High risk of unilateral recurrent laryngeal nerve paralysis after esophagectomy using cervical anastomosis.

The goal of this study was to estimate the incidence of temporary and permanent unilateral recurrent laryngeal nerve paralysis (URLNP) after esophagectomies with cervical anastomosis and to determine the impact of surgical technique, tumor type, tumor localization and age on the incidence of URLNP. From March 2002 to November 2009, 84 patients underwent a laryngoscopical evaluation before and after esophagectomy with cervical anastomosis prospectively. If the postoperative URLNP recovered within 6 months, the paresis was classified as transient; if not, it was defined as permanent. The results indicate that the overall incidence of postoperative URLNP was 50% (42/84). Twenty-four of the 84 patients (28.6%) showed a transient URLNP. A permanent URLNP was observed in 9 of the 84 patients (10.7%). The remaining 9 of the 84 patients (10.7%) were categorized as paresis with unknown clinical outcome due to missing follow-up. There were significantly more postoperative URLNPs in the group operated by transthoracic esophagectomy than by transhiatal esophagectomy (p < 0.001). Multifocal tumors and those localized suprabifurcational showed a higher incidence of postoperative URLNP than unifocal lesions with infrabifurcational localization (p = 0.046). Histological type of tumor and patients' age had no impact on URLNP. The high incidence of URLNP in our study underlines the high risk of URLNP after esophagectomy with cervical anastomosis, and consequently the importance of routine laryngoscopic pre- and postoperative evaluation of the vocal fold motility.

[Examination of biofilm related material deterioration on 20 PROVOX2 voice prostheses by scanning electron microscopy]. / Elektronenmikroskopische Untersuchungen zur Biofilmbildung auf 20 PROVOX2 Stimmventilen.

BACKGROUND: Mechanical impairment of valve function by biofilms is considered to cause loss of function of voice prostheses in laryngectomized patients. Material deterioration and infiltrative growth of Candida associated biofilms have already been observed on Groningen Buttons. Goal of the study was the examination of biofilm formation and material damages on PROVOX2 voice prostheses. METHODS: 20 PROVOX2 voice prostheses were withdrawn from 17 laryngectomized patients due to aspiration (mean in-vivo time: 118 d, median 98 d). Microbial spectrum, colonization patterns and morphologies of prosthesis damage were assessed using standard microbiologic procedures and scanning electron microscopy. RESULTS: Biofilm with various growth patterns predominantly adhered to the esophageal parts of the prostheses. Microbiologic findings showed Candida species as main colonisers on esophageal surfaces. Different morphologies of surface alteration and material infiltration of the polymer material were identified on 8 prostheses with 35 d of in-vivo time minimum. CONCLUSION: Valve dysfunction of PROVOX2 voice prostheses can be attributed to biofilm formation on esophageal surfaces and edges of the valve flap and seating. The identified morphologies of material damage and invasive growth indicate towards lytic processes of the polymer material due to Candida associated biofilms.

Superimposed high-frequency jet ventilation (SHFJV) for endoscopic laryngotracheal surgery in more than 1500 patients.

BACKGROUND: Superimposed high-frequency jet ventilation (SHFJV), which does not require any tracheal tubes or catheters, was developed specifically for use in laryngotracheal surgery. SHFJV uses two jet streams with different frequencies simultaneously and is applied in the supraglottic space using a jet laryngoscope and jet ventilator. METHODS: Between 1990 and 2004, SHFJV was studied in 1515 consecutive patients (including 158 children requiring laryngotracheal surgery) prospectively. Ventilation was performed with an air/oxygen mixture and anaesthesia was administered i.v. RESULTS: Adequate oxygenation and ventilation was achieved in 1512 patients. Arterial blood gas analyses (BGA) were performed between 1990 and 1994; thereafter BGA was only performed in patients with high-grade stenosis of the larynx/trachea or high-risk patients [n=623, mean Pa(O(2)) 133.8 (39.4) mm Hg and mean Pa(CO(2)) 42.3 (10.1) mm Hg]. There were no significant changes in Pa(O(2)) or Pa(CO(2)) during the entire period of SHFJV. No complications secondary to the ventilation technique were observed; in particular, no barotrauma occurred. Three patients required tracheal intubation. SHFJV was also successfully used for laser surgery (n=312). It proved to be a safe mode of ventilation without any complications such as airway fire, major haemorrhage, or aspiration of debris. CONCLUSION: SHFJV is an advanced ventilation mode playing a pivotal role in the (open) ventilatory support/ventilation of patients with laryngotracheal stenosis. It is particularly indicated in cases of severe stenosis and offers optimal conditions for laryngotracheal surgery, including laser surgery and stent implantation techniques.

