The Gruppo Otologico experience of endolymphatic sac tumor.

OBJECTIVE: Endolymphatic sac tumor (ELST) is a rare low grade adenocarcinoma of the skull base. During the past decade the number of the reported cases has increased. This study exposes our experience in the management of ELST with a review of the literature. STUDY DESIGN: Retrospective study of patients with ELST at a quaternary referral otology and skull base center. METHODS: A review of the records from the Gruppo Otologico revealed 7 patients treated for ELST. All papers containing series of three or more cases of ELST published in the English literature were selected for analysis. RESULTS: Hearing loss and tinnitus were present in almost all our cases. All of them were evaluated with audiometric tests, computed tomography and magnetic resonance imaging. All the patients were treated surgically with preservation of the facial nerve and preoperative embolization was performed in 5 patients. Genetic study was performed on all our cases and revealed the presence of von Hippel-Lindau syndrome in one patient who had the tumor as the initial manifestation of his syndrome. None of the patients received postoperative radiotherapy and one of them had recurrence of the tumor 13 years following surgery. CONCLUSIONS: Complete surgical resection with preoperative embolization of large tumors is the mainstay treatment for ELST. The facial nerve should not be sacrificed unless it is totally invaded by the tumor. A long term follow up is recommended and the role of postoperative adjunctive radiotherapy is still controversial.

Salvage surgery of vestibular schwannoma after failed radiotherapy: the Gruppo Otologico experience and review of the literature.

OBJECTIVES: The use of radiation therapy has largely widespread and becomes in many centers the preference modality of treatment for symptomatic patients who are old, medically unfit for surgical therapy, those who refuse surgery and in some recurrent or residual growing tumors. The risk of radiotherapy failure in the treatment of vestibular schwannoma might be underestimated in the literature. The purpose of this study is to show the Gruppo Otologico experience with salvage surgery to better understand the surgical outcomes and difficulties in treating vestibular schwannoma after failed radiotherapy. STUDY DESIGN: Retrospective chart review of patients who required salvage surgery of vestibular schwannoma after failed radiotherapy. SETTINGS: Quaternary referral otology and skull base center. RESULTS: Between 1987 and 2010, 2500 cases of VS underwent surgical treatment at the Gruppo Otologico. Nineteen patients had received stereotactic radiation therapy before the surgical treatment. The interval time between radiotherapy and surgical salvage ranged from 1 to 10 years. In all the cases decision of surgery was taken following an increase in tumor size with or without new onset of symptoms. Complete tumor removal was achieved in 86.6% of the cases through a transotic, transcochlear or enlarged translabyrinthine approach with trans-apical extension. Difficult dissection of the tumor was encountered in 93.3% the cases. The facial nerve was anatomically preserved in 93.3% but its function was worsened in 73.3% of patients after at least 6 months of follow up. Malignant transformation of the vestibular schwannoma was encountered in one patient. CONCLUSION: Complete surgical resection of VS is more difficult after radiotherapy with relatively poor facial nerve outcomes and nearly impossible hearing preservation. Patients who receive radiation therapy for the treatment of vestibular schwannoma should be made aware of its potential complications and risk of failure, especially in young patients and NF2 cases.

Arytenoid asymmetry in relation to posture, neck tension and glottal attack in singers.

OBJECTIVES: To look at the incidence of arytenoid asymmetry in a group of healthy singers and to investigate whether the asymmetry correlates with posture, neck tension and glottal attack. MATERIALS AND METHOD: The medical records and video recordings of 42 singers were reviewed retrospectively. Posture, neck tension and glottal attack were evaluated in relation to arytenoid asymmetry during adduction. RESULTS: The number of singers was 42, with a male-to-female ratio of 2:1. The age range was 16-38 years, with a mean of 24±4.13 years. The total prevalence of arytenoid asymmetry was 50%, with a predominance in males and on the right side. The most common asymmetry was that of the cuneiform cartilages, accounting for 40.5% of the total sample and 81% of the total asymmetries. There was no correlation between arytenoid asymmetry and either posture, neck tension or glottal attack (p=0.343, 0.489 and 0.945, respectively). CONCLUSION: One out of 2 singers is likely to have arytenoid asymmetry during adduction. The presence of asymmetry does not correlate with posture, neck tension or glottal attack.

Effect of fasting on voice in males.

PURPOSE OF THE STUDY: The aim of the study was to study how fasting between 12 and 14 hours affects voice production. STUDY DESIGN: This is a prospective study of male subjects. MATERIAL AND METHOD: A total of 26 healthy male subjects were recruited for the study. The age varied between 22 and 50 years with a mean of 28 years. Exclusion criteria included hoarseness at the time of presentation, history of recent upper respiratory tract infection, or microlaryngeal surgery. Subjects were evaluated while fasting and nonfasting. Each subject was asked about vocal fatigue and ease of phonation. This was followed by acoustic analyses and laryngeal videostroboscopy. RESULTS: The incidence of vocal fatigue was not higher while fasting compared to nonfasting (P = 1.00). Phonatory effort was significantly greater during fasting (P < .001). Fifty percent of the subjects had an increase in their phonatory effort. There was a significant decrease in the habitual pitch, voice turbulence index, and noise-to-harmonic ratio (P = .018, .045, and .001, respectively). There were no laryngeal videostroboscopic changes. CONCLUSION: Fasting in males results in an increase in phonatory effort. These phonatory changes may be secondary to dehydration as well as overall neuromuscular fatigability.

