Videofluoroscopic and laryngoscopic evaluation of the upper airway and larynx of professional bassoon players.

The bassoon is a demanding double-reed woodwind instrument requiring exquisite control of airflow and air pressure to the reed to produce desired tonal characteristics. Little information is available from direct visualization of the vocal tract and larynx of the bassoonist while playing. Of particular interest is the mechanism(s) of vibrato. This study was undertaken to understand more fully the mechanics of the upper airway in bassoonists during music production. Four adult bassoon players served as subjects. Three players were studied with both sound-synchronized videofluoroscopy and fiber-optic nasal endoscopy. The other subject was studied only by fiber-optic endoscopy. All subjects were evaluated while playing various scales and standard passages common in music pedagogy. The results from this study revealed several findings on the mechanics of upper airway activity during playing: (1) firm velopharyngeal closure was a prerequisite for maximal containment of air pressure and regulation of airflow in the oropharyngeal regions; (2) changes in the pitch and intensity were associated with differential expansion of the pharynx; (3) tongue activity was notable because of its shaping the size and shape of the airway, its role in regulating airflow to the reed, and its contributions to conditioning airflow in vibrato; and (4) slight vocal fold displacements from subglottal airflow and epiglottic movements from tongue base activity contributed to airway changes during vibrato. These seemed to further condition subglottal pressure trains derived primarily from expiration.

Airway obstruction in the mentally handicapped.

We have presented a case of laryngomalacia in an 18-year-old mentally retarded woman treated with epiglottoplasty. The preoperative and postoperative appearance of the larynx during aspiration was documented using video and still photography. Diagnosis was made by fiberoptic nasopharyngoscopy and laryngoscopy.

Concomitant cisplatin and hyperfractionated external beam irradiation for advanced malignancy of the head and neck.

The combination of cisplatin and hyperfractionated external beam irradiation (HEBI), followed by salvage surgery when indicated, was evaluated in patients with advanced stage squamous cell carcinoma of the head and neck. Thirty patients with stage III (n = 5) or IV (n = 25) disease received intravenous cisplatin 100 mg/m2 by 6-hour continuous infusion on days 1, 21, and 42 of HEBI. Radiation fractions of 110 cGy were given twice daily, separated by 4 to 6 hours, beginning within 12 hours after cisplatin delivery. Doses to the primary site ranged from 60 to 76.35 Gy (median: 72.3 Gy), with 60 to 74 Gy to nodal sites. Follow-up ranged from 4 to 28 months (median: 19 months). Clinical complete response of the primary site was seen in 27 of 29 patients (93%), and complete clinical clearance of adenopathy in 20 of 26 (76%). A second biopsy 6 to 8 weeks after completion of treatment showed residual disease in both the primary and nodal sites in three patients, and in only the primary site in one patient. Four patients with persistent adenopathy had pathologic confirmation at surgery. Four patients had recurrence after negative biopsy results 6 to 9 months after treatment biopsy. At present, with median follow-up of 19 months, eight patients (26%) have died secondary to uncontrolled primary or nodal disease. Two patients have died of nonrelated causes. Overall, 10 of 30 patients (66%) remain alive with no evidence of disease. Mucositis and weight loss were the most common side effects of treatment. Seven patients developed significant xerostomia, and four have cisplatin-related hearing loss requiring amplification. The early evidence of excellent response (89% pathologic complete response of primary sites; 78% complete response of nodal sites), coupled with acceptable treatment morbidity, warrants further study of this approach.

Effects of short-term endotracheal intubation on vocal function.

Transient voice change associated with endotracheal intubation has generally been attributed to vocal fold trauma. To assess the role of altered vocal fold function in transient voice change, a study was designed to evaluate the audioacoustic, endoscopic, and laryngostroboscopic characteristics of the postintubation voice. Vocal function of 10 patients undergoing short-term outpatient surgical procedures using general anesthesia and endotracheal intubation were studied preoperatively and postoperatively. A second group of 10 patients that did not have surgery or general anesthesia was used as an age-matched control. Fundamental frequency, frequency perturbation, electroglottography, endoscopy (including laryngeal stroboscopy), and subjective speech analysis by experienced listeners were used to assess vocal function. No consistent differences in fundamental frequency were observed, although patient-to-patient variation was marked. Statistically significant increases in cycle-to-cycle fundamental frequency variation (jitter) were found postoperatively in the majority of the postintubation patients (P less than 0.05). Electroglottography, laryngeal endoscopy, and stroboscopic laryngoscopy did not demonstrate consistent changes in glottic mucosal function. Listener judgments characterized the postintubation voice change by decreased intensity, increased roughness, and lowered affect without consistent changes in pitch. The perception of decreased affect in the voices (characterized by reduction in pitch variation, vocal stress, and increases in pause times) was a strong perceptual marker for change in the post-intubation voice. Objective measures of laryngeal function suggest that the glottic contribution to postintubation voice change is minimal and that this dysphonia is probably multifactorial.

Pediatric nasopharyngeal carcinoma: long term follow-up of 29 patients.

