Cost-effective management of pharyngocutaneous fistulas following laryngectomy.

A pharyngocutaneous fistula following a total laryngectomy is not an uncommon occurrence. The incidence of this serious complication ranges worldwide from 7.6 percent to 50 percent. It usually exacerbates post-operative morbidity and increases expense with prolonged hospitalization. This complication often requires additional operative procedures or if untreated may lead to a fatal complication such as carotid artery rupture. There are multiple predisposing factors leading to poor wound healing in this patient population. These factors include prior radiation therapy, chemotherapy, compromised nutrition, and associated surgical procedures including radical neck dissection. A treatment strategy for difficult fistulas with undermining is presented here. The cornerstones of this approach include opening the area large enough for packing and cleansing, diverting the copious pharyngeal secretions and providing an optimal wound environment through the use of an amorphous hydrogel dressing (Intrasite* Gel, Smith & Nephew United, Inc., Largo, FL). This treatment strategy led to complete and sustained healing when utilized by the authors in the following patients. It was successful even in heavily irradiated tissue with its severe changes of compromised vascularity, increased dermal fibrosis and epidermal thinning. The authors have found this technique a cost-effective alternative to secondary surgery, applicable in both the acute and home care settings.

Electromyographic biofeedback training with patients exhibiting a hyperfunctional voice disorder.

Baseline EMG measures of general laryngeal area muscle tension while speaking and during silence were taken from a group of 21 normal subjects and 7 subjects diagnosed through indirect laryngoscopy as having vocal nodules. In an attempt to reduce their baseline scores, the vocal nodule patients underwent 8 EMG biofeedback training sessions followed by a 2-week follow-up session. Sophisticated listeners then judged the qualities of the voices produced during the base-line and follow-up sessions. Measures of sound pressure levels for the speech samples were also taken to determine their effects on EMG scores. Results of the statistical analyses revealed that significant differences in general laryngeal area muscle tension while speaking and in silence exist between normal and pathological subjects; and that subjects with vocal nodules could significantly reduce these tension levels with EMG biofeedback training. A positive correlation was then found between the EMG measures and the judgments of voice qualities. No correlations were found between EMG measures and sound pressure levels.

Why not the eighth nerve? Neurovascular compression--probable cause for pulsatile tinnitus.

Carotid arteriograms on three patients with unilateral pulsatile tinnitus demonstrated an ipsilateral atypical trigeminal artery extending from the cavernous portion of the internal carotid artery to form the posterior inferior cerebellar artery. Illustrations and a dissection of a human fetus with a similar finding show this artery crossing the cochlear nerve near its insertion in the pons. Evidence is presented suggesting that neurovascular compression of the eighth nerve is the source of pulsatile tinnitus in these patients.