Immobile vocal fold secondary to thyroid abscess: a case report.

Vocal fold paralysis as a result of a thyroid abscess is extremely rare. In this article, we report only the second documented case of such a finding. The paralysis was discovered after our patient, a 40-year-old woman, had come to the office with a complaint of discomfort in the right lower neck. Computed tomography confirmed the presence of an abscess in the posterior thyroid gland. Fine-needle aspiration did not identify any inflammatory or suspicious cells. The abscess was treated with hemithyroidectomy, and the paralysis resolved 3 weeks later. There has been no recurrence after 4 years.

Efficacy of DHE photodynamic therapy for respiratory papillomatosis: immediate and long-term results.

OBJECTIVES/HYPOTHESIS: Recurrent respiratory papillomatosis is a potentially life-threatening disease that affects both children and adults and can result in complete respiratory obstruction. Conventional therapies cannot prevent multiple recurrences. The authors have been evaluating photodynamic therapy (PDT) to treat this disease since 1988. This study compared the efficacy of PDT with dihematoporphyrinether (DHE) with traditional therapy. STUDY DESIGN: This was a randomized prospective trial of DHE-PDT. Patients were randomly assigned to receive one of two doses of DHE--3.25 mg/kg or 4.25 mg/kg body weight. They were compared with a concurrent control group. Disease extent was evaluated by direct laryngoscopy before treatment and over a 1-year period following treatment. Results were also compared with two historical cohorts of patients treated with lower doses of DHE. METHODS: Eighty-one patients, ages 4 to 74 years, with moderate to severe recurrent disease were enrolled. Forty-eight received PDT and 33 in the control group were treated with conventional therapy. Both PDT groups received 50 J laser light to activate the drug. Patients received an intravenous infusion of DHE as outpatients 48 to 72 hours before treatment. During direct laryngoscopy, light (630 nm) was delivered by an argon-pumped dye laser. Tissue biopsies were analyzed for presence of human papillomavirus (HPV). RESULTS: There was notable improvement with either drug dose over the first year. Those receiving 4.25 mg/kg DHE experienced a significantly larger decrease in papilloma growth rate. Three-year follow-up of a subset of patients confirmed that improvement was maintained. There was no impact of DHE-PDT on persistence of HPV DNA. CONCLUSION: This therapy holds promise for the treatment of laryngeal papillomas.

High jugular bulb and conductive hearing loss.

A high jugular bulb is often discovered as an incidental finding that is asymptomatic. Conductive hearing loss in association with this anomaly may occur, but has been reported infrequently in the literature. We report five cases of high jugular bulb and associated conductive hearing loss. Mechanisms to explain the conductive hearing loss include contact of the jugular bulb with the tympanic membrane, interference with the ossicular chain, and obstruction of the round window niche. The operative findings, radiographic and audiometric data that support these mechanisms of conductive hearing loss are presented.

Spiral computed tomographic scanning of the chest with three dimensional imaging in the diagnosis and management of paediatric intrathoracic airway obstruction.

BACKGROUND: The usefulness of spiral computed tomographic (CT) scans of the chest with three dimensional imaging (3D-CT) of intrathoracic structures in the diagnosis and management of paediatric intrathoracic airway obstruction was assessed. METHODS: A retrospective review was made of five consecutive cases (age range six months to four years) admitted to the paediatric intensive care unit and paediatric radiology division of a tertiary care children's hospital with severe respiratory decompensation suspected of being caused by intrathoracic large airway obstruction. Under adequate sedation, the patients underwent high speed spiral CT scanning of the thorax. Non-ionic contrast solution was injected in two patients to demonstrate the anatomical relationship between the airway and the intrathoracic large vessels. Using computer software, three-dimensional images of intrathoracic structures were then reconstructed by the radiologist. RESULTS: In all five patients the imaging results were useful in directing the physician to the correct diagnosis and appropriate management. In one patient, who had undergone repair of tetralogy of Fallot with absent pulmonary valve, the 3D-CT image showed bilateral disruptions in the integrity of the tracheobronchial tree due to compression by a dilated pulmonary artery. This patient underwent pulmonary artery aneurysmorrhaphy and required continued home mechanical ventilation via tracheostomy. In three other patients with symptoms of lower airway obstruction the 3D-CT images showed significant stenosis in segments of the tracheobronchial tree in two of them, and subsequent bronchoscopy established a diagnosis of segmental bronchomalacia. These two patients required mechanical ventilation and distending pressure to relieve their bronchospasm. In another patient who had undergone surgical repair of intrathoracic tracheal stenosis three years prior to admission the 3D-CT scan ruled out restenosis as the reason for her acute respiratory decompensation. CONCLUSIONS: 3D-CT scanning is a useful additional diagnostic tool for intrathoracic airway obstruction in paediatric patients.

