Analysis of pepsin in tracheoesophageal puncture sites.

OBJECTIVES: Tracheoesophageal puncture (TEP) and prosthesis insertion is a well-established method of voice rehabilitation after laryngectomy. Maintenance of the prosthesis and tract can be challenging, and reflux to the TEP site has been proposed as a cause. The sites of TEP were evaluated for the presence of pepsin in tissue biopsy specimens and tract secretions to explore this association. METHODS: Patients with TEP were interviewed for a history of symptoms related to reflux, medication use history, TEP voice quality, and incidence of TEP complications. Tissue biopsy specimens and tract secretions were obtained from TEP sites and analyzed for the presence of pepsin via sodium dodecyl sulfate-polyacrylamide gel electrophoresis Western blot analysis. RESULTS: Twelve of 17 patients (47%) had some history of preoperative or postoperative symptoms of gastroesophageal reflux disease or laryngopharyngeal reflux. Pepsin was present within the TEP site in a total of 10 of 17 patients (58%; 7 of 17 tissue biopsy specimens and 6 of 7 secretion samples). There were no statistically significant associations between the presence of pepsin and sex, reflux history, use of acid suppressive medicine, or time since laryngectomy. CONCLUSIONS: Reflux with subsequent pepsin deposition into the TEP tract occurs in a majority of laryngectomy patients. Further studies on the effect of reflux on the health and function of the TEP tract are warranted.

[Usefulness of assessment of voice capabilities in female patients with reflux-related dysphonia].

OBJECTIVES: To analyze vocal capabilities in patients diagnosed with reflux related dysphonia versus controls with healthy voice with selection of the most informative discriminating quantitative parameters and to assess voice changes following treatment. MATERIAL AND METHODS: Six parameters of voice range profile (VRP) and five parameters of speech range profile were taken and analyzed from 60 dysphonic outpatient females with laryngopharyngeal reflux (LPR) diagnosed by reflux-related atypical and typical symptoms, videolaryngoscopic findings, upper gastrointestinal endoscopy, and positive response to empiric 3-month omeprazole treatment. Seventy-six females with healthy voice served as controls. RESULTS: All six parameters of voice range profile and three of 5 parameters of speech range profile showed significant differences comparing LPR patients with controls before omeprazole treatment (P<0.05). Logistic regression analysis revealed VRP maximum-minimum intensity range to be the most informative parameter for discrimination between reflux-related dysphonic and healthy voices (overall prediction accuracy, 86.8%). A threshold value of significant parameter was stated using the receiver operating characteristic curve. Treatment with omeprazole significantly improved voice quality showing the greatest changes in the mean scores of majority of voice range profile parameters. CONCLUSIONS: Vocal capabilities, especially evaluated by voice range profile, are restricted in LPR female patients in comparison to subjects with healthy voice. Quantitative voice assessment with voice range profile may add more objective aspect for screening dysphonia and could be used as a criterion of evaluation of treatment efficacy in such patients.

Surgery of adult bilateral vocal fold paralysis in adduction: history and trends.

Bilateral vocal fold paralysis (BVFP) in adduction is characterised by inspiratory dyspnea, due to the paramedian position of the vocal folds with narrowing of the airway at the glottic level. The condition is often life threatening and therefore requires surgical intervention to prevent acute asphyxiation or pulmonary consequences of chronic airway obstruction. Aside from corticosteroid administration and intubation, which are only temporary measures, the standard approach for improving respiration is to perform a tracheotomy. Over the past century, a vast majority of surgical interventions have been developed and applied to restore the patency of the airway and achieve decannulation. Surgeons can generally choose for every individual patient from various well-established treatment options, which have a predictable outcome. An overview of the surgical techniques for laryngeal airway enlargement in BVFP is presented. Included are operative techniques, which have found application in clinical practice, and only to a small extent in purely anatomic or animal studies. The focus is on two major groups of interventions--for temporary and for definitive glottic enlargement. The major types of interventions include the following: (1) resection of anatomical structures; (2) retailoring and displacing the existing structures, with minimal tissue removal; (3) displacing existing structures, without tissue resection; (4) restoration or substitution of the missing innervation of the laryngeal musculature. The single interventions of these four major types have always followed the development of the medical equipment and anaesthesia. At the beginning of the twentieth century, when medicine was unable to counteract surgical infection, endoscopic or extramucosal surgical techniques were dominant. In the 1950s, the microscopic endoscopic laryngeal surgery boomed. At the end of the twentieth century many of the classical endoscopic operations were performed either with the help of surgical lasers alone, or in combination with other interventions.

