Technique Nuances for Functional Preservation of Lower Cranial Nerves during Surgical Management of Ventral Foramen Magnum Meningiomas Via a Dorsal Lateral Approach.

BACKGROUND: This study established novel technique nuances in surgery for ventral foramen magnum meningiomas (vFMMs) via a dorsal lateral approach. METHODS: From July 2012 to July 2019, 37 patients with vFMMs underwent tumor resection surgery and were operated on with a dorsal lateral approach. Two safe zones were selected as the entrance of the surgical corridor. Safe zone I was located between the dural attachment of the first dental ligament (FDL) and the branches of C1; safe zone II lay between the dural attachment of the FDL and the jugular foramen. The tumor was debulked first through safe zone I and then through safe zone II. The tumor was removed through a trajectory from the caudal to cephalad to allow tumor debulking from below and downward delivery, away from the brainstem and lower cranial nerves. RESULTS: Thirty-three patients underwent gross total resection, and 4 patients underwent subtotal resection. Four patients transiently required a nasogastric feeding tube. All patients recovered within 3 months postoperatively. Three patients (8.1%) developed permanent mild hoarseness and dysphagia as a result of postoperative damage of cranial nerves IX and X. One patient underwent tracheotomy. No patient experienced tumor recurrence during the follow-up period. CONCLUSIONS: We established a minimal retraction principle, in which the selection of 2 safe zones as the entrance of the surgical corridor, tumor removal from the inferior to superior direction, and debulking followed by devascularization were the key elements to implement the minimal retraction principle in vFMM surgery.

Tuberculous mediastinal lymphadenopathy presenting with left vocal cord palsy: A rare entity.

A 23-year-old-male student, never-smoker presented to our hospital outpatient department with complaints of loss of appetite, unintentional weight loss, fatigue and low-grade fever for two months, hoarseness of voice (HOV) for two weeks. He was evaluated for HOV with video laryngoscopy which demonstrated left vocal cord palsy. Contrast enhanced CT Chest (CECT) was performed for evaluation of mediastinal lesions which revealed multiple peripheral enhancing conglomerate mediastinal lymph nodes. EBUS-trans bronchial needle aspiration (TBNA) and endobronchial biopsy were performed and specimens sent for smear and culture for AFB, Xpert MTB/RIF assay and histopathology. Results were consistent with Mycobacterium tuberculosis (MTB) infection and culture was positive for M. tuberculosis complex. Patient had been started on anti tubercular therapy (ATT) and during his 4th month follow up he showed clinicoradiological improvement without recovery of recurrent laryngeal nerve palsy.

Assessment and Diagnostic Accuracy Evaluation of the Reflux Symptom Index (RSI) Scale: Psychometric Properties using Optimal Scaling Techniques.

OBJECTIVES: To investigate the psychometric properties of the reflux symptom index (RSI) as short screening approach for the diagnostic of laryngopharyngeal reflux (LPR) in patients with confirmed diagnosed regarding the 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH). METHODS: From January 2017 to December 2018, 56 patients with LPR symptoms and 71 healthy individuals (control group) were prospectively enrolled. The LPR diagnosis was confirmed through MII-pH results. All subjects (n = 127) fulfilled RSI and the Reflux Finding Score (RFS) was performed through flexible fiberoptic endoscopy. The sensitivity and the specificity of RSI was assessed by ROC (Receiver Operating Characteristic) analysis. RESULTS: A total of 15 LPR patients (26.8%) of the clinical group met MII-pH diagnostic criteria. Among subjects classified as positive for MII- pH diagnoses, RSI and RFS mean scores were respectively 20 (SD ± 10.5) and 7.1 (SD ± 2.5), values not significantly different compared to the negative MII-pH group. The metric analysis of the items led to the realization of a binary recoding of the score. Both versions had similar psychometric properties, α was 0.840 for RSI original version and 0.836 for RSI binary version. High and comparable area under curve (AUC) values indicate a good ability of both scales to discriminate between individuals with and without LPR pathology diagnosis. Based on balanced sensitivity and specificity, the optimal cut-off scores for LPR pathology were ≥ 5 for RSI binary version and ≥ 15 for RSI original version. Both version overestimated LPR prevalence. The original version had more sensitivity and the RSI Binary version had more specificity. CONCLUSIONS: It would be necessary to think about modifying the original RSI in order to improve its sensitivity and specificity (RSI binary version, adding or changing some items), or to introduce new scores in order to better frame the probably affected of LPR patient.

