Dynamic 320-slice CT larynx for detection and management of idiopathic bilateral vocal cord paralysis.

Idiopathic bilateral vocal cord paralysis (VCP) is a rare and difficult condition often undiagnosed and frequently confused with asthma and other respiratory conditions. Accurate diagnosis is crucial since 80% of cases patients require surgical intervention, such as tracheostomy or laser surgery, to relieve symptoms. The "gold standard" for diagnosing VCP has been laryngoscopy. In this case study, we demonstrate for the first time that idiopathic bilateral VCP can be accurately diagnosed by means of a novel noninvasive methodology: dynamic volume 320-slice computed tomography larynx. Three-dimensional reconstruction of laryngeal motion during the breathing cycle permitted functional assessment of the larynx showing absence of vocal cord movements. The new methodology may be valuable for noninvasive diagnosis of vocal cord movement disorders before and for follow-up after surgery.

Measuring vocal function in professional music theater singers: construct validation of the Evaluation of the Ability to Sing Easily (EASE).

OVERVIEW: Working music theater singers (MTS) typically have a heavy vocal load and little is known about their perception of vocal function. The Evaluation of the Ability to Sing Easily (EASE) was used to assess professional MTS' perceptions of current singing voice status and to compare scores across demographic and performance characteristics and to evaluate the construct validity of the EASE and its subscales (VF = Vocal Fatigue, PRI = Pathologic-Risk Indicators). METHODS: Professional MTS (n = 284) completed an online survey including the EASE and two additional Vocal Concern (VC) items. Scores were compared across age, gender, whether currently working, role, perceived vocal load over the past 24 h and self-reported voice problem. RESULTS: For the whole cohort, statistically significant differences were found on all subscales according to whether or not singers perceived themselves to have a voice problem (p < 0.001). Currently performing singers were significantly different from those not performing in a show on the EASE Total (p = 0.014) and VF (p = 0.002), but not for PRI and VC. In the currently performing singer group, significant differences were found for gender, role and perceived voice problem on the EASE Total and all subscales (p < 0.01). Significantly higher VF scores were recorded for singers with heavy vocal load (p = 0.01), but there were no differences on the EASE Total (p = 0.57), PRI (p = 0.19) or VC subscales (p = 0.53). Among these performing singers, no significant age differences were found for any EASE subscales. CONCLUSIONS: These findings provide further validation of the EASE as a useful tool for measuring singers' perceptions of vocal function and suggest that the subscales should be scored separately. Future evaluation of the EASE against objective clinical assessments (e.g., videostroboscopy) is recommended.

Development and preliminary validation of the EASE: a tool to measure perceived singing voice function.

OBJECTIVES: Most voice self-rating tools are disease-specific measures and are not suitable for use with healthy voice users. There is a need for a tool that is sensitive to the subtleties of a singer's voice and to perceived physical changes in the singing voice mechanism as a function of load. The aim of this study was to devise and validate a scale to assess singer's perceptions of the current status of their singing voice. METHODS: Ninety-five vocal health descriptors were collected from focus group interviews of singers. These were reviewed by 25 currently performing music theater (MT) singers. Based on a consensus technique, the number of descriptors was decreased to 42 items. These were administered to a sample of 284 professional MT singers using an online survey to evaluate their perception of current singing voice status. RESULTS: Principal component analysis identified two subsets of items. Rasch analysis was used to evaluate and refine these sets of items to form two 10-item subscales. Both subscales demonstrated good overall fit to the Rasch model, no differential item functioning by sex or age, and good internal consistency reliability. The two subscales were strongly correlated and subsequent Rasch analysis supported their combination to form a single 20-item scale with good psychometric properties. CONCLUSIONS: The Evaluation of the Ability to Sing Easily (EASE) is a concise clinical tool to assess singer's perceptions of the current status of their singing voice with good measurement properties. EASE may prove a useful tool to measure changes in the singing voice as indicators of the effect of vocal load. Furthermore, it may offer a valuable means for the prediction or screening of singers "at risk" of developing voice disorders.

Perspectives on the impact on vocal function of heavy vocal load among working professional music theater performers.

Music theater singers (MTS) typically have a heavy vocal load, but the impact on their voices has not been previously evaluated. A group of 49 MTS from two professional productions were administered the Singing Voice Handicap Index (SVHI). Responses for the SVHI demonstrated that, although the SVHI supported the performers' self-report of healthy vocal status, it lacked the sensitivity to detect potential subtle fluctuations or changes in physical functioning of the voice for working singers. Secondarily, descriptive data regarding professional working singers' perspectives were collected regarding how their singing voices typically responded to performing in a music theater production after a show, across a working week, and across a production season. Seventy-nine currently performing MTS were involved in a series of focus group interviews (n=43) or a written survey (n=36) to detail their perception of the impact of performing in an eight-show per week professional production on their vocal function and vocal health. Thematic analysis revealed the MTS commonly perceived transient and variable changes in their singing voice status in both positive and negative directions after heavy vocal load. Based on these data, a list of 97 descriptors of these perceptual changes was generated using the singers' own terminology and experiences. These included symptoms of vocal impairment and vocal fatigue but also some novel descriptors of positive vocal changes to the physical functioning of the singing voice as a perceived consequence of heavy vocal load. This study offers new and valuable insights into performers' perceptions of the impact of performing in a musical theater production on physical aspects of vocal function.

