Endoscopic resection of low grade, subglottic chondrosarcoma.

INTRODUCTION: This paper evaluates the feasibility of transoral, endoscopic resection of macroscopically localised, low grade, subglottic chondrosarcoma. METHOD: Retrospective case study including patients diagnosed with low grade, subglottic laryngeal chondrosarcoma. Tumours were resected endoscopically via direct laryngoscopy with microlaryngeal technique, under jet ventilation. The post-operative course, vocal fold function, airway patency and oncological results were evaluated. RESULTS: Two male patients aged 49 and 60 years underwent endoscopic, translaryngeal, en bloc resection of low grade chondrosarcoma of the cricoid cartilage. Extubation was performed immediately after surgery. Neither patient required tracheostomy or developed subglottic stenosis. No tumour recurrence was noted after an average follow up of 10.5 months. Voice quality was stable and dyspnoea improved. SUMMARY: Transoral, endoscopic resection of low grade, subglottic chondrosarcoma is a viable technique with good functional outcomes. Extensive resection of subglottic disease is possible, which may afford patients an alternative to total laryngectomy.

The association of laryngoceles with ventricular phonation.

Laryngoceles represent dilatations of the laryngeal saccule that may extend internally into the airway, or externally through the thyrohyoid membrane. Unilateral laryngoceles are uncommon clinical entities and bilateral laryngoceles are rare. Certain activities like glass blowing and playing a wind instrument are associated with laryngocele development, as is laryngeal carcinoma in the ventricular area. This case describes development of bilateral laryngoceles in a patient who chronically uses ventricular phonation during speech. The pathogenesis involves repetitive elevation of intralaryngeal pressure during false vocal cord approximation, exposing the ventricles to abnormally high air pressures. The pathogenesis in this case, as well as in laryngoceles associated with occupational or anatomic risk factors, is discussed.

Presentation of ALS to the otolaryngologist/head and neck surgeon: getting to the neurologist.

Patients with early symptoms of bulbar amyotrophic lateral sclerosis (ALS) are usually referred to the otolaryngologist without a diagnosis. Careful examination of the speech quality and a physical exam, including the vocal cords, should be undertaken. The emotional state of the patient should be considered, and a diagnosis should not be offered before a neurologic consultation has been obtained. Patients with late symptoms of bulbar ALS almost always present with both significant speech and swallowing abnormalities. Evaluation can be difficult because many abnormalities are found on examination. Advanced progression of symptoms is a clear indication for rapid referral to a neurologist if a diagnosis has not already been made. Supportive and symptomatic care should be offered to the patient immediately. The University of Washington Neuromuscular Clinic for Speech and Swallowing Disorders has seen 600 new neurologic patients since 1986, 211 of whom were ALS patients. The introduction of percutaneous gastrostomy has greatly changed the management of ALS patients, and 75 patients have undergone this procedure (32% because of inadequate swallowing, 68% for declining vital capacity). Medical management to improve symptoms may be indicated before surgery. Surgical options for patients with late salivary presentation are uncommon and include removal of the submaxillary glands, tracheostomy, and laryngeal or salivary diversion procedures. Laryngectomy or laryngeal diversion procedures are only very rarely indicated. Although tracheostomy usually interferes with swallowing and worsens aspiration, it may rarely be indicated in patients with late airway presentation for glottic narrowing or artificial respiratory support. Symptomatic management of patients with bulbar ALS is usually best undertaken by a multidisciplinary clinic that can provide a physically and psychologically supportive environment.

Laryngeal electromyographic findings in Charcot-Marie-Tooth disease type II.

Charcot-Marie-Tooth disease is a hereditary motor and sensory neuropathy that exhibits progressive muscular atrophy in the limbs, beginning with the lower extremities. It is now understood to be a heterogeneous group of disorders that can be differentiated both clinically and genetically. In Charcot-Marie-Tooth disease type II C, axonal neuropathy, diaphragm weakness, and vocal cord paralysis are described within kindreds. We used laryngeal electromyography to study a patient with this disorder. This technique has potential in the diagnosis of Charcot-Marie-Tooth disease type II.

Idiopathic bilateral vocal fold weakness.

OBJECTIVE: To describe an unrecognized clinical entity, idiopathic bilateral vocal fold weakness, and propose recommendations regarding the diagnosis and management of these cases. STUDY DESIGN: Retrospective, nonrandomized case study. METHODS: All cases of bilateral vocal fold weakness evaluated at the University of Washington Voice Disorders Clinic between 1991 to 1998 were reviewed. RESULTS: Four patients with bilateral laryngeal weakness were determined to have idiopathic bilateral vocal fold paresis following exhaustive workups, including videostroboscopy, bilateral laryngeal electromyography (EMG), neurological consultation, and other pertinent studies. CONCLUSIONS: Performing bilateral laryngeal EMG is an essential aspect of the workup of any laryngeal weakness case, particularly if the etiology is unknown on presentation. Idiopathic bilateral vocal fold weakness is an underrecognized but real clinical diagnosis that will become more familiar with the increasing utilization of laryngeal EMG in clinical situations.

