Structured oropharynx, hypopharynx and larynx assessment during routine esophagogastroduodenoscopy improves detection of pre- and early cancerous lesions: a multicenter, comparative study.

Background and study aims A structured assessment of the oropharynx, hypopharynx and larynx (OHL) may improve the diagnostic yield for the detection of precancerous and early cancerous lesions (PECLs) during routine esophagogastroduodenoscopy (EGD). Thus, we aimed to compare routine EGDs ± structured OHL assessment (SOHLA), including photo documentation with regard to the detection of PECLs. Patients and methods Consecutive patients with elective EGD were arbitrarily allocated to endoscopy lists with or without SOHLA. All detected OHL abnormalities were assessed by an otolaryngologist-head & neck surgeon (ORL-HNS) and the frequency of PECLS detected during SOHLA vs. standard cohort compared. Results Data from 1000 EGDs with and 1000 EGDs without SOHLA were analyzed. SOHLA was successful in 93.3 % of patients, with a median assessment time of 45 seconds (interquartile range: 40-50). SOHLA identified 46 potential PECLs, including two benign subepithelial lesions (4.6 %, 95 % CI: 3.4-6.1) while without SOHLA, no malignant and only one benign lesion was found ( P  < 0.05). ORL-HNS imaging review classified 23 lesions (2.3 %, 95 % CI: 1.5-3.4) as concerning and ORL-HNS clinic assessment was arranged. This identified six PECLs (0.6 %, 95 % CI: 0.2-1.3) including two pharyngeal squamous cell lesions (0.2 %) demonstrating high-grade dysplasia and carcinoma in situ (CIS) and four premalignant glottic lesions (0.4 %) demonstrating low-grade dysplasia and CIS. Conclusion In the routine setting of a gastrointestinal endoscopy practice precancerous and early cancerous lesions of the oropharynx, hypopharynx, and larynx are rare (< 1 %) but can be detected with a structured assessment of this region during routine upper gastrointestinal endoscopy.

Outcomes of Treating Early Glottic Neoplasms With a Potassium Titanyl Phosphate Laser.

OBJECTIVES:: The aim of this study was to assess the outcome of treating glottic dysplasia and early squamous cell carcinoma (SCC) with potassium titanyl phosphate (KTP) photoangiolytic laser ablation. METHODS:: Patient demographics, comorbidities, and tumor characteristics were recorded. Perceptual, patient-reported, and objective voice outcomes were assessed. Use of treatment modalities in addition to the KTP laser, development of locoregional or metastatic SCC, and overall survival were recorded. RESULTS:: There were 23 patients with glottic dysplasia and 18 patients with glottic SCC. Mean age at treatment was 69 years. Most patients (95%) were male. Posttreatment fundamental frequency fell from 132 ± 35 to 116 ± 24 Hz ( P = .03). Overall, 61% of patients achieved a normal voice. There was a learning-curve, and most treatment failures occurred in the first half of the series. Five-year KTP-only disease-control rates were 87.1% and 53.5% for dysplasia and malignancy, respectively. Five-year overall survival was 56%, with no laryngectomies or deaths due to SCC. CONCLUSIONS:: Ablating dysplasia and early glottic cancer using a KTP laser is a viable treatment option. It has a learning curve and a failure rate but, in this series, no ultimate loss of oncologic control. Its introduction into clinical practice should be managed carefully in the context of multidisciplinary cancer care. LEVEL OF EVIDENCE:: 4.

Bilateral In-Office Injection Laryngoplasty as an Adjunctive Treatment for Recalcitrant Puberphonia: A Case Report and Review of the Literature.

Puberphonia or mutational falsetto is a voice disorder seen in male adolescents. It is defined as the failure of the voice to change from the high pitch of early childhood to the low pitch of adulthood. Puberphonia is usually treated with voice therapy (with or without adjunctive laryngeal manipulation) and psychological counseling. Small series of surgical treatments have also been described. We present the first report of bilateral in-office injection laryngoplasty with hyaluronic acid with voice therapy to treat a 22-year-old male with puberphonia that had not responded to voice therapy. The subject presented with a speaking fundamental frequency of 152 Hz, which decreased to 102 Hz immediately after bilateral injection laryngoplasty and has been maintained at 108 Hz after 24 months.

