Geriatric nutritional risk index as the prognostic factor in older patients with fragility hip fractures.

This study investigated the long-term survival and incidence of secondary fractures after fragility hip fractures. The 5-year survival rate was 62%, and the mortality risk was seen in patients with GNRI < 92. The 5-year incidence of secondary fracture was 22%, which was significantly higher in patients with a BMI < 20. BACKGROUND: Malnutrition negatively influences the postoperative survival of patients with fragility hip fractures (FHFs); however, little is known about their association over the long term. OBJECTIVE: This study evaluated the ability of the geriatric nutritional risk index (GNRI) as a risk factor for long-term mortality after FHFs. METHODS: This study included 623 Japanese patients with FHFs over the age of 60 years. We prospectively collected data on admission and during hospitalization and assessed the patients' conditions after discharge through a questionnaire. We examined the long-term mortality and the incidence of secondary FHFs and assessed the prognostic factors. RESULTS: The mean observation period was 4.0 years (range 0-7 years). The average age at the time of admission was 82 years (range 60-101 years). The overall survival after FHFs (1 year, 91%; 5 years, 62%) and the incidence of secondary FHFs were high (1 year, 4%; 5 years, 22%). The multivariate Cox proportional hazard analysis revealed the risk factors for mortality as older age (hazard ratio [HR] 1.04), male sex (HR 1.96), lower GNRI score (HR 0.96), comorbidities (malignancy, HR 2.51; ischemic heart disease, HR 2.24; revised Hasegawa dementia scale ≤ 20, HR 1.64), no use of active vitamin D3 on admission (HR 0.46), and a lower Barthel index (BI) (on admission, HR 1.00; at discharge, HR 0.99). The GNRI scores were divided into four risk categories: major risk (GNRI, < 82), moderate risk (82-91), low risk (92-98), and no risk (> 98). Patients at major and moderate risks of GNRI had a significantly lower overall survival rate (p < 0.001). Lower body mass index (BMI) was also identified as a prognostic factor for secondary FHFs (HR 0.88 [p = 0.004]). CONCLUSIONS: We showed that older age, male sex, a lower GNRI score, comorbidities, and a lower BI are risk factors for mortality following FHFs. GNRI is a novel and simple predictor of long-term survival after FHFs.

High-speed digital imaging laryngoscopy of the neoglottis following supracricoid laryngectomy with cricohyoidoepiglottopexy.

OBJECTIVES: This study aimed to analyse vocal performance and to investigate the nature of the neoglottal sound source in patients who had undergone supracricoid laryngectomy with cricohyoidoepiglottopexy, using a high-speed digital imaging system. METHODS: High-speed digital imaging analysis of neoglottal kinetics was performed in two patients who had undergone supracricoid laryngectomy with cricohyoidoepiglottopexy; laryngotopography, inverse filtering analysis and multiline kymography were also undertaken. RESULTS: In case one, laryngotopography demonstrated two vibrating areas: one matched with the primary (i.e. fundamental) frequency (75 Hz) and the other with the secondary frequency (150 Hz) at the neoglottis. In case two, laryngotopography showed two vibrating areas matched with the fundamental frequency (172 Hz) at the neoglottis. The interaction between the two areas was considered to be the sound source in both patients. The waveform of the estimated volume flow at the neoglottis, obtained by inverse filtering analysis, corresponded well to the neoglottal vibration patterns derived by multiline kymography. These findings indicated that the specific sites identified at the neoglottis by the present method were likely to be the sound source in each patient. CONCLUSIONS: High-speed digital imaging analysis is effective in locating the sites responsible for voice production in patients who have undergone supracricoid laryngectomy with cricohyoidoepiglottopexy. This is the first study to clearly identify the neoglottal sound source in such patients, using a high-speed digital imaging system.

Empirical Eigenfunctions and medial surface dynamics of a human vocal fold.

