Augmentation techniques in laryngotracheal reconstruction

The treatment of laryngotracheal stenosis remains challenging. Even with the wide variety of current techniques available, optimal reconstruction is not possible for all patients. However, the future of laryngotracheal reconstruction is promising with ongoing development of innovative techniques for repair, as well as the prospect of laryngeal transplantation.

Clinical features as diagnostic guides in obstructive sleep apnea

Obstructive sleep apnea (OSA) may induce psychiatric problems, but clinical risk factors do not reliably predict laboratory-verified OSA. Therefore, OSA diagnosis requires laboratory sleep monitoring. To find additional clinical features that would sharpen indications for sleep monitoring, we applied univariate analyses to clinical data for 137 OSA patients seen in a psychiatry sleep clinic. A symptomatology questionnaire was obtained from 101 of these patients: 71 had morning and 86 had afternoon vigilance tests, and all had upper-airway evaluation and polysomnography. Cigarette consumption but no other clinical features differed among OSA severity groups and total sleep period groups; upper-airway findings differed among vigilance groups. Multidiscriminant clinical predictor terms categorized several patients with severe OSA into less severe OSA categories. Clinical features did not accurately predict OSA. OSA will continue to be identified primarily by sleep laboratory testing. A two-phase laboratory routine, reserving full laboratory testing for patients with negative results on initial, less expensive screening tests, might conserve resources.

A comparison of preservation techniques in a vascularized rat laryngeal transplant model

In earlier laryngeal transplantation studies by Takenouchi, et al., the longest ischemic interval tolerated was 45 minutes. A new animal model and enhanced preservative solutions made reassessment timely. This study evaluated two determinants of graft viability: 1. the duration of ischemia and 2. the composition of the preservative media. Three groups of viable transplants were assessed. Groups I and II were preserved with iced heparinized saline with respective ischemic intervals of 3 and 6 hours. Group III was preserved with the Wisconsin solution during a 20-hour ischemic interval. All animals were sacrificed at 24 hours. Representative sections of group I confirmed viability whereas group II exhibited both clinical and histologic evidence of irreversible vascular change. In contrast, most representative sections in group III had little demonstrable change. These data suggest that laryngeal allografts can endure prolonged ischemic intervals if properly maintained.

Laryngeal transplantation: a program for investigating new parameters

Laryngeal transplantation was actively investigated in the late 1960s and early 1970s using a dog model. An expanded knowledge base in immunobiology, pharmacology, and deglutition makes reassessment timely after an approximately 20-year hiatus. The basic parameters to be evaluated include varied methods of preservation, optimal immunosuppressive drug regimens, and the role of radiation therapy. Our current research protocol addressing the latter considerations is outlined, including a brief introduction of a new animal model developed specifically for this purpose. We will ultimately attempt to answer the question: Is laryngeal transplantation feasible?

An assessment of corn oil as a vehicle for cyclosporin A (CsA) at varied injection sites in preventing rejection of rat laryngeal allografts

This study was designed to determine the efficacy of corn oil as an alternative vehicle to olive oil for emulsifying cyclosporin (CsA) in preventing rejection of transplanted rat larynges. The issue of varied site absorption was also addressed. Thirty animals were transplanted to get 5 viable transplants at two weeks for three varied sites of administration; intramuscular (IM), subcutaneous (SQ) and intraperitoneal (IP). Five mg/kg of CsA in corn oil was the dose administered based on earlier data generated in our laboratory. Postulating selective absorption, the indirect measure of laryngeal histopathology, i.e. rejection, was chosen over blood levels for evaluation. In the IM group 2 grafts evidenced mild rejection whereas 3 showed marked cellular and vascular rejection. The SQ group had 1 mild, 1 moderate and 3 with severe rejections. The IP group had one moderate rejection and 4 severe rejections. Qualitatively the IM and SQ groups were similar. The IP group histologically evidenced far greater cellular rejection. CsA 5mg/kg emulsified in corn oil did not differ substantively in histologic scope or pattern of rejection from CsA in olive oil in experimental rat laryngeal transplantation. Further, the data did not support a change in the administration of CsA from an intramuscular site.

