Management of Laryngopharyngeal Reflux in Asia

Objectives@#. This study was conducted to investigate the current practices of Asian otolaryngologists for laryngopharyngeal reflux (LPR). @*Methods@#. An online survey about LPR was sent to 2,000 members of Asian otolaryngological societies, and a subgroup analysis was performed between Western and Eastern Asian otolaryngologists. The survey was conducted by the Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the International Federation of Oto-rhino-laryngological Societies. @*Results@#. Among approximately 1,600 Asian otolaryngologists, 146 completed the survey (62 from Western Asian countries, 84 from Eastern Asian countries). A substantial majority (73.3%) of the otolaryngologists considered LPR and gastroesophageal reflux disease to be different diseases. The symptoms thought to be closely related to LPR were coughing after lying down, throat clearing, and globus sensation. The findings thought to be closely related to LPR were posterior commissure granulations and hypertrophy, arytenoids, and laryngeal erythema. The respondents indicated that they mostly diagnosed LPR (70%) after an empirical therapeutic trial of proton pump inhibitors (PPIs). Although multichannel intraluminal impedance-pH (MII-pH) monitoring is a useful tool for diagnosing nonacid or mixed LPR, 78% of Asian otolaryngologists never or very rarely used MII-pH. Eastern Asian otolaryngologists more frequently used once-daily PPIs (64.3% vs. 45.2%, P=0.021), whereas Western Asian otolaryngologists preferred to use twice-daily PPIs (58.1% vs. 39.3%, P=0.025). The poor dietary habits of patients were considered to be the main reason for therapeutic failure by Asian otolaryngologists (53.8%). Only 48.6% of Asian otolaryngologists considered themselves to be adequately knowledgeable and skilled regarding LPR. @*Conclusion@#. Significant differences exist between Western and Eastern Asian otolaryngologists in the diagnosis and treatment of LPR. Future consensus statements are needed to establish diagnostic criteria and therapeutic regimens.

Frame by frame analysis of glottic closure in fasting subjects

Objective: The purpose of the study is to examine vocal fold closure in fasting subjects using frame by frame analysis

Subjects and Methods: Twenty-two male subjects were recruited for this study. All subjects were evaluated while fasting and non fasting. Frame by frame analysis of at least three glottic cycles was performed and reported as a mean closed quotient. The degree of phonatory effort and vocal fatigue was also reported

Results: The mean closed quotient for all subjects while non fasting was 0.427 +/- 0.098 and while fasting 0.441 +/- 0.073, with no significant difference between the two [p value 0.417]. There was a significant increase in the phonatory effort while fasting [0.23 non fasting vs. 0.77 fasting, p value 0.036]

Conclusion: There is no change in the mean closed quotient in male subjects while fasting. However, most subjects exhibit a significant increase in phonatory effort

Vocal Symptoms and Acoustic Findings in Menopausal Women in Comparison to Pre-menopause Women with Body Mass Index as a Confounding Variable

OBJECTIVES: To compare the prevalence of phonatory symptoms in menopausal women compared to pre-menopause women with body mass index (BMI) as a confounding variable. METHODS: A total of 69 women, 34 menopausal and 35 pre-menopausal were invited to participate in this study. Demographic variables included age, smoking, and BMI. All subjects were asked about the presence hoarseness, loss of high or low frequencies, pitch breaks, throat clearing, dryness in the throat and vocal fatigue. Acoustic analysis was performed and the Voice Handicap Index (VHI)-10 was filled by all the subjects. RESULTS: There was a significantly higher prevalence of throat clearing and dryness in the menopausal group compared to the pre-menopause group with a P value of 0.035 and 0.032 respectively. When BMI was taken into account, there was no statistically significant difference in the prevalence of any of the phonatory symptoms in menopausal women with high BMI and pre-menopause. There was no statistically significant difference in the means of any of the acoustic parameters between the menopausal group and pre-menopausal group. There was no significant difference in the mean VHI-10 between the menopause group and the pre-menopause (P = 0.652). CONCLUSIONS: The results of this investigation substantiate the importance of fat as an alternative source of estrogen which can mask some of the phonatory symptoms.

Nasalance scores in Lebanese English- speaking adults using nasometric analysis

Objective : To obtain normative data for nasalance scores in Middle Eastern English-speaking adult population

Design : Cross-sectional study

Participants : A total of 102 subjects were recruited in the study, 26 were excluded, thus, 77 Middle Eastern English-speaking adults [mean age = 23.77 +/- 4.295 ; 39 males, 38 females] with normal speech and no hearing problems participated in the study

Interventions: Using Nasometer II 6450, nasalance scores were obtained for each participant's readings of 3 passages: Zoo and Rainbow passages and nasal sentences

Main outcome measures : Mean nasalance score, standard deviation and range

Results : Mean nasalance scores for Zoo passage, Rainbow passage and nasal sentences were 25.21 +/- 11.07, 34.04 +/- 9.30 and 41.29 +/- 9.87 respectively. Mean scores didn't differ significantly between males and females, though scores for the Zoo passage were slightly higher among males [26.51 +/- 11.66] than females [23.87 +/- 10.42]. In within-session reliability testing, 86% of retests for all three passages fell within 5 nasalance points of the previous test. In across-session reliability testing, 93% of retests for all 3 passages were within 5 points of initial test