OBJECTIVES: The purpose of this investigation was to use an excised human larynx to substantiate physical mechanisms of sustained vocal fold oscillation over a variety of phonatory conditions. During sustained, flow-induced oscillation, dynamical data was collected from the medial surface of the vocal fold. The method of Empirical Eigenfunctions was used to analyze the data and to probe physical mechanisms of sustained oscillation. METHODS: Thirty microsutures were mounted on the medial margin of a human vocal fold. Across five distinct phonatory conditions, the vocal fold was set into oscillation and imaged with a high-speed digital imaging system. The position coordinates of the sutures were extracted from the images and converted into physical coordinates. Empirical Eigenfunctions were computed from the time-varying physical coordinates, and mechanisms of sustained oscillation were explored. RESULTS: Using the method of Empirical Eigenfunctions, physical mechanisms of sustained vocal fold oscillation were substantiated. In particular, the essential dynamics of vocal fold vibration were captured by two dominant Empirical Eigenfunctions. The largest Eigenfunction primarily captured the alternating convergent/divergent shape of the medial surface of the vocal fold, while the second largest Eigenfunction primarily captured the lateral vibrations of the vocal fold. CONCLUSIONS: The hemi-larynx setup yielded a view of the medial surface of the vocal folds, revealing the tissue vibrations which produced sound. Through the use of Empirical Eigenfunctions, the underlying modes of vibration were computed, disclosing physical mechanisms of sustained vocal fold oscillation. The investigation substantiated previous theoretical analyses and yielded significant data to help evaluate and refine computational models of vocal fold vibration.

Vocal fold motion impairment in patients with multiple system atrophy: evaluation of its relationship with swallowing function.

BACKGROUND: Vocal fold motion impairment (VFMI), especially vocal fold abductor paralysis, is frequently seen in multiple system atrophy (MSA). Since the regulation system of laryngeal function is closely related to swallowing function, swallowing function is considered to be more involved in MSA patients with VFMI than in patients that do not have VFMI. However, the relationship between dysphagia and VFMI in MSA patients has not been systematically explored. OBJECTIVE: To elucidate the relationship between VFMI and dysphagia in MSA. METHODS: We evaluated swallowing function of 36 MSA patients with and without VFMI, by videofluoroscopy, and investigated the relationship between VFMI and pharyngeal swallowing function. RESULTS: VFMI was found in 17 patients (47.2%). Patients with VFMI had advanced severity of the disease. Although there was a tendency for bolus stasis at the pyriform sinus and the upper oesophageal sphincter opening to be more involved in patients with VFMI, statistical analysis did not show significant differences in swallowing function of MSA patients between with and without VFMI. In contrast, patients who underwent a tracheotomy ultimately required tube feeding or a laryngectomy. CONCLUSIONS: Appearance of VFMI is a sign of disease progression but does not necessary mean patients should change their way of taking nutrition. However, MSA patients who need a tracheotomy might have advanced to a high-risk group for dysphagia. Appropriate evaluation and treatment for VFMI and dysphagia are required to maintain patients' quality of life in MSA.

Bamboo node: primary vocal fold lesion as evidence of autoimmune disease.

Descriptions of vocal fold lesions related to autoimmune diseases are rare in the literature, and focus mainly on rheumatoid nodules. This is the first report in which autoimmune diseases were promptly suspected by the observation of a unique white transverse submucosal lesion in the vocal fold during clinical examination. This lesion, reported only in autoimmune disease, has been called the bamboo node and its features are different from those of rheumatoid nodules. We report here on two patients who did not have a diagnosis of systemic disease before investigation of their main complaint of hoarseness. At the patients' first visit, vocal fold bamboo nodes were seen in the vocal fold and the otolaryngologist suspected the presence of an autoimmune disease. We requested clinical investigation to clarify our suspicion that there was an underlying systemic disease. After the investigation, both patients were shown to have autoimmune disease, Sjögren's syndrome and systemic lupus erythematous, respectively. This paper emphasizes the important role of the otolaryngologist in the detection of these unique lesions in the vocal folds through the conventional laryngeal methods. These methods consisted of direct observation with a rigid laryngeal endoscope and investigation of the patient's distinctive vibratory pattern by means of laryngeal stroboscopy. The method of treatment we used to obtain the best outcome in terms of voice improvement is also discussed.