Carcinoma of the tonsil

Although the experts acknowledge that there is no conclusive evidence linking secondhand smoke to head and neck cancer, a recent report by the Environmental Protection Agency classifies secondhand smoke as a group A carcinogen. There is strong evidence linking it to carcinoma of the lung. Whereas you may not be able to tell your patient that the same cause and effect is present for head and neck cancer, it is the editor's belief that this will one day be proven. Three experts agreed to treat this patient with surgery followed by full-course radiotherapy, although the surgical approaches differed. They included a marginal mandibulectomy, radical neck dissection, and plating of the remaining mandible (Dr. Strome) and a composite resection (Drs. Ward and Johnson). For reconstruction, options included a modified FAMM flap or a split-thickness skin graft (Dr. Strome), tongue flap or pectoralis major myocutaneous flap (Dr. Ward), or a split-thickness skin graft (Dr. Johnson). One consultant suggested resecting the neck mass and treating the primary tumor and neck with radiotherapy. A dental consultation is in order prior to radiotherapy (Dr. Goepfert). With regard to this woman's mental status, all the experts called for counseling. The husband should be included in the discussions (Dr. Strome and Ward) and consideration should be given to the Women's Right Advocacy Group (Dr. Johnson).

The effects of cyclosporin A on transplanted rat allografts

Since 1983, Cyclosporin A (CsA) has been the most successful primary drug in preventing rejection of organ transplants. This study was designed to determine the efficacy and dose response of CsA in preventing rejection of LBNF-1 rat allografts to Lewis recipients. Four groups of animals were studied. Group I served as the control, and groups II, III, and IV were given daily intramuscular doses of CsA for 1 month. The groups were given doses of 5 mg/kg, 7.5 mg/kg, and 10 mg/kg, respectively. Sixty-eight animals were transplanted to get eight viable transplanted animals at 1 month in each CsA group. Laryngeal viability was assessed with both clinical and histological parameters. Groups II, III, and IV had representative clinically viable larynges. The histology varied and had some correlation with CsA dosage. Group II evidenced changes ranging from mild to severe rejection. Group III was more homogeneous with the most severe change being characterized as mild-to-moderate rejection. Group IV was the most uniform with all representative specimens showing only limited infiltration of inflammatory cells with intact mucosa and submucosal glands (mild rejection). None of the CsA groups evidenced the squamous metaplasia characteristic of the control group. CsA can prevent rejection of laryngeal allografts from LBNF-1 donors to Lewis recipients.

Down syndrome: an otolaryngologic perspective

The otolaryngologic manifestations of Down syndrome often masquerade as common and seemingly trivial conditions. Behind this facade lies a broad spectrum of disease which can detract from an inherently diminished level of function and jeopardize survival. This paper examines the pertinent associations between Down syndrome and various pathological entities related to the head and neck. Evaluation of current therapeutic modalities reinforces the need for early diagnosis and treatment so that the potential of this patient group is fulfilled.

Rat model for a vascularized laryngeal allograft

A new rat model was developed to reexamine the potential for laryngeal transplantation. The final anatomic derivation evolved from two earlier developmental phases. The first model had only a single arterial anastomosis; the second had an end-to-end arterial anastomosis with an end-to-end arteriovenous shunt. The final product employed an end-to-side arterial shunt and an end-to-side arteriovenous shunt for revascularization. The allografts were sited in tandem with the intact recipient larynges and were not innervated. A total of 16 animals were studied in phase 3; 2 died and the remaining 14 had a 64% arterial patency at intervals of 1 to 14 days. Our purpose is to detail the relevant technical considerations of this new model and compare it with historical controls.

Histopathologic correlates of acute laryngeal allograft rejection in a rat model

This study used both clinical and histopathologic criteria to define the sequence and time parameters of rejection in histoincompatible vascularized rat laryngeal allografts. Clinical onset of rejection was characterized at 1 week by graft edema. Pathologic examination at this time revealed arterial wall thickening and a diffuse lymphocytic and macrophage mucosal infiltrate. At 14 days, the graft was encased in an inflammatory exudate with no visible cartilaginous structure. This correlated microscopically with a lymphocytic infiltrate of the lamina propria, loss of minor salivary glands, and squamous metaplasia of the surface respiratory epithelium. Arterial thrombosis was always correlated with tissue necrosis, but venous occlusion, occurring more than 2 days after transplantation, was not an independent determinant of graft viability. Definition of the time sequence and histopathology of rejection will allow future determination of the efficacy of various immunosuppressive regimens.

