Short term effect of hubble-bubble smoking on voice.

OBJECTIVE: To investigate the short term effect of hubble-bubble smoking on voice. STUDY DESIGN: Prospective study. MATERIAL: Eighteen non-dysphonic subjects (seven men and 11 women) with a history of hubble-bubble smoking and no history of cigarette smoking underwent acoustic analysis and laryngeal video-stroboscopic examination before and 30 minutes after hubble-bubble smoking. RESULTS: On laryngeal video-stroboscopy, none of the subjects had vocal fold erythema either before or after smoking. Five patients had mild vocal fold oedema both before and after smoking. After smoking, there was a slight increase in the number of subjects with thick mucus between the vocal folds (six, vs four before smoking) and with vocal fold vessel dilation (two, vs one before smoking). Acoustic analysis indicated a drop in habitual pitch, fundamental frequency and voice turbulence index after smoking, and an increase in noise-to-harmonics ratio. CONCLUSION: Even 30 minutes of hubble-bubble smoking can cause a drop in vocal pitch and an increase in laryngeal secretions and vocal fold vasodilation.

Effect of aggressive therapy on laryngeal symptoms and voice characteristics in patients with gastroesophageal reflux.

Gastroesophageal reflux (GER) is associated with a variety of laryngopharyngeal signs and symptoms. Injury of the laryngopharynx as a result of GER can be refractory to conventional antireflux therapy. This prospective study was undertaken to evaluate the prevalence of laryngopharyngeal signs and symptoms in patients with documented GER and to assess the response to a high-dose combination antireflux therapy consisting of cisapride and pantoprazole. Twenty-two patients with symptoms of GER were enrolled. After baseline evaluation using a history questionnaire for symptoms, laryngeal endoscopy and vocal acoustic analysis, patients were started on treatment consisting of pantoprazole 40 mg b.d. and cisapride 20 mg twice daily. Repeat history and otolaryngologic evaluation was performed at 4 weeks. Laryngopharyngeal symptoms were frequent in most patients, with throat clearing and globus being the most prevalent symptoms followed by vocal fatigue and excess mucus production. Almost 90% of the patients had abnormal endoscopic laryngeal findings but the acoustic parameters did not show any abnormal results except for mild elevation in the shimmer. After treatment, all symptoms and endoscopic abnormalities improved significantly except for intermittent dysphonia and laryngeal mucosal redness. Acoustic abnormalities did not change significantly following therapy. Laryngeal symptoms and voice abnormalities are highly prevalent in patients with GER. Combination antireflux therapy with a proton pump inhibitor and a prokinetic agent results in rapid symptomatic and endoscopic response in the majority of patients.

PCR-based detection, restriction endonuclease analysis, and transcription of tonB in Haemophilus influenzae and Haemophilus parainfluenzae isolates obtained from children undergoing tonsillectomy and adenoidectomy.

We developed and evaluated a PCR-based-restriction endonuclease analysis method to detect and analyze the tonB gene of Haemophilus influenzae and Haemophilus parainfluenzae from pediatric patients undergoing tonsillectomy and adenoidectomy. Multiple sites from the same patient, including the surface of adenoids and tonsils, as well as the core of tonsils, were cultured on chocolate agar and identified using standard procedures and the API NH Kit. A total of 55 H. influenzae isolates were recovered from different sites of 20 patients, and 32 H. parainfluenzae isolates were recovered from various sites of 12 patients. DNA was extracted from American Type Culture Collection strains and test isolates by the PureGene kit. Two primers, G1 (21-mer) and G2 (23-mer), were designed by us to amplify by PCR the tonB gene that consists of an 813-bp fragment. A nested PCR using primers T1 (23-mer) and T2 (24-mer) that flank an internal sequence to the gene of the order of 257 bp and restriction endonuclease digestion using XhoI and BglII were done to detect whether heterogeneity within the gene exists between the two species. Reverse transcription-PCR (RT-PCR) was finally done to detect transcription of the gene in both species. Our data have shown that the tonB gene was detected in both species. It is known to encode a virulent protein, TonB, in H. influenzae; however, demonstration of its presence in H. parainfluenzae is novel. Nested-PCR and restriction endonuclease analysis have shown that the tonB gene is apparently structurally the same in both species, with possible differences that may exist in certain H. parainfluenzae isolates. RT-PCR done on selected numbers of H. influenzae and H. parainfluenzae have shown that the tonB gene was transcribed in both species. This shows that the TonB protein, if expressed, may play a different role in the virulence in H. parainfluenzae since it is not needed for heme or heme complexes uptake as with H. influenzae.