Aerodynamic profiles of a hemilarynx with a vocal tract.

The pressure-flow relationship was examined in excised canine and human larynges with and without a vocal tract. Canine and human larynges were prepared and cut in the midsagittal plane from the top to about 10 mm below the vocal folds. The right half was removed and replaced with an acrylic plate. The vocal tract was simulated initially with a 15-cm plastic tube and later with a vocal tract model with an area function resembling "ah." Simultaneous recordings were made of the glottal pressure, mean subglottal pressure, and average airflow at various levels of adduction. Preliminary data indicated that the pressure-flow relationships were similar to those of a full larynx and were almost linear. The addition of the vocal tract increased the glottal resistance by moving these pressure-flow lines to the lower-flow and higher-pressure region. The human larynx appears to phonate more easily than the canine larynx on the laboratory bench and has lower phonation threshold pressures.

Abnormal elevation of resting pressure at the upper esophageal sphincter of Parkinson's disease patients.

We investigated the oral and pharyngeal swallowing function in seven Parkinson's disease (PD) patients, using videomanofluorometry, which is videofluorographic and manometric evaluation conducted simultaneously. Abnormal elevations of resting pressure were found at the upper esophageal sphincter (UES) in three of the seven cases, when they were asked to hold a bolus in the mouth and initiate swallowing. One of these three cases showed an abnormal elevation of resting pressure, intermingled with a normal pressure pattern. Since the UES showed complete relaxation in these three cases, it is inappropriate to suppose that irreversible pathophysiological changes at the level of peripheral nerves had occurred. Our results suggested that altered resting pressure resulted from dysfunction at a more central level, such as a lack of dopaminergic stimulation at the supramedullary level causing skeletal muscle rigidity. Since a tonic abnormality of the UES cannot be measured by only videofluorography, both videofluorographic and manometric evaluation will be necessary to assess the pharyngeal phase of swallowing in PD patients.

High-speed digital imaging of the medial surface of the vocal folds.

High-speed digital imaging of the medial surface of the vocal folds was performed in excised canine larynx experiments. Building on the excised larynx investigations of Baer [Ph.D. dissertation, MIT, Boston, MA (1975)] and hemilarynx investigations of Jiang and Titze [Laryngoscope 103, 872-882 (1993)], nine vocal fold fleshpoints were tracked simultaneously along the medial surface of one coronal plane of the left vocal fold using a Kodak EktaPro 4540 high-speed digital imaging system. By imaging from two distinct views, 3D reconstructions of fleshpoint trajectories were performed with a sampling frequency of 4.5 kHz and a spatial resolution of approximately 0.08 mm. Quantitative results were derived from a typical example of periodic chestlike vibrations. Furthermore, these data were decomposed into empirical eigenfunctions, the building blocks of vocal fold vibration, illuminating basic mechanisms of self-sustained oscillation. Previously, such mechanisms have only been explored theoretically using computer models of vocal fold vibration [Berry et al., J. Acoust. Soc. Am. 95, 3595-3604 (1994)]. Similar to the theoretical studies, two eigenfunctions captured 98% of the variance of the data. Because this investigation utilized high-speed technology, the methodology may also be used to examine complex, aperiodic vibrations. Thus, this technique allows mechanisms of regular and irregular vocal fold vibration to be explored using direct observations of vibrating tissues in the laboratory.

Geometric characterization of the laryngeal cartilage framework for the purpose of biomechanical modeling.

Some new anatomic data on the laryngeal cartilage framework have been obtained for the biomechanical modeling of the larynx. This study attempted to define and measure some biomechanically important morphometric features of the laryngeal framework, including both the human and the canine laryngeal frameworks, because the canine larynx has been frequently used as an animal model in gross morphology and in physiological experiments. The larynges of 9 men, 7 women, and 9 dogs were harvested and dissected after death. Linear and angular geometric measurements on the thyroid cartilage, the cricoid cartilage, and the arytenoid cartilage were made with a digital caliper and a protractor, respectively. The results are useful for constructing quantitative biomechanical models of vocal fold vibration and posturing (abduction and adduction), eg, continuum mechanical models and finite-element models of the vocal folds.