Voice-Related Quality of Life in Patients with Chronic Rhinosinusitis.

OBJECTIVE: Chronic rhinosinusitis (CRS) has long been associated with vocal dysfunction. However, studies quantifying the presence of voice dysfunction in CRS patients or the effects of functional endoscopic sinus surgery (FESS) are sparse. The goal of this study was to determine the voice-related quality of life in patients undergoing FESS for CRS using the validated Voice Related Quality of Life Survey (VRQL). We correlated the preoperative VRQL scores to the Sino-Nasal Outcome Test (SNOT-22) scores, and we determined the effect of FESS on postoperative VRQL scores. METHODS: Consecutive patients undergoing FESS were preoperatively administered both the VRQL and the SNOT-22 surveys. Spearman (ρ) and Pearson (r) correlation coefficients were calculated. The VRQL was mailed to patients postoperatively between 3 and 6 months. The paired t-test was used to compare pre- and post-FESS scores. RESULTS: A total of 102 patients were enrolled, and 81 patients completed the two surveys. A total of 51 (62.9%) patients had raw VRQL score ≥ 10, signifying presence of significant vocal symptoms. The mean ± standard deviation (SD) raw VRQL score of the entire study population was 12.4 ± 4.6, and the mean SNOT-22 score was 37.8 ± 19.2. The Spearman correlation coefficient between VRQL and the total SNOT-22 score was 0.34 (P =.002), and the Pearson correlation coefficient was 0.36 (P = .001). Both correlations were similar, demonstrating that increasing severity of CRS symptoms correlates with decreasing voice-related quality of life (QOL). Seventy patients completed the postoperative survey for an 86% retention rate. Thirty-six of these patients had abnormal preoperative VRQL scores, and these patients improved significantly after FESS. The mean preoperative versus postoperative raw scores were 15.2 ± 5.6 versus 12.5 ± 4.1, respectively (P = .003). CONCLUSION: This study demonstrates the increasing presence of vocal complaints with increasing severity of CRS. It also demonstrates that VRQL scores improve after FESS in those patients with preoperative vocal complaints. LEVEL OF EVIDENCE: IV.

Predictive values of lung cancer alarm symptoms in the general population: a nationwide cohort study.

We aimed to firstly determine the 1-year predictive values of lung cancer alarm symptoms in the general population and to analyse the proportion of alarm symptoms reported prior to diagnosis, and secondly analyse how smoking status and reported contact with general practitioners (GPs) regarding lung cancer alarm symptoms influence the predictive values. The study was a nationwide prospective cohort study of 69,060 individuals aged ≥40 years, randomly selected from the Danish population. Using information gathered in a survey regarding symptoms, lifestyle and healthcare-seeking together with registry information on lung cancer diagnoses in the subsequent year, we calculated the predictive values and likelihood ratios of symptoms that might be indicative of lung cancer. Furthermore, we analysed how smoking status and reported contact with GPs regarding the alarm symptoms affected the predictive values. We found that less than half of the patients had reported an alarm symptom six months prior to lung cancer diagnosis. The positive predictive values of the symptoms were generally very low, even for patients reporting GP contact regarding an alarm symptom. The highest predictive values were found for dyspnoea, hoarseness, loss of appetite and for current heavy smokers. The negative predictive values were high, all close to 100%. Given the low positive predictive values, our findings emphasise that diagnostic strategies should not focus on single, specific alarm symptoms, but should perhaps focus on different clusters of symptoms. For patients not experiencing alarm symptoms, the risk of overlooking lung cancer is very low.

