Sino-nasal bony and cartilaginous destruction associated with cocaine abuse, S. aureus and antineutrophil cytoplasmic antibodies.

Three male patients aged 29, 30 and 34 years and a 36-year-old female are reported with nasal septum perforation and a history of cocaine abuse. Two of the patients also had a perforation of the hard palate. In all four, antineutrophil cytoplasmic antibodies (ANCA) were found. One had a cytoplasmic immunofluorescence-staining pattern (c-ANCA), the other three showed a perinuclear staining pattern (p-ANCA). Furthermore, all patients were found to be nasal carriers of S. aureus. We hypothesise that tissue damage to the nasal and palatal area in patients using cocaine may partly be mediated by the presence of ANCA antibodies. Furthermore, we speculate that S. aureus facilitates the development of these ANCA antibodies.

Analysis of failure of voice production by a sound-producing voice prosthesis.

OBJECTIVE: To analyse the cause of failing voice production by a sound-producing voice prosthesis (SPVP). METHODS: The functioning of a prototype SPVP is described in a female laryngectomee before and after its sound-producing mechanism was impeded by tracheal phlegm. This assessment included: perceptual voice evaluation of read-aloud prose by an expert listener; inspection of the malfunctioning SPVP; and aero-acoustical in vivo registrations using a computer-based data acquisition system. RESULTS: Sound-producing voice prosthesis speech is higher pitched, stronger, contains less aperiodic noise and requires a lower airflow rate than the patient's regular tracheoesophageal (TE) shunt speech. Tracheal phlegm caused malfunction of the vibrating silicone lip of the SPVP by causing it to stick to its stainless steel container in an opened position, thereby reducing the SPVP to no more than a regular TE shunt valve from a functional point of view. Tracheal phonatory pressure and dynamic vocal intensity range were not affected by the functional status of the SPVP. CONCLUSIONS: To exploit the advantages an SPVP could offer female laryngectomees with an atonic or severely hypotonic pharyngoesophageal segment, the sound-producing mechanism of the SPVP needs to be less vulnerable to tracheal phlegm.

A novel tracheal tissue connector for fixation of laryngeal prostheses.

A tissue connector (TC), basically consisting of a ring that will be integrated into the trachea, is under development to study the fixation of laryngeal prostheses. Two experiments have been performed to test the TC in goats. In experiment 1, a polypropylene mesh was implanted around the trachea. The meshes were explanted after 6 and 12 weeks. In experiment 2, the actual TC consisted of two titanium rings (inner ring and outer ring) executed as quarter rings, fixed on each other, and a polypropylene mesh like a sandwich in between. The titanium inner ring was implanted between two tracheal rings thus penetrating the trachea with the mesh around the trachea and the fixed titanium outer ring on the outside of the trachea. The TCs were removed after 12 weeks. Experiment 1 showed that the mesh was entirely infiltrated by host tissue. Inflammatory cells and high vascularisation were observed in 3 of 4 implants. However, in experiment 2, the mesh was completely incorporated by mature connective tissue without inflammation reaction. At some areas, deposition of cartilage tissue was observed. In conclusion, the TC was firmly embedded in the trachea thus being appropriate for its intended use.

Thyroplasty for adductor spasmodic dysphonia: further experiences.

OBJECTIVES: Two different surgical techniques for midline lateralization thyroplasty (type 2 thyroplasty) for adductor spasmodic dysphonia (SD) have been described, one using a composite graft and the other without. Indications and results for each method among different types of SD were compared, together with the theoretical background for the surgery. STUDY DESIGN: Retrospective. METHODS: The medical records of six patients with SD together with the fiberscopic video recording of laryngeal findings before, during, and after surgery were reviewed. The intraoperative video recordings of the surgical procedures were compared with the postoperative findings. RESULTS: The vocal features of SD, diverse preoperatively, disappeared postoperatively and a normal, or almost normal, voice was attained in 5 of 6 cases. The failure in one patient was attributed to combined focal dystonia of the neck muscles and difficulty in lateralization. Type 2 thyroplasty without a graft, which causes bowing of both vocal folds, is simple to perform and effective enough for most SD cases. No recurrence has been noted so far over postoperative periods ranging from 6 months to more than 3 years. CONCLUSION: The results suggest that thyroplasty is an effective therapeutic approach for SD.

Pharyngoesophageal myotomy for vocal rehabilitation of laryngectomees.

