Laryngeal epithelial thickness: a comparison between optical coherence tomography and histology.

OBJECTIVES: Optical coherence tomography, an imaging modality using near-infrared light, produces cross-sectional tissue images with a lateral pixel resolution of 10 microm. However, normative data is first needed on epithelial thickness for lesion characterisation, and, to date, little exists. The purpose of our study is to measure normal laryngeal epithelial thickness by in vivo optical coherence tomography, and compare these values to those obtained from fixed ex-vivo laryngectomy specimens. DESIGN AND SETTING: Prospective at a single medical center in California, United States. PARTICIPANTS: A total of 116 patients undergoing operative endoscopy. MAIN OUTCOME MEASURES: Optical coherence tomography images of clinically normal laryngeal subsites were selected. Calibrated measurements of epithelial thickness at various laryngeal subsites were recorded. Measurements of epithelial thickness from corresponding areas were obtained using optical micrometry on histologically normal regions of 15 total laryngectomy specimens. Descriptive statistics were performed. RESULTS: Mean epithelial optical coherence tomography thicknesses were: true vocal cords (81 microm), false vocal cords (78 microm), subglottis (61 microm), aryepiglottic folds (111 microm), laryngeal epiglottis (116 microm) and lingual epiglottis (170 microm). Epithelial thicknesses in fixed tissues were: true vocal cords (103 microm), false vocal cords (79 microm), aryepiglottic folds (205 microm) subglottis (61 microm), laryngeal epiglottis (38 microm) and lingual epiglottis (130 microm). CONCLUSIONS: Optical coherence tomography does not have the artifacts associated with conventional histologic techniques. The inevitable development of office-based optical coherence tomography devices will increase the precision of laryngeal measurements and contribute to the clinical application of this technology in diagnosing laryngeal disease.

Oromandibular reconstruction with vascularized free flaps: a review of 50 cases.

Fifty cases of oromandibular reconstruction using vascularized free flaps to evaluate functional parameters of results were evaluated. There were 23 iliac crest flaps, 17 fibula flaps, 30 ulnar forearm flaps, and 3 radial forearm flaps with bone. Thirteen female and 37 male patients comprised the study, with a mean age of 57.66 years. Squamous-cell carcinoma (SCC) constituted 86% of cases, of which 60% were T4 lesions and 13.9% were recurrent. Anterolateral mandibular defects constituted 48.7%, and the mean bone gap was 8.13 cm. Functional evaluation was based on the University of Washington Questionnaire (UWQ) through phone calls and personal communication. The mean hospital stay was 12.42 days. The external carotid (75%) and facial (18.3%) were the main recipient arteries. The internal jugular (47.05%) was the main recipient vein. Overall flap survival was 95.9%. Three flaps were lost due to unsalvageable venous thrombosis. Major local complications such as partial flap loss, hematoma, and orocervical fistula constituted 10% of cases. Speech was classified as "excellent" and "good" in 43.3% of cases. Swallowing was identified as "excellent" and "good" in 53.3% of cases. Cosmetic acceptance was rated "good" in 63.3% of cases. Vascularized free flap reconstruction of oromandibular defects provides excellent functional and aesthetic results. The majority of patients are able to tolerate a regular diet. Intelligible speech and acceptable appearance are restored, providing patient satisfaction.

Role of ulnar forearm free flap in oromandibular reconstruction.

The ulnar forearm flap is not frequently utilized for oromandibular reconstruction. This study evaluated the usefulness of the ulnar free flap for reconstruction. A retrospective study of 32 patients was conducted. The ulnar forearm flap was combined with an osseous flap in 24 patients. Nine females and 23 males with a mean age of 58.15 years comprised our study population. Squamous-cell carcinoma was the diagnosis in 93.75% of cases (56.25% T4), of which 20% were recurrent. Functional evaluation of swallowing was based on the University of Washington Questionnaire (UWQ). The mean hospital stay was 9.8 days. The external carotid (100%) was the recipient artery, and the internal jugular (74.07%) was the main recipient vein. Overall flap survival was 96.8%. One flap was lost due to unsalvageable venous thrombosis. Major local complications were seen in 9.4% of cases and included partial flap loss, hematoma, and an orocutaneous fistula. At the time of this study, 21 patients were available for functional evaluation. Speech was rated excellent and good in 33.3% of patients. Swallowing was found good in 28.6% of patients. Chewing was rated excellent and good in 47.6% of patients. Cosmetic acceptance was rated good in 71.4% of cases. The ulnar forearm is a useful free flap in oromandibular reconstruction. It is available when the radial artery is the dominant artery of the hand. Being more hidden, it may be more cosmetically accepted. It affords pliable soft tissue for lining and/or covering of oromandibular defects, and can be used as a second choice after other free-flap failures.