Hoarseness Caused by a Penetrating Proximal Descending Thoracic Aortic Ulcer and Pseudoaneurysm.

We present a case of an 87-year-old female with new-onset hoarseness of unclear etiology. Imaging demonstrated a penetrating aortic ulcer (PAU) in the proximal descending thoracic aorta with an associated pseudoaneurysm that enlarged to a depth of 32 mm over 2 years. This patient was diagnosed with hoarseness being secondary to left recurrent laryngeal nerve (LRLN) palsy, a variant of Ortner syndrome. Patient was treated with endovascular stent-grafting successfully covering of the PAU and pseudoaneurysm with zone 3 proximal landing zone. The patient had moderate improvement in hoarseness after 1 year of follow-up. Endovascular repair is indicated for symptomatic patients with PAUs complicated by enlarging pseudoaneurysms or rupture. Endovascular treatment is effective with low procedural morbidity and mortality. In this case, the PAU and associated pseudoaneurysm at the level of the ligamentum arteriosum caused compression on the LRLN, resulting in a nerve palsy and hoarseness. This case highlights the importance of vascular imaging for patients presenting with unclear etiology of hoarseness or other signs of LRLN palsy. Therefore, aortic arch abnormalities, a variant of Ortner syndrome, even though rare, should be on the differential diagnosis of new onset hoarseness.

A new training method for velopharyngeal dysfunction: Self-inhalation for hypernasality.

OBJECTIVE: There are various methods to treat velopharyngeal dysfunction including　surgery and rehabilitation therapy. Even if a rehabilitation program is effective, the evaluation of its efficacy remains subjective. In this paper, we propose a new method of rehabilitation training for velopharyngeal dysfunction focusing on the objective peak inspiratory flow (PIF) rate. METHODS: Four patients, who were diagnosed with velopharyngeal dysfunction without cleft palate at ENT clinic of the National Hospital Organization, Tokyo Medical Center, participated in this study. All patients underwent our original rehabilitation program for velopharyngeal dysfunction, a method using the In-Check Dial, Turbohaler model. As a self-training rehabilitation program, we asked them to inhale forcefully 10 times daily at home using the In-Check Dial to increase the value of PIF rate for 3 months. We measured the patients' PIF rates with the In-Check Dial at the ENT clinic at the initial visit and after the 3-month training. RESULTS: The PIF rates of the four patients without nasal clips were higher than the rates with nasal clips at the initial visit. After the training, PIF rate without a nasal clip of all patients increased than the rate at the initial visit, which represented significant difference (P < 0.05). Also, after 3 months, PIF rate without a nasal clip was higher or equal than the rates with a nasal clip at the initial visit except one case. Naso-pharyngo-laryngeal fiberscopy did not detect salivary pooling around larynx and mirror fogging test did not show nasal escape in the three of four patients after 3 months of training. All reported improvement in dysphagia and dysarthria. CONCLUSION: This new method can be used not only to evaluate velopharyngeal function but also as an effective self-training treatment.

Unilateral bamboo node of the vocal fold associated with anti-SS-A and anti-SS-B antibody.

Voice disorder is occasionally associated with systemic autoimmune diseases. Bamboo nodes of the vocal fold have a characteristic bamboo-shaped appearance and strongly indicate the presence of an underlying autoimmune disorder. Both mechanical and immunologic mechanisms are assumed to be involved in the pathogenesis of vocal disorder. We present a 27-year-old woman with hoarseness, sore throat, and a unilateral bamboo node of the vocal fold. Serum anti-SS-A and -SS-B antibodies were positive, but she had no systemic signs or symptoms suggestive of Sjögren's syndrome. Oral systemic glucocorticoid treatment was not effective, but surgical resection improved her hoarseness. Histopathologic findings of the resected vocal node revealed fibrosis with hyaline degeneration. Thereafter, she had no recurrence of hoarseness for 2 years. Bamboo nodes of the vocal fold may occur without definitive autoimmune diseases, although immunologic abnormalities such as autoantibody-positivity may occur.