Pharyngoesophageal myotomy, performed in 16 laryngectomees to improve vocal rehabilitation, proved to have some negative side effects. Although no failures of speech rehabilitation using a button were consequently found, a considerable number of button assisted esophageal speakers had a breathy voice. Also, the number of poor injection-esophageal speakers was much higher than in the group of nonmyotomized laryngectomees. A "normal" pseudoglottis could only rarely be identified by fluoroscopy in the myotomized group. A significantly lower intratracheal pressure appeared to be required for tracheo-esophageal phonation after myotomy. To improve the slightly disappointing voice rehabilitation results of the myotomized laryngectomees, a modified myotomy is proposed.

Alternative voice after laryngectomy using a sound-producing voice prosthesis.

OBJECTIVE: To improve the voice quality of female laryngectomees and/or laryngectomees with a hypotonic pharyngoesophageal (PE) segment by means of a pneumatic artificial source of voice incorporated in a regular tracheoesophageal (TE) shunt valve. STUDY DESIGN: Experimental, randomized, crossover trial. METHODS: The new sound source consists of a single silicone lip, which performs an oscillatory movement driven by expired pulmonary air flowing along the outward-striking lip through the TE shunt valve. A prototype of this pneumatic sound source is evaluated in vitro and in six laryngectomees. In vivo evaluation includes speech rate, maximal phonation time, perceptual voice evaluation of read-aloud prose by an expert listener, speech intelligibility measurements with 12 listeners, and self-assessment by the patients. Moreover, extensive acoustical and aerodynamic in vivo registrations are performed using a newly developed data acquisition system. RESULTS: The current prototype seems beneficial in female laryngectomees with a hypotonic PE segment only. For them the sound-producing voice prosthesis improves voice quality and increases the average pitch of voice, without decreasing intelligibility or necessitating other pressure and airflow rates than regular TE shunt speech. Pitch regulation of this prosthetic voice is possible, yet limited. CONCLUSIONS: The mechanism is feasible and does not result in unacceptable airflow resistance. For this new mechanism of alaryngeal voice to become an established technique for postlaryngectomy voice restoration, a voice suitably pitched for male laryngectomees has to be generated and a large part of the melodic and dynamic range of the sound source has to be attainable within physiological airflow rates.

Indirect microlaryngostroboscopic surgery.

Detailed preoperative laryngostroboscopic examination is a prerequisite for phonosurgical correction of organic dysphonia. Although suspension microlaryngoscopic surgery has proved its value in the past, it excludes functional control during the removal of vocal fold swellings. Using an indirect microlaryngostroboscopic surgical technique with topical anesthesia, functional control can be achieved during surgery. This enables the removal of vocal fold swellings with a high degree of precision. Postoperative voice evaluation was performed in 31 patients after suspension microlaryngoscopic or indirect microlaryngostroboscopic surgery. The results showed that indirect microlaryngostroboscopic surgery is at least as good as, and in some respects even better than, suspension microlaryngostroboscopic surgery. Large vocal fold swellings, extensive Reinke's edema, and submucosal swellings are considered less suitable for indirect microlaryngostroboscopic surgery, because such lesions require bimanual instrumentation.

Aerodynamic properties of the low-resistance Groningen button.

Shunt tracheoesophageal speech is currently the most successful form of voice and speech rehabilitation in laryngectomees. Insertion of valve prostheses into the tracheoesophageal shunts has overcome drawbacks caused by stenosis of the shunt and aspiration. In 10 years of satisfactory results with the standard Groningen button valve prosthesis, the overall concept of this device has proved its value. The airflow resistance, however, is relatively high, so that a low-resistance device has been developed without changing the favorable characteristics of the standard device. The design of this low-resistance Groningen button is described. The airflow resistances of the standard and low-resistance Groningen buttons have been measured and compared. The airflow resistance of the low-resistance Groningen button is also compared with the reported airflow resistances of various other valve prostheses.

Oropharynx decontamination preventing Candida vegetation on voice prostheses.

Candida vegetations found in silicone voice prostheses used in postlaryngectomy voice rehabilitation are associated with prosthesis dysfunction. Selective oropharyngeal decontamination with amphotericin B lozenges resulted in sharp decrease of oropharyngeal Candida concentrations with a subsequent reduction of yeast colonization on voice prostheses and in tracheoesophageal fistula in ten patients. A case report suggests that this selective oropharyngeal decontamination can prolong the device's lifetime.

Candida vegetations on silicone voice prostheses.

