Arytenoid adduction as an adjunct to type I thyroplasty for unilateral vocal cord paralysis.

BACKGROUND: Surgical management of unilateral vocal cord paralysis has evolved over the last three decades. The recent use of type I thyroplasty has resulted in improvements in voice, swallowing, and respiration. The study was performed to evaluate our experience in 28 patients undergoing arytenoid adduction as part of their surgical rehabilitation of unilateral vocal cord paralysis. METHODS: Patients undergoing arytenoid adduction with or without silastic medialization for unilateral vocal cord paralysis were entered into a prospective data base. Evaluation included symptomatic improvement in hoarseness, aspiration, dysphagia, dyspnea, and the radiographic documentation of pneumonia. Objective evaluation included mean phonatory air flow and acoustic analysis. Complications associated with surgery were recorded. RESULTS: A satisfactory result was obtained in 27 of 28 (96%) patients. By symptom, improvement in hoarseness was evident in 96%, dyspnea 80%, dysphagia 94%, and aspiration 84%. Improvements in phonatory flow rate (p < .001), estimated mean laryngeal airway resistance (p < .001), and maximally prolonged phonation (p < .01) were identified. Complications occurred in 18% and consisted of local wound sepsis (n = 1), hematoma (n = 1), seroma (n = 1), and transient airway edema (n = 2). There were no episodes of airway obstruction requiring tracheostomy or implant extrusion. CONCLUSIONS: Arytenoid adduction as part of type I thyroplasty is a safe and effective procedure. Subjective analysis confirms marked improvement in laryngeal function in the form of speech, swallowing, and respiration. Objective analysis confirms improvement in voice parameters. Future directions will focus on determination of those patients best served by arytenoid adduction.

Supraspinal accessory lymph node metastases in supraomohyoid neck dissection.

BACKGROUND: Some patients undergoing surgical resection of primary squamous cell carcinoma of the oral cavity and oropharynx also undergo supraomohyoid neck dissection for staging of the negative (N(o)) neck. Dissection of the supraspinal accessory lymph node pad requires significant traction of the spinal accessory nerve. There are currently no data to indicate the incidence of metastases to this site and thus the necessity of performing dissection of these nodes. METHODS: A prospective analysis of a consecutive series of 44 patients with newly diagnosed squamous carcinoma of the oral cavity or oropharynx undergoing surgical management of the primary lesion with staging neck dissection was performed. Patients underwent unilateral (41) or bilateral (3) supraomohyoid neck dissection with separate submission of the supraspinal accessory lymph node pad for pathologic evaluation to determine the incidence of nodal metastases. RESULTS: A total of 15 patients (32%) had microscopic metastatic squamous cell carcinoma involving the supraomohyoid neck dissection specimen. Only 1 patient had a metastatic deposit involving the supraspinal accessory lymph node pad. This patient also had metastases in additional lymph nodes at level II. There was an equal incidence of metastases for all patients when stratifying by T stage. CONCLUSION: This preliminary report reveals a small incidence of supraspinal accessory lymph node metastases in patients with T + NO squamous cell carcinoma of the oral cavity and oropharynx. We continue to accrue patients to determine if the incidence of supraspinal accessory lymph node metastases varies with an increased number of patients.

Dose-dependent response to phenylpropanolamine: inhibition of orthostasis.

Phenylpropanolamine, a widely consumed over-the-counter drug, is known to elevate blood pressure, but the mechanism is unknown; it may be both a direct and indirect sympathomimetic. This study investigated the effects of 75-mg sustained-release phenylpropanolamine, 75-mg phenylpropanolamine plus 400-mg caffeine, and 150-mg phenylpropanolamine on blood pressure, plasma norepinephrine, and epinephrine levels in 16 normotensive subjects in a double-blind, placebo-controlled crossover design. Mean peak phenylpropanolamine levels of 317 +/- 26, 152 +/- 17, and 157 +/- 17 ng/mL for 150-mg phenylpropanolamine, 75-mg phenylpropanolamine, and 75-mg phenylpropanolamine plus 400-mg caffeine, respectively, were reached at about 3.6 hours after dosing. The maximal increases in supine diastolic blood pressures after all three phenylpropanolamine-containing drugs were almost three times that after placebo (P less than .05), but peak blood pressures occurred at about 2.3 hours earlier than peak phenylpropanolamine levels. Blood pressure increases correlated with phenylpropanolamine plasma levels (r = .49 for systolic blood pressure and r = .34 for diastolic blood pressure; P less than .0001 for both). Norepinephrine levels increased after the administration of 150-mg phenylpropanolamine and 75-mg phenylpropanolamine plus 400-mg caffeine; norepinephrine increases correlated with phenylpropanolamine levels (r = .34, P less than .0001). The expected increment in norepinephrine induced by standing was significantly decreased by phenylpropanolamine in a dose-dependent mode. The study supports the idea that phenylpropanolamine as both a direct (at alpha -1 and alpha-2 receptors) and an indirect sympathomimetic agent.