Optical coherence tomography-enhanced microlaryngoscopy: preliminary report of a noncontact optical coherence tomography system integrated with a surgical microscope.

OBJECTIVES: Optical coherence tomography (OCT) is a new imaging modality that uses near-infrared light to produce cross-sectional images of tissue with a resolution approaching that of light microscopy. We have previously reported use of OCT imaging of the vocal folds (VFs) during direct laryngoscopy with a probe held in contact or near-contact with the VFs. This aim of this study was to develop and evaluate a novel OCT system integrated with a surgical microscope to allow hands-free OCT imaging of the VFs, which could be performed simultaneously with microscopic visualization. METHODS: We performed a prospective evaluation of a new method of acquiring OCT images of the VFs. RESULTS: An OCT system was successfully integrated with a surgical microscope to permit noncontact OCT imaging of the VFs of 10 patients. With this novel device we were able to identify VF epithelium and lamina propria; however, the resolution was reduced compared to that achieved with the standard contact or near-contact OCT. CONCLUSIONS: Optical coherence tomography is able to produce high-resolution images of vocal fold mucosa to a maximum depth of 1.6 mm. It may be used in the diagnosis of VF lesions, particularly early squamous cell carcinoma, in which OCT can show disruption of the basement membrane. Mounting the OCT device directly onto the operating microscope allows hands-free noncontact OCT imaging and simultaneous conventional microscopic visualization of the VFs. However, the lateral resolution of the OCT microscope system is 50 microm, in contrast to the conventional handheld probe system (10 microm). Although such images at this resolution are still useful clinically, improved resolution would enhance the system's performance, potentially enabling real-time OCT-guided microsurgery of the larynx.

Long-term botulinum toxin dose consistency for treatment of adductor spasmodic dysphonia.

OBJECTIVES: Botulinum toxin (BTX) injection is currently the primary and most common treatment for adductor spasmodic dysphonia (ADSD). A variety of injection strategies and dosage regimens have been described. This study reports on our experience with the dosage schedule and dosing consistency of BTX for the treatment of ADSD. METHODS: We retrospectively reviewed our laryngeal BTX database for the period 1991 to 2005. Our strict inclusion requirements limited our selection to 13 patients who had received a minimum of 6 injections (average, 11.5; range, 6 to 19) of BTX for ADSD. RESULTS: The average total dose of BTX to the larynx for each treatment episode was 3.9 units (range, 1.5 to 7.5). The total dose administered tended to trend downward among patients who began treatment from 1991 to 1998, indicating that the initial dose (usually 2.5 units per side) may have been high. Those patients who began from 1999 onward had a more stable dose, indicating that the initial dose (usually 1.5 units per side) was more suitable. The subjects underwent an average of 2.2 injections (range, 1 to 5) before reaching their optimal BTX dose. The total number of treatments performed in this group of patients was 150, of which 145 were successful (96.7%). CONCLUSIONS: The BTX dose for the optimal treatment of ADSD usually remains consistent over time, as does the treatment interval. An initial dose of 1.5 units per side or less appears to improve dosing stability, indicating that the initial dosing of 2.5 units per side in our study was often greater than required. The optimal BTX dose was usually ascertained by the second or third injection. In our patient population, the long-term dosing consistency of BTX confirmed that neither tachyphylaxis nor increasing sensitivity to BTX occurred during the course of treatment for ADSD.

Propofol lipemia mimicking chyle leak during neck dissection.

BACKGROUND: Propofol is an intravenous agent used in anesthesia. Lipemia is an uncommon adverse effect of propofol infusion. METHODS: A patient undergoing neck dissection for recurrent chordoma had intraoperative lipemia develop after prolonged propofol infusion. RESULTS: Lipemia gave blood in the surgical field a milky appearance resembling chyle, but no chyle leak was present. Lipemia was confirmed by drawing a sample of blood and leaving it to stand. Layering of the blood with a milky white upper layer was observed. Analysis of a second sample of blood revealed a high lipemic index. CONCLUSIONS: Lipemia is an uncommon adverse effect of propofol infusion, which may give blood a milky appearance and be confused for a chyle leak in a dissected neck. Identification of lipemia is also important because there is a risk of acute pancreatitis, and it may represent the early stage of propofol infusion syndrome.

