Summary Objectives Elective neck dissection is frequently performed during surgery in head and neck cancer patients. The sentinel lymph node (SLN) procedure can prevent the morbidity of a neck ...dissection and improve lymph node staging by fine pathology. Near-infrared (NIR) fluorescence imaging is a promising technique to identify the sentinel lymph node (SLN) intraoperatively. This feasibility study explored the use of indocyanine green adsorbed to human serum albumin (ICG:HSA) for SLN mapping in head and neck cancer patients. Materials and methods A total of 10 consecutive patients with oral cavity or oropharyngeal cancer and a clinical N0 neck were included. After exposure of the neck, 1.6 mL of ICG:HSA (500 μM) was injected at four quadrants around the tumor. During the neck dissection, levels I–IV were measured for fluorescence using the Mini-FLARE imaging system. Results In all 10 patients, NIR fluorescence imaging enabled visualization of one or more SLNs. A total of 17 SLNs were identified. The mean contrast between the fluorescent signal of the lymph nodes and of the surrounding tissue was 8.7 ± 6.4. In 3 patients, of which 1 was false-negative, lymph node metastases were found. After administration of ICG:HSA, the average number of fluorescent lymph nodes significantly increased over time ( P < 0.001). Conclusion This study demonstrated feasibility to detect draining lymph nodes in head and neck cancer patients using NIR fluorescence imaging. However, the fluorescent tracer quickly migrated beyond the SLN to higher tier nodes.
Objective
A study was undertaken to identify the gene underlying DYT4 dystonia, a dominantly inherited form of spasmodic dysphonia combined with other focal or generalized dystonia and a ...characteristic facies and body habitus, in an Australian family.
Methods
Genome‐wide linkage analysis was carried out in 14 family members followed by genome sequencing in 2 individuals. The index patient underwent a detailed neurological follow‐up examination, including electrophysiological studies and magnetic resonance imaging scanning. Biopsies of the skin and olfactory mucosa were obtained, and expression levels of TUBB4 mRNA were determined by quantitative real‐time polymerase chain reaction in 3 different cell types. All exons of TUBB4 were screened for mutations in 394 unrelated dystonia patients.
Results
The disease‐causing gene was mapped to a 23cM region on chromosome 19p13.3‐p13.2 with a maximum multipoint LOD score of 5.338 at markers D9S427 and D9S1034. Genome sequencing revealed a missense variant in the TUBB4 (tubulin beta‐4; Arg2Gly) gene as the likely cause of disease. Sequencing of TUBB4 in 394 unrelated dystonia patients revealed another missense variant (Ala271Thr) in a familial case of segmental dystonia with spasmodic dysphonia. mRNA expression studies demonstrated significantly reduced levels of mutant TUBB4 mRNA in different cell types from a heterozygous Arg2Gly mutation carrier compared to controls.
Interpretation
A mutation in TUBB4 causes DYT4 dystonia in this Australian family with so‐called whispering dysphonia, and other mutations in TUBB4 may contribute to spasmodic dysphonia. Given that TUBB4 is a neuronally expressed tubulin, our results imply abnormal microtubule function as a novel mechanism in the pathophysiology of dystonia. Ann Neurol 2013;73:537–545
An 87-year-old woman presented with progressive solid food dysphagia that had been on-going for over 10 years. Her medical history included sarcoidosis, atrial fibrillation, hypertension, and a ...right-sided hemicolectomy for cecal adenocarcinoma. During gastroenterological consultation in a secondary setting, a barium swallow test revealed severe dilation of the proximal and distal esophagus, stasis of the bolus at the level of the aortic arch, and a “rat-tail” appearance of the esophagogastric junction (Fig. 1). Subsequent gastroscopy showed atony, esophageal dilation, and a narrowed tortuous segment in the distal esophagus (Fig. 2). Dilation was performed with Savary bougies up to 16 mm; however, this did not improve her swallowing. Although no definitive diagnosis could be made, a long-standing non-specific esophageal motility disorder was suspected. As her symptoms were mild, the patient agreed to conservative management with observation.