Speech and swallowing rehabilitation following devastating caustic ingestion: techniques and indicators for success.

Caustic material ingestion, either accidental or intentional, may result in tissue and organ destruction leading to a wide range of complications, including loss of speech and the ability to eat. The esophagus can be reconstructed successfully, but reopening the larynx and upper airway poses a significant therapeutic dilemma. External reconstruction may put the neoesophagus at risk. Loss of the normal swallowing mechanism and the protective supraglottic structures often results in fatal aspiration. The authors present three cases of successful endoscopic laser recannulation of the larynx with esophageal replacement. The discussion includes surgical technique and the tools used to determine the success of the reconstruction, including computed tomographic scanning, modified barium swallow, placement of an upper esophageal anastomosis, psychologic support, and speech and swallowing therapy.

Photodynamic therapy using m-tetra(hydroxyphenyl) chlorin. An animal model.

OBJECTIVE: To evaluate the potent photosensitizer m-tetra (hydroxyphenyl) chlorin (m-THPC) by using rabbits with cottontail rabbit papillomavirus-induced tumors and the canine larynx as model systems. DESIGN: Nonrandomized control trial. SETTING: Division of ear, nose, and throat research at a tertiary care teaching hospital. MATERIALS: Rabbits were used for relative retention ratio studies and tissue tolerance tests. Studies on the swelling of normal tissues in the larynx after photoactivation were done with canines. INTERVENTION: Animals were injected with 0.3 mg/kg of m-THPC. At varying intervals, tissues were exposed to 652 nm of light. OUTCOME MEASURES: Outcome measures consisted of four elements: (1) decay of plasma concentration over time, (2) interval to and duration of maximal ratio between drug concentration in normal tissue and tumor, (3) maximal permissible light exposure to normal tissue (skin and laryngeal mucosa) at an optimal interval, and (4) efficacy--number of tumors with partial and complete response. RESULTS: The largest papilloma to skin ratio (10:1) occurred 4 to 8 days after drug injection. The rabbit skin damage threshold was 40 to 60 J/cm2 at 6 days. The canine laryngeal edema and erythema thresholds were 50 to 70 J. A 75% cure rate of papillomas was achieved with tumors that were less than 100 mm2 in area at light doses that ranged from 25 to 75 J/cm2. CONCLUSIONS: m-THPC shows efficacy in treating papilloma virus-induced tumors. We present a protocol for rapid optimization of the factors required for tumor destruction with minimal normal tissue damage, thus permitting determination of an optimal therapeutic protocol for any photosensitizer.

Variable light-dose effect on photodynamic therapy for laryngeal papillomas.