Duodenogastroesophageal reflux and its effect on extraesophageal tissues: a review.

We conducted a literature review to identify elements of duodenogastroesophageal reflux (DGER)--namely pancreatic fluids, hydrochloric acid, pepsin, and bile--as to the effects each has when refluxed to the extraesophageal structures. Further, we wished to acquaint clinicians with the possibilities that, in addition to hydrochloric acid, the other components of DGER are likewise contributing to disease in the extraesophageal areas. Our review included studies that have indicated reflux of the above mentioned components of DGER to the pharynx, larynx, tracheobronchial tree, oral cavity, nasopharynx, nose and sinuses, eustachian tube, and middle ear. Findings demonstrate that injury to the upper aerodigestive tract can occur from a variety of substances secreted from the stomach and duodenum. Treatment for DGER is nonspecific. We conclude that patients with an incomplete response to acid suppression may have significant involvement of pepsin, bile, or both. Future studies are needed to clarify the importance of these elements and to suggest more precise treatments.

Quality of life in laryngopharyngeal reflux patients.

OBJECTIVES: To evaluate and compare quality of life (QL) parameters in patients with laryngopharyngeal reflux (LPR) versus healthy controls, to determine the impact of clinical signs to QL, and to assess changes in QL parameters after treatment. STUDY DESIGN: Prospective, open, clinical study. MATERIAL AND METHODS: One hundred outpatients with LPR and 109 healthy voice controls were enrolled. LPR patients underwent endoscopy and received omeprazole for 3 months. Results of endoscopy revealed 79 patients without esophagitis and 21 with, giving two subgroups of LPR patients. QL was evaluated using voice handicap index (VHI), hospital anxiety and depression scale, disability in social activities, and well-being in general (W-BVAS). RESULTS: The mean scores for total VHI and functional, physical, and emotional functioning domain subscales were found to be significantly higher in LPR patients versus controls (P < .0001), with no difference among LPR subgroups. Abnormal anxiety was one third in both LPR subgroups versus 6.4% of controls (P < .001). Both LPR subgroups patients had significantly reduced social activities and significantly lower mean W-BVAS score than controls. LPR symptoms had a significant relation with all tested QL parameters, whereas laryngoscopic findings had a significant relation with VHI and W-BVAS only. All mean QL parameters scores improved after 3-month omeprazole treatment. CONCLUSIONS: QL in LPR patients with or without esophagitis is impaired significantly in many aspects. Impairment of QL is more associated with symptoms than laryngoscopic findings. Treatment with omeprazole significantly improved QL in both LPR subgroups patients.

Cricopharyngeal electromyography: patterns of injury based on etiology.

OBJECTIVE: Although cricopharyngeal electromyography (CP-EMG) is recognized as a diagnostic tool for dysphagia assessment, few reports in the literature characterize CP-EMG abnormalities in relation to clinical presentation. The aim of this study was to review a large series of CP-EMG studies, and compare the CP-EMG results with the patients' diagnoses. METHODS: A retrospective review of all CP-EMG performed at our institution over a 10-year period was executed. CP-EMG findings were then compared with the patients' clinical history, focusing on potential etiologies of neurogenic injury. RESULTS: Seventy CP-EMGs were reviewed, with 47 (67%) demonstrating neural injury. Of those cases with neural injury on EMG, 29 (60%) had known vagal injuries, 13 (28%) had idiopathic nerve palsies, and 5 (11%) had central etiologies, such as stroke. Each of these three neurogenic subgroups revealed a distinct pattern of EMG abnormalities. CONCLUSION: This study suggests there is an association between patterns of CP-EMG abnormalities and underlying etiology based on clinical history.

Comparative neuromuscular histopathology of cricopharyngeal achalasia patients with and without previous botulinum toxin treatment.