[Reduced quality of life in patients with unilateral vocal cord paralysis after thoracic surgery]. / Beeinträchtigung der Lebensqualität bei Patienten mit einseitiger Rekurrensparese nach thoraxchirurgischen Eingriffen.

BACKGROUND: Postoperative unilateral vocal cord paralysis (URLNP) may lead to a lower quality of life due to dysphonia, dysphagia, and reduced breathing control. The aim of this study was to evaluate quality of life in a group of patients with URLNP compared to a group without URLNP. PATIENTS AND METHODS: Laryngoscopically, 379 patients were examined before and after thoracic surgery. Of the group with permanent URLNP (n=14), nine patients were compared to ten without URLNP regarding voice function and quality of life using selected European Organization for Research and Treatment of Cancer questionnaires (QLQ-C30, H&N35, OES18, and LC13) and the voice dysfunction index by Nawka. RESULTS: Patients with URLNP reported more voice problems and less effective coughing. Further, they had a reduced of quality of life. CONCLUSION: We recommend early diagnosis of URLNP and therapy management by routine laryngoscopic examinations following thoracic surgery.

[Management of oropharyngeal dysphagia. Current status]. / Management oropharyngealer Dysphagien. Eine Standortbestimmmung.

The diagnostics and therapy of oropharyngeal dysphagia fall within the competence of ENT, phoniatrics and speech language pathology. Due to etiologic diversity, interdisciplinary management is necessary in many cases. After taking a thorough history, focused on swallowing, dynamic instrumental examination methods, i.e. videoendoscopic and videofluoroscopic swallowing studies, allow an evaluation of the morphology and function of the act of swallowing. Videoendoscopic swallowing studies enable the ENT specialist/phoniatrician to decide on further diagnostic steps, to establish a therapy and to recommend the type of feeding (oral, non-oral). Therefore, in clinical routine, knowledge of the diagnostics and therapy of swallowing disorders is indispensable for the ENT specialist/phoniatrician.

How we do it: voice therapy to improve vocal constitution and endurance in female student teachers.

Vocal hypofunction should be regarded as risk factor of occupational voice disorders. Voice therapy is effective to improve vocal endurance and voice constitution. Elucidation of constitutionally weak voices in teachers is recommended prior to their professional career.

[Significance of voice constitution as a predisposition for occupational voice disorders]. / Bedeutung der Stimmkonstitution für die Entstehung von Berufsdysphonien.

Occupational voice disorders have been increasing for years. The aim of this study was to examine whether a constitutionally weak voice should be regarded as a risk factor for developing such voice disorders. In a prospective study, 15 female teacher students with a normal vocal constitution were compared with 18 students with constitutionally weak voices during teaching practice. There was a significant difference in the mean fundamental frequency of both groups after teaching for 30 min. Students with constitutionally weak voices tended to have increased values. Taking into consideration the physiological aspects of an increasing fundamental frequency as a sign of vocal fatigue, a constitutionally weak voice has to be regarded as a potential risk factor for developing a voice disorder in vocally intensive occupations. To prevent future vocal problems by appropriate prophylactic intervention (i.e. voice therapy, introduction to vocal hygiene), a phoniatric examination of vocal constitution and endurance is recommended at the beginning of a voice dependent professional career.