Aquatic activities after total laryngectomy.

OBJECTIVE: To assess the techniques used by patients who have undergone laryngectomies to enable them to participate in aquatic activities. STUDY DESIGN: Unstructured interviews. METHODS: The case histories of 4 patients who have returned to swimming and other aquatic activities after total laryngectomy were obtained by nonstructured interviews emphasizing techniques used to swim, safety precautions taken, any accidents or near accidents, and perceived effect of aquatic activities on sense of well being and quality of life. RESULTS: All 4 of the interviewed subjects swim regularly using commercial breathing aids or manual tracheostomal occlusion. One of the four is a regular surfer, who uses a homemade breathing aid. All were active swimmers prior to the development of laryngeal cancer. A single aquatic-related accident was reported by 1 of the 4 swimmers. All subjects describe feeling an enhanced quality of life resulting from their participation in aquatic activities. CONCLUSION: Despite recommendations of most clinicians, a small number of highly motivated patients will return to aquatic activities after laryngectomy.

New perspectives about human laryngeal muscle: single-fiber analyses and interspecies comparisons.

BACKGROUND: In companion studies on canine and rodent laryngeal muscle, we observed that (1) muscle fibers in both the canine and rodent posterior cricoarytenoid (PCA) muscles have a slower myosin heavy-chain (MyHC) isoform profile than those in the thyroarytenoid (TA) muscle; (2) the muscle fiber composition of PCA and TA muscles in canines and rodents is complex given the presence of so-called hybrid fibers (fibers coexpressing various combinations of MyHC isoforms); (3) the types and proportions of hybrid fibers are both muscle specific and, in some cases, region specific; and (4) the MyHC isoform profile of canine laryngeal muscle appears to be slower than that of rodent laryngeal muscle, suggesting the possibility that larger mammals have a slower MyHC isoform profile. OBJECTIVES: Given the findings of these companion studies and the fact that very little is known about the MyHC isoform composition of laryngeal muscle fibers, the primary objectives of this study were to determine (1) the types of MyHC isoforms found in the human PCA and TA muscles, (2) if there were regional differences in MyHC isoform composition, (3) if hybrid fibers commonly occur in human laryngeal muscle, and (4) if the MyHC isoform profile of human laryngeal muscle is slower than that of canine and rodent laryngeal muscle. RESULTS AND CONCLUSIONS: The findings of this study clearly demonstrate that both the PCA and TA muscles in humans express 3 types of MyHC isoforms (ie, slow type I, fast type IIA, and fast type IIX MyHC isoforms). At the single-fiber level, there were distinct regional differences and hybrid fibers were a common occurrence. Finally, the data demonstrate that the PCA and TA muscles of humans have a slower MyHC profile than that found in either canine or rodent laryngeal muscle.

Chemoprevention of head and neck cancer.

Increasing emphasis has been placed on chemoprevention as understanding of the genetic and molecular events of carcinogenesis has evolved. More than 1000 compounds that inhibit cancer development in vitro or in animal models have been identified, and active research is under way to determine which of these agents will be both effective and nontoxic in human beings. Currently, 13-cis-retinoic acid is the most studied chemopreventive agent against head and neck cancers. Unfortunately, this vitamin A derivative has significant clinical toxicity, which limits its utility in a practice setting. The efficacy of the retinoids, however, has stimulated efforts to find other chemopreventive compounds that are both effective and nontoxic. This review discusses head and neck premalignancy, chemoprevention strategies, retinoids, and several other classes of chemopreventive agents with potential efficacy against head and neck premalignancy.

Single-dose administration of Bowman-Birk inhibitor concentrate in patients with oral leukoplakia.

