Transoral laser microsurgery for polydimethylsiloxane (VOX Implant®) explantation.

INTRODUCTION: Polydimethylsiloxane (VOX Implant®) injection into the larynx is a surgical technique used to restore volume to paralysed or atrophic vocal folds. We present a case series that demonstrates the feasibility of explantation of this non-resorbable material in the event of complications secondary to this injection. DESCRIPTION: We report four cases of VOX Implant® explantation. In every case, explantation was performed following complications such as dysphonia and/or dyspnoea secondary to injection of this material. VOX Implant® explantation was performed via cordotomy using transoral lasermicrosurgical techniques. DISCUSSION: VOX Implant® explantation improved voice and breathing parameters in all patients. Explantation can be performed by transoral microsurgery in the presence of complications related to polydimethylsiloxane injection.

Suspension laryngoscopy-assisted percutaneous dilatational tracheostomy.

We describe an endoscopic-guided, suspension laryngoscopy-assisted percutaneous dilatational tracheostomy technique, which can be performed by all otolaryngologists and is suitable for any patient requiring tracheostomy. It can be performed in the context of elective surgery or as an emergency procedure. This technique was developed using suspension laryngoscopy and ENT endoscopy equipment, as well as a percutaneous dilatational tracheostomy kit. It has the advantage of ensuring optimal control of the patient's ventilation and haemostasis throughout the procedure. The good quality endoscopic vision and easy access to the airway provided by suspension laryngoscopy allow tracheostomy to be performed under optimal safety conditions.

Endoscopic lateralization of the vocal fold.

Vocal fold paralysis in adduction can result in significant breathing difficulties. Techniques such as vocal fold lateralization and/or arytenoidopexy help to improve respiratory function in this setting. These techniques require open approach or specific instruments. The authors describe an original vocal fold lateralization technique performed exclusively via an endoscopic approach. This technique helps to enlarge the glottic aperture, while preserving laryngeal architecture, and permanently improves respiratory function in patients with vocal fold paralysis in adduction.

Office-based endoscopic botulinum toxin injection in laryngeal movement disorders.

INTRODUCTION: Botulinum toxin injection is widely used for the treatment of laryngeal movement disorders. Electromyography-guided percutaneous injection is the technique most commonly used to perform intralaryngeal botulinum toxin injection. OBJECTIVE: We describe an endoscopic approach for intralaryngeal botulinum toxin injection under local anaesthesia without using electromyography. TECHNIQUE: A flexible video-endoscope with an operating channel is used. After local anaesthesia of the larynx by instillation of lidocaine, a flexible needle is inserted into the operating channel in order to inject the desired dose of botulinum toxin into the vocal and/or vestibular folds. CONCLUSION: Endoscopic botulinum toxin injection under local anaesthesia is a reliable technique for the treatment of laryngeal movement disorders. It can be performed by any laryngologist without the need for electromyography. It is easy to perform for the operator and comfortable for the patient.

Epiglottoplasty technique in endoscopic partial laryngectomy.

The main advantage of endoscopic laser surgery for laryngeal cancer is to allow tumour resection, while limiting functional sequelae, thereby improving the postoperative course. In this type of surgery, the epiglottis is often partially resected, leaving a raw zone without any reconstruction. The surgical technique described here involves endoscopic reconstruction of the epiglottis after partial resection. The sectioned edge of the epiglottis is sutured to the base of the tongue to create a neoepiglottis and to reconstruct the vallecula, thus resembling preoperative anatomy, allowing improvement of postoperative swallowing.

Pre-emptive awake airway management under dexmedetomidine sedation in a parturient with spinal muscular atrophy type-2.

Historically, pregnancy in females with spinal muscular atrophy was contraindicated due to the great risk to the parturient, but with improved management and increased survival more patients are becoming pregnant. We describe the management of a pregnant patient with spinal muscular atrophy type-2, who had severe restrictive lung disease, extensive spinal fusion that precluded neuraxial anesthesia, and chronic respiratory failure on nocturnal Bilevel Positive Airway Pressure. Airway management was further complicated by limited mouth opening and cervical spine ankylosis.

Endoscopic pharyngolaryngoplasty: A case report.

INTRODUCTION: Any technique that allows decannulation of tracheostomy-dependent patients relieves their discomfort and reduces health costs. CASE REPORT: We present the case of a 70-year-old tracheostomy-dependent patient with pharyngolaryngeal stenosis and a history of radiation therapy for laryngeal cancer in remission for 13years and multiple decannulation failures. Endoscopic pharyngolaryngoplasty was performed using reconstructive transoral laser microsurgery techniques, allowing permanent decannulation. Endoscopic sutures secured by clips were performed to remodel the pharyngolarynx and prevent recurrence of synechiae. DISCUSSION: Endoscopic surgery of the pharynx and larynx was initially developed for resection of small tumours. Reconstructive transoral laser microsurgery has been developed more recently. One of the objectives of this surgery is to reconstruct the pharyngolarynx to treat functional sequelae following surgery and/or radiation therapy for head and neck cancer. It allows reconstruction of the upper airways to restore mouth breathing in tracheostomy-dependent patients, thereby facilitating permanent decannulation.