Factors leading to the use of alternate treatment modalities following transoral laser excision of T1 and T2 glottic squamous cell carcinoma.

BACKGROUND: CO(2) transoral laser surgery and radiotherapy are both recognized as acceptable treatments for early glottic squamous cell carcinoma (SCC) with similar rates of cure. The reasons why some of the patients in our series undergoing laser resection as their primary modality of treatment subsequently underwent radiotherapy or chemoradiotherapy will be discussed. METHODS: Retrospective study between January 2003 and August 2010 of all T1 and T2 glottic SCCs treated with laser resection at a major tertiary centre. Tis lesions were excluded. A review of the cases in which primary control with laser resection was not achieved was undertaken. Failure was defined as patients treated initially with laser resection who subsequently received radiotherapy, combined chemoradiotherapy or open surgery for the same tumour. Factors leading to failure were analysed, including tumour location, histology, stage and patient factors. RESULTS: Thirty-one patients were identified, with the majority (27) having T1 disease. Mean number of laser excisions per patient was 1.7. Local control rate was 71% with laser alone. One patient had nodal recurrence with no primary recurrence. Mean follow-up was 32 months. Of the nine patients in whom local control was not achieved with laser alone, all had tumour at or crossing the anterior commissure. Four patients were deemed potentially curable with further excision but chose radiotherapy. Two patients were deemed appropriate for radiotherapy and chemoradiotherapy. Three patients had loco-regional recurrence and underwent laryngectomy. All had anterior commissure involvement. CONCLUSION: Transoral laser excision is a safe, function-preserving treatment of early glottic SCC. Anterior commissure involvement was the major factor for potential failure with laser resection in T1 and T2 glottic tumours.

Foreign bodies: aspirated or ingested? A report of two unusual cases.

INTRODUCTION: The diagnosis of foreign bodies in the upper aerodigestive tract is usually straightforward but sometimes it can be delayed or the location of esophageal and upper airway foreign bodies can be mistakenly interchanged. CASE REPORT: We present two interesting cases that caused diagnostic challenges which could have led to serious complications if a greater delay in diagnosis had occurred. CONCLUSION: In order to diagnose upper aerodigestive tract foreign bodies without delay, a careful history and physical examination with proper X-rays are helpful.

Larynx preservation with primary non-surgical treatment for loco-regionally advanced larynx cancer.

INTRODUCTION: The objective of this paper was to review the results of primary non-surgical treatment with the aim of larynx preservation for loco-regionally advanced larynx cancer (LALC). METHODS: All patients with LALC presenting between January 2002 and December 2006 who were selected for primary non-surgical treatment were included in this study. RESULTS: There were 60 patients, 48% with stage III and 52% with stage IV disease. The median follow-up of living patients was 41 months. Larynx preservation with local disease control was achieved in 83% and 77% of patients at 3 and 5 years, respectively. Failure-free survival at 3 and 5 years was 66% and 59%, respectively, and overall survival was 67% and 45%, respectively. All patients with larynx preservation had a functional voice. Two patients became feeding tube dependant. Thirty-nine percent of all deaths were unrelated to LALC. CONCLUSIONS: Primary non-surgical treatment achieves high rates of larynx preservation with a low rate of severe complications but overall survival remains disappointing.

Abnormal vocal cord function in difficult-to-treat asthma.

RATIONALE: Upper airway dysfunction may complicate asthma but has been largely ignored as an etiological factor. Diagnosis using endoscopic evaluation of vocal cord function is difficult to quantify, with limited clinical application. OBJECTIVES: A novel imaging technique, dynamic 320-slice computerized tomography (CT), was used to examine laryngeal behavior in healthy individuals and individuals with asthma. METHODS: Vocal cord movement was imaged using 320-slice CT larynx. Healthy volunteers were studied to develop and validate an analysis algorithm for quantification of normal vocal cord function. Further studies were then conducted in 46 patients with difficult-to-treat asthma. MEASUREMENTS AND MAIN RESULTS: Vocal cord movement was quantified over the breathing cycle by CT using the ratio of vocal cord diameter to tracheal diameter. Normal limits were calculated, validated, and applied to evaluate difficult-to-treat asthma. Vocal cord movement was abnormal with excessive narrowing in 23 of 46 (50%) patients with asthma and severe in 9 (19%) patients (abnormal > 50% of inspiration or expiration time). Imaging also revealed that laryngeal dysfunction characterized the movement abnormality rather than isolated vocal cord dysfunction. CONCLUSIONS: Noninvasive quantification of laryngeal movement was achieved using CT larynx. Significant numbers of patients with difficult-to-treat asthma had excessive narrowing of the vocal cords. This new approach has identified frequent upper airway dysfunction in asthma with potential implications for disease control and treatment.

