Havana syndrome: Overview for otolaryngologists.

Havana Syndrome is used to describe the array of deficits seen in diplomats stationed in Cuba from August 2016 to September 2017.1 Patients from this cohort were clinically studied, investigating their symptoms, audition and vestibular deficits, and imaging abnormalities seen on MRI.1-3 The primary studies were retrospective, looking at how these symptoms could be classified or fit into diagnostic criteria. The cohort had many similarities: a sound at the onset of symptoms, a mix of neurologic and otologic symptoms, and persistent symptoms that lasted for months.1-3 Theories of the cause of Havana Syndrome have led to no conclusive answer. Potential viral etiologies, mass psychogenic illness, and head trauma were examined as causes.1-5 Diseases with established diagnostic criteria were used to compare the patients' symptoms to try to find a disease that fits Havana Syndrome.3 Recent information from the Office of the Director of National Intelligence suggested the most likely cause to be mass psychogenic illness. With the cause of Havana Syndrome still unknown, a review of reported cases and reports helps otolaryngologists understand Havana Syndrome so they diagnose it only when appropriate and do not miss other conditions that may present with similar symptoms and that might respond well to targeted treatment.

Round Window Fistula Caused by Politzerization: An Unreported Complication.

OBJECTIVE: To review Politzerization and describe a complication that has not been reported previously. PATIENTS: Case report. INTERVENTIONS: Clinical details of Politzerization and a complication that has not been reported previously, and a brief review of relevant literature from 1861 to 2022. MAIN OUTCOME MEASURES: Round window fistula was caused by Politzerization. CONCLUSIONS: Although it is extremely rare, transnasal eustachian tube Politzerization can result in perilymph fistula.

5-Fluorouracil for Treatment of Vocal Fold Scar.

BACKGROUND: Vocal fold (VF) scar can result from trauma, neoplasm, inflammatory processes, congenital causes, surgery and other etiologies. In general, once the vibratory margin of the VF has been scarred, it has not been possible to return VF function to normal; but often it can be improved. The drug 5-fluorouracil (5-FU) is a pyrimidine antimetabolic that has many clinical applications ranging from systemic chemotherapy to topical treatment of actinic keratosis and basal cell carcinoma of the skin. Local injection with 5-FU also has been used for hypertrophic scar and keloids. 5-FU was shown to have benefit in animal models of VF scar and subglottic stenosis. OBJECTIVES: The present study aimed to evaluate the effect of 5-FU injection on VF vibratory function in patients with VF scar. Outcomes of 5-FU injection were compared to controls injected with dexamethasone. METHODS: Adult voice center patients who had undergone VF injection with dexamethasone or a series of three 5-FU injections for treatment of VF scar were included in the study. Postoperative outcomes included percentage of subjects demonstrating improvement after injection, change in scar size, glottic closure, and VF stiffness, as well as digital image analysis measurements of mucosal wave. Outcomes were compared between subjects who received 5-FU and those who received dexamethasone. RESULTS: There were 58 VFs injected with 5-FU and 58 historical controls injected with dexamethasone. Baseline subject characteristics and etiology of scar did not differ significantly between the 5-FU and dexamethasone cohorts, except that scar size was greater in the 5-FU group and mucosal wave was worse at baseline. After a series of three 5-FU injections, 61.22% improved, 8.16% demonstrated no change, and 30.61% worsened. In the dexamethasone cohort, 51.06% improved, 0.00% demonstrated no change, and 48.94% worsened. The response differed significantly between the 5-FU and dexamethasone cohorts, with a greater proportion of subjects who underwent 5-FU injection demonstrating improvement postoperatively. In the 5-FU cohort, 32.76% of subjects previously had undergone and failed dexamethasone injection for VF scar: and within that group 84.21% improved, 5.26% demonstrated no change, and 10.53% worsened following 5-FU injection. On digital image analysis, the percent improvement in postoperative mucosal wave was significantly greater in the 5-FU cohort compared to the dexamethasone group, which demonstrated a worsening of mucosal wave. CONCLUSIONS: A series of three intralesional injections with 5-FU outperformed dexamethasone for improving mucosal wave in patients with VF scar. A prior failed trial of dexamethasone injection predicted a favorable response to 5-FU. Further research is encouraged to confirm or refute these findings.

Voice surgery.

There have been many advances in microsurgery for voice professionals over the last three decades. Driven by a greater understanding of the anatomy and physiology of phonation, most of the advances provide greater surgical precision through improved exposure and more delicate instrumentation. Laryngologists who perform laryngoscopic surgery should be familiar with the current state-of-the-art and should use the latest techniques and technology for all voice patients and particularly for voice professionals. Video procedures for surgical management of voice disorders accompany this content online.