Objectives/Hypothesis
The current gold standard of therapy for adductor spasmodic dysphonia (AdSD) is injection of botulinum toxin A (BTX) in the adductor musculature. A surgical procedure could ...potentially offer more stable and long‐lasting voice quality. In this study, we report the long‐term results of endoscopic laser thyroarytenoid (TA) myoneurectomy versus BTX treatment in the same patients with AdSD.
Study Design
Retrospective case series.
Methods
Between July 2013 and September 2016, a total of 22 patients with AdSD were included. Voice outcomes were measured using the Voice Handicap Index and a Likert‐scale patient‐reported voice questionnaire. Data were obtained for each patient at four time points: preoperatively with and without BTX and twice postoperatively at 3 months (short term) and 12 months (long term).
Results
No statistically significant differences were found between voice outcome after BTX injection and the short‐ and long‐term postoperative voice outcomes for the group as a whole. During postoperative follow‐up, 10 of the 22 patients (45%) needed a second procedure after an average of 18 months (interquartile range, 13–22 months) due to recurrence of their original voice problem.
Conclusions
The TA myoneurectomy showed encouraging results, comparable to BTX after follow‐up of 12 months for the group as a whole. However, after good results initially, voice deterioration was seen in 45% of the patients who all underwent a second procedure. These preliminary results provide important insights into the value of TA myoneurectomy as a potential definite treatment for a select group of patients with AdSD. Further research might explore long‐term results after revision surgery.
Level of Evidence
4
Laryngoscope, 130:741–746, 2020
Abstract
Background
There is a considerable diagnostic delay in the diagnosis ‘benign acquired subglottic stenosis in adults’ (SGS, diagnosed by the reference standard, i.e. laryngo- or ...bronchoscopy). Patients are frequently misdiagnosed since symptoms of this rare disease may mimic symptoms of ‘asthma.’ The ‘Expiratory Disproportion Index’ (EDI) obtained by spirometry, may be a simple instrument to detect an SGS-patient. The aim of this study was to evaluate the diagnostic accuracy of the EDI in differentiating SGS patients from asthma patients.
Methods
We calculated the EDI from spirometry results of all SGS-patients in the Leiden University Medical Center (LUMC), who had not received treatment 2 years before their spirometry examination. We compared these EDI results with the EDI results of all true asthma patients between 2011 and 2019, who underwent a bronchoscopy (exclusion of SGS by laryngo- or bronchoscopy).
Results
Fifty patients with SGS and 32 true asthma patients were included. Median and IQR ranges of the EDI for SGS and asthma patients were 67.10 (54.33–79.18) and 37.94 (32.41–44.63), respectively. Area under the curve (ROC) of the accuracy of the EDI at discriminating SGS and asthma patients was 0.92 (95% CI = 0.86–0.98). The best cut-off point for the EDI was > 48 (i.e. possible upper airway obstruction), with a sensitivity of 88.0%% (95%CI = 77.2-95.0%%) and specificity of 84.4% (95%CI = 69.4-94.1%).
Conclusions
The EDI has a good diagnostic accuracy discriminating subglottic stenosis patients from asthma patients, when compared to the reference standard. This measurement from spirometry may potentially shorten the diagnostic delay of SGS patients. Further studies are needed to evaluate clinical reproducibility.
Evaluate long-term voice outcome after bilateral medialisation thyroplasty in glottic insufficiency due to vocal fold atrophy with or without sulcus.
Patients after medialisation thyroplasty for ...vocal fold atrophy with or without sulcus were identified. Long-term post-operative subjective voice outcomes (> 1 year) using Voice Handicap Index-30, subjective ratings on voice aspects and study-specific questionnaire were compared to pre-operative and shorter-term (1 year) values.
Thirty-six patients were identified, of which 26 were included (16 atrophy, 10 sulcus) with median follow up of 6.7 years. Mean Voice Handicap Index score at > 1 year (40.0) showed clinically relevant (≥ 15 for groups) and statistically significant improvement compared to pre-operative score (58.1) and remained stable compared to post-operative score (35.7) at one year. Ten patients (56 per cent) reported clinically relevant improvement (≥ 10) after more than five years.
Long-term improvement in subjective voice outcomes is attainable in a significant proportion of patients undergoing bilateral medialisation thyroplasty for atrophy with or without sulcus.
