The diagnosis, clinical findings and treatment options for Parkinson's disease patients attending a tertiary referral voice clinic.

BACKGROUND: Parkinson's disease is a degenerative disorder of the central nervous system, mainly affecting motor functions including the voice. The aetiology of dysphonia changes throughout the course of disease progression. OBJECTIVES: This study aimed to determine the laryngeal changes seen in early-, mid- and late-stage Parkinson's disease. Thirteen patients with Parkinson's disease are presented, representing the largest series of voice patients with Parkinson's disease seen in a voice clinic in the literature. METHOD: Age, gender, severity of handicap caused by voice disorder and possible associated reflux symptoms were examined. RESULTS: Laryngeal function appeared to change gradually with progression of the disease, and may have been affected by the presence of pre-existing laryngeal pathology. CONCLUSION: Laryngeal function in Parkinson's disease appears to go through a series of changes that may be helped by both therapeutic and surgical interventions. These patients should be treated within the confines of a voice clinic multidisciplinary model.

One hundred years of external approach medialisation thyroplasty.

It has been 100 years since Erwin Payr first developed an operation to improve the effects of a paralysed vocal fold, and operations based on this technique are still in use today. This technique, medialisation thyroplasty, aims to improve the symptoms caused by vocal fold palsy by realigning the lateralised vocal fold into the midline. Whilst the effects of vocal fold palsy were recognised in antiquity, it was only with the development of indirect laryngoscopy in the late nineteenth century that the vocal fold paralysis could be identified as an aetiology for poor phonation and dysphagia. Payr, in 1915, was the first to perform a recognisable form of medialisation thyroplasty, which was further developed in the early twentieth century, but medialisation thyroplasty did not begin to be widely used until the development of the modern technique by Isshiki et al., in 1974. Since then, medialisation thyroplasty has continued to be developed and is currently the most widely used technique for correcting the effects of vocal fold palsy. However, a wide array of therapeutic options is now available for vocal fold palsy and it is impossible to say whether or not medialisation thyroplasty will still be used in another 100 years.

Use of core biopsy in diagnosing cervical lymphadenopathy: a viable alternative to surgical excisional biopsy of lymph nodes?

OBJECTIVES Lymphoma often presents with a neck mass and while fine-needle aspiration cytology may be suggestive, tissue biopsy is required for reliable diagnosis and classification of a lymphoma that is sufficient to deliver the correct treatment for the patient. Traditionally, excisional biopsy of a lymph node has been the standard method of tissue sampling, providing ample tissue for assessment. However, this requires theatre time, and preceding fine-needle aspiration cytology, which may incur a delay. With careful use of tissue, coupled with advances in immunohistochemical and molecular investigative techniques, core biopsy provides a possible alternative to traditional fine-needle aspiration and excisional biopsy. In this study, we aimed to determine the efficacy of diagnosing neck masses. METHOD A retrospective analysis was performed of patients being investigated for a neck mass who were undergoing ultrasound-guided core biopsies of cervical lymph nodes over a 17-month period. The final histology report was scrutinised to assess whether adequate tissue was obtained to allow for full tissue diagnosis. RESULTS Over the 17-month period analysed, 70 patients with cervical lymphadenopathy underwent core biopsy. Of these, 63 (90%) were diagnostic for either lymphoma or other pathology and did not require further tissue sampling. Overall, 19 patients were diagnosed with lymphoma, of which only 1 required further biopsy due to inconclusive initial core biopsy. CONCLUSIONS Current guidelines for investigating lymphomas require that excisional biopsy be performed to obtain ample tissue to allow full nodal architecture assessment and ancillary investigation to reach an accurate histological classification. Within our head and neck multidisciplinary team, however, it is considered that results from core biopsies can be obtained in a more timely fashion and with histological accuracy equal to those of open biopsy. The results obtained demonstrate that core biopsy is an effective tool for investigation. We believe this should be the first-line investigation of choice, as it reduces the need for patients to undergo surgery, is more cost effective and offers a faster diagnosis.

An anatomical study of the myelination of human laryngeal nerves.