Concept for diagnosis and therapy of unilateral recurrent laryngeal nerve paralysis following thoracic surgery.

BACKGROUND: Injury to the recurrent laryngeal nerve is a potential complication in thoracic surgery, and may lead to postoperative dysfunction due to the resulting insufficient glottal closure. The aim of this study was, first, to develop an interdisciplinary concept of early diagnosis and adequate therapy of recurrent laryngeal nerve paralysis (RLNP), and second, to investigate efficiency of this approach. METHODS: 120 patients (77 male, 43 female) aged between 15 and 85 years (mean 57 years) were examined otolaryngologically before and after thoracic surgery. Individual therapeutic modalities were chosen according to established criteria. RESULTS: In 18 patients (15 %), RLNP was found (16 left, 2 right). Five had already been diagnosed preoperatively. Functional voice therapy, stimulation-current therapy or external vocal fold medialization was performed depending on the prognostic criteria. CONCLUSIONS: RLNP following thoracic surgery requires immediate diagnosis and therapeutic strategy to minimize postoperative complications and to overcome impairments in the voice, swallowing, and coughing. The interdisciplinary concept presented in this study is especially advisable in high-risk RLNP procedures.

Implementation of the Vienna Hydrotherapy Group for Laryngectomees--a pilot study.

GOALS: Laryngectomy involves several problems for the individual, such as the need to cope with a stoma, adjustment to tracheostomal breathing, and the formation of a voice. Contact with water, resulting in aspiration, may prove fatal for laryngectomized patients in the absence of appropriate aids. The aim of this pilot study was to conduct a hydrotherapy group for laryngectomized patients and to evaluate its feasibility and outcome in relation to the goals of therapy. PATIENTS AND METHODS: Six male patients who had undergone laryngectomy were included in a pilot study. The patients underwent a structured hydrotherapy rehabilitation program (three times a week for 8 weeks), using a special underwater therapy device. The patients' posture was controlled by posturography and their endurance capacity by standard ergometry and the 6-min walk. The parameters of fatigue, expectoration, mobility, elasticity/flexibility, postural control/coordination, and general well being were registered on a visual analog scale (VAS). Quality of life was assessed by having the patients fill out the German version of the SF-36 Health Survey. MAIN RESULTS: Posturograpy findings showed an improvement of two subtests ( p<0.028). Exercise testing showed an improved endurance capacity ( p<0.028). The patients were able to walk a greater distance in the 6-min walking test ( p<0.028). The VAS also showed an improvement of endurance capacity ( p<0.028), fatigue ( p<0.028), expectoration ( p<0.043), mobility of the neck and shoulder ( p<0.027), flexibility ( p<0.027), postural control and coordination ( p<0.028), and general well being ( p<0.028). On the SF-36 Health Survey, the patients were improved in the items "Physical functioning" ( p<0.027), "Vitality" ( p<0.027) "Role-physical" ( p<0.026), and "Social functioning" ( p<0.043). CONCLUSIONS: A hydrotherapy group for laryngectomized patients proved to be safe, feasible, and effective in this pilot study.

[Results of videostroboscopic examinations of vocally healthy candidates for voice intensive professions]. / Ergebnisse videostroboskopischer Untersuchungen an stimmlich beschwerdefreien Bewerbern für Sprechberufe.

