Patients with isolated laryngopharyngeal reflux are not obese

OBJECTIVES

The gastroenterology literature suggests that gastroesophageal reflux disease (GERD) is often associated with obesity. The National Institutes of Health uses body mass index (BMI) to identify patients who are overweight (BMI 25-30) or obese (BMI > 30). The aim of this study was to determine whether there is a relationship between laryngopharyngeal reflux (LPR) and elevated BMI.

STUDY DESIGN

The study involved a retrospective review of 500 pH-probe studies performed consecutively within the department.

METHODS

Studies performed on antireflux medication or after fundoplication were excluded. From the included study reports, age, sex, height, weight, use of tobacco or alcohol, and pharyngeal and esophageal probe findings were recorded. After controlling for other factors, the relationship between LPR and BMI was determined and statistical analysis performed.

RESULTS

Two hundred and eighty-five of the 500 pH studies met inclusion criteria. The overall mean BMI was 27.9 +/- 6.42. The mean BMI for patients with normal studies was 25.6 +/- 5.07, for those with isolated LPR 25.9 +/- 6.44, for those with isolated GERD 28.3 +/- 6.81, and for those with globally abnormal studies (LPR and GERD) 28.8 +/- 6.55. Abnormal pharyngeal reflux did not correlate with increasing BMI; however, abnormal esophageal reflux events correlated with increasing BMI (P = .002). The mean number of pharyngeal reflux events was not elevated in obese patients, whereas the mean number of esophageal reflux events was significantly elevated in obese (P = .02) when compared with nonobese patients.

CONCLUSION

This study demonstrates that pharyngeal reflux is not associated with increasing BMI or obesity in LPR patients. In contrast, abnormal esophageal reflux (GERD) is associated with increasing BMI and obesity. Because of the LPR patient selection bias of this study, these findings may not be applicable to the GERD populations routinely seen by gastroenterologists.

Endoscopic Management of Extruding Medialization Laryngoplasty Implants

BACKGROUND

Medialization laryngoplasty (ML) is a commonly performed procedure for vocal fold motion impairment with glottic incompetence. Although implant extrusion is a well-known risk of ML, management of this complication is rarely mentioned in the literature. The aim of this study was to review our experience with endoscopic implant retrieval for a group of patients with extruding ML implants.

METHODS

All patients identified in our institution from January 1989 through August 2004 with a history of ML and extruded implants were identified. Case management was reviewed, including information on presentation, management techniques, and outcomes.

RESULTS

Five patients presented with extruding ML (Gore-Tex [n = 2] or silastic [n = 3]) implants. All patients presented with worsening dysphonia and evidence of fullness and/or granulation tissue at the extrusion site. Endoscopic removal was performed using either sharp dissection or CO2 laser dissection. After removal, four patients underwent vocal fold injection augmentation.

CONCLUSIONS

Endoscopic removal appears to be a safe, effective, and even preferred alternative to external transcervical removal in selected cases of extruding implants.

Effects of viscosity, taste, and bolus volume on swallowing apnea duration of normal adults

OBJECTIVE

The effects of viscosity, taste, and nectar-thick liquid bolus volume on swallowing apnea duration (SAD) were examined.

STUDY DESIGN AND SETTING

Twenty-two adults, comprised of 10 males and 12 females, participated. SAD was assessed via nasal airflow during swallow conditions of viscosity (thin liquid, thick liquid, and puree), taste (water, apple juice, lemon concentrate), and nectar-thick liquid bolus volumes (5, 10, 15, and 20 mL) across three trials.

RESULTS

A significant main effect of nectar-thick liquid bolus volume was found (P < 0.05). Viscosity and taste were not significant.

CONCLUSIONS

SAD increased with increases in bolus volume; however, neither changes in bolus viscosity nor changes in taste affected SAD.

SIGNIFICANCE

These findings indicate that since viscosity was not significant, the normative data previously published (by this PI) with 60 healthy adults stratified by age and gender can be utilized for comparison to disordered swallowing without regard to the bolus viscosity being used.

EBM RATING

D.

Transnasal esophagoscopy: revisited (over 700 consecutive cases)

BACKGROUND

High-resolution transnasal esophagoscopy (TNE) allows comprehensive, in-office examination of the esophagus without sedation.

OBJECTIVE

To compare the authors' present experience using TNE with our initial, previously reported experience.

METHODOLOGY

Retrospective review of 611 consecutive patients undergoing TNE was compared with 100 consecutive patients previously reported.

RESULTS

The most frequent indications for TNE were screening examination of the esophagus in reflux, globus, or dysphagia patients (n = 490), biopsy of a lesion in the laryngopharynx, trachea, or esophagus (n = 42), screening examination of the esophagus in head and neck cancer patients (n = 45), and evaluation for an esophageal foreign body (n = 12). Seventeen procedures were aborted secondary to a tight nasal vault. Significant findings were found in 50% (294/592). The most frequent findings were esophagitis (n = 98), hiatal hernia (n = 47), and Barrett's esophagus (n = 27). These results are similar to those previously reported.

CONCLUSIONS

TNE is safe, well tolerated by patients, and is easy to learn with a short learning curve. TNE may replace radiographic imaging of the esophagus in otolaryngology patients with reflux, globus, and dysphagia.