OBJECTIVE: To determine the differences in myelination between the human recurrent laryngeal nerve and superior laryngeal nerve. METHODS: Fifteen confirmed laryngeal nerve specimens were harvested from five cadavers. Cross-sections were examined under a photomicroscope and morphometric analysis performed. RESULTS: There was a significantly greater number of myelinated fibres than unmyelinated fibres, in both the recurrent laryngeal nerve (p = 0.018) and the superior laryngeal nerve (p = 0.012). There was a significantly greater number of myelinated fibres in the superior laryngeal nerve, compared with the recurrent laryngeal nerve (p = 0.028). However, there was no significant difference in the number of unmyelinated fibres, comparing the two nerves (p = 0.116). CONCLUSION: These findings support those of previous studies, and provide further evidence against the historical plexus theory of laryngeal nerve morphology. The differences in the degree of myelination, both within and between the human laryngeal nerves, may have clinical consequence regarding recovery of function following nerve injury.

Hyaluronic acid ester in myringoplasty.

OBJECTIVES: To investigate the use of a new technique to close persistent tympanic membrane perforations under general anaesthesia, in patients in whom this has previously been considered impractical. DESIGN: Twenty patients aged 50 years and over were recruited. All had a persistent, symptomatic tympanic membrane perforation in at least one ear. Pre-operatively, an audiogram was performed and the tympanic membrane was assessed in order to establish the site and size of the perforation. Under general anaesthesia, the edges of the perforation were freshened and a sheet of Epifilm, trimmed to a size roughly 2 mm larger in diameter than the perforation, was tucked through the perforation. The ear was dressed appropriately. Patients were seen two weeks post-operatively in the out-patients department and reassessed. SETTING: The study was based at Poole General Hospital, a District General Hospital. PARTICIPANTS: Twenty patients were recruited from the out-patients clinics of Poole Hospital ENT department. MAIN OUTCOME MEASURES: (1) closure of the perforation, as a percentage of the original size; (2) improvement of hearing, as an average across all frequencies, expressed in dB hearing level; and (3) presence or absence of discharge. RESULTS: Five patients were operated upon and assessed six weeks post-operatively. The Epifilm had dissolved but the perforations remained the same size in all five patients. There were no other adverse effects. Pure tone audiometry at this stage was redundant. The study was subsequently aborted. CONCLUSIONS: The authors conclude that repair of tympanic membrane perforations with hyaluronic acid ester films is not to be recommended.

'Lambing ears': a blistering disorder affecting farmers at lambing time.

BACKGROUND: At lambing time some farmers experience blistering and crusting of the pinnae. This occupational disease, termed 'lambing ears', does not feature in the medical literature. OBJECTIVES: To define the condition and explore its pathogenesis. METHODS: We obtained five biopsies from affected individuals and sent questionnaires to 69 farmers in the U.K. Farming communities abroad were also contacted. RESULTS: The eruption lasts for the duration of the lambing practice. The histological features are dominated by a pandermal perivascular and diffuse, predominantly T-cell lymphocytic infiltrate. Only the pinnae are affected and its incidence is related to the degree of involvement a farmer has with the animals around parturition. The condition also occurs, but less frequently, in farmers who are calving. CONCLUSIONS: This occupational disease occurs with close contact to lambing ewes or calving cows. The histology and distribution are comparable with the juvenile spring eruption variant of polymorphic light eruption, but its demographics are unique.

Effects of pressure on whole blood glucose measurements using the Bayer Glucometer 4 blood glucose meter.

The effect of pressure was investigated on the readings of whole blood glucose obtained from the Bayer Glucometer 4 blood glucose meter which uses the hexokinase enzymatic reaction. Sixteen subjects (eight normal and eight insulin-dependent diabetics) were exercised in a hyperbaric chamber at a depth of 3.7 atm abs. Venous blood samples were monitored at regular intervals for whole blood glucose concentration as measured by a Glucometer 4 inside the chamber. The blood samples were immediately placed in an airlock and taken to 1 atm abs, where whole blood glucose concentrations were measured using an identical instrument. The remaining blood was then analyzed in duplicate for serum glucose concentration using standard laboratory methods. The results show a significant difference between whole blood glucose concentrations measured at pressure and those measured at atmospheric pressure. Significant differences are also observed between whole blood glucose concentrations measured under pressure and serum blood glucose concentrations measured at atmospheric pressure.