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Biomedical subjects

J A Koufman

Publications and source records attributed to J A Koufman.

At least 19 recordsLinked to original sources
PubMed2001

Occult laryngeal pathology in a community-based cohort.

BACKGROUND: Little information is available regarding the prevalence of laryngeal pathology in adults. PURPOSE: To estimate the prevalence of occult laryngeal pathology in a community-based cohort of adults over 40 years of age. METHODS: One hundred consecutive volunteers over age 40 with no history of voice disorders were enrolled. All completed a self-administered laryngeal symptom questionnaire and underwent a comprehensive head and neck examination including transnasal fiberoptic laryngoscopy. RESULTS: The mean age of the cohort was 61 years. Vocal fold bowing (presbylaryngis) was present in 72% of the patients, and findings of laryngopharyngeal reflux were present in 64% of the cohort. In addition, other laryngeal pathology were identified in 21%. Only 12% had a completely normal laryngeal examination. CONCLUSIONS: Occult laryngeal pathology is very common in persons over 40. Findings suggestive of laryngopharyngeal reflux are present in 64%, and vocal fold bowing is present in 72% of persons over 40.

Adult↗
PubMed2001

Diagnostic laryngeal electromyography: The Wake Forest experience 1995-1999.

BACKGROUND: Laryngeal electromyography (LEMG) is a valuable diagnostic/prognostic test for patients with suspected laryngeal neuromuscular disorders. OBJECTIVE: To report our experience with diagnostic LEMG at the Center for Voice Disorders of Wake Forest University and to evaluate the impact of LEMG on clinical management. METHODS: Retrospective chart review of 415 patients who underwent diagnostic LEMG over a 5-year period (1995-1999). RESULTS: Of 415 studies, 83% (346 of 415) were abnormal, indicating a neuropathic process. LEMG results altered the diagnostic evaluation (eg, the type of radiographic imaging) in 11% (46 of 415) of the patients. Unexpected LEMG findings (eg, contralateral neuropathy) were found in 26% (107 of 415) of the patients, and LEMG results differentiated vocal fold paralysis from fixation in 12% (49 of 415). Finally, LEMG results altered the clinical management (eg, changed the timing and/or type of surgical procedure) in 40% (166 of 415) of the patients. CONCLUSIONS: LEMG is a valuable diagnostic test that aids the clinician in the diagnosis and management of laryngeal neuromuscular disorders.

Adult↗
PubMed2001

Proton pump inhibitor resistance in the treatment of laryngopharyngeal reflux.

OBJECTIVE: To describe the occurrence of relative proton pump inhibitor (PPI) drug resistance in the treatment of laryngopharyngeal reflux (LPR). STUDY DESIGN AND SETTING: A retrospective review was performed for 1053 consecutive adults undergoing double-probe (simultaneous esophageal and pharyngeal) pH testing in our laboratory. Two hundred five patients who had pH studies performed while taking at least a daily dose of PPI therapy were identified; 167 qualified for further analysis. The pH data was reviewed for the presence of abnormalities in either esophageal or pharyngeal acid exposure to evaluate drug efficacy. RESULTS: Forty-four percent (74/167) of the study patients demonstrated abnormal levels of acid exposure. Results were further analyzed to compare failure rates based on different dosage regimens. Patients on once daily doses of PPI failed at a rate of 56%, with lower failure rates for higher-dose regimens. CONCLUSIONS: A significant number of LPR patients on PPI therapy demonstrate relative drug resistance.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed2001

Transnasal esophagoscopy.

BACKGROUND: Transnasal esophagoscopy (TNE), a new diagnostic technology, allows comprehensive, in-office examination of the esophagus without sedation. OBJECTIVE: To report the authors' experience using TNE. METHODOLOGY: Retrospective review of 100 consecutive patients undergoing TNE. RESULTS: The most frequent indications for TNE were screening examination of the esophagus in reflux, globus, and/or dysphagia patients (n = 79), biopsy of a lesion in the laryngopharynx, trachea, or esophagus (n = 8), screening examination of the esophagus in head and neck cancer patients (n = 5), tracheoscopy and bronchoscopy (n = 4), and evaluation for an esophageal foreign body (n = 2). Four procedures were aborted secondary to a tight nasal vault. Significant findings were found in 44% (42/96). The most frequent findings were esophagitis (n = 19), Barrett's (n = 6), hiatal hernia (n = 4), and carcinoma (n = 5). CONCLUSIONS: TNE is safe and well tolerated by patients with topical anesthesia alone. TNE may replace radiographic imaging of the esophagus in otolaryngology patients with reflux, globus, and dysphagia.

