The unsolved chapter of vocal fold scars and how tissue engineering could help us solve the problem.

Vocal fold scarring is a relatively small field in scar research with prerequisites found nowhere else. The deterioration of the delicate tri-layered micro-structure of the epithelium of the vocal folds leads to impaired vibration characteristics resulting in a permanent hoarse and breathy voice. Tissue engineering approaches could help to restore the pre-injury status. Despite a considerable progress in this field during the last years, routine clinical applications are not available so far. One reason might be that vocal fold fibroblasts, as the responsible cell type for fibrogenesis, have very particular properties that are only poorly characterized. Moreover, in vivo trials are costly and time consuming and a representative in vitro model does not exist so far. These particular circumstances lead to innovative in vitro strategies and concepts such as macro-molecular crowding that can also be applied in adjacent fields.

Experience of 11 years use of cidofovir in recurrent respiratory papillomatosis.

Recurrent respiratory papillomatosis (RRP) is a viral induced disease, associated with exophytic epithelial lesions affecting the upper airways. Problem of treatment is the high recurrence of papilloma growth after surgical removal; therefore adjuvant therapy schemes have been established. Cidofovir was one of the agents used off-label in adjuvant therapy in the last years. However, there is ongoing discussion about the effectiveness and possible side effects. Aim of our study was to share our experience in treatment of RRP with cidofovir during the last 11 years. We analyzed all the data of patients treated for RRP at the Department for Phoniatrics of the Medical University of Graz between 1999 and 2011. 25 out of the 34 treated patients are at the moment under complete remission, in six patients partial remission could be achieved and two patients showed poor response to therapy, therefore the treatment with cidofovir was stopped. 21 patients received one cycle of monthly cidofovir, 11 patients received two and one patient three cycles of therapy. Number of procedures reached from one to six during each cycle. Average cumulative dose of one cycle was 79.7 mg (15-277.5 mg), in one patient 435 mg were used. One patient developed temporary, borderline neutropenia without symptoms. Despite the retrospective approach of this study with the limitation of several incomplete records, our results show promising long-term effects of adjuvant use of cidofovir. During this period, we did not observe any relevant side effects.

A transthyroidal method for arytenoid adduction: a basic anatomical study.

INTRODUCTION: Arytenoid adduction is a very effective procedure for medializing the posterior part of the vocal fold in vocal fold paralysis. Major drawback of the method is the technically sometimes-difficult access to the arytenoid with increased postoperative morbidity. Aim of this study was to provide basic anatomical data regarding the accessibility of the arytenoid cartilage through a thyroplasty window. Furthermore, to investigate the feasibility of an arytenoid adduction by fixation of a surgical screw to the arytenoid cartilage by using this approach. MATERIALS AND METHODS: 10 cadaver larynges, six female and four male, were dissected and measured for our points of interest. A standard manufacture-made surgical screw attached to a suture was anchored to the fovea oblonga of the arytenoid cartilage. RESULTS: Our anatomical measurements proved a mean distance from the posterior edge of the thyroid window to the arytenoid of about 8-9 mm in male larynges and 7-8 mm in female larynges. The distances did not differ significantly between the sexes. Pulling the anchored surgical screw medializes the posterior part of the vocal fold. DISCUSSION: Our data showed that there is a very constant morphometric relation between the thyroplasty window and the arytenoid cartilage. It is known that gender-related differences result in a veritable laryngeal dimorphism in nearly all absolute laryngeal dimensions. These differences appear to a much lesser extend in the distances from the surface to the depth, as was confirmed in our series. Using these findings led us to identification of the fovea oblonga near the muscular process as the most favorable point for fixation of a surgical screw through a conventional thyroplasty window. Pulling the attached suture medializes the arytenoid cartilage.

[First clinical experience with a moderately bent laryngoscope for endolaryngeal surgery]. / Erste klinische Erfahrungen mit einem gebogenen Laryngoskopierohr für die endolaryngeale Chirurgie.

INTRODUCTION: In this article we describe the successful use of a moderately bent laryngoscope in two different patient cases. MATERIALS: We developed a prototype of a 20 degrees bent laryngoscope. The moderate curvature allows insertion of the laryngoscope without using any optical device. The operation is performed via a laterally attached 30 degrees nasal endoscope and a monitor, with slightly bent instruments. Previous work by our group showed that when a bent laryngoscope was used, the forces on the oropharyngeal tissues were significantly reduced. Furthermore, the use of these laryngoscopes significantly improves the exposure of the endolarynx. RESULTS: We present two cases in which insertion of a conventional straight laryngoscope was not possible due to anatomical reasons. However, the operations could be performed successfully with the bent laryngoscope.

Pitch synchronous changes of the anterior cricothyroid gap by using ultrasonography.