Phenylpropanolamine increases plasma caffeine levels.

The effects of the widely consumed drugs caffeine and phenylpropanolamine are mediated through activation of the central and sympathetic nervous systems. Severe, life-threatening, and occasionally fatal hypertensive reactions have been reported after their combined use. This study examined the possible pharmacokinetic interaction of phenylpropanolamine and caffeine. Sixteen normal subjects received combinations of caffeine, phenylpropanolamine, and placebo. In subjects receiving 400 mg caffeine plus 75 mg phenylpropanolamine, the mean (+/- SEM) peak plasma caffeine concentration of 8.0 +/- 2.2 micrograms/ml was significantly greater than after 400 mg caffeine alone (2.1 +/- 0.3 micrograms/ml; t[24] = 2.4; p less than 0.01). Physical side effects were more frequent after the phenylpropanolamine-caffeine combination than after either drug alone or after placebo. Greater increases in both systolic and diastolic blood pressures occurred after the combination than after either drug alone. Because caffeine levels can be increased greatly when certain other drugs are coconsumed, these data indicate that phenylpropanolamine may enhance absorption or inhibit elimination of caffeine and may explain increased side effects reported after their combined use.

Neurologic sequelae of minor electric burns.

Although neurologic pathology is a well-documented sequela of major electric burns, there are few reports of complications arising from less extensive electrically induced trauma. Two cases of patients with significant disease subsequent to minor electric burns are presented. In one patient with a 2% superficial partial-thickness burn of the right forearm, nerve conduction studies, electromyography, and somatosensory evoked potential studies were consistent with right median mononeuropathy at the wrist and a distal slowing of the right ulnar nerve. The second patient presented with persistent numbness, hyperpathia, and burning in his left hand after an electric shock in a telephone booth. He had a creatine phosphokinase of 2000m mu/mL but no surface burn. A left stellate ganglion block provided complete resolution of his symptoms and established a diagnosis of minor reflex sympathetic dystrophy.

Rehabilitation concerns in electrical burn patients: a review of the literature.

Patients with electrical burns have problems which are unique to their type of injury. In the acute stage, amputations, peripheral neuropathy, and entrapment syndromes occur more commonly in electricity-induced trauma than in thermal burns. In addition, clinicians must be vigilant because peripheral neuropathy, quadriplegia, paraplegia, and entrapment syndromes may have an insidious onset and become manifest days to months after the original injury. Both electrical and thermal burn patients are subjected to two types of trauma: the insult caused by the acute event, and complications which occur because of poor positioning, bulky dressings, intramuscular injections, and neurotoxic medications.

Sorbitol intolerance in adults.

Sorbitol is a commonly used sugar substitute in "sugar-free" food products. Although sorbitol intolerance manifested by abdominal pain, bloating, and diarrhea has been observed in children, it has not been well documented in adults. Forty-two healthy adults (23 whites, 19 nonwhites) participated in this study. After ingestion of 10 g of sorbitol solution, end expiratory breath samples were collected at 15-min intervals for 4 h and analyzed for H2 concentration. Clinical sorbitol intolerance was detected in 43% of the whites and 55% of the nonwhites, the difference not being statistically significant. However, severe clinical sorbitol intolerance was significantly more prevalent in nonwhites (32%) as compared to whites (4%). There was a good correlation between the severity of symptoms and the amount of hydrogen exhaled. Dietetic foods, many of them containing sorbitol, are very popular with diabetics and "weight watchers." Based on our observations, we believe that a large number of adults could be suffering from sorbitol-induced nonspecific abdominal symptoms and diarrhea. These symptoms could lead to an extensive diagnostic work-up and lifelong diagnosis of irritable bowel syndrome.