Biomedical subjects
Publications and source records attributed to A G Maran.
A clinical method of measuring 'hoarseness' is presented. Its value is assessed in 3 different types of vocal cord lesion and compared against normal values. There are shown to be significant differences between the normal and the abnormal voice and also differences between each type of vocal cord lesion. We feel that this quantification of hoarseness is useful in the treatment of patients as well as in monitoring their progress under therapy.
Of 376 patients who were treated by radical radiotherapy for squamous carcinoma of the larynx, 56 subsequently underwent total laryngectomy. Residual or recurrent tumour was identified in 43 of the resection specimens, and necrosis alone in 13 cases, although a positive biopsy had been obtained in 3 of these prior to salvage laryngectomy. No disease related factors such as site or stage of the original tumour, or treatment related factors such as radiation type or dose, were found to be predictive of whether or not tumour was present. The clinical opinion of an experienced surgeon was found to have a positive predictive value of 0.86 for the presence of tumour. The fistula rate of salvage laryngectomy, 15 out of 56, was similar to that of other series. The actuarial cause specific 5-year survival for patients with tumour was 0.589, and for patients with necrosis only was 0.923. Intercurrent, smoking related disease was the cause of death in 16 of the 33 patients who have died.
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Twenty-two trainee surgeons were tested on high level tests of intelligence, a detailed battery of paper-and-pencil and computerized spatial ability tests, and personality tests. They were also rated for operating ability, clinical decision-making ability, and for overall performance by consultant surgeons who knew them well. Ability ratings were high, indicating very little dissatisfaction with the performance of trainee surgeons. There were no significant correlations between surgical ability ratings and intelligence test scores. The only significant correlation between spatial ability and ability ratings was with one subtest, and was in the opposite direction to that expected. Trends in the data suggested that those trainees rated as superior tended to be more introverted and conscientious, and tended to have better stereoscopic depth perception. The discussion questions the necessity for aptitude testing in surgery and points out some statistical pitfalls in the area. It is concluded that little advance may be made with the application of aptitude testing in the selection of surgeons until there are more objective criteria of surgical ability in different surgical specialties.
The aim of the study was to determine the manometric patterns in dysphagic patients with radiologic evidence of upper esophageal sphincter (UES) dysfunction. Nineteen patients with radiographic abnormalities of the UES underwent measurement of several parameters of UES tonic pressure and pharyngoesophageal water swallow dynamics. At least two UES tonic pressures were elevated in six subjects, compared with a control group of 67 healthy volunteers. No patients had UES achalasia. The cricopharyngeal impression in the remaining patients may represent muscular hypertrophy or deficiency of UES opening, despite manometric relaxation, but its relationship to the patient's symptoms remains unknown. Cricopharyngeal myotomy appears to be a reasonable treatment for patients with manometric UES hypertonicity.
The upper esophageal sphincter (UES) receives the full radiation dose during external beam radiotherapy to the adjacent larynx. The aim of the study was to assess the effects, if any, of radical laryngeal radiotherapy on motility patterns in the pharyngoesophageal segment. A strain gauge assembly and a digital manometric recorder were used to assess 19 patients 13 to 71 months after irradiation of T1 to T3 glottic cancer to a central dose of 52.5 to 55.7 Gy in 20 daily fractions. Results were compared with those of 23 healthy controls. Tonic lower esophageal sphincter (LES) pressure, distal peristaltic contraction, tonic UES pressure, and eight parameters of pharyngoesophageal dynamics during water and bread swallows were studied. No difference was found between the two groups in tonic LES pressure, peristaltic amplitude, or tonic UES pressure. Water swallow pharyngoesophageal wave velocity was significantly lower in patients than in controls, and the irradiated group also showed a trend toward increased duration of the distal esophageal peristaltic wave. The reduction in upper esophageal wave velocity was associated with the interval following irradiation. The post-treatment interval was also inversely related to the amplitude of UES after-contraction, and associated with an increase in wave duration throughout the pharyngoesophageal segment. A study of 23 laryngectomy specimens, 5 of which had been removed following radiotherapy, failed to identify pathological features in nerves or muscle which characterised previous laryngopharyngeal irradiation. We conclude that laryngeal irradiation has no effect on upper or lower esophageal sphincter tone but causes an increase in wave duration and a reduction in wave velocity in the pharyngoesophageal segment. These changes are independent of age and sex and are not associated with pathological features like the neural degeneration described in the myenteric plexus of irradiated rectum.
Reinke's oedema (RO) of the vocal folds is a condition of unknown aetiology. Cigarette smoking and vocal abuse may contribute to its development. Hypothyroidism has been described as an aetiological factor but, to date, no controlled study has been published confirming this association. This prospective, controlled study compared thyroid function in 61 consecutive RO patients with an age and sex matched control group (n = 65) without laryngeal disease. Thyroid function was assessed by measuring serum thyroid stimulating hormone (TSH), free thyroxine (T4) and tri-iodothyronine (T3). Hypothyroidism was diagnosed when TSH was above normal with a T3 and T4 below the normal range. Four RO patients were hypothyroid at the time of diagnosis, compared to five of the control group. Six RO patients had past or present hypothyroidism compared to seven of the controls. One RO patient and two controls were euthyroid with marginally elevated TSH levels. Although the incidence of hypothyroidism in this group of Reinke's oedema patients is higher than expected in a normal population, it is similar to that in an age and sex matched control group, reflecting the prevalence of hypothyroidism in middle aged women. This study suggests that hypothyroidism is not an aetiological factor in the development of Reinke's oedema.
