Vocal outcomes after laser resection of early-stage glottic cancer with adjuvant cryotherapy.

OBJECTIVE: To evaluate the vocal outcomes of patients with early-stage glottic carcinoma undergoing laser resection with adjuvant cryoablative therapy. DESIGN: Retrospective review. SETTING: Tertiary care center. Patients Twenty patients with early-stage glottic carcinoma. Intervention Treatment of early-stage glottic carcinoma with endoscopic carbon dioxide laser resection in conjunction with cryoablation. MAIN OUTCOME MEASURES: Disease-free survival and subjective and objective measures of posttreatment voice quality, based on serial videolaryngostroboscopy. RESULTS: There was 1 local treatment failure, with an overall mean disease-free follow-up of 32.6 months (range, 3-93 months). Carbon dioxide laser resection and cryoablative therapy were associated with a significant improvement in subjective voice quality (P<.001). Long-term dysphonia was uniformly improved vis-à-vis the pretreatment condition, even among patients with the most advanced disease undergoing the widest resections. Posttreatment web formation was not noted among 4 patients with anterior commissure involvement. CONCLUSIONS: Endoscopic laser laryngeal surgery performed in conjunction with cryotherapy for early-stage glottic carcinoma yielded excellent primary site control, while improving subjective and objective measures of voice quality. Combined laser surgery and cryotherapy is a possible alternative to radiotherapy for selected patients with early-stage glottic carcinoma who desire curative therapy, while optimizing vocal outcomes.

Surgical fundoplication in laryngopharyngeal reflux unresponsive to aggressive acid suppression: a controlled study.

BACKGROUND & AIMS: In patients with persistent laryngeal symptoms despite aggressive proton pump inhibitor therapy, gastroesophageal reflux disease (GERD) continues to be implicated. The role of surgical fundoplication as the definitive therapy for these patients is uncertain. METHODS: In this prospective concurrent controlled study, 72 patients with suspected GERD-related laryngeal symptoms received aggressive acid-suppressive therapy. Four-month symptomatic nonresponders (<50% improvement) with continued laryngeal inflammation and normalized esophageal acid exposure were offered laparoscopic Nissen fundoplication. The primary outcome was symptom improvement/resolution at 1 year after surgery. RESULTS: Twenty-five of 72 (35%) patients remained unresponsive after 4 months of acid-suppressive therapy. Ten patients (40%) underwent surgical fundoplication (median age, 54 y; men, 4) and 15 patients (60%) continued medical therapy (median age, 52; men, 4). The most common laryngeal symptoms were sore throat, hoarseness, and cough. pH studies at 3 and 12 months were normal in all patients after fundoplication (median % time pH < 4, .0% and .3%; respectively). One of 10 (10%) patients in the surgery group reported improvement of laryngeal symptoms at 1 year compared with 1 of 15 in the control group (6.7%) (P = 1.0). Treatment of causes other than GERD improved symptoms in an additional 2 of 10 (20%) patients in the surgical group, and 10 of 15 (66%) patients in the nonsurgical cohort. CONCLUSIONS: Surgical fundoplication does not improve laryngeal symptoms reliably in patients unresponsive to aggressive proton pump inhibitor therapy. The argument of low volume or intermittent reflux as the cause of persistent laryngeal symptoms needs to be replaced with evaluation and therapy for other potential non-GERD causes.

Chronic laryngitis associated with gastroesophageal reflux: prospective assessment of differences in practice patterns between gastroenterologists and ENT physicians.

OBJECTIVES: Ear, nose, and throat (ENT) physicians often diagnose gastroesophageal reflux disease (GERD)-related laryngitis on the basis of symptoms and laryngeal signs; and may refer patients to gastroenterologists who contend that many such patients do not have reflux. Because of this dichotomy we designed this study to assess the practice pattern differences among ENT physicians and gastroenterologists in relation to the diagnosis and treatment of patients with GERD-related laryngitis. METHODS: Separate surveys were specifically designed for ENT physicians and gastroenterologists to assess the following: the percentage of patients diagnosed with GERD-related laryngitis, dose and duration of therapy, treatment response, and other diagnostic options in nonresponders. A total of 2000 surveys were mailed randomly to members of both the American Academy of Otolaryngology Head and Neck Surgery and the American Gastroenterological Association. RESULTS: Of the total 4,000 surveys sent, 782 (39%) ENT physicians and 565 (28%) gastroenterologists responded. Most respondents (both specialties) were private practitioners (82% and 74%, respectively). From the ENT survey, the diagnosis was most commonly suspected based on the following symptoms: globus = throat clearing > cough > hoarseness. The most useful signs were laryngeal erythema and edema reported by 70% of respondents. Seventy-four percent of ENT physicians reported they made the diagnosis more on symptoms than on laryngeal signs, and initiated therapy most often with proton pump inhibitor (PPI) once daily for 2 months. Gastroenterologists were divided on pre-therapy testing, 50% reporting testing with esophagogastro-duodenoscopy followed by pH monitoring (distal > proximal) prior to therapy, while the remaining 50% reported treating empirically with PPI twice daily for 3 months. Seventy percent of gastroenterologists reported treatment response of less than 60%, while 62% of ENT physicians reported response rate of greater than 60% (p < 0.05). CONCLUSIONS: (1) Globus and throat clearing were considered the most useful symptoms in diagnosing GERD-related laryngitis, while laryngeal erythema and edema were considered the most useful signs for diagnosis and treatment of this condition by ENT physicians. However, these symptoms and signs may represent the least specific markers for reflux. (2) Many gastroenterologists perform pre-therapy testing which has low sensitivity in GERD-related laryngitis. (3) There is a dichotomy in treatment dose, duration, and perceived patient response to therapy between the two specialists. (4) Our study highlights a need for cross communication and education between these two disciplines in understanding and treating GERD-related laryngitis better.