Deposits found on the esophageal surface of silicone voice prostheses (used in postlaryngectomy voice rehabilitation) are held responsible for malfunction of the valve mechanism. Cultures and scanning electron microscopic examinations proved these deposits to consist of Candida organisms growing not only on the surface of the prosthesis but also into the silicone material itself. It is remarkable that the patients are apparently not affected by these Candida organisms. Selective decontamination of the oropharynx and coating of the prosthesis with poly-methyl methacrylates, or impregnation with antimycotic agents or disinfectants, may prove effective methods in prolonging the life of the device.

Selective laryngeal abductor reinnervation in cats using a phrenic nerve transfer and ORG 2766.

Reinnervation of the recurrent laryngeal nerve following nerve injury often leads to laryngeal synkinesis. Selective reinnervation of adductor and abductor muscles might be able to avoid synkinesis. This study presents the results of selective abductor reinnervation in cats, using a phrenic nerve transfer to the recurrent laryngeal nerve and directing all reinnervating axons toward the abductor muscle. Simultaneously, a blind, placebo-controlled, pilot study was performed to evaluate the capacity of ORG 2766, administered subcutaneously (25 micrograms/kg per 48 hours), to facilitate reinnervation by stimulation of axon sprouting. Reinnervation surgery was performed in 10 cats. Postoperative evaluation included videolaryngoscopy, electromyography, histological examination, and quantification of reinnervating axons. Nine cats could be evaluated, of which eight demonstrated electromyographic and laryngoscopic activity as soon as 6 weeks following surgery. The one cat showing no abduction was found to have an inadequate nerve anastomosis and was marked as a surgical failure. After 10 weeks, near-normal or more than normal abduction was seen in the eight cats, and histological proof of reinnervation was obtained in seven of them; one cat could not be evaluated histologically owing to unsuccessful fixation. Although no conclusive evidence was obtained concerning the effect of ORG 2766, the tendencies found warrant further experiments with this compound on laryngeal reinnervation.

Carbon dioxide laser vaporization in early glottic carcinoma.

OBJECTIVE: Presently, widely employed treatment modalities for early glottic carcinoma include radiation therapy, surgical excision, and carbon dioxide laser excision. All these treatments have good oncological results, but poor or questionable functional results in terms of quality of voice and mucosal wave patterns as seen via a laryngostroboscope. We assessed the oncological and functional results of carbon dioxide laser vaporization of the diseased mucosa as a more conservative treatment alternative. DESIGN: Case series. SETTING: Department of Otolaryngology-Head and Neck Surgery in a tertiary care center. PATIENTS: Thirty-three patients with early glottic carcinoma (carcinoma in situ and Tla squamous cell carcinoma) who were referred to our center in the period from 1986 through 1990 were selected for carbon dioxide laser vaporization treatment on the criterion of a still recognizable mucosal wave pattern of the affected vocal fold via a laryngostroboscope. MAIN OUTCOME MEASURES: Local tumor control, voice quality, and a good appearance via a laryngostroboscope. RESULTS: Two patients were excluded from evaluation because a simultaneously diagnosed, incurable second primary tumor precluded frequent follow-up. Of the remaining 31 patients seen during a median follow-up period of 58 months, seven patients died of unrelated causes. A local recurrence of disease developed in two patients and was treated by radiation therapy. A recurrence of disease developed again in one of these patients but was successfully treated by total laryngectomy. Overall, local control of disease was achieved in all patients, with a 97% laryngeal preservation rate. Functional results in terms of voice quality were good in 97% of the patients, 75% of whom even retained a normal voice. Normal or near normal laryngostroboscopic appearance was achieved in 68% of all patients. CONCLUSION: Carbon dioxide laser vaporization is a good treatment alternative for early glottic carcinoma in terms of oncological as well as functional results.

Selective laryngeal reinnervation with separate phrenic and ansa cervicalis nerve transfers.

OBJECTIVE: To perform selective reinnervation of the laryngeal abductor and adductor muscle groups after injury to the recurrent laryngeal nerve, recovering laryngeal function without impairment by synkinesis. DESIGN: Ten cats underwent the surgical procedure. To reinnervate the posterior cricoarytenoid muscle (abductor), a phrenic nerve graft was anastomosed to the main trunk of the recurrent laryngeal nerve. The adductor branch was severed, and the proximal stump was buried in the posterior cricoarytenoid muscle. The sternohyoid branch of the ansa cervicalis was anastomosed to the distal stump to reinnervate the adductor muscle group. After a period of 10 weeks, the laryngeal function was evaluated with videolaryngoscopy and electromyography of the posterior circoarytenoid and vocalis muscles. RESULTS: Of the 10 cats, 9 could be evaluated. Laryngeal abductor function was comparable with the unaffected side in the 9 cats. During respiratory distress conditions, a minor compromise of the maximal abduction was observed in 5 cats. Phonation was not tested, but spontaneous adduction during expiration was seen in all cats. Reflex closure on ipsilateral, supraglottic, tactile mucosal stimulation was seen in only 2 cats. In each cat, evidence of nerve regeneration and reinnervation of both muscle groups was established with electromyography, electrical stimulation, and histological examination. CONCLUSIONS: Using this selective reinnervation procedure, good laryngeal function can be achieved in the cat model, which may be applicable in humans. By reinnervation of the vocalis muscle, muscle tonus is achieved, which is expected to improve voice quality. Using this procedure, however, no active reflex closure may be expected.