OBJECTIVE: We investigated photodynamic therapy (PDT) as an alternative treatment modality for recurrent respiratory papillomatosis. To optimize the effect of PDT, the light dose in this study was increased from 50 to 80 J/cm2. The clinical effect of these two light doses will be discussed and compared. DESIGN: Each patient's response was based on the growth rate of their papilloma before and after PDT. Disease response following 50 J/cm2 was compared with that after 80 J/cm2. The two study groups were also compared with a control group. SETTING: Each patient received the dihematoporphyrin ether as an outpatient and underwent direct laryngoscopy and PDT at our institution. PATIENTS: Twenty-eight patients (16 male and 12 female) with moderate to severe laryngeal disease and an age range of 18 months to 80 years were treated with a light dose of 80 J/cm2, 11 of those had been previously treated with 50 J/cm2. Seven patients had undergone photoactivation to the trachea. INTERVENTION: Twenty-four hours prior to photoactivation, patients received 2.5 mg/kg of dihematoporphyrin ether intravenously. Photodynamic therapy was given using an argon pump dye laser system. MAIN OUTCOME MEASURE: Reduction in disease severity greater than that achieved with 50 J/cm2. RESULTS: For patients treated initially with 80 J/cm2, the mean rate of papilloma growth decreased by approximately 50%, the same response seen with 50 J/cm2 of treatment. No additional benefit was found for those patients initially activated at 50 J/cm2 and then re-treated at 80 J/cm2. CONCLUSION: Although PDT has a beneficial effect on laryngeal papilloma growth rate, no significant change in response was obtained by increasing the light dose from 50 to 80 J/cm2.

Latent infection induced with cottontail rabbit papillomavirus. A model for human papillomavirus latency.

Latent human papillomavirus infection, a very common event, is most likely the source of primary and recurrent papillomas of the respiratory and genital tracts and might also be the source of neoplastic lesions of the female genital tract and the penis. We have developed a simple model for papillomavirus latency using cottontail rabbit papillomavirus. Skin of domestic rabbits was minimally scarified and inoculated with dilutions of a crude virus suspension ranging from 200 ng to 20 pg viral DNA per inoculated site. Dilution of virus to less than 10 ng/site resulted in delayed and reduced efficiency of inducing warts. After follow-up of 1 to 6 months, sites immediately adjacent to papillomas and inoculated sites where papillomas did not form were biopsied and analyzed by Southern blot and polymerase chain reaction. Inoculated tissues that were clinically and histologically normal contained viral DNA at low levels, detectable by polymerase chain reaction. Ability of the latent virus to induce warts was confirmed by activation with mild skin irritation causing wart formation. This simple model system for latent papillomavirus can be used to study mechanisms of viral activation, therapies to prevent activation, and therapies to eliminate latent virus and thus cure the infection.

Comparison of pulsed and continuous wave light in photodynamic therapy of papillomas: an experimental study.

Papillomavirus infection of the upper aerodigestive tract is a serious and potentially life-threatening disease which can result in complete respiratory obstruction. Papillomas are the most common benign neoplasm of the larynx in children but have been shown to have an equal propensity to occur in adults. The hallmark of this disease is one of multiple recurrences despite adequate surgical removal, often resulting in a frustrating and prolonged clinical course. Multiple treatment modalities have been used throughout the years, unfortunately with limited success. Recent reports on the treatment of virally induced lesions with photodynamic therapy (PDT) using hematoporphyrin derivative (HPD) or its newly purified form dihematoporphyrin ether (DHE) as photosensitizing agents have appeared in the literature. The successful treatment of papillomas in both the animal model and humans holds great promise. The most commonly used activating light source has been the argon pumped-dye laser (ADL) which produces a continuous wave of coherent light at 630 nm. Although the ADL has proved efficacious in most studies, its cost, size, special cooling water requirements, and large electrical power requirements with limited power output have made it a less than desirable clinical tool. The gold vapor laser (GVL) has been recently proposed as a possible alternate light source for PDT. This laser appears to be more efficient and offers greater power output while requiring less electrical energy than the ADL. The GVL does not produce the same continuous wave light as the ADL but emits pulsed light with high peak power pulses. Some reports have shown a greater tumor response using the GVL at 628 nm, possibly because of greater tissue penetration from the high-peak power pulses. At this time, no studies have investigated the effects of pulsed light during PDT on virally induced papillomas. The present study was conducted to evaluate the efficacy of pulsed light from a GVL as compared to continuous wave light of the ADL in the treatment of papillomas with DHE phototherapy. Statistical analysis of the rate of tumor response, histological changes, and molecular analysis of viral DNA from the involved tissues were performed. Results have shown that the GVL did produce a greater initial rate of tumor response during the first 3 weeks after PDT but did not improve the overall cure rate. Histological and molecular analysis of the treated tissues demonstrated that similar results were obtained when either the ADL or GVL were used as activating light sources.