Anesthesia, Local↗
PubMed2001

Endoscopic arytenoid repositioning for unilateral arytenoid fixation.

OBJECTIVES: To describe a new endoscopic technique for medialization of the laterally fixed arytenoid. The surgical technique, endoscopic arytenoid repositioning, is described, and the results of a series of cases are discussed. STUDY DESIGN: Retrospective chart review. METHODS: Eight patients underwent the procedure. Six patients were available for long-term follow-up. Preoperative and postoperative voice ratings were compared to evaluate the success of the procedure. Follow-up ranged from 3 to 64 months (mean follow-up, 31.5 mo). RESULTS: Long-term follow-up in six cases revealed that 67% (4 of 6) patients had normal or near-normal postoperative voices and one patient experienced moderate improvement. The mean preoperative voice score was 4.24, and the mean postoperative voice score was 1.83 (range, 1-5). The difference was statistically significant (P < 0.001). CONCLUSIONS: Endoscopic arytenoid repositioning is a newly described procedure with a very specific indication: a unilateral, laterally fixed arytenoid complex resulting in a severely dysphonic voice. Though technically demanding, this procedure provides a promising option for medialization of the posterior glottis in a scarred larynx.

Adult↗
PubMed2001

Unilateral or localized Reinke's edema (pseudocyst) as a manifestation of vocal fold paresis: the paresis podule.

BACKGROUND: The nosology of free-edge vocal fold lesions remains imprecise. In particular, the lesion termed pseudocyst remains enigmatic, because its histology is poorly defined and because its etiology is unknown. We define pseudocyst as a discrete, unilateral, localized area of Reinke's edema (without a capsule), usually occurring at the midportion of the free-edge striking zone. OBJECTIVE: To report the demographic and clinical findings, as well as discuss our diagnostic and therapeutic strategies, in patients with unilateral Reinke's edema or pseudocyst. METHODOLOGY: All patients diagnosed with unilateral Reinke's edema or pseudocyst over a 2-year period (1998-1999) were identified from the clinical database of the Center for Voice Disorders of Wake Forest University, Winston-Salem, North Carolina. The record of each patient was retrospectively reviewed. RESULTS: Thirteen patients were identified, 12 of whom were female. The mean age was 36 years. Sixty-nine percent (9 of 13) had unilateral pseudocyst and 31% (4 of 13) had unilateral Reinke's edema. All patients had documented vocal fold paresis on laryngeal electromyography. The 9 patients with pseudocyst underwent excision of their lesions; 7 had bilateral medialization laryngoplasties, 1 had lipoinjection, and 3 did not have surgical intervention. Significant improvement was noted postoperatively on a self-administered glottal insufficiency (symptom) index (P <.001). CONCLUSION: Unilateral Reinke's edema and localized Reinke's edema (pseudocyst) are distinct clinical entities, occurring most frequently in women in their fourth decade. The finding of unilateral Reinke's edema or pseudocyst should alert the clinician to the likelihood of vocal cord paresis. Surgical intervention with medialization laryngoplasty appears to be beneficial.

Adult↗
PubMed2001

Fascia augmentation of the vocal fold: graft yield in the canine and preliminary clinical experience.