Twenty-nine untreated children diagnosed with nasopharyngeal carcinoma were consecutively admitted to St. Jude Children's Research Hospital from 1962 to 1986. The age of the patients ranged from 6 to 19 years (median of 13) at diagnosis. Histologically, all had lymphoepithelioma. Patients were retrospectively staged in the American Joint Committee System. Disease extent was T1 (n = 5), T2 (n = 7), T3 (n = 9), T4 (n = 8); N0 (n = 1), N2 (n = 7), N3 (n = 21). Two patients had distant metastasis (M1) on admission, both ultimately succumbed to their disease. Twenty-seven patients were seen initially without metastatic disease: one received pre-irradiation vincristine, 17 were treated with concomitant radiotherapy and cyclophosphamide. From 1981 to the present, four patients received pre-irradiation and one received post-irradiation cisplatin-bleomycin, vinblastine (CDDP-BLEO-VLB) regimens. Four patients received radiotherapy alone. All patients completed chemotherapy and radiation therapy. Twenty-five patients had complete tumor clearance and four had a partial response. Overall, 14 patients are alive continuously without relapse with a median follow-up of 11 years (range 4 to 20). All patients who relapsed did so within 2 years postirradiation. Four patients failed locally--all had advanced (T3-T4) local disease at presentation and three of the failures were at the margin of treatment portals. Thirteen patients failed with distant metastasis. The major prognostic factor in these patients was the local extent of disease. Among the 27 M0 patients, all ten patients with T1-2 tumors are disease-free, whereas four of nine patients with T3 and two of eight patients with T4 tumors are alive and well. In the 16 patients who are long term survivors, eight have mild neck atrophy, two have shortening of the clavicles; except for one patient who required a neck brace for shoulder drop, all had normal function. Among the seven pre-pubertal patients who are long term survivors, three have decreased growth, including one with documented decreased growth hormone. Two patients developed irregular menstrual periods. One patient developed hypothyroidism, and another had a thyroid adenoma. One patient developed bleomycin pneumonitis and one patient who received pre- and post-irradiation chemotherapy died of laryngeal edema and fibrosis, in remission. Radiotherapy is the major modality in the therapy of childhood nasopharyngeal carcinoma. The long term toxicity of radiotherapy plus or minus chemotherapy is acceptable. In early stage tumors (T1-2, N1-2), radiotherapy alone (55-60 Gy) appears to be sufficient for disease control.(ABSTRACT TRUNCATED AT 400 WORDS)

Adenotonsillectomy in children: indications and contraindications.

Adenoidectomy and tonsillectomy are the most common major operations done on children. The indications for tonsillectomy in certain clinical situations are constantly being debated in the literature and among professionals. We studied the efficacy (or lack of it) of adenotonsillectomy for chronic tonsillitis (recurrent throat infections), oral nasal obstruction, peritonsillar abscess, elimination of a bacterial carrier state, biopsy, and prevention of tongue thrusting with resultant anterior open bite. Adenoidectomy has been advocated in the literature for the treatment of nasal obstruction, sinusitis, and chronic serous otitis media. Complications of tonsillectomy and adenoidectomy include hemorrhage, anesthetic death, infection, nasopharyngeal stenosis, patulous eustachian tube, and hypernasality. Children at risk for hypernasality are those with mental retardation, cerebral palsy, neuromuscular disorders, and submucous cleft of the soft palate. Because of the severity of the complications that can be encountered in any child, medical and conservative therapy should be attempted before operation is done. Proper antibiotic therapy will often control chronic serous otitis, sinusitis, and chronic, recurrent tonsillitis. Bacterial synergy is important to consider when selecting antibiotic therapy, since beta-lactamase production may protect pathogens commonly considered susceptible to standard antibiotic therapy.

Androgen stimulation and laryngeal development.

Androgen-induced changes in laryngeal growth patterns were studied using a sheep animal model. Forty-eight lambs were divided into eight treatment groups. Lambs in seven of the groups were castrated at birth, while lambs in the eighth group served as an intact (noncastrated) control. Six groups were then treated with varying doses of testosterone and dihydrotestosterone, while the seventh served as a castrated, nontreated control. All animals were killed and gross dissections of the larynges were performed. Thirty-four linear and angular measurements were obtained from each larynx. The mean superior thyroid horn separation showed the most dramatic androgen-induced effect (p = 0.023). Laryngeal anterior-posterior diameter, superior thyroid horn height, posterior thyroid cartilage width, thyroid cartilage angle, and vocal process to arytenoid base distances all demonstrated positive dose-response relationships. Hypoandrogenic levels appeared to have an inhibitory effect upon laryngeal growth when compared to castrated controls.

Granular cell tumor arising in myelinated peripheral nerves. Light and electron microscopy and immunoperoxidase study.

The histologic, immunohistochemical and ultrastructural characteristics of two granular cell tumors arising from the right recurrent laryngeal and left facial nerves are described. S-100 protein was detected both in the nuclei and cytoplasm of the granular cells using the peroxidase-anti-peroxidase method. The ultrastructural findings in both cases support a Schwann cell derivation of the granular cells. It is suggested that the granularity of cells of granular cell tumor may represent a lysosomal disorder affecting most frequently neoplastic and nonneoplastic Schwann cells and occasionally other cells.