Comparison of transnasal esophagoscopy and sedated esophagogastroduodenoscopy in the assessment of laryngopharyngeal reflux.

OBJECTIVE: Transnasal esophagoscopy (TNE) in the awake patient and esophagogastroduodenoscopy (EGD) in sedation are both used in the assessment of laryngopharyngeal reflux (LPR). The objective of this study was to compare these two endoscopic methods in contributing to the diagnosis of LPR. METHODS: This study included 54 patients presenting with signs and symptoms suspicious for LPR, which were examined both by TNE and EGD. The contribution of each method to the diagnosis of LPR was evaluated separately and then compared with each other. RESULTS: In detecting LPR, TNE showed a significant higher sensitivity (94% vs. 60%) and accuracy (93% vs. 59%) than EGD, but their specificity was equal (50% each). The most common pathologic findings in both methods were a hiatal hernia (70% vs. 48%) and gaping cardia (69% vs. 24%), followed by peptic esophagitis (41% vs. 24%). CONCLUSION: The value of EGD is limited in the workup of LPR, as sedation tends to mask the subtle findings in this kind of reflux disease.

Value of Transnasal Esophagoscopy in the Workup of Laryngo-Pharyngeal Reflux.

BACKGROUND: Laryngopharyngeal reflux (LPR) can display a variety of symptoms, and upper endoscopy is occasionally used for its investigation. The aim of the present study was to determine the value of transnasal esophagoscopy (TNE) in the workup of LPR. METHODS: In 200 consecutive patients with suspected LPR, reflux symptom index (RSI), reflux finding score (RFS), oropharyngeal pH-monitoring (PHM) and transnasal esophagoscopy (TNE) were carried out and rated according to the Horvath Score. RESULTS: In the investigation of LPR, TNE showed a sensitivity, specificity and accuracy of 96%, 85% and 95%, respectively. The most common pathologic TNE findings in LPR patients were an insufficient cardia, hiatal hernia, lymphoid follicles and visible reflux. CONCLUSIONS: TNE is a supportive method in the workup of LPR, which can display the underlying pathology and directly affect therapeutic decisions.

Evaluation of Oropharyngeal pH-Monitoring in the Assessment of Laryngopharyngeal Reflux.

BACKGROUND: Laryngopharyngeal reflux (LPR) is a prevalent disorder. The aim of the present retrospective cohort study was to evaluate oropharyngeal pH-monitoring using a novel scoring system for LPR. METHODS: In a total of 180 consecutive patients with possible LPR, reflux symptom index (RSI), reflux finding score (RFS), oropharyngeal pH-monitoring and transnasal esophagoscopy were carried out for further investigation. RESULTS: In our series, 99 (55%) patients had severe LPR, 29 (16%) cases presented with moderate and 23 (13%) with mild severity, 9 (5%) subjects revealed neutral values, and 7 (4%) individuals were alkaline, while 13 (7%) patients had no LPR. In detecting LPR, the sensitivity, specificity and accuracy of oropharyngeal pH-monitoring was 95%, 93% and 94%, respectively. CONCLUSION: Oropharyngeal pH-monitoring is a reliable tool in the assessment of LPR, but the pH graphs have to be precisely analyzed and interpreted in context with other validated diagnostic tests.

A novel scoring system for evaluating laryngopharyngeal reflux.

OBJECTIVE: Although laryngopharyngeal reflux (LPR) is a common condition in daily practice, no gold standard exists for its diagnosis. The objective of this study was to establish a simple and reliable scoring system for evaluating LPR consisting of both subjective and objective criteria. METHODS: This retrospective study includes 124 patients presenting with symptoms of LPR. In all patients, reflux symptom index (RSI), reflux finding score (RFS), oropharyngeal pH monitoring (PHM) and transnasal oesophagoscopy (TNE) were performed and rated in a special scoring system. RESULTS: A Horvath Score of 4-5 for severe LPR was found in 76 patients (61%), a score of 2-3 for non-severe LPR in 38 patients (31%) and a score of 0-1 for non-existing LPR in 10 patients (8%) by combining the 4 validated diagnostic methods. CONCLUSION: The proposed scoring system qualifies as a simple and reliable tool for evaluating LPR in daily practice, directly impacting patient management.

