesions is unusual in Western otorhinolaryngological practice. However, uvulectomy is a common procedure for "throat problems' in Nigeria and some other African countries by traditional surgeons. This is because it is believed that the elongated uvula is the root cause of all throat problems. These traditional surgeons are usually barbers by profession and only practice surgery on a part-time basis. Most of their patients do well but some have to be rushed to the hospital with severe post-operative bleeding. Attention of Europeans and other foreign otolaryngologists who may find themselves practising in any part of Africa is hereby drawn to the procedure.

Surgery for cricopharyngeal dysfunction under local anesthesia.

Six new instances of primary cricopharyngeal achalasia are reported. Since 1961, treatment of these as well as eight other cases of sphincter dysfunction with secondary pharyngoesophageal diverticulum has consisted of posterior division of the muscle and inversion rather than excision of the diverticulum. The validity of this approach is supported by restoration to normal or near normal swallowing based on clinical and cineradiographic evidence. The advantages of performing this surgery under local anesthesia include the opportunity to observe directly the pathophysiology of the swallowing disorder, precise division of the cricopharyngeus muscle, and the ability of this older group of patients to eat, drink, and function normally immediately after operation.