Clinical anatomy and physiology of the voice.

The anatomy and physiology of voice include not only the larynx but also all body systems. The larynx consists of a skeleton, mucosa, intrinsic muscles, and extrinsic muscles. The vocal folds form the oscillator of the vocal tract, the subglottic vocal tract acts as a power source, and the supraglottic vocal tract functions as a resonator. Complex interactions are responsible for voice production.

Medical history in voice professionals.

A careful and thoughtful history is extremely important in helping to elucidate the cause of a patient's voice complaints. An understanding of the patient's performance and rehearsal environment and demands is also important in guiding the treatment process. A thorough history helps the clinician understand the vocal problem and how to interpret findings on physical examination that may be contributing to the pathophysiology of the vocal complaint.

Physical examination of voice professionals.

Comprehensive physical examination is essential when evaluating patients. Often it includes objective voice assessment and measures along with strobovideolaryngoscopy. In all cases physical examination involves a thorough examination of the ears, nose, throat, neck, posture, cranial nerve function (usually), and assessment of the patient's general (systemic) physical condition. Performance assessment usually should be included for professional voice.

Effects of medications on the voice.

Professional singers often present a difficult diagnostic dilemma concerning their medication use. Most drugs are never formally evaluated for effects on the voice and finding details of rare side effects can be time consuming for the practitioner. Common use of over-the-counter medication and herbal remedies, combined with the interaction of prescription medications used to treat other medical conditions, can cause many physical and psychologic interactions in patients that may not intuitively relate to medication use. Some side effects and interactions may be managed easily, whereas others may be much more severe. An open communication with the patient and knowledge of these issues can be helpful in the management of professional voice users.

Vocal process avulsion.

Vocal process avulsion is a rare complication of intubation or external laryngeal trauma that can cause significant dysphonia. The vocal process develops independently from the body of the arytenoid cartilage, which results in a fusion plane that is vulnerable to trauma. The findings of vocal process avulsion may be subtle, and the relationship of the vocal process to the body of the arytenoid cartilage must be examined closely. Stroboscopy is critical in the evaluation. We describe three cases of vocal process avulsion encountered by the senior author (R.T.S.) over the last 5 years and discuss our approaches to evaluation and treatment. All cases were repaired endoscopically. However, we used three different techniques. These include chemical tenotomy with botulinum toxin, closed reduction with fat injection, and open reduction via cordotomy.

Arytenoid cartilage dislocation: a 20-year experience.

SUMMARY: Arytenoid cartilage dislocation is an infrequently diagnosed cause of vocal fold immobility. Seventy-four cases have been reported in the literature to date. Intubation is the most common origin, followed by external laryngeal trauma. Decreased volume and breathiness are the most common presenting symptoms. We report on 63 patients with arytenoid cartilage dislocation treated by the senior author (RTS) since 1983. Significantly more posterior than anterior dislocations were represented. Although reestablishing joint mobility is difficult, endoscopic reduction should be considered to align the heights of the vocal processes. This process may result in significant voice improvement even long after the dislocation. Strobovideolaryngoscopy, laryngeal electromyography, and laryngeal computed tomography (CT) imaging are helpful in the evaluation of patients with vocal fold immobility to help distinguish arytenoid cartilage dislocation from vocal fold paralysis. Familiarity with signs and symptoms of arytenoid cartilage dislocation and current treatment techniques improves the chances for optimal therapeutic results.

Abnormal computerized dynamic posturography findings in dizzy patients with normal ENG results.

The complexities of the balance system create difficulties for professionals interested in testing equilibrium function objectively. Traditionally, electronystagmography (ENG) has been used for this purpose, but it provides information on only a limited portion of the equilibrium system. Computerized dynamic posturography (CDP) is less specific than ENG, but it provides more global insight into a patient's ability to maintain equilibrium under more challenging environmental circumstances. CD Palso appears to be valuable in obtaining objective confirmation of an abnormality in some dizzy patients whose ENG findings are normal. Our review of 33 patients with normal ENG results and abnormal CDP findings suggests that posturography is useful for confirming or quantifying a balance abnormality in some patients whose complaints cannot be confirmed by other tests frequently used by otologists.

Laryngeal sarcoidosis.

Sarcoidosis is a chronic granulomatous disease that tends to involve the lungs, hilar and mediastinal lymph nodes, liver, eyes, skin, bones, and nervous system. Sarcoidosis involves the larynx less commonly than it afflicts these other sites. Laryngeal sarcoidosis may occur in isolation or as a component of systemic sarcoidosis and it may produce hoarseness, dysphagia, and dyspnea. Life-threatening airway obstruction can occur. Treatments used for laryngeal sarcoidosis have included tracheotomy, low-dose radiation, surgical excision, systemic steroids, and intralesional steroids. An autoimmune etiology has been suggested. The patient reported in this manuscript showed marked, sustained improvement following the use of inhaled steroids prescribed for obstructive pulmonary disease. The possible efficacy of steroid inhalers for treatment of laryngeal sarcoidosis warrants further investigation.