Endoscopic stapling of pharyngeal pouch: a 10-year review of single versus multiple staple rows.

OBJECTIVE: To compare the outcomes obtained in patients undergoing endoscopic stapling of pharyngeal pouches with single versus multiple rows of staples. STUDY DESIGN: A retrospective, 10-year review. SUBJECTS AND METHODS: Review of medical records in 38 patients who underwent endoscopic pharyngeal pouch repair. RESULTS: Patients who underwent stapling with multiple rows had a higher postoperative leak rate than patients who were stapled with a single row (36% vs 0%, P < 0.05). Patients with multiple rows also had a more prolonged length of stay and a slower return to both clear fluids and solid diet (P < 0.05). There was no difference in recurrence rate or patient satisfaction between the two groups. CONCLUSION: The technique of endoscopic pharyngeal pouch stapling has the potential to achieve excellent results. The application of more than one row of staples may be necessary to divide the common wall. However, in our series this is associated with a significantly increased risk of esophageal or pouch perforation. Care should be taken during the placement of multiple rows of staples.

Hoarseness - what is the voice trying to tell you?

BACKGROUND: Most episodes of hoarseness are benign and self limiting. METHODS: This article describes the causes and management of hoarseness in adults, outlines the features of common causes of voice disturbance in adults, and highlights a number of red flags that should trigger urgent referral. DISCUSSION: Patients with hoarseness lasting more than 3 weeks require specialist assessment to visualise the larynx.

Frozen section for parotid surgery: should it become routine?

BACKGROUND: The role of fine-needle aspiration (FNA) in salivary gland lesions as a preoperative diagnosis has always been under scrutiny. Several studies have shown that frozen section (FS) is accurate for pathological diagnosis and decision-making during the surgery. This study has been carried out to assess the accuracy of FNA and FS in parotid surgeries. METHODS: All parotid lesions removed between July 1998 and June 2003 by the Department of Otolaryngology, Head and Neck unit at Monash Medical Centre were reviewed. FNA, FS and definitive pathology were collected and discrepancies were identified. RESULTS: Eighty-five parotid tumours had been removed. Thirty-three were malignant in which squamous cell carcinoma was the most common. FS was able to differentiate benign tumours from malignant with 100% accuracy (30 cases). FS was able to alter the surgical decisions in six cases. FNA had been carried out in 62 cases, with sensitivity and specificity of 77.2 and 90%, respectively. CONCLUSION: Frozen section in parotid surgery is accurate, inexpensive and may add important information that alters management and improves the outcome. The use of FS routinely in parotid surgery is recommended.

Adult long-segment tracheal stenosis attributable to complete tracheal rings masquerading as asthma.

OBJECTIVE: a) To report on an adult patient with congenital long-segment tracheal stenosis from complete tracheal rings complicated by tracheomalacia; b) to highlight the fact that some patients with airway narrowing could be misdiagnosed as having bronchial asthma; and c) to discuss our management with a custom-made tracheostomy tube extending to the carina. DESIGN: Case report. SETTING: A university hospital's 14-bed medical/surgical intensive care unit. PATIENT: A 21-yr-old patient, with a history of what was labeled as asthma, was admitted to the intensive care unit with diabetic ketoacidosis, pneumonia, respiratory failure, and septic shock. INTERVENTIONS: Her therapy included assisted mechanical ventilation through an endotracheal tube. Initially, a size 6.0 endotracheal tube was used. Finally, a custom-made tracheostomy tube extending to the carina was inserted to manage her persistent infantile trachea. MEASUREMENT AND MAIN RESULTS: During 4 months in the intensive care unit, she suffered numerous airway problems from her narrow trachea that were eventually attributed to congenital long-segment tracheal stenosis from complete tracheal rings. Bacterial pneumonia, viral tracheobronchitis, and tracheomalacia complicated her course. Multiple attempts at extubation failed and, after translaryngeal endotracheal tubes and tracheostomy tubes of decreasing size, her airway was managed with a size 5.0 custom-made tracheostomy tube with the tip extending to her carina. She was totally dependent on this tube. CONCLUSION: Airway narrowing may masquerade as asthma. Congenital tracheal stenosis is rare and is associated with a high mortality rate. Complete tracheal rings presenting in adulthood are extremely rare, and we report the first case of long-segment pantracheal stenosis presenting in adulthood. Surgical treatment with tracheoplasty is difficult. A custom-made tracheostomy tube to stent the entire trachea is one management option. Tracheal stenosis should be excluded in patients with a chronic lack of response to therapy for asthma.