Intertext Variability of Smoothed Cepstral Peak Prominence, Methods to Control It, and Its Diagnostic Properties.

OBJECTIVES: This study aimed to estimate the intertext variability of smoothed cepstral peak prominence (CPPS), examine whether sound-processing techniques improved its variability and diagnostic capability, and evaluate the degree of intertext variability in detail with reference to the CPPS variabilities in sustained vowels. STUDY DESIGN: This was a retrospective study. METHODS: Text readings of 58 Japanese syllables were recorded from 210 speakers with different diagnoses and varying degrees of dysphonia, and were divided into six passages. Applying the sound-processing techniques to those passages, we prepared three sample types: (1) nonprocessed, (2) only-loud, and (3) only-voiced samples. The intertext CPPS variability and diagnostic properties were compared across the passages and sample types. For detailed analysis, we subsequently extracted 63 normophonic speakers who maintained constant quality in their vowel utterances to evaluate the degree of intertext CPPS variability in relation to the variabilities between repeated identical vowels and across different vowels. RESULTS: Although several combinations of passages showed moderate-to-large CPPS variabilities, those variabilities were decreased by either technique, especially the deletion of silent segments, which resulted in the best diagnostic accuracy. The degree of intertext CPPS variability for the only-voiced samples was comparable to that of the CPPS variabilities in sustained vowels. CONCLUSIONS: The sound-processing technique removing silent segments should be applied to enhance the diagnostic properties of CPPS. The additional technique of deleting unvoiced segments is worth adopting if clinicians and researchers seek to attenuate the influence of text differences in calculating CPPS values.

Spontaneous Giant Laryngeal Granuloma in the Absence of Laryngeal Injury.

The etiology of laryngeal granuloma can typically be attributed to endotracheal intubation, vocal abuse, or gastroesophageal reflux disease. There is a strong male predominance, except in cases due to intubation, where incidence is higher in women. We report a case of spontaneous development of multiple granulomas in a female with no history of intubation who presented with hoarseness and massive bilateral supraglottic masses obscuring her glottis. The disparity between the massive lesions and asymptomatic reflux highlights the need for further research in the pathophysiology of laryngeal granulomas.

[Een rood en gezwollen gelaat na heffen van de armen]. / Een rood en gezwollen gelaat na heffen van de armen.

An 82-year-old woman attended our outpatient clinic because of a swollen right arm and hoarseness. Upon raising both arms, the patient developed a red and swollen face (Pemberton's sign). An MRI of the thorax showed a large intrathoracic goitre, which compressed venous structures and limited blood flow even when she lowered her arms.

Voice hoarseness in a patient with underlying Eisenmenger's syndrome: a case report.

BACKGROUND: The natural history of patients diagnosed with Eisenmenger's Syndrome typically revolve around the pediatric population. Medical advances have allowed these patients to live longer and present with a different subset of symptoms as a result of the progression of their disease process. CASE PRESENTATION: In this case report, we discuss a 77-year-old Caucasian female with Eisenmenger's Syndrome presenting with hoarseness. Clinical and imaging studies reveal a left vocal cord paralysis secondary to a progressively enlarging patent ductus arteriosus (PDA) and dilation of pulmonary arteries causing mass effect on the left recurrent laryngeal nerve. CONCLUSION: From a clinical perspective, this case highlights the need for otolaryngologists to be aware of the pathophysiology of Eisenmenger's Syndrome as it progresses with age.

Electroglottographic and acoustic analysis of voice in children with vocal nodules.

