Patient perception of a randomised, controlled trial of laryngeal reinnervation versus thyroplasty for unilateral vocal fold paralysis.

OBJECTIVES: To explore unilateral vocal fold paralysis patients' perception of a proposed randomised, controlled trial of laryngeal reinnervation versus thyroplasty, and to identify patients' concerns regarding their voice. METHODS: Seventeen patients from five voice clinics in London were identified as being eligible for the randomised, controlled trial. Eleven of these patients (9 females and 2 males; age range, 18-65 years) were interviewed using a semi-structured topic guide (they were given a minimum of 2 weeks to read through the study information sheet). The interviews were recorded, transcribed and analysed using thematic analysis. RESULTS: The patients were satisfied with the clarity of the information sheet. Most of them perceived that reinnervation was a more 'attractive' option than thyroplasty. This may have been the result of certain phraseology used in the information sheet and by recruiters. Patients' main concern was reduced voice strength and the effects of this on work and social life. CONCLUSION: Phraseology that needed changing was identified; these changes may optimise the recruitment process for a trial. We propose using the voice handicap index 10 as the primary measure of outcome in the proposed randomised, controlled trial.

Reliability of OperaVOX against Multidimensional Voice Program (MDVP).

OBJECTIVE: To evaluate the agreement between OperaVOX and MDVP. DESIGN: Cross sectional reliability study. SETTING: University teaching hospital. METHODS: Fifty healthy volunteers and 50 voice disorder patients had supervised recordings in a quiet room using OperaVOX by the iPod's internal microphone with sampling rate of 45 kHz. A five-seconds recording of vowel/a/was used to measure fundamental frequency (F0), jitter, shimmer and noise-to-harmonic ratio (NHR). All healthy volunteers and 21 patients had a second recording. The recorded voices were also analysed using the MDVP. The inter- and intrasoftware reliability was analysed using intraclass correlation (ICC) test and Bland-Altman (BA) method. Mann-Whitney test was used to compare the acoustic parameters between healthy volunteers and patients. RESULTS: Nine of 50 patients had severe aperiodic voice. The ICC was high with a confidence interval of >0.75 for the inter- and intrasoftware reliability except for the NHR. For the intersoftware BA analysis, excluding the severe aperiodic voice data sets, the bias (95% LOA) of F0, jitter, shimmer and NHR was 0.81 (11.32, -9.71); -0.13 (1.26, -1.52); -0.52 (1.68, -2.72); and 0.08 (0.27, -0.10). For the intrasoftware reliability, it was -1.48 (18.43, -21.39); 0.05 (1.31, -1.21); -0.01 (2.87, -2.89); and 0.005 (0.20, -0.18), respectively. Normative data from the healthy volunteers were obtained. There was a significant difference in all acoustic parameters between volunteers and patients measured by the Opera-VOX (P < 0.001) except for F0 in females (P = 0.87). CONCLUSION: OperaVOX is comparable to MDVP and has high internal consistency for measuring the F0, jitter and shimmer of voice except for the NHR.

Silencing of miR-148a in cancer-associated fibroblasts results in WNT10B-mediated stimulation of tumor cell motility.

The tumor microenvironment has an important role in cancer progression. Here we show that miR-148a is downregulated in 15 out of 16 samples (94%) of cancer-associated fibroblasts (CAFs) compared with matched normal tissue fibroblasts (NFs) established from patients with endometrial cancer. Laser-capture microdissection of stromal cells from normal tissue and endometrial cancer confirmed this observation. Treatment of cells with 5-aza-deoxycytidine stimulated the expression of miR-148a in the majority of CAFs implicating DNA methylation in the regulation of miR-148a expression. Investigation of miR-148a function in fibroblasts demonstrated that conditioned media (CM) from CAFs overexpressing miR-148a significantly impaired the migration of five endometrial cancer cell lines without affecting their growth rates in co-culture experiments. Among predicted miR-148a target genes are two WNT family members, WNT1 and WNT10B. Activation of the WNT/ß-catenin pathway in CAFs was confirmed by microarray analysis of gene expression and increased activity of the SuperTOPFlash luciferase reporter. We found elevated levels of WNT10B protein in CAFs and its level decreased when miR-148a was re-introduced by lentiviral infection. The 3'-UTR of WNT10B, cloned downstream of luciferase cDNA, suppressed luciferase activity when co-expressed with miR-148a indicating that WNT10B is a direct target of miR-148a. In contrast to the effect of miR-148a, WNT10B stimulated migration of endometrial cancer cell lines. Our findings have defined a molecular mechanism in the tumor microenvironment that is a novel target for cancer therapy.

