Pleomorphic rhabdomyosarcoma presenting as a hypopharyngeal mass.

BACKGROUND: Rhabdomyosarcoma (RMS) is a rare malignancy derived from skeletal muscle with approximately 40% of cases involving the head and neck. The pleomorphic variant, however, most commonly occurs in the extremities and has never, to our knowledge, been described in the pharynx. METHODS: A 46-year-old man with no significant medical history presented to the emergency department complaining of hemoptysis. A CT scan of the head and neck revealed a hypopharyngeal mass originally favored to be a benign process. RESULTS: Operative endoscopy revealed a previously unseen mucosal ulceration, and subsequent biopsy resulted in the final diagnosis of pleomorphic RMS. CONCLUSION: Although quite rare, RMS should be considered in the differential diagnosis of a hypopharyngeal mass.

Late displacement of a Montgomery thyroplasty implant following endotracheal intubation.

OBJECTIVES: We document a late displacement of a thyroplasty implant following endotracheal intubation. METHODS: A 66-year-old man was referred to our clinic with a chief complaint of breathy dysphonia immediately following an elective inguinal hernia repair under general endotracheal anesthesia. The patient's medical history was significant for a medialization laryngoplasty with a Montgomery implant 14 years earlier. RESULTS: Examination and computed tomographic scanning of the neck confirmed displacement of the implant. The patient underwent revision medialization laryngoplasty with successful restoration of his voice quality. CONCLUSIONS: This case report illustrates a potential complication of endotracheal intubation in patients who have previously undergone vocal fold medialization procedures.

Validity and reliability of the glottal function index.

OBJECTIVE: To evaluate a symptom-focused vocal impairment instrument for the evaluation of patients with voice disorders. DESIGN: Prospective, nonrandomized study of patients with voice disorders undergoing treatment with validation of a new symptom index, the Glottal Function Index (GFI). SETTING: Voice disorders clinic at an academic tertiary care hospital. PATIENTS: Consecutive patients undergoing therapy for glottal insufficiency, adductor spasmodic dysphonia, nodules, and granuloma (40 patients in each group) and 40 control patients. INTERVENTIONS: The Pearson correlation coefficient was used to evaluate GFI reproducibility and to compare it with the Voice Handicap Index (VHI). The paired-samples t test was used to compare pretherapy and posttherapy GFI values. MAIN OUTCOME MEASURES: Correlation of GFI with VHI; comparison of the GFI in normals, and in pretherapy and posttherapy GFI and VHI scores. RESULTS: The mean +/- SD normative GFI score was 0.87 +/- 1.32. The correlation coefficient for GFI between independent pretherapy measurements was 0.56 (P<.001). The correlation coefficient between total GFI and total VHI scores was 0.61 (P<.001). The mean posttherapy GFI scores improved among all groups as follows: glottal insufficiency: presenting GFI score, 12.7 +/- 4.1; posttherapy GFI score, 6.8 +/- 5.4; nodules: presenting GFI score, 12.9 +/- 4.2; posttherapy GFI score, 8.9 +/- 4.6; adductor spasmodic dysphonia: presenting GFI score, 13.2 +/- 4.1; posttherapy GFI score, 8.9 +/- 4.9; and granuloma: presenting GFI score, 7.8 +/- 4.6; posttherapy GFI score, 3.8 +/- 2.1. Relative to controls, the GFI score at presentation was significantly elevated and demonstrated significant reduction following treatment across each of these entities (P<.05). CONCLUSIONS: The GFI is a reliable, reproducible, 4-item, self-administered symptom index with excellent criterion-based and construct validity. Its advantages over existing indexes include brevity and ease of administration. The GFI is a useful adjunct in the evaluation and treatment of patients with glottal dysfunction.

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.

Prolonged postoperative disorientation after methylene blue infusion during parathyroidectomy.

Methylene blue 7.5 mg/kg is frequently given at our institution during parathyroidectomy. The dye preferentially stains the parathyroids so as to provide better surgical visualization. Other than causing a pseudocyanosis, the technique is generally considered to be rather innocuous. We report a case of a patient who, after this procedure, had a postoperative course that was unusual because of slowly resolving altered mental status.

The role of transnasal esophagoscopy in head and neck oncology.

OBJECTIVES/HYPOTHESIS: To review the current role of transnasal esophagoscopy (TNE) in all aspects of head and neck cancer patient treatment. STUDY DESIGN: A retrospective database and chart review. METHODS: A retrospective review of head and neck cancer patients undergoing TNE for a variety of diagnostic and therapeutic indications. RESULTS: In a series of 17 patients with presumed head and neck malignancies, TNE provided 100% accuracy in biopsy results and staging of the tumor when compared with standard panendoscopy. The utility of TNE in other areas of head and neck cancer management, such as stricture dilation and secondary tracheoesophageal puncture, is demonstrated. This preliminary report strongly suggests that TNE may play a vital role in the management of head and neck oncology patients. CONCLUSIONS: Transnasal esophagoscopy gives the surgeon the ability to perform a remarkable variety of procedures in the outpatient setting without sedation. It may obviate the need for routine panendoscopy in head and neck cancer patients.

Clinical manifestations of laryngopharyngeal reflux.

Laryngopharyngeal reflux (LPR) is ubiquitous and associated with many head and neck symptoms and diagnoses. In some cases, the symptom is the diagnosis--for example, LPR can cause sore throat, chronic cough, globus pharyngeus, and laryngospasm. Alternately, LPR can be associated with specific histopathologic lesions--for example, vocal process granulomas. LPR can be the sole cause or an etiologic cofactor in the development of many disorders of the aerodigestive tract.

Pediatric laryngopharyngeal reflux.

Laryngopharyngeal reflux (LPR) is common in children. It often affects the airway, and it has been associated with life-threatening disease. The diagnosis and treatment of LPR in children is somewhat different from that in adults.

Prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux.

OBJECTIVE: To report the prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux. STUDY DESIGN: Prospective study of 58 consecutive patients with documented laryngopharyngeal reflux, all of whom underwent transnasal esophagoscopy as part of their reflux evaluations. METHODS: All patients with a diagnosis of laryngopharyngeal reflux confirmed by abnormal pharyngeal pH monitoring over a 5-month period were included, and all subjects completed a self-administered reflux symptom index and underwent transnasal esophagoscopy with directed biopsy. RESULTS: Of the 58 study patients with pH-documented laryngopharyngeal reflux, the mean age was 49 years (+/- 13 y), and 53% (31 of 58) were women. Of the study group, 40% (23 of 58) had heartburn and 48% (28 of 58) had abnormal esophageal reflux (by pH monitoring criteria); by transnasal esophagoscopy with biopsy, 12% (7 of 58) had esophagitis and another 7% (4 of 58) had Barrett's metaplasia. Thus, 60% of the study cohort had heartburn, and 81% (47 of 58) had normal esophageal epithelium (i.e., esophagitis or Barrett's metaplasia). CONCLUSIONS: In the present series of patients with documented laryngopharyngeal reflux the prevalence of esophagitis and Barrett's metaplasia was only 19%. These data confirm the clinical impression that the patterns, mechanisms, and manifestations of laryngopharyngeal reflux differ from those of classic gastroesophageal reflux disease. Unlike gastroesophageal reflux disease, patients with laryngopharyngeal reflux uncommonly have esophagitis. Thus, although esophagoscopy may be an excellent method for screening the esophagus, it is not the method of choice for diagnosing laryngopharyngeal reflux.