Endoscopic cauterization of congenital pyriform fossa sinus tracts: an 18-year experience.

IMPORTANCE: Congenital pyriform fossa sinus tracts predispose to neck masses and neck abscesses in pediatric and occasionally adult patients. Traditional management involves open excision with substantial potential morbidity. Endoscopic management allows an alternative, less morbid treatment approach. OBJECTIVE: To evaluate the long-term effectiveness of endoscopic cauterization as definitive treatment for pyriform fossa sinus tracts. DESIGN, SETTING, AND PATIENTS: Retrospective review of the medical records of 23 children (aged 7 months to 14 years) with pyriform fossa sinus tracts treated with endoscopic cauterization between 1995 and 2013 at a tertiary care children's hospital. INTERVENTION: Endoscopic electrocauterization of pyriform fossa sinus tract opening. MAIN OUTCOMES AND MEASURES: Recurrence of symptoms after endoscopic treatment. RESULTS: Twenty-one of 23 patients experienced no recurrence after their first endoscopic electrocauterization of the sinus tract. The 2 patients with recurrence experienced symptoms within 1 month of cauterization and were treated with either open excision or recauterization. Endoscopic cauterization was able to definitively treat 9 patients whose treatments with incision and drainage or open excision had failed. Mean (range) follow-up for the 15 patients with follow-up was 7.4 (0.10-14.2) years. No procedure-related morbidity was reported. CONCLUSIONS AND RELEVANCE: Endoscopic cauterization seems to be an effective and potentially permanent treatment for congenital pyriform fossa sinus tracts.

Laryngeal obstruction by cervical and endolaryngeal lymphatic malformations in children: proposed staging system and review of treatment.

OBJECTIVES: We review and stage a series of congenital lymphatic malformations (LMs) that caused laryngeal obstruction according to a proposed staging system, review the treatment modalities utilized, and correlate the stage of disease with clinical outcomes and tracheotomy statuses. METHODS: We present a detailed description of the clinical presentation, management approach, and clinical outcome and tracheotomy status of a series of patients with laryngeal obstruction by LMs. A 4-part staging system (stages I to IV) for congenital LMs obstructing the larynx, based upon our clinical experience, is proposed. The patients were retrospectively reviewed and staged according to the proposed system, and clinical management and outcomes were correlated with the stage of disease. RESULTS: We identified 16 patients with laryngeal obstruction by LMs. Eighty-one percent (13 of 16) received sclerotherapy, and 50% (8 of 16) underwent operative excision or debridement. Forty percent (2 of 5) of stage I lesions, 75% (3 of 4) of stage II lesions, 100% (4 of 4) of stage III lesions, and 100% (3 of 3) of stage IV lesions were in patients who required tracheotomy. All patients who had stage I and II lesions and required tracheotomy have been decannulated, whereas only 2 of the 4 patients with stage III lesions and no patients with stage IV lesions have been successfully decannulated. CONCLUSIONS: Lymphatic malformations obstructing the larynx require a careful and often staged management approach. A proposed staging system helps to predict the need for tracheotomy and the likelihood of long-term tracheotomy dependence.

Multilevel treatment of moderate and severe obstructive sleep apnea with bone-anchored pharyngeal suspension sutures.

Success rates for the surgical treatment of obstructive sleep apnea (OSA) vary, with phase I surgical success ranging from 40 to 75%. Pharyngeal suspension suture procedures are minimally invasive techniques with a reported efficacy of 20 to 78%. We conducted a study to evaluate the effectiveness of pharyngeal suspension suture procedures in conjunction with uvulopalatopharyngoplasty (UPPP) as a multilevel treatment for OSA. We retrospectively reviewed the charts of 30 adults-22 men and 8 women, with a mean age of 49 years and a mean BMI of 30.6-who were treated at a tertiary care academic medical center and a private otolaryngology practice. All patients had moderate or severe OSA, and all had failed continuous positive airway pressure therapy. Of this group, 20 patients underwent tongue base and hyoid suspension (TBHS) and 10 underwent tongue base suspension (TBS) alone; 23 patients had undergone concurrent or previous UPPP, 13 in the TBHS group and all 10 in the TBS group. Polysomnography was performed an average of 3.9 months postoperatively. Surgical success was defined as a reduction in respiratory distress index (RDI) of more than 50% and a postoperative RDI of 20 or less. The overall surgical success rate was 63% (19/30). In the surgical success group, the mean RDI fell from 44.6 to 9.4 (p < 0.0001); in the surgical failure group, the mean RDI rose from 41.3 to 48.9 (p = 0.58). There were 6 complications: 3 seromas, 2 suture breaks, and 1 dislodged screw. We conclude that pharyngeal suspension suture procedures as part of the multilevel treatment of moderate and severe OSA yields better outcomes than conventional surgical treatments with the added benefit of being minimally invasive.