The Bowman-Birk inhibitor (BBI) is a soybean-derived serine protease inhibitor and a potential cancer chemopreventive agent for humans. In this Phase I clinical trial, BBI concentrate was administered as a single oral dose to 24 subjects with oral leukoplakia. Pharmacokinetics of BBI was analyzed, and subjects were monitored clinically for toxic effects. Subjects received between 25 and 800 chymotrypsin inhibitor units (CIU) of the compound in a dose escalation trial. BBI was taken up rapidly, and a metabolic product of BBI was excreted in the urine within 24-48 h. No clinical or laboratory evidence of toxicity was observed in the study. Protease activity was also measured in buccal cells to evaluate usefulness as a biomarker. Single-dose BBI concentrate administered up to 800 CIU was well tolerated and appeared to be nontoxic. Further investigation in Phase II clinical trials is being done.

Clinical modulation of oral leukoplakia and protease activity by Bowman-Birk inhibitor concentrate in a phase IIa chemoprevention trial.

Bowman-Birk inhibitor is a protease inhibitor derived from soybeans that has demonstrated chemopreventive activity in a number of in vitro and animal systems. We conducted a 1-month phase IIa clinical trial of Bowman-Birk inhibitor concentrate (BBIC) in patients with oral leukoplakia. BBIC was administered to 32 subjects with oral leukoplakia for 1 month. We assessed toxicity and clinical and histological response of the lesions, and oral mucosal cell protease activity (PA) and serum micronutrient levels were measured. Clinical response was determined by measurement of pre- and posttreatment individual and total lesion areas and analysis of blinded clinical judgments of photographs. On the basis of prespecified response criteria, 31% of patients achieved a clinical response (two with complete and eight with partial responses). BBIC was nontoxic in doses up to 1066 chymotrypsin inhibitory units. The mean pretreatment total lesion area decreased from 615 to 438 mm2 after BBIC treatment (P < 0.004). A linear fit of the dose-response relationship between dose of BBIC and decrease in total lesion area was suggested (P < 0.08), and analysis of blinded clinical impression from lesion photographs confirmed this relationship (P < 0.01). Overall, at all doses tested, a 24.2% decrease in total lesion area was observed following treatment (sign rank = -142; P < 0.004). High pretreatment PA was associated with greater decreases in PA after BBIC administration (P < 0.02). BBIC demonstrated clinical activity after oral administration to patients with oral leukoplakia. These results indicate that BBIC should be investigated for chemopreventive activity in a randomized clinical trial.

Head and neck computed tomography virtual endoscopy: evaluation of a new imaging technique.

OBJECTIVE: To evaluate a new radiographic imaging technique: computed tomography virtual endoscopy (CTVE) for head and neck tumors. STUDY DESIGN: Twenty-one patients presenting with head and neck masses who underwent axial computed tomography (CT) scan with contrast were evaluated by CTVE. Comparisons were made with video-recorded images and operative records to evaluate the potential utility of this new imaging technique. METHODS: Twenty-one patients with aerodigestive head and neck tumors were evaluated by CTVE. One patient had a nasal cylindrical cell papilloma; the remainder, squamous cell carcinomas distributed throughout the upper aerodigestive tract. Patients underwent complete head and neck examination, flexible laryngoscopy, axial CT with contrast, CTVE, and in most cases, operative endoscopy. Available clinical and radiographic evaluations were compared and correlated to CTVE findings. RESULTS: CTVE accurately demonstrated abnormalities caused by intraluminal tumor, but where there was apposition of normal tissue against tumor, inaccurate depictions of surface contour occurred. Contour resolution was limited, and mucosal irregularity could not be defined. There was very good overall correlation between virtual images, flexible laryngoscopic findings, rigid endoscopy, and operative evaluation in cases where oncological resections were performed. CTVE appears to be most accurate in evaluation of subglottic and nasopharyngeal anatomy in our series of patients. CONCLUSION: CTVE is a new radiographic technique that provides surface-contour details. The technique is undergoing rapid technical evolution, and although the image quality is limited in situations where there is apposition of tissue folds, there are a number of potential applications for this new imaging technique.

Functional hemitongue reconstruction with the microvascular ulnar forearm flap.