Evaluation of ultrasound and fine-needle aspiration in the assessment of head and neck lesions.

PURPOSE: Neck masses of uncertain character need further investigation through imaging and tissue sampling. This is the most extensive study in the literature of clinician-operated ultrasound and fine-needle aspiration (US + FNA) of the head and neck with histological verification, itemized into organ system. The purpose of the present study was to comprehensively evaluate the combination of US + FNA in the assessment of various kinds of head and neck lesions in the hand of the clinician in one single study. METHODS: A total of 408 histologically verified head and neck lesions in 376 consecutive patients undergoing all three diagnostic steps (US, FNA, US + FNA) were included. Excisional biopsy or core-needle biopsy served as a gold standard. US and FNA were evaluated alone and in combination to distinguish between malignant and benign lesions as well as to establish an approximate and specific diagnosis. Each calculation was itemized by organ system. RESULTS: In detecting malignancy, US + FNA showed a significantly higher accuracy (97% vs 86% and 92%) than US and FNA alone. An approximate diagnosis was established in 93%, and a specific diagnosis in 88%, which was significantly better than that of US and FNA alone. CONCLUSION: US + FNA is suited for an efficient evaluation of head and neck masses. This combined method should be the first line of investigation in such lesions before any other imaging and/or sampling methods. While discrepancies in diagnostic findings potentially occur, the key is the interpretation of the package (US and cytologic findings, clinical information) made in one consultation by one clinician to proceed in proper decision making regarding an adequate treatment plan. Consequently US + FNA belong to the standard armamentarium of the otolaryngologist.

Salmonella enterica Subspecies diarizonae Maxillary Sinusitis in a Snake Handler: First Report.

In this study, we report the first case of reptile-associated maxillary sinusitis due to Salmonella enterica subspecies diarizonae in a snake handler and the third case of salmonella-associated sinusitis worldwide. The case highlights the potential of respiratory transmission and atypical salmonellosis presentations.

Endoscopic ultrasound of the larynx.

PURPOSE OF REVIEW: Endoscopic ultrasound (EUS) of the larynx is a vertical endoscopic imaging technique that gives further information about the extension of a lesion apart from normal white light endoscopy, chromoendoscopy, as well as palpation. It combines the advantages of ultrasound and endoscopy. Miniprobes or ultrasound endoscopes with 10-20 MHz are applied. The present review is focused on the use of EUS in the larynx especially in the management of laryngeal cancer. RECENT FINDINGS: At present, the larynx is routinely assessed by computed tomography and MRI. Alternatively, endoscopic endoluminal application of miniprobes enables the laryngologist to predict the exact extension of a laryngeal tumor larger than 3 mm during microlaryngoscopy before surgery is performed. Generally, tumors are hypoechoic and can easily be differentiated from the surrounding tissue especially in the hyperechoic supraglottic structures. Thyroid cartilage infiltration can be detected by the interruption of the hyperechoic inner perichondrium. SUMMARY: EUS proved to be a reliable imaging tool for the investigation of laryngeal lesions and can easily be used during microlaryngoscopy. It offers a higher image resolution compared with computed tomography and MRI and allows a complete sonographic evaluation of the larynx as well as its pathological changes, especially laryngeal cancer. VIDEO FILE LINK: http://links.lww.com/COOH/A19.

Value of narrow band imaging in the early diagnosis of laryngeal cancer.

BACKGROUND: Narrow band imaging (NBI) is a new imaging technique for the depiction of tumor-specific neoangiogenesis. The purpose of the present study was to assess the value of NBI in the early diagnosis of laryngeal cancer. METHODS: This prospective study includes 205 consecutive patients with a laryngeal lesion scheduled for microlaryngoscopy. NBI was immediately performed after white light endoscopy (WLE), whereas excisional biopsy was carried out for histologic verification of diagnosis. RESULTS: In identifying laryngeal cancer and its precursor lesions, NBI with WLE showed a significantly higher sensitivity (97% vs 79%) and accuracy (97% vs 90%) than WLE alone, but the specificity (96% vs 95%) was essentially equal in both methods. CONCLUSION: NBI qualifies for rapid detection and delineation of suspicious lesions. Additionally, this noninvasive method is also beneficial in a variety of benign lesions.