OBJECTIVES: Botulinum toxin injection (BTX) and cricopharyngeal (CP) myotomy are performed in the treatment of CP achalasia (CA). The objective of this study was to examine the effects of BTX on neuromuscular histopathologic findings and to make direct comparisons between specimens of muscle from CA patients who had received BTX to the upper esophageal sphincter and from CA patients who had no previous exposure to BTX. METHODS: We performed a retrospective review (2001 to 2005) of CP muscle specimens from all patients who underwent myotomy for CA. Cases of Zenker's diverticulum were excluded. Patient demographics, clinical course, and neuromuscular pathology findings were noted from the chart. RESULTS: Nineteen patients with CA were identified: 10 male and 9 female, with a mean age of 57 years. Eleven had no prior BTX (6 male and 5 female; mean age, 62 years); 8 had previous treatment with BTX (4 male and 4 female; mean age, 51 years). Eight of the 11 BTX-naive patients revealed predominantly myopathic changes on histology. Those with previous BTX tended to be younger; 6 of the 8 had a clinical benefit from their BTX and ultimately went on to myotomy. The CP muscle specimens featured both mixed and neurogenic pathologic changes in 5 of the 8 patients with BTX. Although these findings suggest some impact of BTX on the CP muscle, the difference between the groups was not statistically significant (p < .20, chi2 test). CONCLUSIONS: Treatment with BTX may have some clinical and histopathologic impact on the upper esophageal sphincter of patients with CA. Although neuropathic changes were noted in the CP muscle of previously injected patients at the time of their CP myotomy, the neuromuscular pathologic findings overall were not significantly different from those of BTX-naive patients.

Receptor-mediated uptake of pepsin by laryngeal epithelial cells.

OBJECTIVES: Previous data suggest a mechanistic link between exposure to pepsin and cellular changes that lead to laryngopharyngeal disorders. Initial confocal microscopy analysis of pepsin uptake by cultured hypopharyngeal epithelial cells revealed that pepsin may be taken up by a specific process. The objective of this study was to use electron microscopy to confirm the initial confocal findings and to determine whether uptake of pepsin by laryngeal epithelial cells is receptor-mediated. METHODS: Cultured human hypopharyngeal FaDu cells and human laryngeal biopsy specimens, taken from the posterior larynx of "control" patients without symptoms or findings of laryngopharyngeal reflux, were exposed to purified human pepsin 3b with or without transferrin (a marker for receptor-mediated endocytosis) in vitro. Uptake of pepsin was documented by electron microscopy. RESULTS: Pepsin co-localized with transferrin in intracellular vesicles; this finding confirms that pepsin is taken up by laryngeal epithelial cells by receptor-mediated endocytosis. CONCLUSIONS: This is a novel finding that further defines the role and mechanism of pepsin-mediated injury in laryngopharyngeal reflux. The objective of ongoing research is to identify the receptor and investigate potential antagonists as a new therapeutic option for patients with reflux-attributed disease--in particular, those patients who have persistent symptoms despite acid suppression therapy.

The prevalence of diabetes in a series of patients with subglottic stenosis.

Diabetes, which is present in 4 to 8% of adults in the United States, is a risk factor for surgical failure in laryngotracheal airway operations. We conducted a retrospective study to characterize a population of patients with subglottic stenosis-including the prevalence of diabetes, which has not been widely reported. We performed a retrospective chart review of 30 patients--22 women and 8 men, aged 17 to 77 years (mean: 47.5)--with subglottic stenosis who had presented to our facility between July 2001 and June 2004. Diabetes was present in 5 patients (16.7%); the prevalence of diabetes in our study was not significantly different from regional population-adjusted norms (8%). Although higher-grade stenosis was significantly more common in the diabetic patients than in the nondiabetic patients (p < 0.05), we were unable to conclude that diabetes plays an independent role in the development of subglottic stenosis. We intend to conduct a meta-analysis to assess the role that diabetes plays as both a risk factor for and an obstacle to the treatment of airway stenosis.

Mitomycin-c application in airway stenosis surgery: analysis of safety and costs.

