Anterograde-retrograde rendezvous approach for radiation-induced complete upper oesophageal sphincter stenosis: case report and literature review.

BACKGROUND: Strictures of the hypopharynx and oesophagus are frequently observed following (chemo)radiation. Anterograde dilatation of a complete stenosis carries a high risk of perforation. An alternative is described: a combined anterograde-retrograde approach. CASE REPORT: A 75-year-old man developed complete stenosis of the oesophageal inlet after primary radiotherapy for laryngeal carcinoma and full percutaneous endoscopic gastrostomy feeding. To prevent creation of a false route into the mediastinum, a dilatation wire was introduced in a retrograde fashion into the oesophagus, through the gastrostomy opening. The wire was endoscopically identified from the proximal side and then passed through a perforation created by CO2 laser. Anterograde dilatation was safely performed, and the patient returned to a normal diet. There is consensus in the literature that blind anterograde dilatation carries a high risk of perforation; therefore, an anterograde-retrograde rendezvous technique is advisable. CONCLUSION: In cases of complete obstruction of the oesophageal inlet, anterograde-retrograde dilatation represents a safe technique with which to restore enteric continuity.

Anterior cervical osteophytes resulting in severe dysphagia and aspiration: two case reports and literature review.

OBJECTIVE: We report two cases in which dysphagia and aspiration, caused by anterior cervical osteophytes, were so severe that surgical resection was performed. METHOD: Case reports and a review of the world literature concerning dysphagia caused by anterior cervical osteophytes, in regard to pathogenesis, diagnosis and treatment. RESULTS: Two patients, aged 71 and 70 years, had long-standing, slowly progressive dysphagia and aspiration; one patient had recurrent episodes of aspiration pneumonia as a result. Both patients were diagnosed on videofluoroscopy with large bony anterior cervical osteophytes. Immediate relief of symptoms was obtained after resection of the osteophytes via an anterolateral, extrapharyngeal approach. Anterior cervical osteophytes are relatively common in the elderly, although not frequently diagnosed, and are mostly seen in cases of diffuse idiopathic skeletal hyperostosis. If therapy is indicated it is mainly conservative; resection is rarely needed. CONCLUSION: In patients with anterior cervical osteophytes, surgical treatment is indicated only for selected cases with large, bony osteophytes and severe symptoms.

Voice in early glottic cancer compared to benign voice pathology.

The purpose of this study is to compare (Dutch) Voice Handicap Index (VHIvumc) scores from a selected group of patients with voice problems after treatment for early glottic cancer with patients with benign voice disorders and subjects from the normal population. The study included a group of 35 patients with voice problems after treatment for early glottic cancer and a group of 197 patients with benign voice disorders. Furthermore, VHI scores were collected from 123 subjects randomly chosen from the normal population. VHI reliability was high with high internal consistency and test-retest stability. VHI scores of glottic cancer patients were similar to those of patients with voice problems due to benign lesions. Both groups of patients were clearly deviant from the normal population. Within the normal population, 16% appeared to have not-normal voices. Based on ROC curves a cut-off score of 15 points was defined to identify patients with voice problems in daily life. A clinical relevant difference score of 10 points was defined to be used for individual patients and of 15 points to be used in study designs with groups. Patients with voice problems after treatment for early glottic cancer encounter the same amount of problems in daily life as the other voice-impaired patients. The VHI proved to be an adequate tool for baseline and effectiveness measurement of voice.

Review article: The laryngological manifestations of reflux disease; why the scepticism?