Diagnostic value of core needle biopsy and fine-needle aspiration in salivary gland lesions.

BACKGROUND: Core needle biopsy (CNB) has gained acceptance as a minimally invasive procedure in the head and neck. Nevertheless, many concerns arise regarding the value and safety of this method in the assessment of salivary gland lesions. METHODS: This prospective study comprises 111 patients with a salivary gland lesion. The results of ultrasound-guided CNB were compared with those of fine-needle aspiration (FNA) in the 103 histologically verified cases. RESULTS: CNB achieved a higher accuracy than FNA in identifying true neoplasms (98% vs 91%) and detecting malignancy (99% vs 87%), and was also superior to FNA providing a specific diagnosis (93% vs 74%). In both methods, no complications, such as bleeding, infection, nerve injury, or tumor-cell seeding, occurred. CONCLUSION: CNB is a simple, safe, and highly accurate procedure, which should be considered as an additional diagnostic tool in the assessment of salivary gland lesions. © 2015 Wiley Periodicals, Inc. Head Neck 38: E346-E352, 2016.

Evaluation of optical coherence tomography to discriminate lesions of the upper aerodigestive tract.

BACKGROUND: This study evaluated the capability of optical coherence tomography (OCT) to differentiate premalignant and early malignant lesions of the upper aerodigestive tract (UADT). METHODS: An OCT screening was performed in 52 healthy volunteers. Epithelial thicknesses on 38 OCT images and histopathological slides were correlated. One hundred primary lesions were rated via OCT concerning invasiveness by an "unblinded" investigator, then biopsied, and the results correlated. All OCT images were evaluated by 3 "blinded" investigators. Forty-eight images underwent retrospective image analysis. RESULTS: Screening showed large differences concerning epithelial thicknesses, but good correlation (κ = 0.63) between OCT and histopathological slides. In the unblinded evaluation, noninvasive and invasive lesions could be distinguished with a sensitivity of 88.9% and specificity of 89.0% whereas the blinded evaluations led to sensitivities of 100%, 66.7%, and 77.8% and specificities of 75.8%, 71.4%, and 70.3%. The difference of mean intraepithelial intensity reductions in dysplasias (38.7%) and hyperplasias (18.9%) was statistically significant. CONCLUSION: OCT complements visual inspection for differentiating UADT-lesions.

Clinical value of endosonography in the assessment of laryngeal cancer.

BACKGROUND: Endosonography has been successfully used in staging gastrointestinal cancer, but its value is as yet undetermined in laryngology. METHODS: This prospective study includes 84 patients undergoing microlaryngoscopy for laryngeal cancer. The results of endosonography were compared with those of CT and MRI in the 76 surgical cases. RESULTS: In the assessment of laryngal cancer, endosonography was superior to current imaging techniques, whereas CT and MRI showed similar results (accuracy of 89% vs 77% and 77%, respectively). CONCLUSIONS: This study confirms that endosonography is highly effective in staging laryngeal cancer. Therefore, the latter may constitute a complementary diagnostic tool in these tumors and additionally may assist in choosing an adequate treatment.

Measurement of epithelial thickness within the oral cavity using optical coherence tomography.

BACKGROUND: The purpose of the present study was to determine normal values of epithelial thickness within the oral cavity by using optical coherence tomography (OCT). METHODS: In a total of 143 healthy test persons, epithelial thickness of the oral mucosa was determined with the help of OCT separately for each side at 7 different locations. Special attention was directed to those sites having the highest incidence for the development of dysplasias and carcinomas. RESULTS: The epithelium demonstrated a varying thickness depending on its location within the oral cavity. The highest values were found in the region of the buccal mucosa (294 µm) and the hard palate (239 µm), whereas the thinnest epithelium was measured at the floor of the mouth (99 µm). CONCLUSION: Our data serve as reference values for detecting oral malignancy and determining the approximate grade of dysplasia. In this circumstance, a differentiated view of the different regions is important due to a variation in thickness of the epithelium within the oral cavity.