OBJECTIVE: This study describes a large series of patients receiving topical mitomycin-c (MMC) during airway surgery, including complications, and carries out a cost analysis for its use in laryngotracheal stenosis. STUDY DESIGN AND SETTING: Retrospective review, tertiary center. Airway patients receiving MMC are reviewed for demographics, stenosis characteristics, and MMC usage. A basic cost analysis is carried out. RESULTS: Fifty patients underwent 93 MMC applications (mean = 50.8 years, 25 male, 25 female). In 89 of 93 applications (96%), the concentration of MMC was 0.4 mg/ml. One major complication occurred (1.1%). The expense for MMC is $455; the mean cost for airway surgery is $7,840. It is estimated that if 1 of 17 MMC treated patients requires one less operation, the cost ratio is favorable. CONCLUSIONS: This large series contributes to literature that MMC is a safe adjunct to laryngotracheal surgery. The marginal cost for MMC application is favorable based on our basic cost analysis and existing efficacy data. SIGNIFICANCE: Mitomycin-c seems to be safe and cost-effective in endoscopic airway surgery. EBM RATING: C-4.

Perceptual voice analysis of patients with subglottic stenosis.

OBJECTIVES: To characterize the perceptual assessment of vocal quality in subglottic stenosis (SGS) patients and to identify risk factors for dysphonia. STUDY DESIGN AND SETTING: Retrospective review, academic center. METHODS: Perceptual voice assessment using GRBAS scale (Grade, Roughness, Breathiness, Asthenia, Strain); patient characteristics determined for 31 SGS cases. RESULTS: The mean GRBAS (0 to 3 scale, 0 = normal quality) for SGS patients at their initial visit was G(1.4)R(1.2)B(0.5)A(0.5)S(1.1). For males vs females: G(2.1 vs 1.1)R(2.0 vs 0.8)B(1.0 vs 0.4)A(1.0 vs 0.3)S(1.7 vs 0.9). The Grade (P < 0.03), Breathiness (P < 0.04), and Asthenia (P < 0.02) assessments were significantly more dysphonic in patients with multilevel stenosis; vocal fold motion impairment (VFMI) also impacted overall Grade (P < 0.01). Overall Grade (P < 0.002), Roughness (P < 0.007), and Breathiness (P < 0.006) were significantly worse in patients with prior airway surgery. CONCLUSION: SGS patients demonstrate a mild to moderate change in perceptual voice characteristics with males in this series being more affected than females. Negative risk factors include multiple stenoses, VFMI, and previous airway surgery. SIGNIFICANCE: This is the first systematic report of perceptual voice assessment in subglottic stenosis. SGS patients have notable degrees of dysphonia with identifiable risk factors.

Association of airway abnormalities and risk factors in 37 subglottic stenosis patients.

OBJECTIVES: The study objective is to characterize the airway abnormalities in a series of patients with subglottic stenosis (SGS) as they relate to etiology and risk factors. STUDY DESIGN AND SETTING: Retrospective review, academic medical center. Airway characteristics, patient demographics, and suspected risk factors were recorded from a database of SGS cases from 2001 to 2004. RESULTS: Thirty-seven patients with SGS were identified; 22 of 37 had isolated SGS (59%). Intubation (10 of 37, 27%), high tracheotomy (4 of 37, 11%), and reflux (5 of 37, 14%) comprised the bulk of cases; 13 of 37 (35%) were considered idiopathic. Of 22 patients with isolated SGS, the majority 18 of 22 (P = 0.06) were women, 59% of which were idiopathic. Multiple-level cases (0 of 15) were idiopathic (P < 0.001). Intubation was the most common cause of multiple site stenosis (6 of 15, 40%). CONCLUSIONS: The majority of patients in this study had isolated lesions. These patients tend to have no apparent risk factors. Multi-level cases are associated with prolonged intubation and known injuries. The nature of "idiopathic" stenoses is discussed. SIGNIFICANCE: Clinical examination of SGS may be meaningful in understanding the etiology of the stenosis.

Electromyography findings of the cricopharyngeus in association with ipsilateral pharyngeal and laryngeal muscles.