Changes in the hypopharynx may suggest supraesophageal reflux disease.

Supraesophageal reflux disease is difficult to diagnose because its markers are not well defined. However, debate among gastroenterologists continues about the possibility that changes in the appearance and function of the hypopharynx can be valid indicators of atypical reflux disease. Detecting these indicators presents a challenge, albeit a necessary one, if reflux disease is to be identified and treated appropriately. This paper reviews the anatomical and functional characteristics of supraesophageal reflux disease.

Method and clinical results of a new transthyrotomy closure of the supraglottic larynx for the treatment of intractable aspiration.

A new procedure has been developed to surgically separate the pharynx from the trachea that employs the best features of the Montgomery technique, but restricts the closure to only the epiglottis and the aryepiglottic folds. The petiole of the epiglottis is plicated to the false vocal folds and the interarytenoid mucosa. It is performed entirely through a midline thyrotomy approach and avoids injury to any of the structures within the rima glottidis. It has been successfully performed on seven very ill patients to date. The surgical decision-making process involved, a complete description of the surgical procedure, and a summary of the patients' preoperative condition, workup, and outcomes are presented and discussed.

Anatomic considerations in botulinum toxin type A therapy for spasmodic dysphonia.

Chemodenervation by injection of botulinum toxin type A into the vocal fold(s) has become the preferred treatment for patients with adductor spasmodic dysphonia. Injection may be done either perorally or transcutaneously; each method has its advocates and advantages. The authors have used the transcutaneous transcricothyroid membrane route exclusively with satisfactory results in more than 50 patients. Temporary breathliness and aspiration are common. The preferred injection site should be as close as possible to the motor end plates of the affected muscle. The thyroarytenoid muscle end plates are distributed throughout the muscle, whereas in the lateral cricoarytenoid muscle they are located in band in the center of the muscle. The transcutaneous injection site is below and posterior to the midpoint of the vibrating vocal fold as visualized by indirect laryngoscopy. The proximity of this site to the lateral cricoarytenoid muscle suggests that postinjection breathiness and aspiration may be related to spread of botulinum toxin type A to the lateral cricoarytenoid muscle. However, it is likely that thyroarytenoid muscle paresis is mainly responsible for this side effect and that the rapid clearing of the breathy dysphonia in the face of prolonged relief of spasmodic dysphonia symptoms suggests the action of an adaptive neural response, such as axonal sprouting. Further research of this subject is warranted.

Evidence for peptide aggregation.

Evidence is presented that peptides may occur in aggregated form. Addition of 125I-Tyr-DSIP to serum resulted in four peaks after gel filtration chromatography on a column of Sephadex G-25. One of the peaks (C) eluted at the same position as the labeled peptide standard. Two Peaks (A and B) eluted before the standard and one (peak D) afterwards. The first peak (A) eluted at void volume, a position expected for labeled peptide bound to protein. The other two peaks (B and D), corresponding to smaller molecular size material, were greatly reduced by addition of glacial acetic acid or the chelating agent 1,10-phenanthroline before or even after mixing of the peptide with serum. Iron was one of the ions found to interact with 125I-Tyr-DSIP, and chromatography of a mixture of ferric chloride and peptide without serum resulted in the additional formation of peak B. A substantial portion of peaks A, B, and C (but not D) reacted with a specific DSIP antibody, indicating the presence of intact peptide. The results are consistent with the concept that peptides may occur in multiple forms.

Differential penetration of DSIP peptides into rat brain.

Delta sleep-inducing peptide (DSIP) or five closely related peptides were injected peripherally and the levels of DSIP-like immunoreactivity measured in the brains of 100 g and 500 g rats decapitated a minute later after washout with 0.9% NaCl. Higher concentrations of immunoreactive material were found in brain tissue with injection of des Trp1-DSIP, D-Ala4-DSIP, and, after correction for cross-reactivity, with D-Ala4-DSIP-NH2 than with the other peptides. Both peptides substituted in the fourth position with D-alanine resulted in higher concentrations in 500 g rats than in 100 g rats, indicating a possible effect of age. The 5-10 fold greater brain to blood ratios of radioactivity after 125I-N-Tyr-DSIP than after 125-I radioiodinated serum albumin (RISA) provided additional evidence against non-specific leakage or contamination of the brains with substantial amounts of residual blood. The results suggest that penetration of the blood-brain barrier (BBB) by small amounts of peptides, at least DSIP peptides, may be somewhat selective.

Radioimmunoassay of DSIP-like material in human blood: possible protein binding.

A radioimmunoassay (RIA) for DSIP-like material was established in unextracted human plasma. Most of the immunoreactivity was found in a "large" fraction while a much smaller amount co-eluted with DSIP from Sephadex as a "free" fraction. Both peaks progressively increased with increasing amounts of added DSIP. Acidification, but not treatment with charcoal-dextran, resulted in a relative decrease in the "large" peak and an increase in the "free" peak. This RIA, therefore, appears to measure both bound and free forms of DSIP-like immunoreactivity, the levels of which were higher at 4 p.m. than at 8 a.m.