Conclusions and Relevance: This study provides normative data for nasalance scores among Middle-Eastern adults, which can help make nasometer and determination of nasalance more clinically useful in this population

Formant characteristics of English-speaking Lebanese men

Objective : To report the formant characteristics of English-speaking Lebanese men during steady prolongation of vowels /a/ and /i/

Design : Cross-sectional study involving volunteer participants

Participants : Fifty healthy English-speaking males with a mean age of 32 +/- 4.027 years and a range of 42 years [18-60]

Materials and Methods : A total of 50 healthy males between the age of 18 and 60 were recruited for the study. Each subject was asked to phonate a sustained /a/ and /i/ sound at a comfortable pitch and intensity level. Measures were made in real-time and formant frequencies across F1, F2, F3 and F4 were determined using the Real-time Spectrogram VP 3950 [Kay Elemetrics, New Jersey]

Main outcome measures : The formant frequencies across F1, F2, F3 and F4 were recorded

Results: For the vowel /a/, the mean values of F1, F2, F3 and F4 were 622.86 +/- 61.293 Hz, 1264 +/- 78.602 Hz, 2610.90 +/- 206.359Hz and 3483.56 +/- 206.833 Hz, respectively. For the vowel /i/, the corresponding values were 378.88 +/- 51.825 Hz, 2210.34 +/- 124.077 Hz, 2847 +/- 168.770 Hz and 3576.82 +/- 242.760 Hz, respectively

Conclusion: Formant characteristics vary among cultures and ethnic groups

Primary malignant melanoma of the trachea

Tracheal melanomas represent the rarest type of extracutaneous melanomas. The clinical manifestation is similar to other tracheal tumors and ranges from symptoms of airway obstruction such as dyspnea and stridor to other nonspecific symptoms such as hoarseness, cough and hemoptysis. Bronchoscopy is required to draw the origin of the lesion biopsy is needed to establish histologic diagnosis. Treatment consists of either palliative surgery aiming at restoring the airway or tracheal resection and end to end anastmosis. We would like to present here below a rare case of tracheal melanoma and discuss the various diagnostic and therapeutic means

Tracheal schwannoma: a misleading entity

Primary tracheal tumors are rare with the majority being malignant. Benign lesions are less frequent with primary tracheal schwannomas accounting for less than 0.5% of tracheal tumors. They are more common in females and their clinical presentation is non-specific. Chronic cough, progressive respiratory distress and even asthma-like conditions prevail as presenting symptoms and signs. Laryngotracheal endoscopy reveals a solitary, well encapsulated mass arising most often from the posterior tracheal wall. The diagnosis of tracheal schwannomas is primarily pathological. Endoscopic excision, sleeve excision or tracheal resection, are all commonly accepted treatment modalities. Proper awarness of these lesions is crucial in the pre-operative work-up of patients presenting with stridor

Persistant dysphonia following endotracheal intubation

Voice production is a complex process that involves more than one system, yet most causes of dysphonia are attributed to disturbances in the laryngeal structures and little attention is paid to extralaryngeal factors. Persistent dysphonia after general anesthesia is a challenge to both anesthesiologists and otolaryngologists. The etiology is often multivariable and necessitates a team approach for proper diagnosis. Laryngeal symptoms are subdivided into phonatory disturbances and airway related complaints. When they become persistent for more than 72 hours or are coupled with airway symptoms such as hemoptysis, stridor, dyspnea or aspiration, the anesthesiologist should suspect injury to the vocal folds or cricoarytenoid joints. Here-below, the laryngeal manifestations of endotracheal intubation and the pathophysiology of vocal fold scarring are discussed

Laryngeal involvement in rheumatoid arthritis

Patient with rheumatoid arthritis should be screened prior to surgery for any laryngeal manifestation. A thorough history and physical examination coupled with indirect or direct laryngoscopy are mandatory. Nonspecific laryngeal symptoms in patients with rheumatoid arthritis should raise suspicion of laryngeal involvement. Phonatory disturbances or airway difficulties may reflect advanced stages of the disease. Their presence is usually coupled with high resolution computerized tomography findings. Aggressive therapy should be started and corticosteroid injection should be contemplated in cases of failure of conventional treatment. The anesthesiologist should handle with extreme care the inflamed laryngeal structures and be least aggressive in securing the airway

Paradoxical vocal cord motion: an alarming stridor for a benign condition - Case reports

Paradoxical vocal cord motion presents a challenge to medical practitioners in various specialties. Physicians in general and anesthesiologists should suspect this condition in a patient presenting with stridor or a history of choking or asthma not responding to medical treatment. Women are usually more affected than men and more often there is history of anxiety and/or a precipitating factor such as cough or hyperventilation. Accurate diagnosis relies on visualizing adduction of the vocal cords during inspiration or throughout the respiratory cycle using fiberoptic nasopharyngeal laryngoscopy or telescopic examination. The etiology varies from organic causes such as brainstem compression or lower motor neuron injury to non-organic causes such as malingering or conversion disorders. The pathophysiology is believed to be accentuation of the glottic closure reflex. Many modalities of treatment are available ranging from sedation, voice therapy and breathing exercises to Heliox administration, Botulinum toxin type A injection, intubation and at times tracheostomy