Use of botulinum toxin in voice restoration after laryngectomy.

BACKGROUND: Following laryngectomy, a distinct population of patients fails to achieve successful tracheoesophageal voice. These patients' voices range from strained and effortful to none at all. Such patients may present with severe hypertonicity or spasm of the pharyngoesophageal segment. Botulinum toxin has been used to chemically denervate the pharyngeal musculature, and is an alternative to invasive surgical procedures. The aim of this article is to review the evidence for using botulinum toxin to achieve an improvement in post-laryngectomy voice. METHODS: A Medline literature review (1966 to January 2009) and a search of the Cochrane database were performed. Foreign language articles and those not pertaining to post-laryngectomy voice restoration were excluded. RESULTS: Nine articles reporting a total of 134 patients were identified. Although there were differences in the outcome measures used, objective improvement in voice production occurred in between 70 and 100 per cent of cases. CONCLUSION: Botulinum toxin can be used as a safe and cost-effective treatment in patients with confirmed pharyngoesophageal segment hypertonicity and/or spasm following laryngectomy, to obtain an improvement in voice quality.

Management of posterior epistaxis by endoscopic clipping of the sphenopalatine artery.

Posterior epistaxis poses a challenge to the otolaryngologist as the bleeding point itself cannot easily be identified. Haemostasis by conventional means is usually nasal packing and this results in repeated/persistent haemorrhage, morbidity and prolonged bed occupancy. In recent years the increased availability of rigid endoscopes and a better understanding of the anatomy of the nasal cavity have facilitated a direct approach to the sphenopalatine artery. Using a 0 degrees or 30 degrees rigid nasendoscope the sphenopalatine artery-the main blood supply to the nose-can be clearly identified and treated. Over the last 12 months we have employed endoscopic intranasal clipping of the said artery under a general anaesthetic to control persistent posterior nasal bleeding. Twelve patients have undergone 14 procedures within 48 h of failure of their conservative management. In all the epistaxis was controlled no complications were noted. The average follow-up period in our series was nine months. We believe that intranasal endoscopic clipping of the sphenopalatine artery is effective and less traumatic than either any other site of arterial ligation technique or repeated packing. In this series we employed only clipping of the artery and not diathermy/electrocautery to reduce the theoretical risk to adjacent structures

The management of dysphasia in skeletal hyperostosis.

Diffuse idiopathic skeletal hyperostosis (DISH), or Forestier's disease, is an ossifying condition frequently encountered in otolaryngology as it affects 12-28 per cent of the adult population. This form of hyperostosis can manifest clinically with dysphagia, food impaction, hoarseness, stridor, myelopathies and other neurological problems. Judicious management of severe dysphagia proves challenging. The failure of conservative care often leaves surgery as the only option. In this report an anterolateral transcervical surgical approach to the confluent osteophytes is discussed and the value of videofluoroscopic swallow highlighted.

Effect of caffeine on the vocal folds: a pilot study.

Caffeine is considered to be a dehydrating agent with detrimental effects on the quality of voice of persons ingesting it. This has led medical personnel dealing with voice disorders, especially in the case of professional voice users, to give advice against the use of caffeine. Yet this is an anecdotal truth as an extensive Medline literature search did not reveal any scientific evidence of caffeine being proven to have adverse effects on the vocal folds. We, therefore, initiated this pilot study to ascertain the connection between caffeine and voice quality on a laboratory basis. Two hundred and fifty mg of caffeine were provided to eight volunteers in tablet form, and blood levels along with laryngograph readings were recorded to document the changes produced. Analysing the irregularities of frequencies in a) free speech b) a reading passage and c) singing 'Happy Birthday', substantial changes were seen to authenticate the fact that caffeine does produce alterations in voice quality but these alterations have considerable intra-subject variability. A full study with wider parameters is to be performed on this subject as we consider it to be of importance in the management of voice disorders.

Access to the traumatized vertebral artery: an unusual approach.