BACKGROUND: Despite increasing clinical and experimental evidence of its existence, otolaryngological manifestations of reflux disease remain controversial, concerning diagnosis as well as treatment. AIM: Proper understanding of laryngopharyngeal reflux disease (LPRD). METHOD: Review of literature. RESULTS: Scepticism concerning LPRD is based upon differences between gastro-oesophageal reflux disease and LPRD; lack of specificity and sensitivity of diagnostic tests to confirm LPRD; non-specificity of laryngological symptoms, which are difficult to distinguish from other causes of upper respiratory tract inflammation; non-specificity of laryngological signs in laryngoscopy, with high intra- and inter-observer variability in evaluation; diagnosis of LPRD is essentially only based on a combination of diagnostic signs and symptoms, which cannot be attributed to other pathology; slow, or sometimes lack of, response of LPRD symptoms to proton pump inhibitor (PPI) medication and lack of evidence concerning efficacy of PPIs in placebo-controlled trials. CONCLUSIONS: LPRD remains a diagnosis by exclusion and resolution of symptoms following 4-month trial of 40 mg PPI twice daily is, for all practical purposes, considered proof of the initial diagnosis. However, non-response does not exclude LPRD as PPIs have no influence on noxious non-acid components of the refluxate.

Development of a double-membrane sound generator for application in a voice-producing element for laryngectomized patients.

For voice rehabilitation after total laryngectomy a shunt valve is usually placed in the tracheo-esophageal (TE) wall, thereby enabling the production of a TE voice. Some patients, however, are unable to produce a voice of sufficient quality. Furthermore, the TE voice is low pitched, which presents a problem especially for female laryngectomized patients. The voice quality after laryngectomy might be improved by introducing a voice-producing element (VPE) into the TE shunt valve. In this study a sound generator was developed that is suitable for application in such a VPE. This sound generator consists of two elastic membranes placed parallel inside a circular housing. A substitute voice source is created when the membranes start to vibrate via a constant flow of air passing between them. To determine the optimal membrane configuration for proper functioning under physiological conditions, up-scaled physical VPE models with different membrane geometries were evaluated using in vitro experimental tests. For certain membrane geometries the tests showed that a basic sound, containing multiple harmonics, could be successfully produced under physiological air pressure and airflow conditions. The fundamental frequency (60-95 Hz) and sound pressure level (57-78 dB, at 15 cm microphone distance) were regulated via changes in the driving pressure, thereby enabling the possibility of intonation in laryngectomized patients' speech. The obtained frequency range is considered appropriate for producing a substitute voice source for female patients. The geometry considerations in this study can be used for the development of a true scale VPE that can be evaluated clinically, to eventually replace the voice after laryngectomy.

Sino-nasal bony and cartilaginous destruction associated with cocaine abuse, S. aureus and antineutrophil cytoplasmic antibodies.

Three male patients aged 29, 30 and 34 years and a 36-year-old female are reported with nasal septum perforation and a history of cocaine abuse. Two of the patients also had a perforation of the hard palate. In all four, antineutrophil cytoplasmic antibodies (ANCA) were found. One had a cytoplasmic immunofluorescence-staining pattern (c-ANCA), the other three showed a perinuclear staining pattern (p-ANCA). Furthermore, all patients were found to be nasal carriers of S. aureus. We hypothesise that tissue damage to the nasal and palatal area in patients using cocaine may partly be mediated by the presence of ANCA antibodies. Furthermore, we speculate that S. aureus facilitates the development of these ANCA antibodies.

Analysis of failure of voice production by a sound-producing voice prosthesis.

OBJECTIVE: To analyse the cause of failing voice production by a sound-producing voice prosthesis (SPVP). METHODS: The functioning of a prototype SPVP is described in a female laryngectomee before and after its sound-producing mechanism was impeded by tracheal phlegm. This assessment included: perceptual voice evaluation of read-aloud prose by an expert listener; inspection of the malfunctioning SPVP; and aero-acoustical in vivo registrations using a computer-based data acquisition system. RESULTS: Sound-producing voice prosthesis speech is higher pitched, stronger, contains less aperiodic noise and requires a lower airflow rate than the patient's regular tracheoesophageal (TE) shunt speech. Tracheal phlegm caused malfunction of the vibrating silicone lip of the SPVP by causing it to stick to its stainless steel container in an opened position, thereby reducing the SPVP to no more than a regular TE shunt valve from a functional point of view. Tracheal phonatory pressure and dynamic vocal intensity range were not affected by the functional status of the SPVP. CONCLUSIONS: To exploit the advantages an SPVP could offer female laryngectomees with an atonic or severely hypotonic pharyngoesophageal segment, the sound-producing mechanism of the SPVP needs to be less vulnerable to tracheal phlegm.