Nasoseptal variation in relation to sinusitis. A computerized tomographic evaluation.

Paraseptal structural abnormalities are common in patients with sinusitis. They may coexist with radiographic changes suggestive of sinusitis. Their etiological role in patients with no history of sinus disease is still controversial. In this study, computerized tomographic scan of orbits of 89 cases with no history of sinusitis were reviewed between 1996 and 1998. The incidence of septal deviation, concha bullosa and paradoxical middle turbinates was looked at. Their correlation with sinusitis was analyzed using CM-square statistical method. Results showed that the presence of these anatomical abnormalities is not associated with an increased incidence of sinusitis as shown radiologically. We conclude that the presence of septal deviation or large middle turbine on routine rhinoscopy does not mandate further radiological evaluation of the sinuses in the absence of history of sinusitis.

The etiologic role of the osteo-meatal complex in the pathogenesis of sinusitis: a retrospective study of clinical, CT and endoscopic findings in 143 patients.

UNLABELLED: The etiological role of the osteo-meatal complex (OMC) in the pathogenesis of sinus disease is a debatable issue. The charts of 143 patients who underwent endoscopic sinus surgery at the American University of Beirut Medical Center between 1992 and 1995 were reviewed. Clinical symptoms included facial pain, nasal obstruction, headache, and postnasal drip. CT scan and endoscopic findings were reviewed. The presence of OMC disease radiologically was correlated with all the clinical, nasal endoscopic and other radiologic findings (disease in the rest of paranasal sinuses, or presence of concha bullosa). Its etiological role in patients with sinusitis is discussed. RESULTS: No endoscopic findings could be statistically correlated with the OMC disease. Facial pain and postnasal drip were the only clinical symptoms that statistically correlated with the OMC disease (p-value = 0.009 and 0.008, respectively). The OMC disease correlated with the radiological evidence of sinusitis in any of the sinuses.

Viral supraglottitis in an adult: a case presentation and literature update.

Viral epiglottitis (supraglottitis) is a rare entity but its presentation can mimic that of bacterial epiglottis. Regardless of the causative agent, supraglottitis is a serious disease mostly affecting children and rarely seen in adults. Early suspicion and proper evaluation are mandatory to prevent a life-threatening crisis. In both children and adults the infectious aetiology in supraglottitis is predominantly bacterial while viruses are rare, especially in adults. We describe a case of supraglottitis in an adult in which the symptoms were insidious and blood indices suggested a bacterial aetiology. However, laryngoscopic examination revealed an ulcer over the left aryepiglottic fold and serology was positive for Herpes simplex virus (HSV) IgM. Because supraglottitis due to HSV is a rare entity with few reported cases in the literature, this case is presented to highlight the viral involvement in this disease and its management.

Pharmacologic partial salvage of a failing free flap with recombinant tissue plasminogen activator (rt-PA).

Despite all the technical improvements in microvascular surgery and the experience gained in clinical practice, thrombosis at the site of microanastomosis remains a significant problem and a continuous source of frustration to most microsurgeons. Early recognition of vascular complications and prompt reexploration with vascular revision remain an essential and standard conduct for salvage. However, in situations where conditions for no-reflow have been established due to severe vasospasm or prolonged ischemia time, it becomes obvious that surgical reexploration alone is not enough to salvage a failing flap or a replanted limb. In such situations, the loss of the revascularized tissues seems to be inevitable. The authors describe their experience in partially salvaging a failing free flap with recombinant tissue plasminogen activator (rt-PA), reversing an established state of no-reflow. Pharmacologic manipulation of the complex and variable factors influencing anastomotic patency in microvascular tissue transfer seems to offer a new hope for preventing failures, as well as for salvaging failing flaps. It appears also that free-tissue transfer failure is not an all-or-none phenomenon.

Predicting airway risk in angioedema: staging system based on presentation.