Clinical effects of photodynamic therapy on recurrent laryngeal papillomas.

Thirty-three patients with moderate to severe recurrent laryngeal papillomatosis underwent photodynamic therapy at our institution. All received 2.5 mg/kg of dihematoporphyrin ether intravenously either 48 or 72 hours prior to photoactivation with an argon pump dye laser system. Photosensitivity was the only side effect seen. Statistical analysis showed a significant decrease, by approximately 50%, in the average rate of laryngeal papilloma growth following treatment. The response was especially pronounced in patients with the worst disease. In addition, three patients have now remained free of disease for extended periods following photodynamic therapy. Latent infection with human papillomavirus continues to persist in clinically normal tissue following photodynamic therapy. The results and potential of this exciting new therapy for laryngeal papillomatosis are described.

Sudden sensorineural hearing loss.

Hearing is one of our most important senses and its sudden loss can be frightening and frustrating for the patient and his or her physician. Despite multiple reports of sudden SNHL over the years, we still do not have a universally accepted definition. This has led to further confusion in reporting and evaluating the treatment and prognosis of this disease. We generally define any SNHL occurring over 3 days as sudden SNHL. The overall incidence of this disease appears to be low. However, the true incidence may be higher, because those patients who spontaneously recover may never seek medical attention. The etiology is often difficult to identify, leaving a large population of patients labeled as idiopathic SNHL. Before accepting the idiopathic label, the physician must maintain a high level of suspicion to be sure that the SNHL is not a symptom of a larger underlying systemic disorder. Several theories have been proposed to try to explain SNHL. These include the infectious theory, vascular theory, and rupture theory. In addition to these, metabolic imbalances, drug toxicity, and various disease entities may contribute to sudden SNHL. Over the years, many treatment protocols have appeared in the literature, each claiming various rates of success. Unfortunately, they are often based on emotional and empiric considerations, because an exact etiology is unknown. Drugs have been chosen from several categories including the following: vasodilators, diuretics, anticoagulants, plasma expanders, corticosteroids, and contrast material. These medications have been used singly or in combination therapies. One must always be aware of the potential side effects. One factor that appears to be constant in each reported therapy is that those patients who seek medical attention early do better. The type of hearing loss also seems to play a role in the outcome of sudden SNHL; patients with low-frequency hearing losses or upward-sloping audiograms have a better prognosis. The patient must take the first step in seeking medical attention. Once the problem has been recognized, prompt attention by the physician to the medical workup and timely initiation of therapy will offer the patient the best possible chance for recovery. Time is often the greatest factor in the overall recovery, and the physician should reassure the patient that everything is being done to speed this along. However, patience may be the greatest healer of all.

Endolaryngeal jet ventilation: a 10-year review.

Jet ventilation for microsurgery of the larynx has been in common use at our institution since 1978. There were 942 cases performed, with ages ranging from 7 days to 90 years. A specially modified laryngoscope with multiple ports into which a 14- or 16-gauge ventilation needle can be advanced just distal to the vocal cords simplifies this form of anesthesia and ventilation. Jet ventilation has been advocated in place of conventional ventilation methods during carbon dioxide laser surgery because it eliminates the potential fire hazard of the endotracheal tube and allows superior visibility of the vocal cords. Despite these advantages, it is still not in common use. We will review the airway mechanics and special anesthesia considerations that make jet ventilation a safe and time-proven technique.

Dihematoporphyrin ether-induced photosensitivity in laryngeal papilloma patients.