Role of ultrasound-guided core-needle biopsy in the assessment of head and neck lesions: a meta-analysis and systematic review of the literature.

BACKGROUND: Core-needle biopsy (CNB) has occasionally been used in the work-up of head and neck lesions. However, no systematic review of this simple, minimally invasive method has yet been performed. METHODS: A systematic review of the literature and meta-analysis of data extracted from 16 included studies were performed. A total of 1291 cervical lesions in 1267 patients were examined by CNB. This resulted in 1232 adequate samples, from which 554 were subsequently confirmed by excisional biopsy. RESULTS: CNB was able to identify true neoplasms and detect malignancy in head and neck lesions with an overall accuracy of 94% and 96%, respectively, even though there was a significant difference between the histologically verified and all adequate samples. CNB provided a correct specific diagnosis in 87% of cases without major complications and achieved a higher accuracy than that of fine-needle aspiration in detecting malignancy. CONCLUSIONS: This meta-analysis confirms that CNB is an excellent method in the assessment of salivary gland lesions and lymphadenopathies inclusive of malignant lymphoma, but it is not ideal for evaluating thyroid lesions.

Value of fluorescence endoscopy for the early diagnosis of laryngeal cancer and its precursor lesions.

BACKGROUND: Fluorescence endoscopy is used for the early detection and delineation of laryngeal cancer and its precursor lesions. No systematic review of these promising imaging techniques has yet been performed. METHODS: A systematic review of the published literature and meta-analysis of data extracted from 16 included studies were performed. A total of 1000 laryngeal lesions were examined by autofluorescence endoscopy (AFE), 318 mucosal changes by induced fluorescence endoscopy (IFE), and 679 laryngeal pathologies underwent normal white light endoscopy (WLE). RESULTS: In identifying precancerous and cancerous lesions of the larynx, sensitivity (91% vs 73%), specificity (84% vs 79%), and accuracy (88% vs 77%) of AFE were superior to WLE alone, whereas IFE showed an even higher sensitivity (95% vs 73%) at the expense of specificity (62% vs 79%). Therefore, AFE also achieved a higher specificity (84% vs 62%) and accuracy (88% vs 76%) than did IFE in detecting these kinds of lesions. However, the sensitivity (91% vs 95%) did not differ significantly between both methods. CONCLUSIONS: This meta-analysis confirms that fluorescence endoscopy is highly effective in the early diagnosis of laryngeal cancer and its precursor lesions. Thus, AFE can be used immediately without drug administration or possible side effects, whereas IFE is more suited for the detection of recurrent disease following initial surgery.

Optical and molecular techniques to identify tumor margins within the larynx.

Failure to remove tumor cells from the larynx significantly increases the risk of local recurrence following surgical excision. Healthy tissue must be preserved to optimize long-term vocal and swallowing function. It is essential to accurately distinguish between healthy mucosa, dysplasia, and invasive carcinoma. Optical and molecular examining technologies have been developed to improve tumor margin identification in vivo. We aimed to review the efficacy of these technologies. Published articles were identified using MEDLINE, EMBASE, and Cochrane central register of controlled trials (CENTRAL). Randomized clinical trials are required to establish the benefit to patients and cost to the health service of using 5-aminolevulinic acid (ALA)-induced fluorescent imaging, contact endoscopy, and optical coherence tomography (OCT). Furthermore, primary research is required to validate other techniques, such as confocal endomicroscopy and Raman spectroscopy, and to develop their clinical applications in the larynx.

Anatomical landmarks for endosonography of the larynx.