Angioedema is an immunologically mediated, anatomically limited, nonpitting edema that can lead to life-threatening airway obstruction. To predict the risk of airway compromise in angioedema, we retrospectively reviewed 93 episodes in 80 patients from 1985 to 1995. Intubation or tracheotomy was necessary in 9 (9.7%) cases. Angiotensin-converting enzyme inhibitor use in 36 cases (39%) was associated with intensive care unit (ICU) admission (P = 0.05). ICU stay correlated significantly with presentation with voice change, hoarseness, dyspnea, and rash (P < 0.05). Voice change, hoarseness, dyspnea, and stridor were present in patients requiring airway intervention (P < 0.05). On the basis of our data, we propose a staging system by which airway risk may be predicted from the anatomic site of presentation. Patients with facial rash, facial edema, lip edema (stage I), and soft palate edema (stage II) were treated as outpatients and on the hospital ward. Patients with lingual edema (stage III) usually required ICU admission. All patients with laryngeal edema (stage IV) were admitted to the ICU. Airway intervention was necessary in 7% of stage III patients and in 24% of stage IV cases. No deaths were caused by angioedema. Airway risk in angioedema may be predicted by anatomic site of presentation, allowing appropriate triage with preparation for airway intervention in selected cases.

Use of postoperative chest x-ray after elective adult tracheotomy.

Surgeons have been creating tracheotomies since at least 124 AD, when first reported by Asclepiades (Price HC, Postma DS. Ear Nose Throat J 1983;62:44-59). Intraoperative and postoperative complications specifically associated with this procedure have been well established. The incidence of pneumothorax ranges from 0% to 17%, depending on the age group studied. To evaluate this complication, it is generally accepted that a postoperative chest film should routinely be obtained after a tracheotomy in adult patients. In adult nonemergent tracheotomies, the routine use of a postoperative chest film has a low yield for detecting a pneumothorax in patients without clinical findings of pneumothorax. To evaluate the use of postoperative chest x-ray in adult tracheotomy patients, a retrospective review of tracheotomies performed at the Boston Medical Center from January 1994 to June 1996 was undertaken. Data examined consisted of age, sex, surgical indication, urgency, operating service, intraoperative and postoperative complications, difficulty of procedure, anesthetic technique, findings on postoperative chest film, signs and symptoms of pneumothorax, and specific treatment of pneumothorax if present. In total, 250 patients were identified. The main indication for tracheostomy in this study was ventilator dependence, accounting for 77% of the procedures. A complication rate of 11.6% was encountered, with no deaths. Postoperative hemorrhage was the most common complication (3.6%). Pneumothorax was documented by chest x-ray in 3 (1.2%) patients, 1 of whom had bilateral pneumothoraces. The most common symptom of a pneumothorax was tachycardia, with 8.8% of the patients exhibiting at least 1 episode. Of the 3 cases of pneumothorax in this study, only 1 was clinically relevant and required treatment. Furthermore, the clinical signs and symptoms in this patient clearly supported the diagnosis of pneumothorax before a postoperative chest film was obtained. Thus postoperative chest radiographs did not change the treatment or outcome of any of the patients undergoing a tracheotomy. This suggests that postoperative chest x-ray after adult tracheotomy is not required in routine cases. Chest radiographs should be obtained after emergent procedures, after difficult procedures, or in patients exhibiting signs or symptoms of pneumothorax.

Metachronous cancer: prognostic factors including prior irradiation.

In this article we evaluate two factors that may be responsible for the reported increased mortality rate in metachronous cancers: prior radiation therapy and stage at presentation. A select group of 358 patients was split into three groups: no prior cancer (group 1), prior cancer treated with radiation therapy (group 2), and prior cancer treated with surgery alone (group 3). We compared survival among the three groups according to stage (T1 or T2 vs. T3 or T4) using the Lifetest procedure. Survival in patients with advanced (T3 or T4) cancers was uniformly poor, and survival in patients with low-staged (T1 or T2) cancers was disproportionately poor only for patients in group 2. Metachronous cancers are not necessarily more lethal, except when the cancer arises within prior irradiated tissue. Initial treatment decisions for patients with primary cancers must always provide for the contingency of a metachronous cancer, and the judicious use of radiation therapy is essential.

Loss of heterozygosity at 11q23 in squamous cell carcinoma of the head and neck is associated with recurrent disease.