OBJECTIVES: We reviewed a large series of cricopharyngeal (CP) muscle electromyography (EMG) results and compared them with the EMG results from the inferior constrictor (IC), thyroarytenoid, (TA), cricothyroid (CT), and posterior cricoarytenoid (PCA) muscles. METHODS: We performed a retrospective review of all CP muscle EMG reports from studies performed between January 1996 and June 2003. All of the tested elements from the CP muscle EMG reports were recorded. The EMG results were recorded for the ipsilateral IC, TA, CT, and PCA muscles if they were simultaneously tested. Each muscle result was classified as normal, neurogenic inactive axonal injury (IAI), or neurogenic active axonal injury (AAI), and the muscle findings were compared. A patient chart review was performed to determine a clinical correlation. RESULTS: Fifty-nine patients underwent CP muscle EMG. Eighteen patients had bilateral EMG studies, making a total of 77 CP muscle studies. Nineteen sets of CP muscle results were normal, 43 demonstrated neurogenic IAI, and 15 demonstrated neurogenic AAI. The ipsilateral IC and CP muscles had the same innervation status in 27 of 28 studies (p < .0001). When the ipsilateral TA muscle was studied simultaneously with the CP muscle, 31 of 50 studies had the same innervation status (p = .005). The ipsilateral CT and CP muscles demonstrated the same innervation status in 40 of 50 studies (p < .0001). The correlations between the CP and IC muscle findings and between the CP and CT muscle findings were both stronger than the correlation between the CP and TA muscle findings (p < .0001 and p = .024, respectively). The chart review demonstrated the clinical findings to be consistent with the EMG results. CONCLUSIONS: The EMG studies demonstrated that CP muscle findings have the strongest correlation with IC muscle findings, followed by the CT and TA muscles. This outcome does not support theories indicating that the recurrent laryngeal nerve innervates the CP muscle in all cases.

Laryngeal electromyography for adult unilateral vocal fold immobility: a survey of the American Broncho-Esophagological Association.

OBJECTIVES: Diagnostic and management strategies for adult unilateral vocal fold immobility (UVFI) vary among otolaryngologists. The aim of this study was to determine the current attitudes and practices regarding laryngeal electromyography (LEMG) for the management of adult UVFI within a cohort of subspecialty laryngologists. METHODS: A 19-item instrument focused on diagnosis and management of adult UVFI was mailed to active members (n = 249) of the American Broncho-Esophagological Association (ABEA). The subset of questions related to LEMG is reviewed in this report. Statistical analysis using a chi2 test was performed. RESULTS: The survey response rate was 34% (n = 84), with 8 surveys returned incomplete because of pediatric-limited practices. Of the respondents, 75% (n = 57) rely on LEMG for evaluation of UVFI, whereas 25% (n = 19) do not use LEMG. Of those who use LEMG, 54% place their own electrodes and 44% interpret the LEMG results themselves. Monopolar electrodes are used by 57% (n = 25), bipolar electrodes by 27% (n = 12), and hooked-wire electrodes by 17% (n = 7). Muscles evaluated by LEMG include the thyroarytenoid (100%), cricothyroid (94%), posterior cricoarytenoid (70%), lateral cricoarytenoid (43%), cricopharyngeus (27%), and interarytenoid (17%). The LEMG is performed in an unblinded fashion by most respondents (85%), and many (66%) feel a more accurate result is obtained when clinical information is known. There was no statistically significant difference in use of LEMG, placement of electrodes, and interpretation of LEMG according to percentage of laryngology practice. CONCLUSIONS: The survey results demonstrate congruence among ABEA members in the utility of LEMG in the management of adult UVFI. Some variability was noted in the methods by which LEMG is performed and interpreted.

Meta-analysis of upper probe measurements in normal subjects and patients with laryngopharyngeal reflux.

We report a meta-analysis of a series of studies in which 24-hour ambulatory pH monitoring was performed in 1) normal subjects, 2) the normal control subjects in studies of laryngopharyngeal reflux (LPR), and 3) the patients with LPR in these controlled studies. The statistical analysis utilized the fixed-effects model by Mantel-Haenszel and the random-effects mixed model. There were 16 studies from the past 12 years that fulfilled the inclusion criteria. They involved 793 subjects (264 normal and 529 with LPR). The numbers of positive pharyngeal reflux events for normal subjects and for patients with LPR differed with a p value of <.0001. There was also a significant difference in the mean percentage of acid exposure times between normal subjects and patients with LPR (p = .003). We conclude that the upper probe gives accurate and consistent information in normal subjects and patients with LPR. The numbers of reflux events and acid exposure times are most important in distinguishing normal subjects from patients with LPR. The technology and methodology of probe testing is quite reliable and is consistent on a worldwide basis.

The utility of routine chest radiography following jet ventilation in elective laryngotracheal surgery.