Thyroid cartilage fracture repair in rabbits: comparing healing with wire and miniplate fixation.

OBJECTIVES: Evaluate cartilaginous healing in rabbits in response to surgically created thyroid cartilage fractures. Compare healing between laryngeal fracture repair techniques. STUDY DESIGN: Animal model. MATERIALS AND METHODS: Laryngectomy specimens were analyzed at 10 weeks, following paired wire fixation (n = 7) and miniplate fixation (n = 7) of thyroid cartilage fractures. RESULTS: Cartilaginous unions were present in all seven of the miniplated repairs, while fibrous unions were present in six of the wired repairs. The measure of distraction at the fracture site was significantly greater in the wired repairs compared with the plated repairs (P = .005). Furthermore, in five of seven miniplated repairs no distraction at the healed fracture site was present. CONCLUSIONS: The results demonstrate the ease, tolerability, and superiority of the miniplate fixation technique for the thyroid cartilage fractures, based on a rabbit model.

Dysphagia caused by neurologic deficits.

This article provides a brief review of the neurophysiology behind the normal swallow. The examination and work-up of a patient with dysphagia is then detailed. Finally, the major neurologic conditions associated with dysphagia are considered.

Homology requirements for targeting heterologous sequences during P-induced gap repair in Drosophila melanogaster.

The effect of homology on gene targeting was studied in the context of P-element-induced double-strand breaks at the white locus of Drosophila melanogaster. Double-strand breaks were made by excision of P-w(hd), a P-element insertion in the white gene. A nested set of repair templates was generated that contained the 8 kilobase (kb) yellow gene embedded within varying amounts of white gene sequence. Repair with unlimited homology was also analyzed. Files were scored phenotypically for conversion of the yellow gene to the white locus. Targeting of the yellow gene was abolished when all of the 3' homology was removed. Increases in template homology up to 51 base pairs (bp) did not significantly promote targeting. Maximum conversion was observed with a construct containing 493 bp of homology, without a significant increase in frequency when homology extended to the tips of the chromosome. These results demonstrate that the homology requirements for targeting a large heterologous insertion are quite different than those for a point mutation. Furthermore, heterologous insertions strongly affect the homology requirements for the conversion of distal point mutations. Several aberrant conversion tracts, which arose from templates that contained reduced homology, also were examined and characterized.

Intraoperative ketorolac and posttonsillectomy bleeding.

OBJECTIVE: To determine the occurrence of posttonsillectomy bleeding in patients who received intraoperative ketorolac tromethamine. DESIGN: Retrospective analysis. SETTING: Academic tertiary care center. PATIENTS: Three hundred eleven patients who underwent tonsillectomy in an 18-month period. MAIN OUTCOME MEASURE: Occurrence of bleeding complications in patients who received ketorolac during tonsillectomy. RESULTS: Fifty-eight of 311 patients who underwent tonsillectomy received intraoperative ketorolac with an overall postoperative bleeding rate of 17%. This high rate of bleeding complications compares with 4.4% in the remaining 253 patients who received traditional opioid analgesics. CONCLUSIONS: Until further controlled studies have been conducted, the use of ketorolac in patients undergoing tonsillectomy should be avoided because of the increased incidence of postoperative bleeding complications.

Gene targeting of a plasmid-borne sequence to a double-strand DNA break in Drosophila melanogaster.

We report an efficient and specific gene targeting method for transforming the germ line of Drosophila melanogaster. The targeting occurs during the repair of a double-strand DNA break that is induced at the white locus by the excision of a P transposable element. The break is repaired when homologous sequence is copied from a plasmid injected into the Drosophila embryo. The procedure efficiently integrates DNA into the targeted locus of the Drosophila genome. Heterologous sequence of up to 13 kbp in length can be inserted, permitting the intergration of entire genes into a common genomic site for further study.

Angiogenesis as a prognostic marker in early head and neck cancer.

Experimental evidence suggests that tumor growth beyond the earliest stages is dependent on angiogenesis, or neovascularization, and that angiogenesis may also promote metastasis. Recent clinical studies demonstrate that angiogenesis is a prognostic marker in breast, lung, and prostate cancer. To investigate whether tumor angiogenesis also correlates with metastasis and survival in early head and neck carcinoma, we quantified the microvascularity of 106 primary carcinomas prior to treatment and correlated the counts with eventual outcome after 3 to 15 years of follow-up. Microvessels were stained immunocytochemically for von Willebrand factor and then counted by light microscopy. Microvessels were counted per 200x and 400x fields, and their density was graded from 1 to 4, in the area of most intense neovascularization. We found that neither microvessel counts nor density grades correlated with metastatic disease, local recurrence, or survival in early head and neck carcinoma. These results are in contradistinction to those recently reported for other tumor sites.