Correlation between symptoms and laryngeal signs in laryngopharyngeal reflux.

OBJECTIVE/HYPOTHESIS: Laryngopharyngeal reflux (LPR) is diagnosed by the presence of laryngeal signs and symptoms. Some studies have noted that signs and symptoms may be nonspecific and may have poor correlation. However, many such studies were either observational or had short-term follow-up. Therefore, we conducted subgroup analysis of a prospective concurrent controlled study with a 1 year follow-up to study the correlation between signs and symptoms. STUDY DESIGN: Prospective study. METHODS: Seventy-two patients with suspected gastroesophageal reflux disease related laryngeal symptoms/signs received a 4 month trial of aggressive acid-suppressive therapy. Four month symptomatic nonresponders (<50% improvement) with continued laryngeal inflammation and normalized esophageal acid exposure were then offered laparoscopic Nissen fundoplication. The primary outcome was laryngeal symptom-sign correlation at 1 year postsurgery. RESULTS: Twenty-five of 72 (35%) patients remained unresponsive after 4 months of aggressive acid suppressive therapy. Ten (40%) patients agreed to undergo surgical fundoplication (mean age = 50, male = 4). The most common laryngeal symptoms were sore throat (40%), hoarseness (30%), and cough (20%), whereas the most common signs were medial arytenoid wall erythema/edema (60%), interarytenoid erythema (50%), and arytenoid complex erythema/edema (50%). At 1 year postfundoplication, laryngeal symptoms improved in only 1 of 10 (10%) patient, whereas signs improved in 8 of 10 (80%) patients. CONCLUSIONS: There appears to be poor correlation between signs and symptoms of LPR, particularly when monitoring therapeutic outcomes. In patients unresponsive to twice-daily proton-pump inhibitor therapy for 4 months, further aggressive therapy is unlikely to bring additional symptomatic benefit.

Prevalence of laryngeal irritation signs associated with reflux in asymptomatic volunteers: impact of endoscopic technique (rigid vs. flexible laryngoscope).

OBJECTIVES: The objectives of this study were to 1) determine the prevalence of ENT findings in the normal asymptomatic population and 2) to compare findings between flexible and rigid laryngoscopes in an attempt to increase specificity of diagnosis of reflux in endoscopic laryngeal examinations. STUDY DESIGN: Prospective study. METHODS: Fifty-two nonsmoker volunteers (24 male, 28 female), mean age of 42.7 years, with no history of ENT abnormalities or gastroesophageal reflux disease, underwent both rigid and flexible videolaryngologic examinations with a digital endoscopic unit. A group of three expert judges reviewed the oral and transnasal examinations blindly and independently for physical signs of irritation/inflammation commonly associated with reflux. RESULTS: Atleast one sign of tissue irritation was detected in 93% and 83% of the population when using a flexible and a rigid laryngoscope, respectively. Results showed a high incidence of posterior commissure bar (53.2% and 51.9%), arytenoid complex edema/erythema (76.3% and 53.2%), and pseudosulcus (37.2% and 7.7%). Most signs were more frequently detected on flexible transasal examinations than with rigid transoral examinations: posterior pharyngeal wall (<0.01), interarytenoid irritation (<0.01), arytenoids complex irritation (<0.01), ventricular obliteration (<0.01), and pseudosulcus (<0.01). CONCLUSIONS: Several signs of posterior laryngeal irritation (e.g., interarytenoid bar, erythema of the medial wall of the arytenoids), which are generally considered to be signs of laryngopharyngeal reflux, are present in a high percentage of nonsymptomatic individuals, raising question about their diagnostic specificity. In addition, these signs were more often detected with flexible than with rigid laryngoscopes, suggesting that flexible laryngoscopy is more sensitive but less specific in identifying laryngeal tissue irritation.