Cartilage regeneration in the rabbit nasal septum.

OBJECTIVE: Rhinoplasty frequently includes harvesting of nasal septal cartilage. The objective of this prospective basic investigation is to determine whether cartilage can regenerate after submucosal resection (SMR) of the nasal septum in the rabbit. Neocartilage formation has not heretofore been described in this model. METHODS: By lateral rhinotomy, SMR was performed on 17 rabbits followed by reapproximation of the perichondrium. After 7 months, septi were fixed, sectioned, and examined histologically. Findings were photographed and data tabulated according to location and extent. RESULTS: Sites of matrix-secreting isogenous chondrocyte islands were identified between the perichondrial flaps of every animal, principally in the anterior inferior septum. The width of the islands averaged 190 microm, and the mean neocartilage height was found to be 840 microm. The newly formed cartilage consisted of chondrocytes within chondrons and was comparable in shape and structure to native septal cartilage. CONCLUSIONS: After SMR, rabbit cartilage tissue can regenerate and form matrix within the potential space created by surgery. The surrounding stem cell-rich perichondrium may be the site of origin for these chondrocytes. These findings suggest that after SMR of the human nasal septum, it may be possible for new cartilage tissue to develop provided the mucosa is well approximated. This biologic effect may be enhanced by insertion of cytokine-rich tissue scaffolds that exploit the native ability of septal perichondrium to regenerate and repair cartilage tissue.

Optical coherence tomography of laryngeal cancer.

OBJECTIVES: Optical coherence tomography (OCT) is a high-resolution optical imaging technique that produces cross-sectional images of living tissues using light in a manner similar to ultrasound. This prospective study evaluated the ability of OCT to identify the characteristics of laryngeal cancer and measure changes in the basement membrane, tissue microstructure, and the transition zone at the edge of tumors. MATERIALS AND METHODS: One hundred thirty-three patients underwent OCT examination during surgical endoscopy of the head and neck. Twenty-two patients with laryngeal cancer or a history of laryngeal cancer were imaged with a fiberoptic OCT system. Tumor and adjacent transition zones were imaged along with uninvolved subsites. OCT images were correlated with histopathology. RESULTS: Twenty-six OCT examinations were performed in 22 patients. Basement membrane disruption was seen in 18 subjects, all of whom had histology showing classic features of cancer. A transition zone to uninvolved epithelium at the tumor periphery was also often observed. In six studies, benign or premalignant processes were histologically confirmed. In three thin, superficial lesions, an intact basement membrane was observed. The basement membrane could not be identified in three other bulky exophytic, premalignant lesions, primarily because of increased superficial signal backscattering observed in pathologic tissues. CONCLUSIONS: OCT clearly identifies basement membrane violation from laryngeal cancer and can identify transition zones at the cancer margin. In bulky exophytic lesions, OCT signal may not penetrate deeply enough to show the basement membrane, but for many suspicious lesions that require exclusion of cancer, OCT shows potential for assisting in diagnostic assessment.

Endovascular treatment of epistaxis.

AIM: Embolization of external carotid vessels in the treatment of intractable epistaxis is not well documented in Australasia. The aim of the present retrospective study was to audit our experience with the technique, and to compare it with other centres. METHODS: Retrospective review. RESULTS: Twenty-nine embolizations were performed in 28 patients. Embolization was successful in 24 out of 28 patients (86%). Three patients required ligation of the anterior ethmoidal arteries, one of whom subsequently underwent successful repeat embolization. There were minor complications in 6/29 procedures (21%), and no major complications. CONCLUSION: Our outcomes compare favourably with those of larger centres. Embolization is an effective tool in the management of patients with intractable epistaxis.