Although injuries to the vertebral arteries are relatively uncommon, there are several different methods used to gain access to these vessels, and to control any bleeding arising from them. We describe a case of torrential oropharyngeal bleeding following a stab wound to the neck in which rapid access to the vertebral artery was gained using a paramedian mandibulotomy; this approach has not previously been documented. The other approaches are discussed.

Oncocytomas of the upper jaw.

BACKGROUND: Oncocytomas are rare tumors; they occur most often in the parotid gland and here behave in a benign fashion. Few of these tumours have been described arising from tissues of the upper jaw. The reviews of the literature in these cases often appear incomplete. It has been suggested that outside the major salivary glands oncocytomas should be considered to be low-grade adenocarcinomas. METHODS: We present a case of a 78-year-old woman with a frankly malignant oncocytoma of the lateral nasal wall, treated with radical local excision. A search of the world literature was undertaken and a review conducted. RESULTS: We found a total of 19 cases affecting the upper jaw, in a wide age distribution, 10 male and 9 female. Thirteen cases were malignant, 3 with metastases. CONCLUSIONS: When affecting the upper jaw, these tumors must be considered malignant. Radical surgical excision is the treatment most often employed.

Management of verrucous carcinoma of the larynx.

Eight patients with a verrucous carcinoma of the larynx have been seen at the Charing Cross Hospital between 1970 and 1985. Seven patients were treated by primary radiotherapy and one by primary endoscopic laser excision. Four of those treated with radiotherapy developed recurrent disease which was treated by radical surgery in three and by endoscopic laser excision in one. The place of radiotherapy in the management of this condition requires further evaluation in view of the high rate of recurrence. Endoscopic laser excision may be a reasonable alternative to more radical surgery in this highly differentiated neoplasm.

[Calcium alginate as a nasal pack]. / L'intérêt de l'alginate de calcium comme tampon nasal.

Alginates are highly absorbent, gel-forming materials with haemostatic properties. The aim of this study was to compare calcium alginate to Telfa as a postoperative nasal pack in a prospective randomised clinical trial. Eighty two patients entered the trial. There were 55 males and 27 females whose ages ranged from 13 to 74 years (mean 34.7 years). Immediate postoperative bleeding was controlled in all cases irrespective of the pack used. There was no difference in the incidence of postoperative complications between the two groups. Calcium alginate is a safe and effective alternative to Telfa as a postoperative nasal pack.

The influence of calcium alginate haemostatic swabs upon operative blood loss in adenotonsillectomy.

Although adenotonsillectomy is regarded as a minor procedure, it has been shown that 18% of patients may experience an operative blood loss of 10-20% of the total blood volume. The aim of this study was to determine whether calcium alginate haemostatic swabs reduce operative blood loss in adenotonsillectomy. Seventy-two patients (ages 2-12 years) entered a prospective trial in which the operation was performed either with normal gauze swabs or calcium alginate swabs. Thirty-six children were randomized to each group. The mean blood loss was found to be 34.9 ml (2.07% of total blood volume) and 47.8 ml (2.97% of total blood volume) respectively. Although there was no significant reduction in operative blood loss using calcium alginate, in both groups the blood loss was much smaller than that stated by the majority of previous workers.

Multiple submucosal out-fractures of interior turbinates.

Nasal obstruction caused by the inferior turbinate is a common clinical problem. There are many surgical procedures which attempt to relieve it, but all of them have associated difficulties. We describe, for the first time, a new method, namely multiple submucosal out-fractures of the inferior turbinates, which is both effective and free from serious complication.

Fasting in children for day case surgery.

Thirty-four children admitted for day case surgery were studied to determine the period of preoperative fasting and blood sugar concentrations at the time of induction of anaesthesia. Of these, 88% fasted for 12 h or more, 20% fasted for 16 h or more. Three were found to be hypoglycaemic. The introduction of routine 'mid-day' operating lists for paediatric day case surgery is suggested as a method of reducing the period of fasting and risk of hypoglycaemia.