Loss of heterozygosity (LOH) at chromosome 11q23 has been found in a variety of epithelial human neoplasms, suggesting that this region contains a tumor suppressor gene(s) important to tumorigenesis. We investigated whether LOH at 11q23 could be detected in squamous cell carcinoma of the head and neck (SCCHN), and whether loss at this site was associated with specific clinical parameters. Fifty-six matched blood and SCCHN tumor samples taken at the time of diagnosis were evaluated for LOH at three microsatellite markers at 11q23. Multiplex PCRs with [alpha-32P]dCTP labeling of the amplified DNA strands were performed. Clinical data were obtained from medical record review. LOH at 11q23 was found in 13 of 52 (25%) evaluable tumors. There was no association between LOH at 11q23 and amplification of the CCND1 (cyclin D1) oncogene or inactivation of the p53 gene, which had been determined previously. With a mean follow-up of 24 months, an association independent of tumor size or stage was found between LOH at 11q23 and recurrent disease (P = 0.04). Among subjects who received radiotherapy (RT) as a component of their treatment, LOH at 11q23 was associated with persistent or recurrent locoregional disease (P = 0.05). LOH at 11q23 occurs in a subset of SCCHN. It is associated with a higher likelihood of recurrent disease, perhaps related to resistance to RT. The specific gene(s) and mechanism(s) responsible remain to be identified. Until then, LOH at 11q23 might become a marker identifying patients likely to do poorly with conventional therapy.

Symptoms in early head and neck cancer: an inadequate indicator.

Screening programs show promise in increasing the rate of early detection of head and neck cancers in high-risk populations. Prout et al (Otolaryngol Head Neck Surg 1997;116:201-8) examined the usefulness of a large-scale screening program for head and neck cancer in an inner city population by primary care physicians. Symptom assessment was based on the American Cancer Society's "Seven Warning Signs for Cancer," (Cancer manual. 8th ed. Boston: American Cancer Society, Massachusetts Division; 1990. p. 40-64) 4 of which are relevant to the head and neck. However, these signs may be insufficient for detection of early head and neck cancer. We analyzed these and other typical symptoms to determine their role in early detection. Coincident medical problems, tobacco abuse, and alcohol abuse were also analyzed. Our findings indicate that no symptom or symptom complex is strongly correlated with early head and neck cancer for any subsite except the glottis. Symptom duration is an unreliable indicator of the duration of disease. However, patients under medical supervision are more likely to have their cancers detected early, supporting the value of surveillance by the primary care physician. The absence of definite early warning signs for most head and neck cancers suggests the need to develop essential screening criteria. Defining the population that is at high risk for head and neck cancer and subjecting it to an aggressive screening protocol is essential.

Inactivation of p53 and amplification of cyclin D1 correlate with clinical outcome in head and neck cancer.

The authors have investigated whether genetic abnormalities in two genes, loss of heterozygosity (LOH) of p53 and amplification of the cyclin D1 gene, correlate with clinical outcome in 56 matched pairs of blood and tumor from patients with squamous cell carcinoma of the head and neck (SCCHN). Frequency of p53 LOH was 47.4%, of cyclin D1 amplification 33.9%, and of both abnormalities together 23.7%. p53 LOH was associated with T4 (P = 0.003) and stage IV (P = 0.015) tumors. Cyclin D1 amplification was associated with recurrences and/or metachronous tumors (P = 0.007). The total number of p53 and cyclin D1 abnormalities (scored as zero, one, and two) show a pattern that seems to be additive; the increase in the number of these abnormalities is associated with a proportional increase in the frequency of T4, stage IV, presence of recurrences and/or metachronous tumors, and possibly a proportional decrease in the disease-free interval in the sample. The association of the markers with recurrences and/or metachronous tumors persists if the tumor stage effect is mathematically removed. The combined analysis of the p53 and cyclin D1 abnormalities seems to be more informative than either of them individually and may have predictive value in SCCHN.

The transvestibular approach to the nasal tip and dorsum: a new refinement in rhinoplasty.

The limited exposure of the lower lateral cartilage using the transcartilaginous approach may result in significant asymmetries in the nasal tip, especially in the region of the nasal domes and intermediate or middle crura. The author presents a new technique for exposing the lower lateral cartilage. Through a marginal incision, the whole endonasal surface of the lower lateral cartilage can be exposed, allowing the performance of different reduction and rearrangement techniques to the lateral and medial crura. The author discusses results of his experience using this new approach, emphasizing the surgical steps, advantages, and disadvantages. The transvestibular approach has proven to be a reliable approach that improves the predictability of endonasal rhinoplasty.