OBJECTIVES/HYPOTHESIS: Jet ventilation is a useful mode of airway management for laryngotracheal surgery. The objective of this study is to evaluate the utility of routine chest radiography following jet ventilation for these cases. STUDY DESIGN: Retrospective chart review. METHODS: Thirty-four elective surgical procedures performed from 1998 to 2002 are reviewed for postoperative airway and pulmonary complications. Data were collected from clinical notes as well as from the results of chest radiographs. This included the need for tracheotomy, reintubation, pneumothorax, pneumomediastinum, and atelectasis. RESULTS: A retrospective chart examination revealed no major complications. Twenty-nine of the 34 cases had postoperative chest radiography (CXR) performed on a routine basis. Atelectasis was present in 12 of 29 CXR (41%); no intervention was required in these cases. CONCLUSIONS: Routine postoperative CXR may not be useful following jet ventilation for elective laryngotracheal surgery. The safety of jet ventilation is discussed.

Perspectives in laryngopharyngeal reflux: an international survey.

OBJECTIVES: Although data exists to support the relationship between laryngopharyngeal reflux (LPR) and laryngitis, there is variability among otolaryngologists regarding the methods and criteria used to make the diagnosis. This study was undertaken to discern the current attitudes and practices of a select cohort of otolaryngologists in regards to LPR. METHODS: Four hundred fifteen surveys were mailed to members of the American Broncho-Esophagological Association. Survey recipients were asked to rate patient symptomatology and physical examination findings in terms of their relationship to LPR and their preferred laryngeal visualization procedure in terms of clinical use and diagnostic accuracy. The role and validity of adjunctive diagnostic tests were also surveyed. RESULTS: Survey response rate was 38%. Symptoms felt to be most related to reflux were: throat clearing (98.3%), persistent cough (96.6%), heartburn/dyspepsia (95.7%), globus sensation (94.9%), and voice quality change (94.9%). The physical examination findings felt to be most related to reflux included: arytenoid erythema (97.5%), vocal cord erythema (95.7%) and edema (95.7%), posterior commissure hypertrophy (94.9%), and arytenoid edema (94.0%). Fiberoptic laryngoscopy was the most commonly performed diagnostic visualization procedure (75.7%) and was also considered to be most sensitive and specific (45.0%). The most commonly ordered adjunctive test was a double pH probe (37.2%), which was also felt to be the most sensitive and specific adjunctive test (75.9%). CONCLUSION: A polling of a select group of otolaryngologists demonstrated agreement in the criteria used to diagnose reflux laryngitis, although some variability exists. The development of objective guidelines for the diagnosis of LPR is a critical initial step toward evaluating the manifestations and therapeutic interventions for this disease process.

Nissen fundoplication surgery for extraesophageal manifestations of gastroesophageal reflux (EER).

OBJECTIVE: To determine the outcome of Nissen fundoplication surgery for the treatment of patients with chronic extraesophageal manifestations of reflux (EER). METHODS: A retrospective medical record analysis was performed. Patient demographics, extraesophageal disease secondary to gastroesophageal reflux (GER), methods of GER diagnosis, acid suppression therapy before antireflux surgery, and response to surgical intervention were evaluated. RESULTS: The charts of 29 patients who underwent Nissen fundoplication surgery for EER were included in the study. Hoarseness was present in 17 patients; laryngopharyngeal reflux (LPR) was the most common diagnosis (n = 20). Barium esophagram was done in all patients and revealed abnormalities indicative of GER in 26 patients. Twenty-four-hour ambulatory pH study was done in 27 patients and pharyngeal reflux was present in 19. Preoperative esophageal endoscopy was performed in 22 patients. This study revealed evidence of gastroesophageal reflux disease (GERD) in 14 patients with 8 having evidence of Barrett's esophagus. Sixteen of the 29 patients had symptoms or findings of GERD. Twenty-eight patients had laparoscopic Nissen fundoplication (LNF) and 1 had an open procedure. Twenty-five of the 29 patients (follow-up ranging from 6-108 mo) had excellent results with near-total freedom from symptoms and are taking no acid-suppressive medications. CONCLUSIONS: GER has an important role in the cause of many otolaryngologic and pulmonary disorders. Nissen fundoplication is an effective modality to treat EER in selected cases.

Management of cerebrospinal fluid rhinorrhea: the Medical College of Wisconsin experience.