Thirteen patients with squamous cell carcinoma of the tongue underwent full-thickness longitudinal resection of the hemitongue and immediate microvascular reconstruction using a large, contoured ulnar forearm flap. Six of the 13 patients had a composite resection for which an additional vascularized iliac crest graft was used to reconstruct the mandible and to provide support to the overlying contoured flap. To increase tongue mobility, the skin flap was designed for independent reconstruction of the hemitongue and the floor of mouth. Twelve patients were evaluated for swallowing and speech, including dietary assessment, cineradiography, and voice spectrographic analysis. Contrast cineradiography was performed to determine oral tongue mobility during the first phase of swallow. Nine patients with a narrow reconstructed tongue root and a large surface area in the floor of the mouth had good tongue mobility, allowing them to transfer food dynamically from the mouth into the pharynx for swallowing. The remaining three patients, who had a wide tongue root and an ill-defined floor of the mouth, had decreased tongue mobility and poor oral transport. The functional outcome of swallowing and speech strongly correlated with the shape of the root of the tongue, the proximity of the reconstructed tongue to the palate, and the surface area of the floor of the mouth.

Relationship between protease activity and neu oncogene expression in patients with oral leukoplakia treated with the Bowman Birk Inhibitor.

The protease catalyzing the hydrolysis of the tripeptide fluorescence substrate, butoxycarbonyl-valine-proline-arginine-(7-amino-4-methylcoumarin) (Boc-Val-Pro-Arg-MCA) and the neu oncogenic protein are potentially useful biomarkers for human cancer prevention studies. In the present study, we standardized a specific substrate hydrolysis method for measuring this protease activity in human oral mucosal cells and characterized the relationship between neu oncogene expression and protease activity in patients enrolled in an oral cancer prevention trial using Bowman Birk Inhibitor Concentrate (BBIC) as the cancer preventive agent. The results demonstrate that changes in the protease activity in oral mucosal cells after BBIC treatment correlated with the changes in the neu protein levels in oral mucosal cells (r = 0.726, P < 0.001) and serum (r = 0.675, P < 0.001), suggesting that the Boc-Val-Pro-Arg-MCA hydrolyzing activity can be as useful as neu oncogene expression as a cancer biomarker. In the 25 patients enrolled in the study, the level of neu protein in oral mucosal cells correlated with the serum neu protein concentration in the patients before BBIC treatment (r = 0.645, P < 0.001). However, such a correlation was not observed after the BBIC treatment, suggesting that BBI may inhibit serine protease(s) involved in the cleavage of neu protein on the cell surface, thereby preventing the release of the extracellular domain of neu protein into the circulation. By inhibiting the cleavage of neu protein on the cell surface, BBI could prevent malignant and premalignant cells expressing high levels of neu protein antigen from escaping host immunological surveillance control.

Kimura's disease: two case reports and a literature review.

Kimura's disease (KD) is an allergic, inflammatory disorder of unknown cause. The typical presentation is in a young Oriental male with nontender subcutaneous swellings in the head and neck region, lymphadenopathy, peripheral eosinophilia, and elevated serum IgE. Many patients with KD also develop renal involvement. Treatment options range from conservative observation for asymptomatic patients to surgical excision, steroid therapy, and radiotherapy for symptomatic patients. Two cases of KD are presented. These emphasize not only the variability of disease presentation, but also the pitfalls of therapy leading to frequent recurrences. The literature is reviewed, summarizing patient presentation, differential diagnosis, current theories on causation, and therapy. A treatment protocol is also proposed.

Is this lump in the neck anything to worry about? .

Neck masses are common and often the result of self-limited inflammation or infection. Congenital masses and neoplasms are additional benign causes. However, a neck mass can signal a malignant tumor, so it is important to understand what represents an abnormal mass and to recognize warning signs and symptoms. Patients at risk of serious clinical problems may be identified through findings on history taking (e.g., progressive enlargement of the mass, prolonged hoarseness) and physical examination (e.g., unilateral nasal obstruction, intraoral induration). Suspicion of a malignant process calls for referral to a subspecialist in head and neck disorders.

Management of external penetrating injuries into the hypopharyngeal-cervical esophageal funnel.

OBJECTIVE: To compare outcomes related to observation versus exploration for the hypopharynx and the cervical esophagus as the site of proven external penetrating injuries. METHODS: The records of 70 patients (47 with hypopharyngeal and 23 with cervical esophageal wounds) were retrospectively reviewed. RESULTS: No patient, observed or explored, who sustained a penetration into the hypopharynx above the level of the tips of the arytenoid cartilages of the larynx developed a complication. However, 22% of the patients with a hypopharyngeal injury below this level and 39% of patients with a cervical esophageal injury developed either a deep neck infection that required drainage or a postsurgical salivary fistula. CONCLUSIONS: Overall, the consequences of an external penetrating injury become more serious in the descending levels of the funnel formed by the hypopharynx and cervical esophagus. Injuries located in the upper portion of the hypopharynx can be routinely managed without surgical intervention. Neck exploration and adequate drainage of the deep neck spaces are, however, mandatory for all penetrating injuries into the cervical esophagus and most injuries into the lower portion of the hypopharynx.