Three-dimensional anatomic characterization of the canine laryngeal abductor and adductor musculature.

The biomechanics of vocal fold abduction and adduction during phonation, respiration, and airway protection are not completely understood. Specifically, the rotational and translational forces on the arytenoid cartilages that result from intrinsic laryngeal muscle contraction have not been fully described. Anatomic data on the lines of action and moment arms for the intrinsic laryngeal muscles are also lacking. This study was conducted to quantify the 3-dimensional orientations and the relative cross-sectional areas of the intrinsic abductor and adductor musculature of the canine larynx. Eight canine larynges were used to evaluate the 3 muscles primarily responsible for vocal fold abduction and adduction: the posterior cricoarytenoid, the lateral cricoarytenoid, and the interarytenoid muscles. Each muscle was exposed and divided into discrete fiber bundles whose coordinate positions were digitized in 3-dimensional space. The mass, length, relative cross-sectional area, and angle of orientation for each muscle bundle were obtained to allow for the calculations of average lines of action and moment arms for each muscle. This mapping of the canine laryngeal abductor and adductor musculature provides important anatomic data for use in laryngeal biomechanical modeling. These data may also be useful in surgical procedures such as arytenoid adduction.

Role of laryngeal movement and effect of aging on swallowing pressure in the pharynx and upper esophageal sphincter.

OBJECTIVES: Describe contribution of laryngeal movement to pressure changes at the upper esophageal sphincter (UES) and the effect of aging on the swallowing function. STUDY DESIGN: Manofluorography on 56 nondysphagic adults divided into three age groups: the 21- to 31-year-old group (n = 32), the 61- to 74-year-old group (n = 12) and the 75- to 89-year-old group (n = 12). Analyses of the bolus transit time, the amplitudes and durations of pharyngeal pressures, the timing of a pressure fall at the UES and the laryngeal movements. METHODS: Intraluminal strain-gauge sensors recorded pressure changes in the oropharynx, hypopharynx and the UES. Motion pictures of the videotapes were fed into a personal computer, and movements of the hyoid bone were measured in both the horizontal and vertical directions as an indication of laryngeal movement. RESULTS: In 26- and 70-year-old men with calcification of the thyroid cartilage, it was determined that the larynx and hyoid bone moved in consonance until the end of the rapid hyoid movements in both the superior and anterior directions. In the 21- to 31-year-old group, the magnitude of the pressure fall at the UES was maximal before or almost at the same time as the bolus arrival, in preparation for smooth passage of the bolus from the pharynx to the esophagus. The rapid superior movements of the hyoid bone started significantly early as compared with its anterior movements (P = .0001). The rapid anterior movements of the hyoid bone started simultaneously with the pressure fall at the UES. In the elderly, all segmental transit times were significantly increased. The timing of the pressure fall at the UES was significantly delayed and the UES pressure reached its minimum value after arrival of the bolus at the UES. The minimum pressure at the UES increased to a significantly positive value. The rapid anterior movements of the hyoid were significantly delayed, suggesting that this delay causes the delay in the pressure fall at the UES. CONCLUSIONS: The rapid superior and anterior movements of the hyoid bone are considered to start at the same time as those of the larynx. In the young group, it is suggested that superior laryngeal movement protects the lower airway prior to the anterior laryngeal movement, causing the pressure fall at the UES to enable the passage of a bolus into the UES. In the elderly, smooth passage of the bolus from the pharynx to the esophagus is hindered and the system that prevents aspiration is rendered inefficient by changes in the swallowing pressures and laryngeal movements with aging.

Diagnosis and physiopathology of laryngeal deposits in autoimmune disease.