Vocal changes in patients with polycystic ovary syndrome.

PURPOSE: The purpose of this study is to look at the prevalence of vocal symptoms and acoustic changes in patients with polycystic ovary syndrome (PCOS). MATERIALS AND METHOD: A total of 17 patients with PCOS diagnosed on the basis of three criteria: the presence of irregular menstrual cycles, hirsutism, and polycystic ovaries were included in the study. Twenty-one normal females' frequencies matched on age with the cases were used as controls. The following vocal symptoms were investigated: throat clearing, deepening of the voice, loss of voice, lump in the throat, and difficulty being heard. Acoustic analysis and laryngeal videostroboscopy were performed. RESULTS: The age range was between 19 and 38 years with a mean age of 26 years. The most common prevailing symptom was throat clearing present in 76.5% versus 4.8% in the controls, followed by loss of voice (47.6%), lump in the throat (41.2%), and deepening of voice (35.3%). The differences in the prevalence of throat clearing, deepening of voice, lump in the throat, and difficulty being heard were statistically significant compared with controls (P value<0.05). There was no statistically significant difference in the acoustic parameters except for an increase in the relative average perturbation (P value=0.035) and a decrease in maximum phonation time (P value=0.001) in patients with PCOS. In the PCOS group, three patients had evidence of mild vocal fold edema and one patient had vocal fold nodules. In the control group, one subject had vocal fold edema and one subject had vocal fold nodules. CONCLUSION: Patients with PCOS seem to have more vocal symptoms compared with controls. Physicians should be aware of vocal changes in hirsute subjects with PCOS.

Cricothyroid joint abnormalities in patients with rheumatoid arthritis.

The objective of this study was to assess structural and functional abnormalities of the cricothyroid joint (CTJ) in patients with advanced rheumatoid arthritis (RA). A total of 19 subjects--11 patients with advanced RA and eight normal controls--were considered. All subjects underwent laryngeal endoscopy, acoustic analysis, and high-resolution computerized tomography (HRCT). Vocal symptoms, such as hoarseness, loss of range, vocal fatigue, and dyspnea were inquired and acoustic parameters, mainly pitch range, fundamental frequency, habitual pitch, perturbation parameters, and noise-to-harmonic ratio (NHR) and voice turbulence index were measured. Frequencies and means were calculated for categorical and continuous variables. Cases and controls were compared with respect to acoustic analysis, HRCT findings and laryngeal symptoms using nonparametric tests, Mann-Whitney U test for continuous variables and Fishers exact test for categorical variables. Almost half of the patients with RA had loss range and two-thirds had vocal fatigue. Thirty-six percent experienced hoarseness compared with 25% in the control group. 9.1% had decrease in vocal fold mobility and 27% had moderate/severe edema of the vocal folds/arytenoids compared with none in the control group. HRCT showed narrowing in the CTJ in 81.8% and ankylosis in 9.1% compared with none in the control group. 45.5% had an increase in the CTJ density compared with 12.5% in the control group. Acoustic analysis revealed significant decrease in pitch range and maximum phonation time (MPT) and significant increase in perturbation parameters. CTJ is commonly affected in patients with RA. Functional disabilities are crucial especially in professional voice users. Proper awareness is important for early detection and intervention.

Leishmaniasis of the auricle mimicking carcinoma.

Leishmaniasis of the auricle has been rarely reported in our region of the world, where it is labeled as "Old World Leishmaniasis." It may mimic other pathologies, such as malignancies or other infectious processes. We present a case of an auricular Leishmania lesion which was first suspected to be a carcinoma. Four previous auricular Old World Leishmania cases have been reported. The epidemiology, clinical presentation, diagnosis, and treatment of this entity are briefly reviewed.

Vocal changes following radiotherapy to the head and neck for non-laryngeal tumors.

To investigate vocal changes in patients following the neck irradiation for non-laryngeal tumors sparing the glottic region. Fifteen patients were enrolled for the study. Phonatory effort and voice evaluation were reported. Perceptual evaluation and acoustic analysis were performed. Men/women ratio was 6/9. The mean age was 54 years with a range from 24 to 84. The most common primary site of tumor was the nasopharynx and tongue. The mean phonatory effort was significantly greater in the irradiated group versus controls (0.54 vs. 0.08 with a P value 0.01). Fifteen percent reported their voice as being poor and almost 85% as being fair. All the parameters of the GRABS perceptual evaluation were significantly worse in the irradiated group. There were no statistically significant differences between all the acoustic variables in both groups except for an decrease in the Habitual pitch in the irradiated patients. Radiation therapy to head and neck region can affect voice even if the radiation beams spare the vocal folds.