Efficacy of super high dose proton pump inhibitor administration in refractory laryngopharyngeal reflux: a pilot study.

OBJECTIVES: Proton pump inhibitors (PPIs) are the mainstay of current medical management for laryngopharyngeal reflux (LPR) but may be insufficient in managing some patients' disease. This study was designed to investigate the effectiveness of superdose PPI therapy in the improvement of 24-hour pH impedance studies and stroboscopy findings in patients with LPR refractory to standard dosing (BID PPI). STUDY DESIGN: Retrospective chart review. METHODS: This study examined 35 patients ranging from 20 to 76 years diagnosed with refractory LPR who were treated with super high dose PPIs. Reflux finding scores (RFS) obtained by three blinded raters and 24-hour pH impedance study scores were compared for patients on standard and then super high dose PPI regimens. RESULTS: Statistical analysis of the stroboscopy evaluation revealed a modest but statistically significant decrease in the RFS scores for those patients on super high dose therapy, with good intrarater reliability. The DeMeester score showed no significant change between standard and super high dose regimens. The results of the 24-hour pH impedance monitoring showed no statistically significant decrease in acid reflux episodes despite an average of 7.6 fewer proximal acid reflux episodes. CONCLUSION: Super high dose therapy seems to improve laryngeal signs of irritation as reflected by RFS. This improvement was not reflected in our patient population's severity of reflux while on super high dose therapy when compared with standard LPR therapy as measured by 24-hour pH impedance monitoring, although this finding may reflect selection bias. RFS and 24-hour pH impedance may be insufficiently sensitive to detect improvements in LPR with adequate treatment.

Efficacy of anti-reflux surgery on refractory laryngopharyngeal reflux disease in professional voice users: a pilot study.

OBJECTIVES: Laryngopharyngeal reflux (LPR) is a pervasive disorder that may cause hoarseness, throat clearing, and other symptoms. These symptoms are particularly problematic in professional voice users. Proton pump inhibitors (PPIs) are the mainstay of current medical management for LPR but may be insufficient in managing some patients' symptoms. Laparoscopic Nissen fundoplication (LNF) is well established for treatment of gastroesophageal reflux disease with a high success rate, but its role in the treatment of LPR remains uncertain. This study was designed to investigate the effectiveness of anti-reflux surgery in managing disease refractory to medical reflux therapy (twice of more per day PPIs). STUDY DESIGN: Retrospective medical record review. METHODS: This study examined 25 professional voice users, age ranging from 14 to 75 years, diagnosed with refractory LPR treated twice daily or more with PPIs. Reflux finding scores (RFS) were graded by blinded raters and compared for initial, preoperative, postoperative, and final visits. Twenty-four-hour pH-impedance study scores were obtained pre- and postoperatively. RESULTS: Sixty percent of patients were on no-reflux medications postoperatively and an additional 24% were on less medication. RFS was not significantly different between pre- and postoperative evaluations with good inter- and intrarater reliability; postoperative examinations occurred on less or no pharmaceutical reflux treatment. Twenty-four-hour pH-impedance testing revealed significant reductions in reflux and a nearly significant reduction in total acid. Ninety percent of positive symptom indices preoperatively were negative postoperatively. Seventy-six percent of patients on BID dosing of PPIs and 86% of those receiving super-high-dose PPI administration who underwent LNF were satisfied with the results for their LPR disease. CONCLUSION: LNF should be considered as a treatment option for professional voice users with LPR with symptoms refractory to standard or super-high-dose medical management. LNF may decrease or eliminate the need for postoperative PPI usage. The RFS may not be sensitive enough to monitor changes in LPR severity. Patients, especially those on super-high-dose medication administration, are satisfied with the improvement in LPR symptoms after anti-reflux surgery.

Reflux laryngitis: an update, 2009-2012.

PURPOSE OF REVIEW: The importance of laryngopharyngeal reflux (LPR) is acknowledged widely. However, controversy remains regarding pathophysiology, diagnosis, and treatment. This review addresses current literature from late 2009 through the first half of 2012 and complements our previous review of literature from 2006 through the middle of 2009. Both reviews highlight controversies and current research. RECENT FINDINGS: Although controversies have not been resolved fully, additional research has expanded approaches to diagnosis and treatment of LPR. Recent studies shed additional light on pathophysiology. New imaging techniques have been introduced and they prove particularly useful in assessing LPR. Research has improved the understanding of the value of selected acid measurement techniques. The efficacy of treatment remains controversial. SUMMARY: LPR clearly is an important entity. However, disagreements persist regarding optimal diagnosis techniques, criteria of normalcy, and treatment efficacy. Additional studies are encouraged to further our understanding of pathophysiology, diagnosis, treatment, and the long-term effects of LPR and LPR treatment.