Objective
To evaluate the short- and long-term voice outcomes after unilateral medialization thyroplasty (MT) and unilateral medialization thyroplasty with arytenoid adduction (MT + AA) in patients ...with unilateral vocal fold paralysis.
Methods
Voice outcomes were assessed preoperatively, and postoperatively at 3 and 12 months according to a standardized protocol. Voice assessment was performed using Voice Handicap Index (VHI), GRBAS Grade, Maximum Phonation Time (MPT), s/z-ratio and subjective numeric rating scales on voice quality, effort, performance and influence on life.
Results
Sixty-one patients were included (34 MT and 27 MT + AA). Significant pre- to postoperative improvements were seen in all voice outcome parameters. No significant differences in post-operative values were identified between the groups.
Conclusion
Based on our findings, we conclude that patients with unilateral vocal fold paralysis who undergo MT and MT + AA achieve comparable and significant long time voice improvement, although voices do not completely normalize. We also conclude that this does not mean that AA is a superfluous procedure, but can indicate the accurate identification of patients in need of the additional AA procedure based on clinical parameters.
Uniform evaluation of treatment effect on the quality of voice in adductor spasmodic dysphonia (AdSD) is challenging due to the broad variety of available outcome measurement instruments (OMIs). The ...European Laryngological Society categorized five types of measurement domains for voice quality evaluations: patient-reported outcome measures, perceptual analyses, acoustic analyses, visual analyses, and aerodynamic measurements. The aim of this study was to propose a core outcome set (COS) for these domains, enabling systematic assessments of treatment effects on the quality of voice in patients with AdSD.
The PubMed, Embase, and Cochrane databases were searched for eligible studies published before July 2019. The results were systematically analyzed following the protocol of the COnsensus-based Standards for the selection of health Measurement INstruments/Core Outcome Measures in Effectiveness Trials initiative. The proposed COS is based on the prevalence of OMIs, quality of the included studies, criteria for good measurement properties, and correlations to other OMI domains.
A total of 76 articles were included, with nearly all studies and OMIs found to be of moderate or low quality. The 19 studies that reported on the correlation of OMIs demonstrated conflicting results. Appraising the best available evidence, our proposed COS consisted of patient-reported outcome measures (voice handicap index), perceptual measurements (grade, roughness, breathiness, strain, and voice breaks) and acoustic measurements (voice breaks, voice onset time, aperiodicity, and multiparameter algorithms).
A review of OMIs evaluating treatment effects in AdSD was conducted. Based on this review, a uniform COS was proposed. However, evidence for the selected instruments was limited. Further exploration into the validity and reliability of OMIs for AdSD is recommended.
Purpose
The purpose of this study was to evaluate short- and long-term outcome of injection augmentation with autologous adipose tissue (AAT) and calcium hydroxylapatite injection (CAHA) in patients ...with a unilateral vocal fold paralysis (UVFP).
Design/methods
A retrospective cohort study was performed in patients diagnosed with UVFP, who had received injection augmentation with AAT or CAHA. Multidimensional voice analysis was performed before, 3 and 12 months after injection. This analysis included patient self-assessment (Voice Handicap Index-30), perceptual (overall dysphonia grade according to the GRBAS scale), aerodynamic (MPT, s/z ratio) and acoustic (fundamental frequency, dynamic range) parameters. Effects were assessed using a linear mixed model analysis.
Results
Forty-six patients were available for evaluation, with a total of 53 injection augmentations (AAT
n
= 39; CAHA
n
= 14). We found significant improvement of patient self-assessment and perceptive voice outcome at 3 months, which were maintained at 12 months. In the CAHA group, s/z ratio and dynamic range of extreme frequencies also improved significantly over time. No statistically significant differences were found between the two treatments (AAT vs. CAHA). No major complications were reported.
Conclusion
This study, using a guide-line recommended panel of outcome parameters, shows a high success rate of injection augmentation with AAT or CAHA for patients with UVFP at 12 months with significant improvement in most voice outcome parameters, although voices do not completely normalize. There is no significant difference in outcome between the two materials.
PDF