OBJECTIVES: The purpose of this study was to describe changes of the anterior cricothyroid space during respiration and phonation by using ultrasonography. Furthermore, to assess and correlate laryngeal dimensions in a large cohort of voice healthy men. STUDY DESIGN: Epidemiological study. METHODS: Ultrasound examinations of the laryngeal skeleton, as well as of the cricothyroid space were performed in 64 voice healthy, elderly male subjects. This was done during respiration, phonation in midrange, and high phonation. RESULTS: We could not find any significant correlation concerning lengths of the cricothyroid space when correlated with voice range, highest or lowest frequency. General anthropometric parameters such as body height, weight, or body mass index did not show any considerable correlation with dimensions of the laryngeal skeleton. CONCLUSION: Functionally orientated surgery of the larynx requires exact knowledge of the anatomy and landmarks of the laryngeal skeleton. Topographic relations and dimensions between the thyroid and cricoid cartilages play an important role in cricoid approximation.

[Do clinical symptoms and laryngoscopic findings of laryngo-pharyngeal reflux correlate?]. / Korrelieren die klinischen Symptome und lupenlaryngoskopischen Befunde des laryngo-pharyngealen Refluxes miteinander?

BACKGROUND: ENT specialists are often confronted with symptoms which are related to laryngo-pharyngeal reflux. The high prevalence, as well as therapy with PPIs (proton pump inhibitors) has recently raised controversies. Goal of our study was to survey laryngeal tissue irritation signs, as well as reflux associated complaints in a cohort of "healthy" men. Furthermore to describe if and to which grade subjective symptoms correlate with clinical signs. METHODS: We surveyed in a prospective, population based study cohort of 64 men the prevalence of laryngeal irritation signs with laryngoscopy (based on the Reflux Finding Score--RFS) and reflux associated complaints (Reflux Symptoms Index--RSI). RESULTS: A third of all volunteers had pathological values as assessed by the RSI questionnaire. Laryngoscopy revealed only in six men signs suspicious of LPR. Symptoms and laryngoscopic findings did not correlate. CONCLUSION: In most cases no clinical substrate could be identified in symptoms usually contributed to LPR. These are often non specific and a careful examination of other factors should be taken.

Hyperplastic epithelial lesions of the vocal folds: combined use of exfoliative cytology and laryngostroboscopy in differential diagnosis.

The mainstay of successful tumor therapy is early detection of neoplastic tissue. Although exfoliative cytology has proven to be a reliable tool, its importance is still underestimated. Laryngostroboscopy is the most important tool for functional investigation in laryngological and phoniatric diagnosis. Stroboscopic evaluation allows early detection of infiltrative processes of the vocal folds. Aim of our study was to demonstrate that combination of both, exfoliative cytology and stroboscopy, provides a highly sensitive and easy to perform method in differential diagnosis of epithelial hyperplastic lesions of the vocal folds. In 130 patients with varying degrees of vocal fold keratosis up to glottic cancer, preoperative layngostroboscopy was performed. Stroboscopy was classified pathological in case of reduced or abolished amplitude of vocal fold vibration and/or reduced or abolished mucosal wave propagation. Under general anaesthesia histology with corresponding cytological specimens were obtained. The latter were classified in three groups reaching from normal (I), dysplastic (II), up to malignant (III) cytology. Invasive carcinoma was diagnosed in 32 cases by histology, corresponding malignant cytology was found in 21 specimens (sensitivity: 74%). By certain combination of cytology with pathological stroboscopy, a sensitivity of more than 97% can be achieved. Combination of cytology and stroboscopy allows detection of glottic cancer with a sensitivity of 97%, in contrast to 74% as found by cytology alone. This combination can be used as preliminary or sorting procedure and gives the opportunity of early detection, as well as for follow-up examinations. For repeated biopsies can cause scars with consecutive voice impairment, this procedure is very smooth but nevertheless reliable method.

Incidence and clinical relevance of herniation of the mylohyoid muscle with penetration of the sublingual gland.

Swelling of the submandibular region may cause problems in daily clinical diagnosis and requires further exploration. Ultrasonic examination provides a simple, non-invasive and radiation-free method. The goal of our study was to show the high incidence of herniation of the mylohyoid muscle with penetration of the sublingual glands, in some cases clinically imposing as permanent swelling. Penetration was classified into four grades (Grade 0-III). In course of routine examinations of the neck by ultrasound, the anterior part of the mylohyoid muscle was observed in 124 consecutive patients from our outpatient's clinic, presenting with unclear swelling of the neck, mostly due to lymph nodes. In resting position and during swallowing the degree of penetration of the sublingual gland through the mylohyoid muscle was staged. Almost 60% of patients showed an affection of the mylohyoid muscle at either site of varying degrees. In 40% only a thinning of the muscle could be noticed (grade I), whereas in 21 patients (17%) a significant herniation of the gland during swallowing could be observed (grade II). In two patients (2%) a constant breach of the mylohyoid muscle with permanent herniation of the gland imposing as swelling could be seen (grade III). Occasional or permanent penetration of the sublingual gland through the mylohyoid muscle is not a rare finding and can be found in almost every fifth individual using ultrasound. This may impose clinically as permanent swelling and may be of value in the differential diagnosis of swelling in the submandibular region.