New concepts in vocal fold imaging: a review.

OBJECTIVE: To review new imaging technology potentially useful in the clinical practice of laryngology. HYPOTHESIS: Narrow band imaging, iScan (Pentax Medical Company, Montvale, NJ), optical computed tomography, and confocal microscopy have potential value for enhancing diagnosis of laryngeal pathology. DESIGN: Literature review. METHODS: Literature search of computer databases including MEDLINE and PubMed. RESULTS: A review of 50 articles suggests that new imaging technologies may enhance clinical diagnostic capabilities. CONCLUSION: The probable value of new imaging technologies suggests that further research is needed to refine these technologies and define their clinical efficacy.

Viscosity of materials for laryngeal injection: a review of current knowledge and clinical implications.

OBJECTIVE: Over the past several decades, researchers have sought the ideal substances for use in injection laryngoplasty. This search has inspired several basic science studies centering on the viscoelastic properties of popularly used injectables as well as of experimental substances. Unfortunately, these studies have used various techniques and different units for measuring viscosity. For clinical purposes, there has been a need for a concise compilation of these data, converted into consistent units, to permit easy comparison of the reported viscosities of various substances. The literature has been reviewed to address this need. METHOD: Scholarly review. RESULTS: Comparable data are available for various substances, including vocal fold mucosa, subcutaneous fat, bovine dermal collagen, glutaraldehyde cross-linked collagen, polytetrafluoroethylene, and hyaluronic acid products. The values for difference substances vary widely. CONCLUSION: There appears to be a growing body of useful knowledge about viscosity of substances used for medial (vibratory margin) injection. However, decisions regarding viscosity of substances for lateral injection medialization appear to have been made without the benefit of evidence-based research. It is possible that the trend toward relatively low viscosity materials for lateral injection is based on ease of surgical use through a small needle, but that the low viscosity may adversely affect the control over the position of the injected substance. Research is needed comparing viscosity with predictability of surgical deposition of injected substances.

Reliability of objective voice measures of normal speaking voices.

OBJECTIVE: To determine the reliability of objective voice measures used commonly in clinical practice. SUBJECTS: Eighteen healthy volunteers (nine males and nine females). METHODS: Objective voice measures were performed on 18 healthy volunteers on 10 occasions under similar conditions over a 30-day period. Consistency of measures was analyzed to determine reliability. RESULTS: Using currently accepted normative values, intraclass correlation coefficients were moderate (>0.6) for consistency over the 10 testing sessions for most acoustic measures that do not depend on intensity, measures of laryngeal efficiency, and perturbation measures of fundamental frequency (F0) for both genders. For females, cepstral peak prominence (CPP) had moderate reliability, whereas for males, the smoothed CPP was reliable. Other than F0, none of the perturbation measures are reliable for females. However, jitter, relative average perturbation, and standard deviation of F0 are reliable for males. Noise-to-harmonic ratios (NHRs) had the lowest consistency of all measures over the course of the 10 sessions. CONCLUSIONS: Clinicians should be cautious in their use of acoustic voice measures that depend on the intensity and in their use of most perturbation measures. NHR was found to be the least reliable measure. Additionally, the reliability of CPP measure varies by gender. Understanding the degree of within-person variability on some objective voice measures and whether that variation is due to biological differences or measurement error will lead clinicians to consider the need for a more standardized testing protocol. Additional research is needed to investigate what factors within the testing protocol and/or changes to the measurement instruments may lead to more consistent test results.

Deep brain stimulation for treatment of voice disorders.

OBJECTIVES: Vocal tremor is a common, troublesome disorder that is difficult to treat. Efficacy of deep brain stimulation (DBS) was reported more than a decade ago. Most laryngologists are not familiar with the technique or its potential. This review was undertaken to assemble relevant literature written over the past decade and assess the clinical implications of that literature. DESIGN: Literature review. METHODS: PubMed search from 2002 through 2011. RESULTS: A small number of articles on the topic have been identified, some of which appear to provide information of potential clinical importance for voice patients. CONCLUSION: A review of the literature from 2002 through 2011 has revealed several studies supporting the efficacy of DBS as well as adverse consequences of specific technical approaches (such as high-frequency DBS). In the aging population, the prevalence of this voice tremor is likely to increase. We suspect that DBS may be underused; and laryngologists should collaborate with neurosurgeons, speech-language pathologists, and voice scientists to study more extensively the safety and efficacy of DBS for treatment of voice disorders.