BACKGROUND: A precise knowledge of anatomy is necessary to allow a correct interpretation of sonographic images when investigating a particular region of the body. The objective of the present study was to establish anatomical landmarks for endosonography of the larynx. METHODS: In an experimental study, a total of 32 normal human larynges were examined endosonographically, and the classical landmarks were correlated to horizontal whole-organ sections of the scanned specimens. RESULTS: All laryngeal specimens showed a similar and reproducible sonoanatomy, which could be verified consistently on corresponding histological cross sections. Anatomical structures readily identified included the laryngeal framework, the vocal ligament, the vocal muscle, the ventricular fold, the preepiglottic and paraglottic space, and the epiglottis. CONCLUSIONS: Due to a reproducible sonoanatomy of the larynx, endosonography might be an interesting complementary tool in the diagnostic investigation of laryngeal lesions such as medium-sized tumors, cysts, laryngoceles, and stenoses.

Clinical value of optical coherence tomography in laryngology.

BACKGROUND: Optical coherence tomography (OCT) is a new, noninvasive imaging technology for the evaluation of superficial lesions. The objective of this study is to evaluate microlaryngoscopy in combination with OCT compared with microlaryngoscopy alone (ie, without OCT) in supplying a specific diagnosis, predicting invasive tumor growth and epithelial dysplasia in the larynx. METHODS: This was a prospective study including 217 laryngeal lesions in a total of 193 patients undergoing surgery. Intraoperative suspicion diagnosis gained by microlaryngoscopy with and without OCT was compared with conventional histopathology after excisional biopsy. RESULTS: Microlaryngoscopy with OCT supplied a specific diagnosis in 89% of cases, but in only 80% of cases with microlaryngoscopy alone. In particular, our results in malignant and benign pathologies were correct in 93% each, and the exact grade of dysplasia could be predicted in 71% of precancerous lesions. Microlaryngoscopy with OCT presented a higher sensitivity than microlaryngoscopy alone in predicting invasive tumor growth (93% vs 87%) and epithelial dysplasia (78% vs 66%), but the specificity and accuracy were comparable in both methods. CONCLUSIONS: OCT is a simple, rapid, and reliable aid in the diagnostic investigation and intraoperative monitoring of laryngeal disease.

Comparison of ultrasound-guided core-needle biopsy and fine-needle aspiration in the assessment of head and neck lesions.

BACKGROUND: Core-needle biopsy (CNB) has been successfully applied in other medical specialties, but its value is undetermined in otolaryngology. METHODS: This prospective study includes 75 patients, who were seen at our institution with a cervical mass. The results of CNB were compared with those of fine-needle aspiration (FNA) in the 68 histologically verified cases. RESULTS: CNB was superior to FNA providing a specific diagnosis (90% vs 66%) and achieved a higher accuracy in identifying true neoplasms (100% vs 93%) and detecting malignancy (99% vs 90%). However, the sensitivity and specificity did not differ significantly between both methods. CONCLUSIONS: Sonography and if necessary FNA should continue to be the investigation method of first choice for head and neck lesions. The main indication for CNB is after repeated failures of FNA to provide a diagnosis. It can also be performed in patients who are not surgical candidates or in those who refuse surgery.

Parotid gland metastasis from glioblastoma multiforme: a case report and review of the literature.

We describe a rare case of glioblastoma multiforme with extracranial metastasis to the right parotid gland. A 58-year-old man presented with a parotid tumor and facial paralysis 15 months after craniotomy and partial lobectomy for glioblastoma multiforme of the right temporal lobe. Diagnosis was confirmed by ultrasound guided core-needle biopsy. By this means, a second hospitalization with open surgical biopsy of the parotid gland under general anesthesia for diagnosis only was avoided in this obviously palliative situation. The possible mechanisms of metastasic spread in this highly aggressive tumor and its diagnostic investigation are discussed and compared with the literature.

Technique of optical coherence tomography of the larynx during microlaryngoscopy.

Optical coherence tomography (OCT) is a new, noninvasive imaging technology for the evaluation of superficial lesions. Because of a penetrating depth of a few millimeters and an ultrahigh tissue resolution, it qualifies for use in the larynx and might in the near future play an important role in the pre-, intra-, and postoperative investigation of early laryngeal cancer and its precursor lesions. Especially directed to otolaryngologists, this paper describes the technique of in vivo OCT imaging of the larynx in detail during microlaryngoscopy and supplies a number of personal hints.