[3D cross section of the laryngotracheal tract. A new method for visualization and quantification of tracheal stenoses]. / 3D-Querschnittsprofil des Laryngotrachealtrakts. Eine neue Methode zur Visualisierung und Quantifizierung von Trachealstenosen.

PURPOSE: Demonstration of a technique for 3D assessment of tracheal stenoses, regarding site, length and degree, based on spiral computed tomography (S-CT). PATIENTS AND METHODS: S-CT scanning and automated segmentation of the laryngo-tracheal tract (LTT) was followed by the extraction of the LTT medial axis using a skeletonisation algorithm. Orthogonal to the medial axis the LTT 3D cross sectional profile was computed and presented as line charts, where degree and length were obtained. Values for both parameters were compared between 36 patients and 18 normal controls separately. Accuracy and precision was derived from 17 phantom studies. RESULTS: Average degree and length of tracheal stenoses were found to be 60.5% and 4.32 cm in patients compared to minor caliber changes of 8.8% and 2.31 cm in normal controls (p <0.005). For the phantoms an excellent correlation between the true and computed 3D cross sectional profile was found (p <0.005) and an accuracy for length and degree measurements of 2.14 mm and 2.53% respectively could be determined. The corresponding figures for the precision were found to be 0.92 mm and 2.56%. CONCLUSION: LTT 3D cross sectional profiles permit objective, accurate and precise assessment of LTT caliber changes. Minor LTT caliber changes can be observed even in normals and, in case of an otherwise normal S-CT study, can be regarded as artefacts.

Effect of pantoprazole on the course of reflux-associated laryngitis: a placebo-controlled double-blind crossover study.

BACKGROUND: The optimal management of patients with reflux-associated laryngitis is unclear. We performed a placebo-controlled crossover trial in patients with proven reflux disease and associated laryngitis to determine the effect of pantoprazole and to gain information on the natural course of the disease. METHODS: Sixty-two consecutive non-smoking patients with hoarseness and proven laryngitis were examined. Scores with respect to the larynx and for subjective complaints were determined and 24-h pH-metry to assess acid reflux in the lower oesophagus and pharynx was performed. Patients with pathologic reflux were given the chance to enter a double-blinded randomized crossover trial with pantoprazole 40 mg b.i.d. and placebo for a duration of 3 months each, separated by a 2-week washout period. RESULTS: Twenty-four of 62 patients showed pathological reflux; 21 patients were included in the study and 14 concluded all parts of the study. Both pantoprazole and placebo resulted in a marked improvement in laryngitis scores (decrease of 8.0 +/- 1.4 versus 5.6 +/- 2.6; no significant difference between the 2 treatments) and symptoms after the first 3 months (decrease of oesophageal symptom score of 2.2 +/- 1.4 versus 5.4 +/- 2.8; decrease of laryngeal scores of 8.3 +/- 3.6 versus 10.3 +/- 3.9; also no significant difference between the 2 treatments). A second pH-metry 2 weeks thereafter proved the persistence of reflux in most of these patients. Switching to pantoprazole led to a further improvement of scores. In the group switched to placebo there was recurrence only in a minority of patients. CONCLUSIONS: The self-limited nature of reflux-associated laryngitis in non-smokers is largely underestimated. Laryngitis improves despite the persistence of reflux. Pantoprazole may be helpful especially in relieving acute symptoms, but the advantage of long-term treatment over placebo has been greatly overestimated.

Laryngeal manifestation of gout: a case report of a subglottic gout tophus.

A subglottic tophaceous deposition of urate crystals is a rare finding. We report on a case of a male Caucasian who had a moderate dysphonia without any further laryngeal symptoms. The laryngoscopy revealed a hemispheric lesion on the left subglottic region. An excision biopsy was performed, and the histopathological examination of the dissected specimen showed a tophus. Diagnostic and therapeutic strategies are discussed.

Hypernasality--a rare initial symptom of a cerebellar astrocytoma.

Nasality is a disorder due to nasal resonance, which may be induced by a variety of etiologies. Transitional hypernasality is frequently seen in children after adenoidectomy. The alleged post-surgical hypernasality in the case presented was shown to be related to the late detection of an astrocytoma of the cerebellum and the brain stem in a 6-year-old boy. This case was characterized by increased hypernasality which failed speech therapy. A developing one-sided vocal fold palsy in combination with an ipsilateral soft-palate palsy indicated further investigation. Computerized tomography (CT) and magnetic resonance imaging (MRI) revealed a brain stem-tumor with a maximum size of 6 cm involving parts of the cerebellum. These findings demonstrated the need for a strict follow-up, even after adenoidectomy, in the presence of hypernasality for identifying concurrent etiologies as well as cases suitable for speech therapy.