Assessment of alaryngeal speech using a sound-producing voice prosthesis in relation to sex and pharyngoesophageal segment tonicity.

BACKGROUND: A pneumatic artificial sound source incorporated in a regular tracheoesophageal shunt valve may improve alaryngeal voice quality. METHODS: In 20 laryngectomees categorized for sex and pharyngoesophageal segment tonicity, a prototype sound-producing voice prosthesis (SPVP) is evaluated for a brief period and compared with their regular tracheoesophageal shunt speech. RESULTS: Perceptual voice evaluation by an expert listener and acoustical analysis demonstrate a uniform rise of vocal pitch when using the SPVP. Female laryngectomees with an atonic pharyngoesophageal segment gain vocal strength with the SPVP. Exerted tracheal pressure and airflow rate are equivalent to those required for regular tracheoesophageal shunt valves. However, communicative suitability and speech intelligibility deteriorate by the SPVP for most patients. Tracheal phlegm clogging the SPVP is a hindrance for most patients. CONCLUSIONS: The SPVP raises vocal pitch. Female laryngectomees with an atonic or severely hypotonic pharyngoesophageal segment can benefit from a stronger voice with the SPVP.

[CO2-laser decortication: an efficient alternative to radiotherapy in the treatment of T1a carcinomas of the glottis]. / Decorticatie met CO2-laser; een doelmatig alternatief voor radiotherapie in de behandeling van T1a-carcinomen van de glottis.

OBJECTIVE: Given that CO2-laser decortication and radiotherapy are equally effective in the treatment of T1a glottic carcinomas, to determine which of the two is most efficient with respect to treatment costs. DESIGN: Retrospective analysis. METHOD: The costs of both treatment modalities from the first visit to the Free University Medical Centre, Amsterdam, the Netherlands, until two years after the start of the treatment were calculated, based on the medical consumption of 89 patients who were treated with curative intent for a T1a glottic carcinoma in the years 1995-1999. RESULTS: The total costs from diagnosis until two years after the start of treatment were [symbol: see text] 7,253,- for radiotherapy and [symbol: see text] 3,864,- for CO2-laser decortication. These amounts included the costs of diagnosis and treatment of any recurrence or benign laryngeal disorders occurring within the two-year interval. The difference was statistically significant. CONCLUSION: Radiotherapy was significantly more expensive than CO2-laser decortication. Therefore CO2-laser decortication is an efficient alternative to radiotherapy in the treatment of eligible patients with T1a glottic carcinoma.

The ultra-low resistance Groningen voice prosthesis: clinical experiences.

The performance of the ULR Groningen prosthesis was assessed in 21 laryngectomees. The intratracheal phonatory pressures (PITP), voice parameters (speech rate, maximal phonation time, maximal vocal intensity, dynamic vocal intensity range), device lifetime and patient's subjective acceptances were recorded and compared to identical parameters for other prostheses reported in the literature and to data obtained from an age-matched group of normal laryngeal speakers. The low airflow resistance of the ULR Groningen voice prosthesis objectively (PITP = 2.7 kPa) and subjectively leads to a low effort to phonate. Compared to "normals" maximal phonation time shows no significant difference, but speech rate, maximal vocal intensity and dynamic vocal intensity range show a significant worse outcome. The mean device lifetime of the ULR Groningen prosthesis is more than 13.6 weeks, which is comparable to other indwelling voice prostheses. In conclusion, the ULR Groningen voice prothesis enables easier tracheoesophageal phonation than the low-resistance Groningen type.

Laryngeal framework surgery: a proposal for classification and nomenclature by the Phonosurgery Committee of the European Laryngological Society.