BACKGROUND: Questions regarding the vocal aptitude for voice professions are common in the daily phoniatrical and otorhinolaryngological practice. According to the classification by Koufman, Isaccson and Stemple professions can be classified into four groups. While it is common to perform laryngeal investigations and analyses of the vocal efficacy for candidates of elite vocal performers (level 1), i. e. singers and actors, those examinations are usually not executed for voice and speaking intensive professions (level 2) like teachers, as there is no legal base. This group is, however, predisposed with regard to professional voice disorders. METHODS: Aim of the study was therefore to determine the frequency of laryngeal findings in a group of previously asymptomatic subjects using videostroboscopic examinations and to assess the risk concerning the emergence of professional voice disorders. 545 candidates for voice intensive professions have been examined with regard to the existence of any organic or secondary organic alterations on the vocal folds. RESULTS: One third of the subjects showed benign laryngeal alterations, which were not consequentially associated with auditive alterations of the voice sound and/or a consciousness of a voice disorder. Apart from 33 organic laryngeal alterations 129 phonation associated alterations of the vocal fold were determined. CONCLUSIONS: These subjects should especially in cases of excessive vocal demand and additional the efficacy reducing factors be regarded as a high risk group with regard to the emergence of professional voice disorders. The results underline the necessity to require vocal examinations and vocal assessment analyses for candidates of voice intensive professions in order to avoid professional voice disorders.

[Ductus arteriosus apertus as the cause of recurrent nerve paralysis. A case report]. / Der Ductus arteriosus apertus als Ursache einer Parese des N. recurrens. Ein Fallbericht.

There are various reasons for paralysis of the vocal folds, which consequently imposes great demands on differential diagnostics. Angiocardiopathies are regarded as very rare cases of etiopathogenesis. In the present case, a persistent arterial duct could be identified as the reason for the paralysis of the left recurrent nerve of a 59-year-old female patient. The necessity of interdisciplinary diagnostics going beyond the field of otorhinolaryngology is emphasized, especially in cases of a paralysis of the recurrent nerve.

Short-term effect of auditory feedback on fundamental frequency after cochlear implantation.

The present study evaluates the short-term effect of cochlear implantation on the fundamental frequency (FO) of 13 deaf patients. All patients were provided with the Combi 40+ cochlear implant. Voice recording was made pre- and 3 months post-implantation. The FO was analysed using X-Tools software. The results showed that 38 per cent of our subjects had a statistically significant decrease of their mean F0 (p=0.001) at 3 months following implantation. It was also observed that the patients tended to have a lower F0 postoperatively approaching the normal range of F0. A large variability in F0 was noticed among the deaf subjects but no correlation with the duration of deafness was seen. There was also no correlation between speech recognition and speech production.

[Stroboscopy and imaging in interdisciplinary diagnosis of early stages of laryngeal carcinoma]. / Stroboskopie und Bildgebung in der interdisziplinären Diagnostik von Frühstadien des Larynxkarzinoms.

The laryngostroboscopy is regarded to be the most important functional investigation in laryngologic and phoniatric diagnostics. She allows an analysis of vocal fold vibrations during phonation. Stroboscopic evaluations permit to early detect infiltrative processes of the vocal folds. Superficial alterations of the mucous membrane that invade into the muscle cause a phonatory "standstill" of the vocal fold in the stroboscopy, i.e. a complete lack of vibratory motion. If such a phonatory standstill persists for more than 2 or 3 weeks, a biopsy via microlaryngoscopy is indicated for diagnostic purposes. In comparison to stroboscopy, imaging techniques are not of such great significance in early laryngeal cancer. But in case of suspected infiltration of the tumor a further diagnostic evaluation with CT or MRI is necessary to detect possible neoplastic invasion of the laryngeal cartilage or of extralaryngeal structures. In this paper, we present the principle of laryngostroboscopy, the examination procedure and the stroboscopic parameters. Case reports of early laryngeal cancer illustrate the interdisciplinary diagnostic procedure with CT, MRI and stroboscopy.

[Laser surgical excision of a hypopharyngeal hemangioma using the CO2/Nd: YAG combination laser]. / Laserchirurgische Exstirpation eines hypopharyngealen Hämangioms mittels CO2/Nd: YAG-Kombinationslaser.