Review article: diagnosis and management of night-time reflux

Symptoms of gastro-oesophageal reflux disease (GERD) range from mild to severe and, when they occur during night-time hours, can interfere with sleep patterns and reduce overall quality of life. The clinical presentation of GERD is characterized by oesophageal as well as supra-oesophageal symptoms, including otolaryngologic and pulmonary complications. However, GERD may be overlooked as the cause of a patient's supra-oesophageal symptoms because these complaints can occur in the absence of oesophageal symptoms or endoscopic changes. The role of available tools used for GERD diagnosis, including endoscopy, oesophageal pH monitoring and an empirical course of proton pump inhibitor therapy, is discussed. Interventions available to achieve the therapeutic goals of symptom relief and prevention include specific lifestyle modifications and over-the-counter as well as prescription pharmacological agents. Patient-initiated, as-needed treatment may not be the best choice for managing persistent night-time reflux because it requires patient arousal from sleep. Proton pump inhibitor therapy remains the treatment of choice for patients with more severe symptoms and those with erosive oesophagitis. Few studies have specifically evaluated the role of pharmacological agents in the management of night-time reflux and comparisons are difficult due to the variability in study design and endpoints assessed.

Vocal fold augmentation with calcium hydroxylapatite

OBJECTIVES

Voice disorders affect more than 3% of the general population. Vocal fold atrophy is a part of the normal aging process, with up to 60% of 60-year-old individuals displaying evidence of glottal insufficiency. A safe, effective, and durable substance for injection augmentation of the vocal folds is not currently available. The purpose of this investigation was to describe our preliminary experience with calcium hydroxylapatite (CaHA) for vocal fold augmentation.

METHODOLOGY

All patients undergoing injection augmentation of the vocal folds with CaHA between January 1, 2002 and June 1, 2003 were prospectively evaluated. Data concerning indications, technique, functional outcome, and complications were collected. In addition, the larynx donated from a woman who underwent vocal fold augmentation with CaHA and subsequently died from terminal cancer was histologically examined.

RESULTS

A total of 39 vocal folds in 23 individuals were injected with CaHA. The mean age of the cohort was 62. Fifty-two percent were male. The indications for augmentation were unilateral vocal fold paralysis (9/23), unilateral vocal fold paresis (5/23), presbylarynx (3/23), Parkinson's (3/23), bilateral vocal fold paresis (2/23), and abductor spasmodic dysphonia (1/20). There were no adverse reactions. All individuals reported improvement on a self-administered disease-specific outcome measure (P < 0.001). The pathology from the donated larynx 3 months after injection revealed intact CaHA spherules in good position with a minimal, monocellular inflammatory reaction to the gel carrier and no evidence of implant rejection.

CONCLUSIONS

Initial experience with vocal fold augmentation using CaHA is promising. Long-term safety and efficacy needs to be established.

Cricoid Chondrosarcoma Presenting as Arytenoid Hypertelorism

BACKGROUND

Arytenoid hypertelorism (arytenoid cartilages spaced too widely apart) appears to be the most common initial recognizable physical finding of cricoid chondrosarcoma. Nine cases from the Center for Voice Disorders are presented. With arytenoid hypertelorism caused by cricoid chondrosarcoma, usually the posterior larynx is open. In fact, patients with arytenoid hypertelorism caused by cricoid chondrosarcoma may be aphonic even though the anterior membranous vocal folds make contact during attempted phonation.

METHODS

Between 1991 and 2002, nine patients were diagnosed with cricoid chondrosarcoma. Patients' charts and video examinations were retrospectively evaluated for symptoms and the presence of arytenoid hypertelorism on endoscopic evaluation. Two were women, and seven were men, with a mean age of 70 (range 53-72) years at diagnosis.

RESULTS

Eight (88%) patients had aphonia or dysphonia caused by arytenoid hypertelorism as their presenting symptom. Six were diagnosed after failed medialization laryngoplasty or other laryngeal rehabilitation surgery. All nine patients had a low-grade tumor. The initial treatment in eight patients was hemicricoidectomy, and one patient had a total laryngectomy. In four cases, a second procedure was needed 1 to 6 years later because of recurrence. Seven patients are alive without clinically significant disease; one is alive with moderate disease, and one has died from an unrelated cause.

CONCLUSIONS

Severely dysphonic, elderly patients presenting with arytenoid hypertelorism of unknown cause should be evaluated by fiberoptic laryngoscopy and by computed tomography scan to rule out cricoid chondrosarcoma. Because these tumors behave so benignly, the authors recommend conservative surgery (unilateral hemicricoidectomy) as the diagnostic/treatment modality of choice.

Fundoplication for laryngopharyngeal reflux disease

BACKGROUND

Laryngopharyngeal reflux (LPR) disease arises from the effects of refluxed gastric contents on the proximal aerodigestive tract. LPR patients are often lumped into the category of "atypical" reflux. LPR symptoms are hoarseness, globus, cough, and pharyngitis. Severe disease is associated with subglottic stenosis and laryngeal cancer. Treatment includes lifestyle modifications and medications. The role of fundoplication for LPR has yet to be defined.

STUDY DESIGN

Forty-one patients underwent fundoplication for LPR. They were prospectively followed with three outcomes measures: The Reflux Symptom Index, a laryngoscopic grading scale (Reflux Finding Score), and a reflux-based specific quality-of-life scale.

RESULTS

Average early followup was at 4 months and late followup was at 14 months. The Reflux Symptom Index improved by 5.4 early (p < 0.05) and 6.5 late (p < 0.05). Improvement between early and late periods approached significance (p < 0.09). Reflux Finding Score improved 3.8 (p < 0.05) early and 4.4 (p < 0.05) late. The Quality of Life Index improved 0.6 early and 2.3 (p < 0.05) late. By Reflux Symptom Index criteria, 26 patients were improved early versus 35 late (p < 0.05). Factors associated with poor outcomes were structural laryngeal changes in five patients (p < 0.05) and no response to proton pump inhibitors in six patients (p < 0.05).

CONCLUSIONS

Fundoplication augments treatment of LPR. Improvement of symptoms continues past the first 4 months. Laryngoscopy is critical in patient selection because selected findings are associated with outcomes, diagnosis, and management.