Laryngeal abductor reinnervation with a phrenic nerve transfer after a 9-month delay.

BACKGROUND: Successful restoration of laryngeal abductor function, using the phrenic nerve, has been described in the cat model in the acute phase. However, in clinical practice there is usually a considerable delay between injury to the RLN and presentation for treatment. Delayed reinnervation therefore would be more suitable in clinical practice. OBJECTIVE: To test the feasibility of delayed selective abductor reinnervation following transection of the recurrent laryngeal nerve (RLN). MATERIALS AND METHODS: In 12 cats, the right RLN was severed. Nine months later, the phrenic nerve was anastomosed to the distal RLN stump with all its branches directed toward the posterior cricoarytenoid muscle. For 10 weeks after the reconstruction, electromyography and videolaryngoscopy were performed weekly. Finally, histological analysis of the RLN was performed. RESULTS: Evaluation was possible in 11 cats. Reinnervation of the right posterior cricoarytenoid muscle with the phrenic nerve occurred in 10 cats following nerve anastomosis, but results of videolaryngoscopy showed adequate to good abduction in only 4 cats. The main limiting factor was reduced mobility of the cricoarytenoid joint. Evidence of spontaneous subclinical reinnervation after the delay was observed in 7 cats but apparently did not impede the surgical reinnervation. CONCLUSIONS: Delayed selective laryngeal abductor reinnervation was feasible, but function recovery was less successful than if performed immediately. Future investigations should concentrate on early determinants of spontaneous restoration of function to allow early selection of patients who are eligible for reinnervation surgery.

Laryngeal abductor function after recurrent laryngeal nerve injury in cats.

OBJECTIVE: To determine the influence of severity of neural injury of t he recurrent laryngeal nerve on recovery of laryngeal abductor function and the importance of synkinesis. DESIGN: The recovery of laryngeal abductor function was studied in 30 cats after crushing (second-degree injury) or transection followed by neurorrhaphy (fifth-degree injury) of the recurrent laryngeal nerve, with a reinnervation period of 10 weeks. MAIN OUTCOME MEASURES: Recovery of laryngeal abductor function was evaluated by videolaryngoscopy of spontaneous laryngeal abduction during respiration and electromyography of the posterior cricoarytenoid and vocalis muscles. Neural lesions were applied unilaterally, and recovery of laryngeal function was compared with the contralateral unimpaired hemilarynx. Reinnervation was confirmed by histologic examination. RESULTS: After the recurrent laryngeal nerve was crushed, laryngeal abductor function was similar to normal after a 10-week reinnervation period in 19 of the 20 cats; after neurorrhaphy, no notable recovery of laryngeal abduction resulted in any of 10 cats. Electromyographic recordings disclosed synkinesis after neurorrhaphy and recovery of normal activity patterns after crush injuries. CONCLUSIONS: Severity of neural injury to the recurrent laryngeal nerve influences the recovery of laryngeal abductor function. Damage to the endoneurium leads to misdirection of regenerating axons, inappropriate reinnervation, and synkinesis. No effective laryngeal function can then be expected.

Biofilm formation in vivo on perfluoro-alkylsiloxane-modified voice prostheses.