We report the clinical features and pathology of a previously unreported form of vocal fold disease seen in 4 patients, 3 of whom were diagnosed as autoimmune disease. The characteristic features of these lesions were found as bilateral transverse lesions in the mid portion of the vocal folds. The patients had dysphonia and diplophonia. Stroboscopic examinations showed 180-degree phase shifts between the anterior and posterior portion of the vocal folds. Case 1 had systemic lupus erythematosus, case 2 had Hashimoto's thyroiditis, and case 3 had progressive systemic sclerosis. Prior to the onset of hoarseness, autoimmune antibody titers were increased. These cases need differential diagnosis from vocal fold nodules and cysts. Two cases were recurrent after endoscopic surgery, 1 recurring 3 times. Glucocorticoid was effective in preventing the recurrence in the early phase. Recurrence may have occurred because the surgical strategy was the same as that used for vocal fold nodules or cysts.

Stroboscopic observation of the larynx after radiation in patients with T1 glottic carcinoma.

We studied laryngeal video stroboscopy (LVS) system for evaluation of patients with glottic carcinoma (T1N0M0) before and after radiotherapy. There were 10 patients with T1 glottic squamous cell carcinoma (9 men and 1 woman) who received radiotherapy at the Hitachi General Hospital. We performed LVS before and after radiotherapy. The presence or absence of mucosal waves (MW) was particularly noted. No MW were present before radiotherapy but at 1-6 months after, MW gradually appeared. One year after radiotherapy all patients showed MW on LVS. In patients with glottic carcinoma MW recovered after radiation therapy. LVS may be useful for the clinical follow-up of post-radiation patients for early detection of recurrence of glottic carcinoma.

[Assessment of Swallowing Ability Scale for oral and oropharyngeal cancer patients].

The Swallowing Ability Scale (SAS) has been recently reported by us. This scale is a new method to assess dysphagia after therapy for oral and oropharyngeal cancer. The preliminary results on 23 patients showed that the scale was reliable and sensitive to functional differences across a broad spectrum of oropharyngeal dysphagia after therapy. This paper confirmed the above facts in 73 oral and oropharyngeal cancer patients who were treated in two hospitals between 1995 and 1996. As stated in the previous paper, SAS consists of a 2-step questionnaire: the MTF score and the Dysphagia score. The MTF score is a simple and practical assessment tool consisting of three subscales: 1) Method of intake, 2) Time of intake, and 3) Food. The Dysphagia score is a relevant assessment tool for defining patients' anatomic or physiologic swallowing disorders. In 40 patients with wide resection of the tongue, the Dysphagia score (p < 0.05) and the MTF score (p < 0.01) were significantly decreased. And we found a correlation between the MTF score and the Dysphagia score (r = 0.78, p < 0.001) in 73 patients. The usefulness of the SAS will be further studied for the assessment of rehabilitation to improve postoperative dysphagia.

Safe and effective topical application dose of lidocaine for surgery with laryngomicroscopy.

A clinical case of a patient in whom seizure developed after topical application of lidocaine to the oropharyngeal region was described. The exploratory studies on the optimal dosage of lidocaine in the surgery under laryngomicroscope was performed in 22 patients. During the application of 2% lidocaine viscous and 4% lidocaine solution to the oropharyngeal region, the patient was instructed to expectorate the excess intermittently to avoid absorption. In addition, the oropharyngeal region was swabbed with gauze. The serum lidocaine concentrations after application were less than 1.8 micrograms/ml. The total application dose of the drug was within the range of 324 to 640 mg, and the total recovery rate from the saliva and gauze was 52% to 81%. We found a good correlation between net application dose (total application dose minus excessive lidocaine dose) and serum lidocaine concentration. In this study, it was shown that the safe and effective net application dose of lidocaine for the surgery may be within the range of 127 to 260 mg.

Surgical management of the plunging ranula: a review of seven cases.