Hemangiomas of the upper aerodigestive tract may present a therapeutic challenge depending on their size, location and symptoms. We present a rare case of cavernous hemangioma of the aryepiglottic fold applaning in an adult. First symptoms were dysphagia and hoarseness. Surgical removal was performed with a CO2/Nd: YAG combination laser under microscopic control. After a regular postoperative course the patient has remained disease-free after a 2 year follow up period. We suggest the use of the CO2/Nd: YAG combination laser as preferred treatment in cases of exophytic hemangiomas, because of the favorable combination of excision with photocoagulation effects.

The effect of occlusal splint therapy on different curve parameters of axiographic TMJ tracings.

Computerized axiography was used as an objective instrumental method of evaluating the response of patients with temporomandibular joint (TMJ) symptomatology to occlusal splint therapy. Diagnosis was performed in a standardized manner by systematically analyzing TMJ path tracings obtained by computerized axiography. Thirty-six patients were axiographed before and after therapy with full-arch occlusal stabilizing appliances, followed by assessing the effect of therapy on various path curve parameters. The data obtained for the patient group treated with splints was compared to that of six patients also axiographed, but left untreated for a period of six weeks before a second TMJ tracing was obtained. The results show that splints have a certain effect on reciprocal TMJ clicking (response rate 67%). Retral stability and path characteristics are also substantially improved (response rates 44% and 40%). Less influence was noted on hypomobile joint paths (response rate 29%), the quality of movements (response rate 28%) and Bennett angle values (response rate 23%). Patients with disk displacements without reduction were not treated with splints, they underwent surgery. Their results will be reported later. By contrast, TMJ tracings in the control group remained essentially unchanged.

[Laryngeal surgery with a 3-D technique. Early results with the jet-laryngoscope in superimposed high-frequency jet ventilation]. / Laryngeale Eingriffe in 3-D-Technik. Erste Erfahrungen mit dem Jet-Laryngoskop unter Superponierter Hochfrequenz-Jet-Ventilation.

Surgery by three-dimensional (3D) endoscopy is being used routinely in abdominal surgery and, in special cases, in thoracic surgery; however, it has not been reported as being used in microlaryngeal surgery. METHODS. We inserted a 3-D endoscope into a jet laryngoscope and studied the pressure properties at the tip of the laryngoscope as well as intrapulmonary pressures while applying superimposed high-frequency jet ventilation. The studies were conducted initially using a lung simulator, and then in seven patients undergoing microlaryngeal surgery. RESULTS. Due to the rather large 3-D endoscope, the diameter of the jet laryngoscope was reduced by between 25.2% and 70.9%, depending on its size. The measurements on the lung simulator revealed that reduction of laryngoscope diameter leads to an increase in the following parameters: expiratory resistance, tidal volume, and peak inspiratory pressure. The mean FiO2 was 0.74 +/- 0.1; the mean paO2 was 169.2 +/- 80.4 mmHg; and the mean paCO2 was 40.9 +/- 2.4 mmHg. The mean airway pressure was 19 +/- 5.3 mmHg prior to insertion of the endoscope and 12.3 +/- 6.9 mmHg after insertion. The mean positive end-expiratory pressure values increased from 2 +/- 0.6 to 3.6 +/- 2.3 mmHg. Reduction of the working pressure resulted in restoration of the initial inspiratory pressures and tidal volumes. CONCLUSIONS. In the clinical application of 3-D endoscopy via a jet laryngoscope, it was possible to achieve sufficient ventilation, inspection of the surgical field, and performance of the surgical procedure. A CO2 laser was used without changing the ventilation regime. Although technical alterations would be desirable for its application to microlaryngeal surgery, it is presently possible to safely use the 3-D endoscope via the jet laryngoscope for microlaryngeal surgery, presenting the surgeon with new possibilities in voice-improving microsurgery of the larynx.

[3-D endoscopy for laryngeal interventions in tubeless superimposed high frequency jet ventilation. A clinical trial]. / 3D-Endoskopie für laryngeale Eingriffe bei tubusloser superponierter Hochfrequenz-Jet-Ventilation. Eine klinische Erprobung.