Laryngeal framework surgery, developed by Isshiki in the 1970s, is one of the most dynamic areas of phonosurgery and these procedures have served to considerably widen our spectrum and options for surgical improvement and/or changing of voice. As these techniques became more accepted and became common throughout the world, several new surgical modifications and different terms have been introduced. These new developments have lead to a confusion regarding terminology and types which make it difficult to communicate between and to compare the results of different authors. In an effort to create a more precise and descriptive list of definitions and terms, the Phonosurgery Committee of the European Laryngological Society has developed a new terminology for laryngeal framework surgery. In accordance with the concept of Isshiki, four types can be separated according to the intended purpose of the surgery: -Approximation laryngoplasty: medialization thyroplasty, arytenoid adduction. -Expansion laryngoplasty: lateralization thyroplasty, vocal fold abduction. -Relaxation laryngoplasty: shortening thyroplasty -Tensioning laryngoplasty: cricothyroid approximation, elongation thyroplasty. The proposed terms are functionally oriented and related closely to the intended purpose of the procedure or related to the underlying pathogenesis of the dysphonia. This new classification should provide a general framework suited not only to classify the current techniques but also to easily apply and adapt to include new procedures and future developments as necessary.

Female-pitched sound-producing voice prostheses--initial experimental and clinical results.

In order to improve voice quality in female laryngectomees and/or laryngectomees with a hypotonic pharyngo-oesophageal segment, a sound-producing voice prosthesis was designed. The new source of voice consists of either one or two bent silicone lips which perform an oscillatory movement driven by the expired pulmonary air that flows along the outward-striking lips through the tracheo-oesophageal shunt valve. Four different prototypes of this pneumatic sound source were evaluated in vitro and in two female laryngectomees, testing the feasibility and characteristics of this new mechanism for alternative alaryngeal voice production. In vivo evaluation included acoustic analyses of both sustained vowels and read-aloud prose, videofluoroscopy, speech rate, and registration of tracheal phonatory pressure and vocal intensity. The mechanism proved feasible and did not result in unacceptable airflow resistance. The average pitch of voice increased and clarity improved in female laryngectomees. Pitch regulation of this prosthetic voice is possible with sufficient modulation to avoid monotony. The quality of voice attained through the sound-producing voice prostheses depends on a patient's ability to let pulmonary air flow easily through the pharyngo-oesophageal segment without evoking the low-frequency mucosal vibrations that form the regular tracheo-oesophageal shunt voice. These initial experimental and clinical results provide directions for the future development of sound-producing voice prostheses. A single relatively long lip in a container with a rectangular lumen that hardly protrudes from the voice prosthesis may have the most promising characteristics.

Deviant vocal fold vibration as observed during videokymography: the effect on voice quality.

Videokymographic images of deviant or irregular vocal fold vibration, including diplophonia, the transition from falsetto to modal voice, irregular vibration onset and offset, and phonation following partial laryngectomy were compared with the synchronously recorded acoustic speech signals. A clear relation was shown between videokymographic image sequences and acoustic speech signals, and the effect of irregular or incomplete vocal fold vibration patterns was recognized in the amount of perceived breathiness and roughness and by the harmonics-to-noise ratio in the speech signal. Mechanisms causing roughness are the presence of mucus, phase differences between the left and right vocal fold, and short-term frequency and amplitude modulation. It can be concluded that the use of simultaneously recorded videokymographic image sequences and speech signals contributes to the understanding of the effect of irregular vocal fold vibration on voice quality.

Thyroplasty for adductor spasmodic dysphonia: further experiences.

OBJECTIVES: Two different surgical techniques for midline lateralization thyroplasty (type 2 thyroplasty) for adductor spasmodic dysphonia (SD) have been described, one using a composite graft and the other without. Indications and results for each method among different types of SD were compared, together with the theoretical background for the surgery. STUDY DESIGN: Retrospective. METHODS: The medical records of six patients with SD together with the fiberscopic video recording of laryngeal findings before, during, and after surgery were reviewed. The intraoperative video recordings of the surgical procedures were compared with the postoperative findings. RESULTS: The vocal features of SD, diverse preoperatively, disappeared postoperatively and a normal, or almost normal, voice was attained in 5 of 6 cases. The failure in one patient was attributed to combined focal dystonia of the neck muscles and difficulty in lateralization. Type 2 thyroplasty without a graft, which causes bowing of both vocal folds, is simple to perform and effective enough for most SD cases. No recurrence has been noted so far over postoperative periods ranging from 6 months to more than 3 years. CONCLUSION: The results suggest that thyroplasty is an effective therapeutic approach for SD.