The use of lipid microtubes as a novel slow-release delivery system for laryngeal injection.

OBJECTIVES/HYPOTHESIS: The potential utility of direct injection of bioactive substances in the treatment of vocal fold tissue fibrosis is limited by rapid clearance from the injection site. The objective of this study is to evaluate the potential of a lipid-based microtube delivery system to preserve the biological activity of injected substances and prolong their duration of pharmacological effects in the larynx. STUDY DESIGN: Prospective in vitro and case-control in vivo murine study METHODS: Lipid-based microtubes were loaded with Texas red-dextran (MT-TR) and hepatocyte growth factor (MT-HGF). In vitro and in vivo (using a murine vocal fold injection model) release of MT-TR and MT-HGF were determined to assess duration of microtube-mediated delivery. The biologic effects of MT-HGF on fibroblasts were assessed after treatment in the presence of transforming growth factor (TGF)-ß. RESULTS: In vitro release kinetics demonstrated slow release of MT-TR and MT-HGF, correlating with in vivo results demonstrating persistence of MT-HGF at 4 weeks postinjection. Bioefficacy was maintained, as MT-HGF was shown to inhibit TGF-ß-mediated induction of procollagen mRNA levels in vitro 24 hours after treatment in fibroblast cells. Sustained release of HGF from microtubes at 6 days exacerbated the effects of TGF-ß and increased levels of procollagen mRNA. CONCLUSIONS: Microtubes have significant potential utility as an efficacious means of sustained-release delivery of bioactive agents to the larynx. Atthough the role of HGF as an antifibrotic agent is questioned, its sustained bioefficacy after microtube encapsulation distinguishes microtubes from other delivery vehicles.

Pathologic effects of external-beam irradiation on human vocal folds.

OBJECTIVES: We sought to better characterize pathologic changes that occur in the human vocal fold after radiotherapy for head and neck cancer. METHODS: In a blinded, controlled study of archived tissue, we evaluated postirradiation salvage laryngectomy vocal fold tissue without evidence of malignant disease. Clinical and demographic patient data were collected. In a blinded fashion, irradiated tissue was compared to nonirradiated, benign control tissue. Histomorphometric analysis was used to assess muscle and collagen organization, superficial lamina propria (SLP) and vocal ligament thickness, vocalis muscle fiber area, collagen content, and hyaluronic acid content. Immunohistochemical analysis was used to assess the content of type I collagen, type IV collagen, vimentin, fibronectin, alpha-smooth muscle actin, matrix metalloproteinase 9, and laminin. RESULTS: Twenty irradiated vocal folds were evaluated and compared to control specimens. Collagen and muscle disorganization was noted in the irradiated specimens. The SLP and vocal ligament thicknesses and the mean muscle fiber diameters did not differ significantly. The SLP fibronectin and the vocalis muscle and SLP collagen content were significantly increased in the irradiated vocal folds, and the SLP collagen content increased significantly with time between irradiation and resection. The laminin content of irradiated vocalis muscles was significantly decreased. CONCLUSIONS: Radiotherapy results in significant vocal fold tissue changes. Having more precisely defined these changes, we plan continued investigation seeking targeted preventive and therapeutic interventions for improved vocal quality following radiotherapy.

Office-based sclerotherapy for benign parotid lymphoepithelial cysts in the HIV-positive patient.