Airway obstruction secondary to rhinoscleroma during pregnancy.

Dyspnea is a fairly common complaint during pregnancy. However, if one excludes allergic nasal congestion of pregnancy, upper airway obstruction is a distinctly uncommon cause of dyspnea in the pregnant patient. Three cases of laryngeal rhinoscleroma in pregnant women requiring tracheostomy for airway management are reported. All three delivered healthy infants vaginally. Postpartum, two of the three were successfully decannulated, while the third became pregnant again before decannulation was accomplished. Treatment options and a review of the literature are presented.

Anatomy of the larynx, trachea, and bronchi.

This article reviews the anatomy of the larynx, trachea, and bronchi. It emphasizes the structure of the laryngeal framework, the innervation and blood supply of the larynx and trachea, the anatomic differences between the pediatric and adult larynx and trachea, and the relational anatomy of structures surrounding the trachea and bronchi.

Carotid body tumors: a review of 30 patients with 46 tumors.

Minimal morbidity occurs with resection of most carotid body tumors (CBT). With larger tumors significant injury to the cranial nerves has been reported. In order to assess the operative sequelae rate, 30 patients with CBT were reviewed. Sixteen patients either presented with bilateral carotid body tumors or had previously undergone a resection of the contralateral carotid body tumors, for a total carotid body tumor count of 46. Sixteen patients demonstrated a familial pattern while 14 were nonfamilial. Within the familial group, 14 of 16 presented with multiple paragangliomas as compared to 6 of 14 in the nonfamilial group. Tumor size ranged from 0.8 to 12 cm. Vascular replacement occurred in 2 of 20 patients with tumors < 5.0 cm, compared with 5 of 9 with tumors > 5.0 cm. Four patients lost cranial nerves with the resection: superior laryngeal nerve (SLN), 4; cranial nerve X, 1; cranial nerve XII, 1. Ten patients developed baroreceptor failure secondary to bilateral loss of carotid sinus function. First-bite pain occurred in 10 of 25 operative patients. Cranial nerve loss can be minimal with resection of carotid body tumors, however, baroreceptor failure and first-bite pain are postoperative sequelae that are often disregarded in the postoperative period.

Management of traumatic hypopharyngeal injuries.

Violation of the hypopharynx by external penetrating trauma is an uncommon occurrence that may lead to life-threatening infectious complications if not recognized promptly and treated appropriately. A retrospective review of 48 such injuries seen during a 10-year period showed that flexible fiberoptic endoscopic examination is the best screening tool for recognition of a possible hypopharyngeal mucosal violation. Direct laryngopharyngoscopy is the best method of definitively diagnosing the injury. Size of the visualized mucosal violation alone is not sufficient information on which to base the decision for medical management versus surgical intervention (i.e., immediate exploration and drainage). Rather, the size, exact site of injury, and mechanism of the injury must be considered to have equal importance. Associated vertebral body fractures may negatively influence acute outcome if diagnosis and treatment of the hypopharyngeal injury are delayed by the cervical spine injury.

Diagnosis and management of external penetrating cervical esophageal injuries.

External penetrating injuries of the esophagus are more likely to cause serious morbidity and even mortality than those involving the pharynx. However, the cervical esophagus is extrathoracic in location, and controversy exists regarding the diagnosis and surgical management of penetrating injuries at this level. A retrospective review of 23 such injuries showed that contrast esophagography had only a 62% success rate in identification of cervical esophageal violations, compared to 100% for rigid esophagoscopy. Even large penetrations were successfully treated with limited debridement, primary repair when possible, muscle interposition flaps to separate common injuries of the tracheal wall, and, most important, external drainage of the adjacent neck spaces. Esophageal stricture occurred only when complex esophageal diversion procedures were performed, either as an unnecessary primary operation, or as a lifesaving secondary operation necessitated by infectious complications caused by delayed diagnosis and treatment of the esophageal violation. Penetrating injuries of the cervical esophagus can therefore be managed more as a pharyngeal injury if diagnosis and appropriate surgical treatment occur in a timely fashion.