PURPOSE: Vocal fold nodules are usually caused by voice overuse or vocal hyperfunction, and their symptoms include persistent hoarseness - a disturbance in the vocal fold vibrations which results in a turbulent passage of air in the glottis, manifested as a raspy, rough voice. The aim of the study was to present data concerning voice quality in patients with vocal nodules and to compare electroglottographic analysis (EGG) with acoustic analysis. METHODS: The study examined 57 children with vocal fold nodules (Group 1). Each patient underwent a phoniatric evaluation of the vocal tract, a videolaryngoscopic examination, and a voice quality assessment, employing electroglottographic and acoustic analyses. The control group consisted of 37 healthy children (Group 2). The following parameters were analyzed: Closed Quotient (EGG signal), Peak Slope, Normalized Amplitude Quotient and Cepstral Peak Prominence (acoustic signal - waveform). RESULTS: Changes in the EGG signal could be detected in 95% of the patients with vocal nodules, indicating the occurrence of vocal nodules and glottal insufficiency. The acoustic analysis confirmed breathy phonation in 63% of the patients. The Closed Quotient parameter proved to be more effective than Peak Slope. Closed Quotient, Peak Slope and Normalized Amplitude Quotient allowed for the differentiation of the EGG signal and the acoustic signal in groups 1 and 2 in a statistically significant way. CONCLUSIONS: The results of electroglottographic and acoustic analysis show incorrect voice parameters in patients with vocal nodules with reference to the control group. At the same time, the EGG analysis proved to be more effective than the analysis of the acoustic signal.

Successful Thoracic Endovascular Aortic Repair in Ortner's Syndrome.

We present the case of an 89-year-old man with 3-month history of hoarseness and no other significant clinical manifestations. Flexible laryngoscopy revealed a paralyzed left vocal cord, and contrast-enhanced computed tomography showed a thoracic dissecting aortic aneurysm of the distal aortic arch and proximal descending aorta. The aortic aneurysm was repaired through implantation of an endovascular stent graft, and the patient was discharged uneventfully after a week. The false lumen was completely thrombosed, and the patient had a partial resolution of hoarseness at the 1-year follow-up.

Bamboo Nodes on a Series of 15 Patients: Vocal Fold Lesion as a Sign of Autoimmune Disease and Microphonotrauma.

OBJECTIVES: Bamboo nodes are band-like submucosal deposits of the middle third of the vocal fold. They are often related to connective tissue disorders, but can also precede them. The aim of this study was to report our experience with conservative treatment of those rare lesions. METHODS: This is a retrospective series of 15 patients consulting for hoarseness and presenting bamboo nodes from 2010 to 2016. RESULTS: All patients were women of mean age of 38 years with a moderate or high degree of daily vocal effort. Nine patients (60%) presented with known autoimmune disease at the phoniatric appointment. The other patients (40%) benefited from a systematic biological research for autoimmune disease, which retrieved two poorly symptomatic connective tissue disorders. Patients were clinically improved by speech therapy (53%) or by an optimization or introduction of immunosuppressive treatment (46%). A spontaneous improvement was observed for three patients after voice rest (one after retirement, one after professional change, and last one after resuming professional singing). In our series, no phonosurgery was performed. The vocal profile at last appointment found a moderate Voice Handicap Index at 35.3/120, a low maximum time of phonation at 13.6 seconds, and a high jitter at 1.4, sign of instability of the vibrator. CONCLUSION: This series emphasizes the importance of diagnosing bamboo nodes in middle-aged female presenting an autoimmune disease. Vice versa for each patient with bamboo nodes, a systematic autoimmune check-up has to be realized to detect a biological asymptomatic autoimmune disease.

Respiratory Tract Infections and Voice Quality in 4-Year-old Children in the STEPS Study.