A novel tracheal tissue connector for fixation of laryngeal prostheses.

A tissue connector (TC), basically consisting of a ring that will be integrated into the trachea, is under development to study the fixation of laryngeal prostheses. Two experiments have been performed to test the TC in goats. In experiment 1, a polypropylene mesh was implanted around the trachea. The meshes were explanted after 6 and 12 weeks. In experiment 2, the actual TC consisted of two titanium rings (inner ring and outer ring) executed as quarter rings, fixed on each other, and a polypropylene mesh like a sandwich in between. The titanium inner ring was implanted between two tracheal rings thus penetrating the trachea with the mesh around the trachea and the fixed titanium outer ring on the outside of the trachea. The TCs were removed after 12 weeks. Experiment 1 showed that the mesh was entirely infiltrated by host tissue. Inflammatory cells and high vascularisation were observed in 3 of 4 implants. However, in experiment 2, the mesh was completely incorporated by mature connective tissue without inflammation reaction. At some areas, deposition of cartilage tissue was observed. In conclusion, the TC was firmly embedded in the trachea thus being appropriate for its intended use.

Alternative voice after laryngectomy using a sound-producing voice prosthesis.

OBJECTIVE: To improve the voice quality of female laryngectomees and/or laryngectomees with a hypotonic pharyngoesophageal (PE) segment by means of a pneumatic artificial source of voice incorporated in a regular tracheoesophageal (TE) shunt valve. STUDY DESIGN: Experimental, randomized, crossover trial. METHODS: The new sound source consists of a single silicone lip, which performs an oscillatory movement driven by expired pulmonary air flowing along the outward-striking lip through the TE shunt valve. A prototype of this pneumatic sound source is evaluated in vitro and in six laryngectomees. In vivo evaluation includes speech rate, maximal phonation time, perceptual voice evaluation of read-aloud prose by an expert listener, speech intelligibility measurements with 12 listeners, and self-assessment by the patients. Moreover, extensive acoustical and aerodynamic in vivo registrations are performed using a newly developed data acquisition system. RESULTS: The current prototype seems beneficial in female laryngectomees with a hypotonic PE segment only. For them the sound-producing voice prosthesis improves voice quality and increases the average pitch of voice, without decreasing intelligibility or necessitating other pressure and airflow rates than regular TE shunt speech. Pitch regulation of this prosthetic voice is possible, yet limited. CONCLUSIONS: The mechanism is feasible and does not result in unacceptable airflow resistance. For this new mechanism of alaryngeal voice to become an established technique for postlaryngectomy voice restoration, a voice suitably pitched for male laryngectomees has to be generated and a large part of the melodic and dynamic range of the sound source has to be attainable within physiological airflow rates.

Aero-acoustics of silicone rubber lip reeds for alternative voice production in laryngectomees.

To improve voice quality after laryngectomy, a small pneumatic sound source to be incorporated in a regular tracheoesophageal shunt valve was designed. This artificial voice source consists of a single floppy lip reed, which performs self-sustaining flutter-type oscillations driven by the expired pulmonary air that flows through the tracheoesophageal shunt valve along the outward-striking lip reed. In this in vitro study, aero-acoustic data and detailed high-speed digital image sequences of lip reed behavior are obtained for 10 lip configurations. The high-speed visualizations provide a more explicit understanding and reveal details of lip reed behavior, such as the onset of vibration, beating of the lip against the walls of its housing, and chaotic behavior at high volume flow. We discuss several aspects of lip reed behavior in general and implications for its application as an artificial voice source. For pressures above the sounding threshold, volume flow, fundamental frequency and sound pressure level generated by the floppy lip reed are almost linear functions of the driving force, static pressure difference across the lip. Observed irregularities in these relations are mainly caused by transitions from one type of beating behavior of the lip against the walls of its housing to another. This beating explains the wide range and the driving force dependence of fundamental frequency, and seems to have a strong effect on the spectral content. The thickness of the lip base is linearly related to the fundamental frequency of lip reed oscillation.