Laryngeal transplantation. The future

The ethics, justification, history, future, and rejection of laryngeal transplantation are examined in this article. The authors believe that laryngeal transplantation will be a viable alternative for a select group of patients before the end of this century.

Gax collagen as an adjunctive measure for the incontinent myomucosal shunt

Clinically important aspiration following the creation of a phonatory myomucosal shunt has occurred in 16% of our cases. Gax collagen was used in three cases therapeutically with excellent results. We report the technique used, the properties that make it efficacious, and the case specifics.

A long-term assessment of cryotherapy for treating vasomotor instability

Cryotherapy was used to treat severe nasal vasomotor instability in 21 patients who had failed several varied medical regimens. Treatment was given via a closed nitrous oxide system for intervals of 60 to 75 seconds. Anatomic sites treated included the medial aspect of the pterygopalatine fossa, posterior inferior middle turbinate, and posterior superior inferior turbinate. The minimum follow-up interval was two years. The conditions of 18 of 21 patients were substantively improved with one surgical freeze, and an additional patient responded favorably to three procedures. Three of four patients with associated obstructive sleep apnea also had apnea relieved. The technique presented warrants further evaluation in a larger series of patients.

Myomucosal shunt following total laryngectomy: a report of 31 cases

An original technique of voice rehabilitation following total laryngectomy based on the concept of a myomuscosal unit was originally described by Strome. Thirty-one cases of myomucosal shunts (MMS) are analyzed in the present report. The 14 initial cases failed because of a lack clinical and surgical experience and insufficient selection of the patients. Among the last 17 cases, 1 was lost to follow-up, 1 had an insufficient follow-up, and 2 patients refused to speak with the MMS instead of a patent shunt; 5 of the remaining patients had voices evaluated as excellent, 7 had voices interpreted as good and only 1 patient had a voice evaluated as poor. Aspiration was not a problem. Eleven patients were found to stenose their shunt, but fistula were recalibrated successfully. The MMs can be used safely in oncological surgery and only 1 of 31 deaths in our total experience was due to a local recurrence. These findings show that the MMS is a reliable procedure for voice restoration following total laryngectomy; a prosthesis is not required and there are currently no oncological limits to the procedure. However, a very close follow-up of the patients is required after surgery.

Circulating immune complexes and chemotherapy response in patients with head and neck cancer

An assay which could prospectively predict a response to chemotherapy prior to instituting therapy would be beneficial, especially for nonresponders. We evaluated at random a total of 50 patients with previously untreated stage III and IV head and neck squamous cell carcinoma for T-cell subsets and levels of circulating immune complexes (CIC). Of this group 23 patients had induction chemotherapy as their first modality of treatment. These patients received standard protocols of therapy consisting of cisplatin, 5-fluorouracil, methotrexate, and bleomycin. Of the laboratory measures assessed, only CIC correlated with clinical response to chemotherapy [no response (NR), partial response (PR), complete response (CR)] at the completion of the induction period (two to four cycles). Levels of CIC were determined by a polyethylene glycol (PEG) precipitation assay, and measured by spectrophotometry at 280 nm. In our population of all head and neck cancer patients, CIC were elevated (mean +/- SD values: 0.475 +/- 3.8 compared with controls: 0.184 +/- 0.07). In the NR group, the mean +/- SD was 0.707 +/- 0.43 (P = 0.001). Complete responders had a mean value of 0.332 +/- 0.21; partial responders had a mean value of 0.255 +/- 0.13. On the basis of the values determined, patients with markedly elevated levels of CIC would be predicted to respond poorly, or not all, to current induction chemotherapy protocols.

Voice evaluation of myomucosal shunt after total laryngectomy: comparison with esophageal speech

The vocal quality attained with a tracheoesophageal myomucosal shunt (MMS) as described by Strome was evaluated in four patients and compared with three esophageal speakers and two normal subjects. The patients with MMSs acquired speech sooner. Fundamental frequency, pitch, timbre, and melody were analyzed with computerized electroglottography and sonography. Intelligibility was deemed better after the MMS primarily because phonation time approximated that of normal speech, and this study suggests that, following total laryngectomy, the vocal quality achieved using the MMS is preferrable to that of esophageal speech.

Postanginal sepsis

Postanginal sepsis is a septicemia resulting from an antecedent pharyngitis that causes an internal jugular vein thrombophlebitis. Because of the severity of the disease and the difficulty in its diagnosis, familiarity with all aspects of the disease is essential. We present three cases and review the literature on postanginal sepsis. The clinical course of the disease is described and its evaluation and treatment are outlined.