OBJECTIVES: Health-related factors are part of the multifactorial background of dysphonia in children. Respiratory tract infections affect the same systems and structures that are used for voice production. The purpose of this study was to investigate if the number of respiratory tract infections or the viral etiology were significant predictors for a more hoarse voice quality. METHODS: The participants were 4-year-old children who participated in the multidisciplinary STEPS study (Steps to the Healthy Development and Well-being of Children) where they were followed up from pregnancy or birth to 4 years of age. Data were collected through questionnaires and a health diary filled in by the parents. Some of the children were followed up more intensively for respiratory tract infections during the first 2 years of life, and nasal swab samples were taken at the onset of respiratory symptoms. Our participants were 489 of these children who had participated in the follow-up for at least 1 year and for whom data on respiratory tract infections and data on voice quality were available. RESULTS: The number of hospitalizations due to respiratory tract infections was a significant predictor for a more hoarse voice quality. Neither the number of rhinovirus infections nor the number of respiratory syncytial virus infections was statistically significant predictors for a more hoarse voice quality. CONCLUSIONS: Based on our results, we would suggest including questions on the presence of respiratory tract infections that have led to hospitalization in the pediatric voice anamnesis. Whether the viral etiology of respiratory tract infections is of importance or not requires further research.

Primary Laryngeal Tuberculosis: Our Experiences at a Tertiary Care Teaching Hospital in Eastern India.

INTRODUCTION: Primary laryngeal tuberculosis is a chronic bacterial infection of the larynx by Mycobacterium tuberculosis without affecting the lungs. It is a rare type of extrapulmonary tuberculosis seen in clinical practice. OBJECTIVES: This study aimed to evaluate the clinical presentation, diagnosis, and treatment of primary laryngeal tuberculosis at a tertiary care teaching hospital in eastern India. MATERIALS AND METHODS: This is a retrospective study of 11 cases of primary laryngeal tuberculosis managed between December 2013 and January 2018. The detailed clinical presentations, investigations, and treatment of primary laryngeal tuberculosis of the patients were studied. RESULTS: Primary laryngeal tuberculosis is common in men with mean age of 38.63 years. Hoarseness of the voice is the most common symptom, and the most common site for primary laryngeal tuberculosis is the vocal fold with ulcerative lesion. Endoscopic examinations of the larynx in laryngeal tuberculosis are nonspecific and are to be confused with laryngeal cancer. Histopathological and bacteriological examinations are confirmatory tests for the diagnosis. After confirmation of the diagnosis, all patients had taken antitubercular therapy for 6 months, which gave excellent outcome. CONCLUSIONS: Delayed diagnosis or untreatable laryngeal tuberculosis will lead to high morbidity and mortality of the patient. Although primary laryngeal tuberculosis has nonspecific clinical presentations, it is very important to have a high index of suspiciousness to rule out tubercular lesion in the larynx as this disease is curable.

An Innovative Voice Analyzer "VA" Smart Phone Program for Quantitative Analysis of Voice Quality.

OBJECTIVE: The 'VA' Windows program that we developed in 2011 for analyzing voice quality quantitatively uses zerocross picking to find individual basic pitch periods. It has a simple and user-friendly user interface and high accuracy. This program determines the fundamental frequency, jitter, shimmer, PPQ, APQ, and signal-to-noise ratio (Ra). It needs only a general-purpose Windows PC, USB audio interface and a microphone. The aim of this study is to improve the version of the VA Windows program in English and to develop a VA smart phone program to allow wider use of objective acoustic analysis. STUDY DESIGN: Cross-sectional study. METHODS: Sustained vowel /a/ sounds from 40 subjects without evident vocal problems, and 40 subjects with slight hoarseness, were examined. We compared the analyzed data with data from other software (MDVP and Praat). For a comparison between VA for Windows and VA for a smart phone, sustained vowel /a/ sounds from six subjects without hoarseness were recorded with each system simultaneously. RESULTS: The normal voice and slightly hoarse voice data analyzed with VA showed a high correlation with most parameters from both MDVP and Praat. There was a strong correlation between the Windows and smart phone versions of VA in terms of the fundamental frequency and Ra. CONCLUSIONS: The results showed that the VA software was not inferior to the other acoustic analysis software tested. The simple and easy to use smart phone version may facilitate our goal of creating an objective, widely available method to evaluate hoarseness.