UNLABELLED: Surgery by 3-dimensional (3D) endoscopy is being used routinely in abdominal surgery and, in special cases, in thoracic surgery; however, it has not been reported to be used in laryngeal surgery. METHODS: We inserted a 3-D endoscope into a jet laryngoscope and studied the pressure properties at the tip of the jet laryngoscope as well as the intrapulmonary pressures while applying SHFJV. The studies were conducted initially using a lung simulator, and then in 6 patients undergoing endoscopic laryngeal surgery. RESULTS: Due to the rather large 3-D endoscope the diameter of the jet laryngoscope was reduced between 25.2% and 70.9% depending on the size of the jet laryngoscope. The measurements on the lung simulator revealed that the reduction of the diameter of the jet laryngoscope leads to an increase in the following parameters: expiratory resistance, tidal volume, and peak inspiratory pressure. The mean FiO2 was 0.74 +/- 0.1; the mean airway pressure was 19 +/- 5.3 mmHg prior to the insertion of the endoscope and 12.3 +/- 6.9 mmHg after the insertion. The mean PEEP values increased from 2 +/- 0.6 to 3.6 +/- 2.3 mmHg. Reduction of the working pressure resulted in regaining the initial inspiratory pressures and tidal volumes. CONCLUSIONS: In the clinical application of 3-D endoscopy via a jet laryngoscope it was possible to achieve sufficient ventilation, inspection of the surgical field and performance of the surgical procedure. A CO2 laser was used without changing the ventilation regime.(ABSTRACT TRUNCATED AT 250 WORDS)

[Holmium:YAG laser surgery. Possibilities for use in inflammatory paranasal sinus diseases]. / Holmium: YAG-Laserchirurgie. Anwendungsmöglichkeiten bei entzündlichen Nasennebenhöhlenerkrankungen.

A pulsed Holmium: YAG laser (lambda = 2120 nm) was used during functional endoscopic endonasal surgery in ten patients with recurrent chronic inflammation of the paranasal sinuses. The Holmium: YAG laser energy was coupled to a 600 microns core diameter nylon fiber. Power settings of 950 mJ per 2.5 microseconds pulse at 5 pulses per second were used. Tissue responses to treatment were examined by light microscopy. The photoablative mechanism of the laser-tissue interaction led to bone and soft tissue ablation with only a minor thermal component in the target zone. In comparison with other laser types available clinically, there was no carbonization zone after use of the Holmium-YAG laser. The area of tissue damage produced was significantly smaller (370-520 microns only) and wound healing proceeded without complication. The physical settings of the laser equipment are described with regard to their significance in photoablation when using flexible light-conducting fibers. The possible role of the Holmium: YAG laser in clinical surgery is discussed on the basis of the present experience.

Myofunctional therapy in patients with orofacial dysfunctions affecting speech.

Tongue thrusting, deviate swallowing, mouth breathing, orofacial muscle imbalance, deviate mandibular movement and malocclusion are the most important orofacial dysfunctions underlying disorders of articulation. Their development is linked to early bottle feeding and sucking habits. The phoniatrician is charged with the early detection of orofacial dysfunctions affecting speech. Early correction of habits and retraining by speech therapy are important preventive measures. Case histories, phoniatric and myofunctional diagnoses and dental/orthodontic findings were compiled for a total of 103 patients aged 3-30 years (11 +/- 4 years). Forty-five patients have completed a regimen of myofunctional therapy. For these patients highly significant improvements in lip strength, lip closure, breathing and tongue placement as well as in the swallowing pattern and orofacial muscle balance have been observed. Concomitantly, two thirds of the patients (66%) attained normal articulation. Speech defects were resistant to therapy in only 2 cases. In dental/orthodontic practice myofunctional therapy is used for retraining abnormal positions and functions of the orofacial muscles so as to create a normal occlusal relationship. The results of this study show that myofunctional therapy is highly instrumental also in phoniatrics as a special form of treatment for disorders of articulation.