Functional endoscopic sinus surgery (FESS) requires cadaver-based practice to acquire the necessary technical expertise. To enable this to be undertaken as a bench-top activity the Edinburgh FESS Training system has been developed. This involves the en-bloc removal of the relevant parts of the nasal cavity and sinuses from cadavers and their embedding and mounting in a simulated head.
A follow-up study of 104 patients with globus sensation was performed by postal questionnaire. All were asked to complete the Eysenck Personality Questionnaire (EPQ) and a 12-item Throat Symptom Questionnaire. Seventy-two of these patients were sent a follow-up General Health Questionnaire (GHQ). Replies were received from 89 patients (86%), 68 females and 21 males, a mean of 31 months after initial presentation. The feeling of something stuck in the throat had disappeared completely in 27% of patients, but only 4% were never aware of the throat. Throat symptoms showed a reduction with increasing age, but not with increasing interval since presentation. The 15 patients initially treated with antacid therapy had significantly greater dyspepsia scores at review than untreated patients, but no other difference was found between the two groups. GHQ scores showed a small but significant reduction over time. Of EPQ parameters, only the lower lie score in female patients showed any significant difference on repeat testing. Those with persistently high throat scores had significantly lower EPQ lie scores and a trend towards higher GHQ scores at follow-up. None of the psychological parameters measured at the first interview was found to be of prognostic significance. We conclude that, although there is a reduction in occult psychiatric morbidity in patients with the globus sensation over time, underlying personality traits remain stable and that there is a remarkable persistence of pharyngeal symptoms.
Parotid gland enlargement occurs in about 25% of patients with the binge eating syndrome of bulimia nervosa. The parotid salivary secretory patterns in 28 bulimics were determined in order to investigate the functional abnormality in the glands. Bulimia patients had a reduced resting flow rate. Bulimics who developed sialadenosis (4 patients) had reduced resting and stimulated flow rates. The salivary amylase activity was increased in both the resting and stimulated states in bulimics and the sialadenosis group. The resting total protein levels were greater in the bulimics. The electrolyte and immunoglobulin levels were within normal limits. The possibility of protein and enzymatic secretory disturbances due to autonomic nerve disorders as an explanation for the development of sialadenosis in bulimia nervosa is discussed.
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Pleomorphic adenomas of the salivary gland are usually regarded as benign tumours. We report a case in which a solitary pulmonary metastasis arose from a pleomorphic adenoma of the right parotid gland. The mechanism of metastasis is discussed.
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Informed consent is the fastest growing problem in the medical negligence debate. It was highlighted recently in the United Kingdom in the Sidaway case. Informed consent comprises the advice you would give the patient, the consequences of not taking your advice, the specific risks of the surgery or treatment you have in mind, and the risks of surgery in general. In an attempt to identify what the present practice in otolaryngology was, a postal survey was carried out of the members of the Scottish and North of England Otolaryngological Societies.
Cigarette smoking influences the risk of orogastrointestinal disease in both protective (ulcerative colitis), and inductive (squamous tumours of the head, neck and oesophagus) roles. In order to study the effects of smoking on mucosal immunity, salivary immunoglobulins were measured in pure parotid saliva from groups of healthy non-smokers, smokers, and exsmokers and from patients with epithelial head and neck tumours, both untreated and after radiotherapy. Of the healthy individuals, smokers had significantly lower salivary IgA and higher IgM concentrations than did non-smokers. The effect on IgA was dose related, and reversible after cessation of smoking. Likewise, in patients with head and neck tumours (the majority being smokers), salivary IgA concentration was reduced and IgM increased when compared with non-smoking controls. Results were similar before and after radiotherapy. This study provides evidence of the effects of smoking on mucosal immunity as evaluated by parotid salivary immunoglobulins. Further studies of the influence of smoking on secretory immunity are indicated.
The experience of the uvulopalatopharyngoplasty operation, performed on 24 patients for the relief of loud or heroic snoring, is presented. The operation successfully reduced the severity of snoring in 96% of patients. Postoperative complications were uncommon but included nasal regurgitation and intrapharyngeal adhesions in one patient. The role of the uvulopalatopharyngoplasty operation in the treatment of obstructive sleep apnoea is undecided but the authors do not perform this operation on such patients.
It is a decade since the last review article on otolaryngology in this Journal. In that time there have been significant advances in the practice of an ever-changing specialty which originally started off as a surgical specialty designed to drain abscesses from the bony boxes in the head, namely the mastoids and the sinuses. It is impossible, in an article like this, to do anything other than superficially indicate the changes but a list of further reading is given for each section.
Previous reports of normal pharyngoesophageal motility have described normal ranges in small numbers of young adults. In this study, the results of upper esophageal sphincter (UES) manometry with a microtransducer assembly in 67 healthy volunteers aged 17-77 yr have been analyzed for possible effects of age, sex, and cigarette smoking. Older subjects were found to have only marginally lower UES tonic pressures, but markedly elevated pharyngeal contraction pressures. Increasing age was associated with a reduction in duration of upper esophageal contractions and, for bread swallows, an increase in pharyngoesophageal wave velocity which may represent compensatory mechanisms for airway protection. Male subjects showed greater UES axial asymmetry than females, perhaps due to sex differences in laryngeal anatomy, whereas females had greater UES wet swallow after-contraction pressures which may be relevant to the generation of globus sensation. All results were independent of cigarette smoking. We conclude that normal values obtained in small numbers of young adults form an inadequate basis for the interpretation of UES tonic and pharyngeal contraction pressures, which are reported to be abnormal in older patients with dysphagia, and that manometric investigation of dysphagic patients requires the analysis of multiple parameters of dynamic pharyngoesophageal function.