The putative involvement of the transabdominal muscles in dysphonia: a preliminary study and thoughts.

OBJECTIVES/HYPOTHESIS: Real-time ultrasound was used as an adjunct to assess patterns of periabdominal musculature in 14 individual with dysphonia and muscle tension dysphonia. MATERIALS: Fourteen individuals with muscle tension dysphonia were evaluated with real-time ultrasound as a part of their initial evaluation and management. RESULTS: In 13 of 14 individuals, there was an imbalance found during phonation between the transversus abdominis muscles (TAs) and internal oblique muscles (IOs), whereby the IOs were found to be overactive and the TAs underactive. After physiotherapy, this pattern was reversed. CONCLUSION: The abdominal muscle pattern of overactivity of the internal oblique and underactivity of the TA during phonation was found to be present in the large majority of patients in this pilot sample who had presented with muscle tension dysphonia. The significance of this is unclear but deserves further review.

Laryngeal manual therapy: a preliminary study to examine its treatment effects in the management of muscle tension dysphonia.

The objectives of this study were to determine appropriate acoustic and outcome measures for the evaluation of a method of laryngeal manual therapy (LMT) used in the treatment of patients with muscle tension dysphonia (MTD). The effects of this technique were also investigated. The study was based on the hypotheses that the vertical position of the larynx in the vocal tract would lower, that the quality of the voice would normalize, and that a reduction in any vocal tract discomfort (VTD) would occur after LMT. This was a small, prospective, repeated measures pilot study in which each member of the research team was "blinded" to all other stages of the study and during which all data were anonymized until the final stage of data analysis. Ten subjects presenting with MTD completed outcome measures and provided audiorecordings immediately before, immediately after, and 1 week after LMT. The Kay CSL 4150 was used for signal acquisition and for some acoustic measurements. Spectrographic evaluation was accomplished with Praat. A new perceptual, self-rating scale, the VTD scale, and a new proforma for use by the clinician for palpatory evaluation, were developed for the study. Relative average perturbation during connected speech was significantly reduced after LMT, indicating a reduction in abnormal vocal function. The severity and frequency of VTD was shown to have reduced after LMT. This pilot study showed positive evidence for LMT as a method of therapy in the treatment of hyperfunctional voice disorders. Its effects were shown to be measurable with both acoustical analysis and the VTD scale.

Foreign body reaction to polymethylsiloxane gel (Bioplastique) after vocal fold augmentation.

STATEMENT OF PROBLEM: The consequences of vocal fold paralysis include voice change, airway problems and difficulty swallowing. Medialisation procedures using injected material have been used for many decades, with varying outcomes, mainly secondary to lifespan, tissue reaction or migration. Newer materials have recently become clinically available which are easier to manage and supposedly less likely to elicit foreign body reaction. METHOD OF STUDY: Case report. RESULTS: We report a case of foreign body reaction and possible migration of polymethylsiloxane gel (Bioplastique), one such material, after vocal fold injection. To our knowledge, this is the second such case described. CONCLUSIONS: This case highlights the fact that the risk of foreign body reaction and migration is still present for this material, albeit low. We also highlight the fact that, although this material can cause foreign body reactions and may possibly migrate, it is removable by microlaryngoscopy via the microflap technique, with vocal improvement.

Phoniatric provision and training: current European perspectives.

Communication disorders represent a major and growing problem worldwide. In Europe, the specialty of phoniatrics has developed partly in response to this important issue. This article reviews training and workforce issues in phoniatrics and raises key questions and issues that need resolution in the future.

The prevalence of Helicobacter pylori infection in malignant and premalignant conditions of the head and neck.

Helicobacter pylori is an accepted cause of chronic active gastritis and has a major causative role in peptic ulceration. It is a gastric carcinogen. Its role in non-ulcer dyspepsia (NUD) is less clear; yet 50 per cent of patients with NUD are infected with H pylori. H pylori has been investigated in several other organ systems, but has not been investigated extensively in squamous cell carcinoma of the upper aerodigestive tract, a region which could be directly exposed to the bacterium by gastro-oesophageal reflux (GOR). In this study 61 patients with severe laryngeal dysplasia or frank carcinoma of the head and neck are striated by age, investigated for the presence of antibodies to H pylori and compared to age and sex matched controls. In the age group of 46-61 years, the presence of H pylori antibodies was marginally greater in the experimental (63.0 per cent) than the control group (40.7 per cent) (Pearson Chi square p = 0.055, Fisher 2-sided exact test p = 0.066). When combining this age group with the younger age group and thereby creating two roughly equal groups (n = 31 and n = 30) there was also a statistical trend towards increased positivity in the experimental group. These findings are discussed in the light of other studies with gastro-oesophageal reflux disease (GORD).