Long-term effects of micronized Alloderm injection for unilateral vocal fold paralysis.

OBJECTIVES: Micronized Alloderm (Cymetra) is a relatively new product used for vocal fold augmentation. Previous studies evaluating possible long-term effectiveness of this product have shown mixed results. The objective of this present study is to reassess possible long-term results of Cymetra injection laryngoplasty in patients with unilateral true vocal fold paralysis. STUDY DESIGN: Retrospective review of patients with unilateral true vocal fold paralysis who received Cymetra injection laryngoplasty between March 2001 and March 2004. METHODS: Preoperative voice samples and videostroboscopic findings were compared with the most recently available postoperative data to assess efficacy of the procedure. A panel of voice experts analyzed both vocal and vibratory function in these samples. In addition, pre- and postoperative voice-related quality of life measures and patients' self-ratings of voice outcomes were compared. RESULTS: Twenty patients (7 male, 13 female; 14 with left-sided paralysis, 6 with right-sided paralysis) were identified in the study population. Cymetra injection was performed an average of 45.1 months after onset of vocal fold paralysis (range -216 months), and average follow-up postinjection was 11.2 (range -35) months. Comparing pre- and postoperative measures, voice quality (P < .0001), glottal closure (P < .0001), and degree of vocal fold bowing (P < .0001) were all improved by injection. Quality of life measures and patients' self-perceptions of vocal quality were also improved (P < .01). Fifteen (75%) patients showed long-lasting results. Eight patients showed improvement for more than 12 months after injection. CONCLUSION: Cymetra injection laryngoplasty offers improved vocal and vibratory function to patients with unilateral true vocal fold paralysis. The benefits of such medialization may be longer lasting than previously reported, and further long-term study is warranted.

Laryngopharyngeal reflux: prospective cohort study evaluating optimal dose of proton-pump inhibitor therapy and pretherapy predictors of response.

PURPOSE: Laryngopharyngeal reflux (LPR) is frequently treated with empiric proton-pump inhibitors (PPI), but the optimal dosing and duration is unknown. We performed an open label prospective cohort study to evaluate whether twice-daily (BID) PPI is more effective than once-daily (QD) PPI for the treatment of LPR. METHODS: Patients diagnosed with LPR based on ear, nose, and throat (ENT) symptoms and laryngoscopy findings were enrolled. Questionnaire assessed demographics, ENT symptoms, symptom severity, and exposure to other potential laryngeal irritants. Esophageal manometry, ambulatory 24-hour pH monitoring, and upper gastrointestinal endoscopy were performed before initiation of therapy. Patients were consecutively assigned to three groups: BID PPI (lansoprazole 30 mg BID), BID PPI + H2 receptor antagonist (H2RA; omeprazole 20 mg BID + ranitidine 300 mg each night), or QD PPI (esomeprazole 40 mg QD). Greater than 50% primary symptom improvement from baseline defined symptom response. At 2 month follow-up, the same PPI dose was continued for responders, and PPIs were doubled for nonresponders for an additional 2 months. Repeat symptom assessment and laryngoscopy performed at 4 month follow-up. RESULTS: Eighty-five patients were enrolled (median age 49 years, interquartile range 44.0 - 65.0; 76% white; 34% male). Treatment groups were BID PPI for 30 patients, BID PPI + H2RA for 30 patients, and QD PPI for 25 patients. RESPONSE TO THERAPY: At 2 months, BID response occurred among 15 of 30 (50%) patients, BID + H2RA for 15 of 30 (50%), and QD for 7 of 25 (28%) (P = .03). No statistical difference found between the two BID PPI groups with and without H2RA. Among the QD group nonresponders, 7 of 13 (54%) achieved symptom response with additional 2 months of BID dosing. At 4 month follow-up, an additional 22% of responses were obtained from the two BID groups (43/60, 72%). The overall response rate for all three groups was 70% (54/77). PREDICTORS OF OUTCOME: Pretherapy interarytenoid mucosa and true vocal folds abnormalities were associated with twofold increase in symptom response (odds ratio 1.99 and 1.96, respectively, P = .017). CONCLUSION: BID PPI appears to be more effective than QD PPI in achieving clinical symptom response in suspected LPR. More response was achieved at 4 months compared with 2 months. Therefore, aggressive acid suppression with BID PPI for at least 4 months is warranted for treatment of LPR.

Safety and efficacy of powered intracapsular tonsillectomy in children: a multi-center retrospective case series.