INTRODUCTION: The management of cerebrospinal fluid (CSF) rhinorrhea has evolved in recent years. The purpose of this comprehensive retrospective study is to assess issues related to the management of skull base defects associated with CSF rhinorrhea involving the nose and paranasal sinuses. METHODS: A retrospective review of CSF leak management was conducted. This study included patients with CSF rhinorrhea managed by the Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI, from 1992 to 2002. Data collected included site of leak, surgical approach, and any recurrence of leak. RESULTS: Fifty-seven CSF leaks occurred in 53 patients with CSF rhinorrhea originating from the nose or paranasal sinuses. Twenty-eight of the 53 had iatrogenic injuries resulting in CSF rhinorrhea, 16 had leaks from trauma, and 13 developed spontaneous CSF leaks. Ten patients responded to nonoperative management with bed rest with or without lumbar drain placement. Forty-three patients with 47 leaks underwent surgical repair of CSF rhinorrhea, of which 38 resolved after initial repair. Five of these patients developed recurrent CSF leaks at the repair site but resolved with subsequent surgery. Of these, two initially presented with spontaneous CSF leaks, one patient had a gunshot wound with massive skull base injury, and two recurred after repair of an iatrogenic injury. Factors associated with failure included lateral sphenoid leaks and elevated body mass index (BMI). DISCUSSION: Multiple approaches to the management of CSF rhinorrhea can be successful. An endoscopic repair results in resolution of CSF rhinorrhea in the majority of cases. Patients with spontaneous CSF rhinorrhea, elevated BMI, lateral sphenoid leaks, and extensive skull base defects are at increased risk for recurrence. Alternative management options may need to be considered in these cases.

Videofluoroscopic swallow studies in unilateral cricopharyngeal dysfunction.

OBJECTIVES/HYPOTHESIS: Although the cricopharyngeus muscle is a ring-like structure, unilateral cricopharyngeal dysfunction can produce significant dysphagia. This entity has not been well described in the literature. The aims of the study were to identify the characteristic findings on videofluoroscopic swallow studies in patients with dysphagia secondary to unilateral cricopharyngeal dysfunction, to note the associated vagal nerve injury, and to evaluate patient outcomes following ipsilateral cricopharyngeal myotomy. STUDY DESIGN: Retrospective clinical investigation. METHODS: The clinic charts, electromyographic tests, videostroboscopic examinations, and videofluoroscopic swallow studies were reviewed from a series of patients who presented to our institution from 1993 to 2001 with dysphagia and findings on videofluoroscopic swallow studies suggestive of unilateral cricopharyngeal dysfunction on posterior-anterior view. In patients treated with ipsilateral cricopharyngeal myotomy, postoperative findings on swallow studies and patient outcomes were also reviewed. RESULTS: Eighteen patients demonstrated findings characteristic of unilateral cricopharyngeal muscle dysfunction on videofluoroscopic swallow study. The common feature was a unilateral shelf-like barrier at the cricopharyngeus on the posterior-anterior view with pooling of liquid bolus in the ipsilateral pyriform sinus and episodic shunting to the contralateral side. Eight patients did not have evidence of cricopharyngeal dysfunction (ie, cricopharyngeal bar) on lateral films. Of the 18 patients, 14 had histories consistent with vagal injury secondary to trauma (n = 2), neoplastic involvement (n = 7), iatrogenic injury (n = 2), or central nervous system disease (n = 3). Results of videostroboscopic examinations demonstrated vocal fold motion impairment in 14 patients, and electromyographic test results confirmed unilateral vagal injuries in those who underwent electromyographic testing (n = 6). In the remaining 4 of 18 patients, videostroboscopic examinations demonstrated normal vocal fold abduction but impaired lengthening with a posterior glottic gap, and electromyographic test results (n = 4) indicated unilateral superior laryngeal nerve involvement. Of the 15 patients treated with ipsilateral cricopharyngeal myotomy, 1 patient required postoperative esophageal dilations for an esophageal stricture distal to the cricopharyngeus, whereas the remaining 14 patients had functional resolution of their dysphagia. CONCLUSION: In patients presenting with dysphagia and evidence of unilateral vagal injury, careful assessment of posterior-anterior view on videofluoroscopic swallow study should be included to evaluate for unilateral cricopharyngeal dysfunction.