The prevalence of Helicobacter pylori infection in benign laryngeal disorders.

Helicobacter pylori (HP) is an accepted cause of chronic active gastritis and has a major causative role in peptic ulcers. It is a gastric carcinogen. Its role in nonulcer dyspepsia (NUD) is less clear, yet 50% of patients with NUD are infected with HP, and some recent literature demonstrates long-term improvement of symptoms following eradication. HP has been investigated in several other organ systems, but has not been investigated to any major degree in laryngeal disorders, a region that could be directly exposed to the bacterium from pharyngolaryngeal reflux. This study represents one arm of a larger study designed to investigate such a relationship. Of 101 patients with nonmalignant voice disorders presenting to our voice clinics, 54.5% tested positive for the H. pylori organism. Of the controls, 47.1% tested positive. When striated into age groups of < 45 years, 46-61 years, and > 62 years, and then age-matched with the controls, the likelihood of infection with the H. pylori organism was greater in both the experimental middle group, and in the middle group when combined with the elder group, than in the matched controls, and this difference demonstrated a trend approaching statistical significance. This finding is discussed in the light of other studies on HP and on gastroesophageal reflex (GER).

Dissociation of heparan sulfate and receptor binding domains of hepatocyte growth factor reveals that heparan sulfate-c-met interaction facilitates signaling.

Hepatocyte growth factor (HGF) is a secreted, heparan sulfate (HS) glycosaminoglycan-binding protein that stimulates mitogenesis, motogenesis, and morphogenesis in a wide array of cellular targets, including hepatocytes and other epithelial cells, melanocytes, endothelial cells, and hematopoietic cells. NK1 is an alternative HGF isoform that consists of the N-terminal (N) and first kringle (K1) domains of full-length HGF and stimulates all major HGF biological activities. Within NK1, the N domain retains the HS binding properties of full-length HGF and mediates HS-stimulated ligand oligomerization but lacks significant mitogenic or motogenic activity. In contrast, K1 does not bind HS, but it stimulates receptor and mitogen-activated protein kinase activation, mitogenesis, and motogenesis, demonstrating that structurally distinct and dissociable domains of HGF are the primary mediators of HS binding and receptor activation. Despite the absence of HS-K1 binding, K1 mitogenic activity in HS-negative cells is strictly dependent on added soluble heparin, whereas K1-stimulated motility is not. We also found that, like the receptors for fibroblast growth factors, the HGF receptor c-Met binds tightly to HS. These data suggest that HS can facilitate HGF signaling through interaction with c-Met that is independent of HGF-HS interaction and that the recruitment of specific intracellular effectors that mediate distinct HGF responses such as mitogenesis and motility is regulated by HS-c-Met interaction at the cell surface.

Secreted Frizzled-related proteins can regulate metanephric development.

Wnt-4 signaling plays a critical role in kidney development and is associated with the epithelial conversion of the metanephric mesenchyme. Furthermore, secreted Frizzled-related proteins (sFRPs) that can bind Wnts are normally expressed in the developing metanephros, and function in other systems as modulators of Wnt signaling. sfrp-1 is distributed throughout the medullary and cortical stroma in the metanephros, but is absent from condensed mesenchyme and primitive tubular epithelia of the developing nephron where wnt-4 is highly expressed. In contrast, sfrp-2 is expressed in primitive tubules. To determine their role in kidney development, recombinant sFRP-1, sFRP-2 or combinations of both were applied to cultures of 13-dpc rat metanephroi. Both tubule formation and bud branching were markedly inhibited by sFRP-1, but concurrent sFRP-2 treatment restored some tubular differentiation and bud branching. sFRP-2 itself showed no effect on cultures of metanephroi. In cultures of isolated, induced rat metanephric mesenchymes, sFRP-1 blocked events associated with epithelial conversion (tubulogenesis and expression of lim-1, sfrp-2 and E-cadherin); however, it had no demonstrable effect on early events (compaction of mesenchyme and expression of wt1). As shown herein, sFRP-1 binds Wnt-4 with considerable avidity and inhibits the DNA-binding activity of TCF, an effector of Wnt signaling, while sFRP-2 had no effect on TCF activation. These observations suggest that sFRP-1 and sFRP-2 compete locally to regulate Wnt signaling during renal organogenesis. The antagonistic effect of sFRP-1 may be important either in preventing inappropriate development within differentiated areas of the medulla or in maintaining a population of cortical blastemal cells to facilitate further renal expansion. On the other hand, sFRP-2 might promote tubule formation by permitting Wnt-4 signaling in the presence of sFRP-1.