We have treated seven patients with a plunging ranula during the past 10 years. All patients underwent surgery via a cervical approach. In two, the ranula reached the anterior neck by passing through a dehiscence in the mylohyoid muscle, while in the other five the plunging ranula passed posteriorly to the mylohyoid muscle. A pseudocyst was extirpated in each patient. Although total sublingual gland excision was not performed in two patients, no recurrence was observed in any patient. Incision of the pseudocyst facilitated subsequent procedures and decreased the incidence of transient facial paralysis. In the presence of a cervical mass without swelling of the oral floor, a cervical approach may still be the method of choice either for the first operation or for salvage surgery after recurrence subsequent to intraoral procedures. It is based on the fact that there may be ectopic sublingual glands residing on the inferior surface of the mylohyoid muscle.

[Dysphagia in amyotrophic lateral sclerosis--the mechanism and managements].

Amyotrophic lateral sclerosis (ALS) raises progressive dysphagia that causes aspiration. This diseases affects oral phase first and then pharyngeal phase of swallowing. Aspiration pneumonia by dysphagia becomes major problem from clinical aspect to cause aggravation of vital prognosis. We explain the mechanism of dysphagia from deglutition dynamics and discuss the clinical managements. Several functional operations such as cricopharyngeal myotomy, laryngeal suspension and so forth, have been applied to prevent aspiration, with satisfactory results in cases with mild dysphagia. However, in cases of ALS patients with severe aspiration, the results are poor. Then we have to divide airway from digestive tract completely to prevent aspiration by laryngectomy. However, the larynx is a multi-functional organ, loss of the larynx does improve the swallowing but loose phonatory function. We need to evaluate a deglutition function before starting of treatments of dysphagia. Besides, we also need to put hopes and life style of patients in consideration. We have to be very careful to choose the way of surgical treatment and the time of operation. We can conclude that laryngectomy is useful for vital prognosis and amelioration of QOL in ALS patients.

A minor laryngeal cleft (type 1-a) diagnosed in infancy.

We report a case of laryngeal cleft. The patient showed tachypnea, stridor, and cyanosis with feeding, when the diagnosis was made by laryngo-fiberscopy at 2 days of life. At the age of 7 months, a direct laryngoscopy showed a 5 mm length of cleft behind the vocal cord at the level of the interarytenoid portion. Gastrostomy and tracheostomy were performed at the same time. For small type 1 clefts, some authors have proposed the possibility of treatment without surgery. In this case, we tried to minimize the defect by injecting collagen into the sub-mucosal space of the arytenoids. The patient was decanulated at the age of 2 years and 2 months. This case represents an example of earliest diagnosis of minimal laryngeal clefts (Armitage's type 1-a), which has been usually identified at older ages.

Hormone-dependent enhancement in binding of oto- and nephrotoxic aminoglycoside antibiotics.

Intraperitoneal administration of gentamicin (40 mg/ml) to the guinea pig is known to cause damage of the tissue of the kidneys and auditory organs. By indirect immunohistochemical staining with anti-gentamicin antiserum, those cells with high affinity to gentamicin in the auditory organs and kidneys were the hair cells in the cochlea and the epithelial cells in the renal tubules. The concentrations of gentamicin in the serum and perilymph of the guinea pig with tissue damage were found to be 2 and 0.6 mg/ml at the maximal levels, respectively, by high performance liquid chromatography. The same concentration of gentamicin, 2 mg/ml, also inhibited cell growth and resulted in cell damage of the renal tubule-derived cell lines, JTC-12 and MDCK. Among the antibiotics examined, i.e. streptomycin, gentamicin, fradiomycin and kanamycin, gentamicin showed the strongest effect on growth inhibition of the renal tubule-derived cells, when these cells were cultured in a medium with 5% fetal calf serum. Although the number of JTC-12 cells in the medium without fetal calf serum remained the same for a week, even with the addition of either gentamicin (0.5 mg/ml) or parathyroid hormone (2 mM) the coadministration of gentamicin and parathyroid hormone resulted in a loss of cells due to cellular death, and the amount of gentamicin bound onto the cells cultured with gentamicin plus parathyroid hormone was significantly higher than that with gentamicin alone. These results indicate that the expression of the receptor for gentamicin on the cell surface is greatly enhanced by hormonal stimulation.