Twenty-six patients with recurrent laryngeal papillomatosis received 2.5 mg/kg of Dihematoporphyrin Ether (DHE) intravenously prior to photodynamic therapy. All patients experienced some degree of photosensitivity, the only known side effect of DHE. Reported reactions included mild erythema and inflammation (88%), swelling (58%), blistering (23%), ocular discomfort (61.5%), pruritus (38%), and skin hyperpigmentation (46%). Length of sensitivity ranged from 4-17 weeks, with an average duration of 9 weeks. No long-term debilitating sequelae were noted. Degree of skin reaction mainly depended on how compliant the patient was in following precaution instructions. Although restrictive precautions were often difficult to strictly adhere to, most patients felt the potential benefits of the therapy far outweighed any inconvenience.

Biodistribution of indium 111-labeled dihematoporphyrin ether in papillomas and body tissues. Relevance to photodynamic therapy.

Hematoporphyrin derivative and its newly purified form, dihematoporphyrin ether, have been shown to localize selectively in malignant tissues and virally induced papillomas. Its use as a probe to distinguish tumors from normal tissues has been largely based on its fluorescence when activated by UV light. These findings are largely subjective, and a direct correlation to its use as a photosensitizing agent to selectively kill transformed cells when activated by an appropriate wavelength of light could not be made. The efficacy of dihematoporphyrin ether photodynamic therapy to selectively kill papillomavirus-transformed cells is based on the increased localization of dihematoporphyrin ether within these tissues as compared with normal tissues. Using cottontail rabbit papillomavirus, cutaneous papillomas were induced on the backs of Dutch belted rabbits. Dihematoporphyrin ether was labeled with indium 111 and intravenously injected into the rabbits. The animals were scanned twice daily for indium 111 activity on a large-field-of-view gamma camera. At 50 hours after injection, the rabbits were killed and papillomas, skin, and major organs collected for biodistribution studies. The results of this study and their relationship to dihematoporphyrin ether photodynamic therapy for the treatment of virally induced papilloma disease is discussed.

Anatomic reconstruction and functional rehabilitation of oromandibular defects with rigid internal fixation.

Fifteen consecutive patients undergoing extensive surgery for head and neck cancer involving the oral cavity and oropharynx were reconstructed using the technique of rigid internal fixation combined with various vascularized flaps. The follow-up ranged from 6 to 18 months. Modifications in various myocutaneous or vascularized free flaps combined with an analysis of the radiation physics necessary to make this procedure a viable alternative for immediate and delayed mandibular reconstruction will be discussed. Consistently satisfactory functional and cosmetic results have been achieved.

Histological and molecular analysis of cottontail rabbit papillomavirus-induced papillomas treated with hematoporphyrin derivative photodynamic therapy.

The clinical regression of cottontail rabbit papillomavirus-induced cutaneous papillomas on Dutch-belted rabbits following treatment with hematoporphyrin derivative photodynamic therapy was recently reported. Those papillomas that underwent total regression failed to recur at 18 months. Tissues from totally regressed papillomas and adjacent sites failed to reveal the presence of papilloma on histological examination. These findings were confirmed by the absence of viral DNA following analysis by Southern blots for cottontail rabbit papillomavirus viral copy number and DNA restriction pattern. Partially regressed papillomas and untreated papillomas revealed histologically typical papillary features with approximately equal amounts of viral DNA.

The pathologic effects of photodynamic therapy on the larynx. Experimental study.

Using an argon pump dye laser at a wavelength of 630 nm, varying amounts of energy (10 to 170 J/cm2) were delivered to the presensitized (hematoporphyrin derivative) canine larynx. There appear to be four energy zones that result in progressive degrees of tissue response. Between 10 and 40 J/cm2 the larynx appears normal, with only mild erythema noted at 60 J/cm2. Above 100 J/cm2 moderate to severe erythema and edema were seen, with two upper-airway deaths observed. Transmission pattern analysis revealed that by either increasing the total energy applied and/or positioning the cylindrical diffuser tip at different levels of the larynx, the entire structure including the undersurface of the vocal cord and subglottic region could be exposed to red light.