Akt participation in the Wnt signaling pathway through Dishevelled.

Inactivation of glycogen synthase kinase 3beta (GSK3beta) and the resulting stabilization of free beta-catenin are critical steps in the activation of Wnt target genes. While Akt regulates GSK3alpha/beta in the phosphatidylinositide 3-OH kinase signaling pathway, its role in Wnt signaling is unknown. Here we report that expression of Wnt or Dishevelled (Dvl) increased Akt activity. Activated Akt bound to the Axin-GSK3beta complex in the presence of Dvl, phosphorylated GSK3beta and increased free beta-catenin levels. Furthermore, in Wnt-overexpressing PC12 cells, dominant-negative Akt decreased free beta-catenin and derepressed nerve growth factor-induced differentiation. Therefore, Akt acts in association with Dvl as an important regulator of the Wnt signaling pathway.

TGF beta 2, LIF and FGF2 cooperate to induce nephrogenesis.

The metanephric kidney develops from interactions between the epithelial ureteric bud and adjacent metanephric mesenchyme, which is induced by the bud to form the epithelia of the nephron. We have found that leukemia inhibitory factor (LIF) and transforming growth factor beta 2 (TGF beta 2) are secreted by inductive rat bud cells and cooperate to enhance and accelerate renal tubule formation in uninduced rat metanephric mesenchymal explants. LIF alone or TGF beta 2 with fibroblast growth factor 2 induced numerous tubules in isolated mesenchymes over an 8 day period, while (in combination) all three caused abundant tubule formation in 72 hours. Furthermore, neutralization of Wnt ligands with antagonist-secreted Frizzled-related protein 1 abrogated these responses and combinatorial cytokine/growth factor stimulation of explants augmented nuclear activation of Tcf1/Lef1, suggesting that LIF and TGF beta 2/FGF2 cooperate to regulate nephrogenesis through a common Wnt-dependent mechanism.

Keratinocyte growth factor facilitates alloengraftment and ameliorates graft-versus-host disease in mice by a mechanism independent of repair of conditioning-induced tissue injury.

We have previously shown that pretreatment of mice with keratinocyte growth factor (KGF), an epithelial tissue repair factor, can ameliorate graft-versus-host disease (GVHD) after intensive chemoradiotherapeutic conditioning and allogeneic bone marrow transplantation (BMT). To determine whether this effect was dependent on a KGF-mediated mechanism affecting repair of conditioning-induced epithelial cell injury, we studied GVHD in the absence of conditioning using BALB/c severe combined immune-deficient (SCID) recipients given C57BL/6 T cells. KGF (5 mg/kg per day, subcutaneously) given either before or after T-cell transfer enhanced body weights and extended survival. KGF-treated recipients had elevated serum levels of the Th2 cytokine interleukin 13 (IL-13) on day 6 after T-cell transfer concomitant with reduced levels of the inflammatory cytokines tumor necrosis factor-alpha (TNF-alpha) and interferon gamma (IFN-gamma). A 3-day KGF pretreatment also depressed the secondary in vitro mixed lymphocyte response (MLR) of C57BL/6 splenocytes taken 7 days after in vivo alloimmunization with irradiated BALB/c spleen cells. To determine whether KGF would inhibit host-antidonor-mediated BM rejection, pan-T-cell-depleted BALB/c BM cells were infused into sublethally irradiated C57BL/6 mice and administered KGF either before or before and after BMT. Surprisingly, all KGF schedules tested actually resulted in enhanced alloengraftment. The presence of KGF receptor on donor antihost alloreactive T cells could not be detected by binding studies with radiolabeled KGF, reverse transcriptase-polymerase chain reaction, and Western blotting. Therefore, the mechanism of action of KGF on inhibiting T-cell-mediated immune effects may not be due to a direct effect of KGF on T cells. These studies demonstrate that KGF, by mechanisms independent of repair of conditioning-induced injury, has great potential as an anti-GVHD therapeutic agent with the added benefit of inhibiting the rejection of pan-T-cell-depleted donor BM allografts. (Blood. 2000;96:4350-4356)

muc-1 gene expression in head and neck squamous cell carcinomas.