Further experience with the myomucosal tracheoesophageal shunt

A follow-up study to the initial work of Strome and colleagues in advancing the concept of the myomucosal flap for voicing following total laryngectomy is described. Data are evaluated from 30 patients. Seven of the eight original patients have functioning shunts with excellent voicing and six remain tumor free at more than two years. In the Laennec Hospital (Paris) series of 22 patients, seven shunts are functioning independently. Eleven of 20 inferiorly based flaps stenosed, and all stenoses occurred at the posterior tracheal wall. Technique refinements improved the patency percentage with the seven successes occurring in the last 13 procedures. Four patients in the series had flap necrosis, two of whom had diabetes mellitus and two others extensive paratracheal resections. The technique continues to merit consideration, recognizing that there is a learning curve before success can be anticipated.

Relief of sleep apnea by revision of the adult upper airway. A review of clinical experience

Surgical revision of the upper airway for obstructive sleep apnea has repeatedly improved subjective more than objective laboratory outcome measures. To examine this disparity, we obtained subjective sleepiness questionnaire scores, Continuous Performance test, and polysomnography (PSG) in 40 patients with mild to moderate obstructive sleep apnea (mean apnea index, 33.9; mean minimum oxygen saturation during sleep, 75.4%). Continuous Performance test confirmed abnormal daytime sleepiness and correlated with minimum oxygen saturation and number of transitions between stages. Postoperatively, questionnaire scores fell a mean of 62%, indicating a marked improvement in subjective sleepiness. Changes in questionnaire score correlated with changes in minimum oxygen saturation. Mean PSG indexes showed no change. Individual patients without PSG improvement reported long-term improvement in daytime functioning, as confirmed by family members. These results suggest that measures in addition to PSG, including patient subjective response, would more fully characterize the outcome of revision of the upper airway for sleep apnea.

Vagaries of thyroglossal duct cysts

The thyroglossal duct cyst is the most common congenital cyst found in the neck, classically presenting as a paramidline mass in a healthy young adult. Fifty-three cases managed at the Brigham and Women's Hospital and Boston's Beth Israel Hospital over the past 10 years were reviewed. The unique presentation of papillary adenocarcinoma in TGDCs and findings in the elderly population are discussed. These cases represent both diagnostic and therapeutic challenges. The existing literature is correlated with our data, providing a treatise on management.

Staging in the treatment of maxillary carcinoma revisited

The site of origin of maxillary sinus carcinoma will not infrequently predetermine the varied neurological signs at presentation. Modifying Ohngren's division, the maxillary sinus can be divided into four quadrants based on anatomical nerve correlates, thus facilitating identification of the primary site. An inclusive classification of maxillary sinus carcinoma based on Broder's grading, site of origin, the TNM classification and the patient's general condition, serves as the basis for a correlative therapeutic regimen.

Hyperlipidemia in association with childhood sensorineural hearing loss

In adults there has been an association noted between hyperlipidemia and sensorineural hearing loss. Etiologic considerations include hyperviscosity of the serum, vascular occlusion and an increased susceptibility to noise. Until now this correlation, to our knowledge, has not been made in the pediatric population. Several children with bilateral fluctuating sensorineural hearing losses have been identified with hyperlipidemia. The fluctuations in hearing varied with lipid levels. With dietary controls, the cholesterol levels returned to what would be near the norm for the pediatric population and hearing returned to near baseline. Unexplained fluctuating sensorineural hearing losses in children warrant the consideration of hyperlipidemia. Discovering a potentially reversible etiology for hearing loss is significant but more importantly, may lead to the early detection of hyperlipidemia in the young patient.

The effects of anesthesia on middle-ear effusions

Surgeons occasionally note a discrepancy between preoperative assessment of middle-ear effusion and operative observation during the placement of ventilating tubes in children's ears. This study was designed to determine whether this variance is secondary to the effects of inhalation anesthesia or misinterpretation of the preoperative exam. Observations were recorded by three distinctly different methods of measurement: the surgeon, the MD-2 Impedance Analyzer, and the Acoustic Otoscope immediately before and after induction of anesthesia. These results were then analyzed and compared with the operative findings. Anesthetic induction was shown to cause alteration in the presence of middle-ear fluid in less than 10% of cases.