OBJECTIVE: To study the influence of perfluoroalkylsiloxane (PA) surface modification of silicone rubber voice prostheses on biofouling. DESIGN: Placebo-controlled clinical trial. SETTING: Tertiary referral center, with specialization in head and neck cancer treatment. PATIENTS: Eighteen consecutive patients with laryngectomies and experienced in the use of a voice prosthesis who visited the outpatient clinic for prosthesis replacement. MATERIAL: Eighteen partially surface-modified voice prostheses (3 with short-chain PAs [1 fluorocarbon unit] and 15 with long-chain PAs [8 fluorocarbon units]) were inserted via the patients' tracheoesophageal shunts and remained in place for 2 to 8 weeks. INTERVENTION: Replacement of the prostheses. MAIN OUTCOME MEASURES: Evaluation of biofilm formation on short- and long-chain PA-modified and original silicone rubber surfaces on the esophageal side of the voice prosthesis. RESULTS: The planimetrical biofilm scores of the surfaces of all 3 short-chain PA-treated voice prostheses indicated more biofouling on the treated surfaces than on the untreated surfaces of the same prostheses. For the long-chain PA-treated prostheses, the planimetrical biofilm scores, as well as the numbers of colony-forming units per cm(-2) for bacteria and yeasts, indicated less biofouling on the treated side than on the control side for 9 of the 13 prostheses that could be analyzed (2 were lost to analysis). Identical fungal strains, mainly Candida sp, were isolated from biofilms on each side of the esophageal flange. CONCLUSIONS: Chemisorption of long-chain PAs by the silicone rubber used for voice prostheses reduces biofilm formation in vivo and therefore can be expected to prolong the life of these prostheses. Chemisorption of short-chain PAs by silicone rubber seems to have an adverse effect.

Teratoma in a newborn: an unusual cause of airway obstruction.

We report the case of a newborn girl who presented with an inspiratory stridor and apneic episodes due to a mass in the oropharynx. On flexible pharyngo-laryngoscopy, it appeared that on inspiration this swelling, originating from the oropharynx, was sucked into the larynx, obstructing the airway. After intubation under flexible optic control the swelling was excised using the CO2-laser. Histopathological examination showed a teratoma of the oropharynx. The postoperative course was uneventful. Teratomas of the oropharynx are rare and are treated by surgical excision. If respiratory distress accompanies the lesion, priority must be given to securing the airway.

Design and in vitro testing of a voice-producing element for laryngectomized patients.

A voice-producing element has been developed to improve speech quality after laryngectomy. The design process started with the formulation of a list of requirements. The lip principle has the best potential for fulfilling the requirements. A numerical model was made to find the optimal geometry of an element based on the lip principle. Extensive in vitro tests were performed to check all requirements. For this a test set-up with realistic acoustic and aerodynamic properties was developed. Results show that the protruding lip length dominates fundamental frequency, cross-sectional area dominates flow resistance and relation between flow and fundamental frequency. Most requirements have been fulfilled; both for males and females a potentially good functioning prototype could be selected. Clinical experiments will be performed to confirm the quality of the voice-producing prosthesis.

Deviant vocal fold vibration as observed during videokymography: the effect on voice quality.

Videokymographic images of deviant or irregular vocal fold vibration, including diplophonia, the transition from falsetto to modal voice, irregular vibration onset and offset, and phonation following partial laryngectomy were compared with the synchronously recorded acoustic speech signals. A clear relation was shown between videokymographic image sequences and acoustic speech signals, and the effect of irregular or incomplete vocal fold vibration patterns was recognized in the amount of perceived breathiness and roughness and by the harmonics-to-noise ratio in the speech signal. Mechanisms causing roughness are the presence of mucus, phase differences between the left and right vocal fold, and short-term frequency and amplitude modulation. It can be concluded that the use of simultaneously recorded videokymographic image sequences and speech signals contributes to the understanding of the effect of irregular vocal fold vibration on voice quality.

[CO2 laser treatment; an effective and minimally disruptive endoscopic therapy for small glottic laryngeal carcinomas]. / CO2-laserbehandeling; een effectieve en weinig belastende endoscopische therapie voor kleine glottische larynxcarcinomen.

OBJECTIVE: To evaluate endoscopic CO2 laser vaporization as a treatment of small glottic laryngeal carcinomas selected by means of video laryngo-stroboscopy. DESIGN: Prospective. SETTING: ENT department, University hospital, Free University Amsterdam. METHODS: Patients with a small glottic laryngeal carcinoma (stage Tis or T1a), were selected by means of video-laryngo-stroboscopy for a single stage endoscopic CO2 laser vaporization treatment as an alternative for radiotherapy. They were followed up for at least 24 months. RESULTS: Three of the 46 patients (6%) developed a local recurrence within 2 years; one of these could be treated once more with the CO2 laser, the other two were irradiated. None of these patients developed metastases in cervical lymph nodes or distant metastases. Most patients (41, 89%) assessed their voices after CO2 laser vaporization as normal or almost normal. Slight dysphonia was reported by five patients (11%). No serious dysphonia or aphonia occurred. CONCLUSION: Endoscopic CO2 laser vaporization, compared with radiotherapy or more extensive surgery, constitutes an adequate treatment for selected patients with small glottic laryngeal carcinomas. As a result of this treatment, it will be possible to preserve the larynx in more patients.