Polymorphic epithelial mucin (PEM), the protein product of the gene muc-1, is a surface glycoprotein that is produced by a range of normal epithelial cells, but has been shown to be expressed at high levels in a range of adenocarcinomas. It has not been investigated extensively in head and neck related tissues, and not at all in head and neck squamous cell carcinomas (HNSCC). This immunohistochemical investigation using two monoclonal antibodies to muc-1 represents a baseline study of 18 HNSCC. In 13 cases, the glycoprotein was expressed at varying levels, usually in keratinizing foci. Although less prominent, expression was also present to some degree in nine of 23 control specimens of non-neoplastic mucosa, mostly at an epithelial level early in the parakeratinization process. Both antibodies showed a pattern of staining. The cellular basis for muc-1 expression is speculative at present and although it is at a lower level than in adenocarcinomas, it may help to provide further insight into epithelial cell differentiation in squamous cell carcinomas.

Dysphonia associated with inhaled steroids.

The use of inhaled steroids in the treatment of asthma is not without its complications. In some studies up to 50% of such patients complain of oropharyngeal and voice problems. We present the findings in 22 patients complaining of dysphonia who underwent videostrobolaryngoscopy (VSL) and computerized speech analysis. A number of abnormalities were identified. On VSL, these included mucosal changes (noted in 58%), apposition abnormalities (noted in 43%), and supraglottic hyperfunction (noted in 40%). On speech analysis, cycle-to-cycle irregularity was frequently noted (mean of 39%). Maximum phonation time was reduced in 73%. Our findings did not confirm the widely held views that steroid dysphonia is due primarily to a fungal infection or a steroid-induced adductor myasthenia of the larynx. A larger-scale prospective study is indicated.

Unexpected overnight admissions following day-case surgery: an analysis of a dedicated ENT day care unit.

Day-case surgery is an integral part of otolaryngology, and many procedures can be performed as day-cases provided strict criteria are applied in the selection of patients. We reviewed patients who required unexpected admission from the day-case unit at the Royal National Throat, Nose and Ear Hospital, London between April 1997 and March 1998. The total number of patients undergoing surgery was 1642. Of the total, 29 (1.8%) had to be admitted unexpectedly for overnight stay: 24 of these patients had undergone nasal surgery, representing 5.4% of all the nasal procedures performed--and the cause of all these admissions was haemorrhage. Further analysis revealed 22 of these 24 nasal operations had included a septoplasty. The total number of septoplasties performed was 163; thus, septoplasty had an unexpected admission rate of 13.4%. This information has been used to formulate stricter guidelines for day-case septoplasty admissions in our unit.

Laryngeal manipulation.

This article presents the authors' philosophy regarding the use of physical manipulation of the larynx and the neck in patients presenting with voice disorders from the context of the anatomy and physiology of the larynx. The biomechanics of the laryngeal structures are reviewed. Potential indications for manipulation are discussed. The examination of the larynx and perilaryngeal structures is presented from a mechanical standpoint. Some basic tenets in laryngeal manipulation, including potential risks and contraindications, are offered.

A Rho-specific exchange factor Ect2 is induced from S to M phases in regenerating mouse liver.

The ect2 oncogene was originally identified as a transforming complementary DNA (cDNA) from mouse epithelial cells in an expression cloning approach and encodes a product related to Rho-specific exchange factors and yeast cell cycle regulators. To explore the potential role of ect2 in the cell cycle, we examined the expression of the ect2 proto-oncogene in a liver regeneration model in mice after partial (two thirds) hepatectomy. We found that the expression of the ect2 transcript and protein were markedly elevated with the onset of DNA synthesis and remained elevated during G2 and M phases. The timing of ect2 expression matched that of proliferating cell nuclear antigen (PCNA) and partially overlapped cell division cycle 2 (Cdc2) expression. In situ hybridization analysis showed that ect2 was expressed at a high level in cells undergoing mitosis in regenerating liver. Moreover, expression of a dominant negative or an oncogenic mutant of ect2 in cultured mouse hepatocytes resulted in a large increase in the number of binucleated cells. These findings showed that Ect2 is expressed in a cell cycle-dependent manner during liver regeneration, and suggest that it has an important role in the regulation of cytokinesis.