OBJECTIVE: To determine the efficacy of sodium morrhuate injection therapy in the control of benign lymphoepithelial cysts of the parotid gland. STUDY DESIGN: Retrospective review. METHODS: The medical records of human immunodeficiency virus (HIV)-positive patients who presented to an indigent care hospital for the evaluation and management of benign lymphoepithelial cysts of the parotid gland are reviewed. Cyst laterality, aspiration and injection volumes, and noted complications were recorded. When applicable, elapsed time between recurrent interventions was recorded. RESULTS: Medical records were available for a total of nine patients who underwent aspiration and injection of 34 cysts. Five of the nine patients required therapy for additional cyst formation an average of 11.8 months after initial intervention. There have been no known instances of facial nerve or parotid gland injury, and the only recorded postprocedure complaints were pain and mild edema. CONCLUSIONS: While multiple cysts may arise and serial intervention may be required, we believe that in association with broader clinical experience, the data presented here support aspiration and sodium morrhuate injection as a safe, minimally invasive, and efficacious technique in the treatment of benign lymphoepithelial cysts of the parotid gland in the HIV-positive population.

Voice therapy improves quality of life in age-related dysphonia: a case-control study.

The objective of the study is to determine the efficacy of voice therapy in the treatment of age-related dysphonia. The study was conducted using a retrospective case-control chart review. The medical records of 54 patients older than 60 years diagnosed with age-related dysphonia without complicating diagnoses were reviewed. Patients who chose to undergo voice therapy were grouped as cases. Patients who chose not to undergo voice therapy were grouped as controls. The voice-related quality of life (VRQOL) measure was used to measure outcomes before and after treatment in cases and at a minimum 2-month follow-up in controls. Of the 54 patients, 19 (10 female, 9 male; mean age 73 years) chose to undergo voice therapy and filled in >1 VRQOL questionnaire. Six patients (3 female, 3 male; mean age 66 years) chose not to undergo voice therapy and filled in >1 VRQOL questionnaire. The 19 cases experienced a mean improvement in VRQOL score of 19.21 (2-tailed matched pairs t test P=0.00038) after a mean of 4.1 voice therapy sessions and 5.1 months. The six controls experienced a mean change in VRQOL score of 0.42 (2-tailed matched pairs t test P=0.96) after a mean of 3.3 months. Voice therapy leads to statistically significant improvement in the VRQOL life in elderly patients with age-related dysphonia. It is an efficacious noninvasive therapy for this disease.

Intramolecular electrocatalysis of 8-oxo-guanine oxidation: secondary structure control of electron transfer in osmium-labeled oligonucleotides.

A phosphoramidite containing Os(bpy)(3)(2+) (Os; bpy, 2,2'-bipyridine) with a three-carbon linker was synthesized and used to prepare oligonucleotides with the Os redox catalyst appended to the 5'-end. The electrogenerated Os(III) is capable of oxidizing 7,8-dihydro-8-oxo-guanine (8G), but 8G is not electrochemically reactive at indium tin oxide electrodes because of poor electrode kinetics for the direct reaction. The hairpin-forming oligonucleotide Os-5'-ATG TCA GAT TAG CAG GCC TGA CAT 8G was synthesized and characterized by thermal denaturation and native gel electrophoresis both in the hairpin form and when hybridized to its Watson-Crick complement. The redox potential in both forms of the appended Os(III/II) couple was 0.63 V (all potentials vs Ag/AgCl), which is identical to that for the free complex. The diffusion coefficients of the hairpin form (10.2 x 10(-)(7) cm(2)/s) and the duplex form (8.7 x 10(-)(7) cm(2)/s) were consistent with values expected from studies of noncovalently bound redox labels, which suggest that the measured diffusion coefficient should be that of the appended DNA molecule. The oligonucleotide was designed such that in the duplex form, the 8G is far from the Os(III/II) couple, but in the hairpin form, the 8G is situated close to the redox center. For the duplex form, cyclic voltammetry studies showed that mediated oxidation of the 8G nucleobase occurred only through bimolecular reaction of the electrogenerated Os(III) of one duplex with the 8G of another duplex. However, in the hairpin form, intramolecular electron transfer from 8G to Os(III) in the same molecule was apparent in both chronoamperometry and cyclic voltammetry.