OBJECTIVE: To determine the efficacy of powered intracapsular tonsillectomy (PIT, e.g. regrowth rate) in children who underwent PIT at three different institutions. We also wanted to determine if the trend to greater safety through reduced bleeding and re-admission for dehydration, noted in our initial reports, would become statistically significant in a larger sample. STUDY DESIGN AND SETTING: Multi-center retrospective case series. PATIENTS AND METHODS: We retrospectively reviewed all charts' of children who underwent PIT at three different institutions: the Children's Hospital at the Cleveland Clinic, Alfred I. DuPont Hospital for Children, and the New York Otolaryngology Institute. For comparison, we reviewed the outpatient and inpatient records of all children who underwent conventional tonsillectomy performed by the same surgeons at the Children's Hospital at the Cleveland Clinic and Alfred I. DuPont Hospital for Children during the same period. No comparison group was available for the New York Otolaryngology Institute group. Three outcome measures were recorded: regrowth, bleeding and re-admission for dehydration rates. All statistical analyses were performed using SAS, and P < 0.05 was considered statistically significant. RESULTS: We identified 870 children that underwent PIT at three different institutions. In addition, 1121 children underwent conventional tonsillectomy at two of the three institutions. The mean follow-up for the PIT group was 1.2 years (range, 0.1-2.6 years) and 1.5 years (range, 0.1-3.0 years) for the conventional tonsillectomy group. The incidence of and 95% CI for the outcome measures were as follows regrowth 0.5% (0%, 1.4%), delayed post-operative bleeding 0.7% (0%, 1.9%), re-admission for dehydration 1.3% (0.05%, 2.6%), and overall major complications 0.46% (0.009%, 0.9%). When comparing conventional tonsillectomy to PIT, the bleeding rate, re-admission for dehydration, and the overall incidence of major complications were significantly lower in the PIT group (P = 0.001, P = 0.002, and P < 0.001, respectively). CONCLUSION: PIT is a safe and effective technique in the management of obstructive sleep disordered breathing in children. PIT has the advantages of decreased pain, dehydration and post-operative bleeding, and with a mean follow-up of 1.2 years, a low incidence of tonsillar regrowth thus far.

Intracapsular tonsillar reduction (partial tonsillectomy): reviving a historical procedure for obstructive sleep disordered breathing in children.

OBJECTIVE: We sought to reintroduce a historical procedure-intracapsular tonsillar reduction (partial tonsillectomy or tonsillotomy)-for tonsillar hypertrophy causing obstructive sleep disordered breathing (OSDB) in children, as well as to determine whether partial tonsillectomy, compared with conventional (total) tonsillectomy when performed by more than one surgeon, is equally effective for the relief of OSDB while resulting in less pain and more rapid recovery. STUDY DESIGN: We conducted a retrospective case series at a tertiary children's hospital. The charts of children who underwent partial tonsillectomy and total tonsillectomy (1998 through 2002) for postoperative complications were reviewed. The caregivers were surveyed to assess postoperative pain, rapidity of recovery, and effectiveness of surgery for relieving symptoms of OSDB. RESULTS: Two hundred forty-three children underwent partial tonsillectomy and 107 children underwent total tonsillectomy. There were no significant differences in immediate and delayed complications between the groups. Both operations were equally effective in relieving OSDB. Children who had partial tonsillectomy had significantly less postoperative pain and significantly more rapid recovery. CONCLUSION: Intracapsular tonsillar reduction with an endoscopic microdebrider relieves OSDB as effectively as conventional tonsillectomy, but results in less postoperative pain and a more rapid recovery.

Laryngeal signs and symptoms and gastroesophageal reflux disease (GERD): a critical assessment of cause and effect association.

Gastroesophageal reflux disease (GERD) has been associated increasingly with ear, nose, and throat (ENT) signs and symptoms. However, the cause and effect relationship between these two clinical entities are far from established. Many patients diagnosed initially with GERD as the cause of laryngeal signs do not symptomatically or laryngoscopically respond to aggressive acid suppression and do not have abnormal esophageal acid exposure by pH monitoring. This has resulted in frustration on the part of both gastroenterologists and ENT physicians and confusion on the part of patients. In this article we discuss the reasons for this controversy and highlight the recent data attempting to clarify this complex area.

The prevalence of hypopharynx findings associated with gastroesophageal reflux in normal volunteers.

Routine laryngeal examination of patients with otolaryngologic complaints often reveals findings thought to result from gastroesophageal reflux. The direct association between these mucosal findings and uncontrolled reflux is not well established. To begin exploring the specificity of tissue signs, 105 normal, healthy, adult volunteers were examined by routine video fiber-optic endoscopy for the presence of findings attributed to reflux disease. Medical conditions, lifestyle factors, and ENT complaints were surveyed to reveal potential airway irritants, while the study design attempted to eliminate silent reflux. The majority of subjects (86%) had findings associated with reflux and certain signs reached a prevalence of 70%. Prevalence was not affected by ENT complaint, smoking, alcohol, or asthma. Intraexaminer and interexaminer agreement information is provided. The traditional attribution of hypopharynx irritation signs to reflux is challenged; the need for improved diagnostic specificity is highlighted.