INTRODUCTION: Glottal insufficiency resulting from vocal fold bowing, hypomobility, or scar is frequently treated by injection augmentation. Injection augmentation with fat, collagen, gel foam, polytef, and recently, fascia lata has been previously reported. Variable graft yield and poor host-tissue tolerance have motivated the continued search for an ideal graft substance. STUDY DESIGN: A prospective trial of autologous fascia augmentation of the vocal cord in the human and in an animal model. METHODS: Autologous fascia injection augmentation (AFIA) was evaluated in 8 canines and 40 patients at our institution between 1998 and 2000. The animal study compared graft yield from AFIA with autologous fat yield. The outcome measure was graft yield calculated from histological examination of larynges 12 weeks after injection augmentation. Clinical trial outcome measures included symptom surveys, acoustical voice analyses, and subjective voice assessments. Mean follow-up was 9 months. RESULTS: In the canine larynx, the mean graft yield for AFIA was 33% (range, 5%-84%) compared with autologous lipoinjection (47%; range, 7%-96%; P =.57). Subjective improvement in vocal quality was reported by 95% of patients (38 of 40) after AFIA. Preoperative and postoperative voice analysis data were obtained from 26 patients. Subjective voice rating demonstrated a significant improvement after AFIA (P <.0001). Acoustical parameters of jitter, shimmer, noise-to-harmonic ratio, phonatory range, and degree unvoiced improved significantly (P <.05) in all patients after fascia augmentation. CONCLUSIONS: Based on the animal study, we concluded that graft yields are excellent but variable for AFIA. The result is similar in variability and overall yield to autologous lipoinjection. Subjective and objective analyses of voice outcomes after AFIA are universally improved. Fascia appears to be an excellent alternative to lipoinjection in properly selected cases of glottic insufficiency.

Adipose Tissue↗
PubMed2001

Laryngopharyngeal reflux symptoms improve before changes in physical findings.

BACKGROUND: Patients with laryngopharyngeal reflux (LPR) undergoing treatment appear to have improvement in symptoms before the complete resolution of the laryngeal findings. OBJECTIVE: To determine whether patients with LPR experience an improvement in symptoms before the complete resolution of the laryngeal findings. METHODOLOGY: Forty consecutive patients with LPR documented by double-probe pH monitoring were evaluated prospectively. Symptom response to therapy with proton pump inhibitors was assessed at 2, 4, and 6 months of treatment with a self-administered reflux symptom index (RSI). In addition, transnasal fiberoptic laryngoscopy (TFL) was performed and a reflux finding score (RFS) was determined for each patient at each visit. RESULTS: The mean RSI at entry was 19.3 (+/- 8.9 standard deviation) and it improved to 13.9 (+/- 8.8) at 2 months of treatment (P <.05). No further significant improvement was noted at 4 months (13.1 +/- 9.8) or 6 months (12.2 +/- 8.1) of treatment. The RFS at entry was 11.5 (+/- 5.2), and it improved to 9.4 (+/- 4.7) at 2 months, 7.3 (+/- 5.5) at 4 months, and 6.1 (+/- 5.2) after 6 months of treatment (P <.05 with trend). CONCLUSIONS: Symptoms of LPR improve over 2 months of therapy. No significant improvement in symptoms occurs after 2 months. This preliminary report demonstrates that the physical findings of LPR resolve more slowly than the symptoms and this continues throughout at least 6 months of treatment. These data imply that the physical findings of LPR are not always associated with patient symptoms, and that treatment should continue for a minimum of 6 months or until complete resolution of the physical findings.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed2001

The validity and reliability of the reflux finding score (RFS).

BACKGROUND: The evaluation of medical and surgical outcomes relies on methods of accurately quantifying treatment results. Currently, there is no validated instrument whose purpose is to document the physical findings and severity of laryngopharyngeal reflux (LPR). OBJECTIVE: To evaluate the validity and reliability of the reflux finding score (RFS). METHODS: Forty patients with LPR confirmed by double-probe pH monitoring were evaluated pretreatment and 2, 4, and 6 months after treatment. The RFS was documented for each patient at each visit. For test-retest intraobserver reliability assessment, a blinded laryngologist determined the RFS on two separate occasions. To evaluate interobserver reliability, the RFS was determined by two different blinded laryngologists. RESULTS: The mean age of the cohort was 50 years (+/- 12 standard deviation [SD]). Seventy-three percent were women. The RFS at entry was 11.5 (+/- 5.2 SD). This score improved to 9.3 (+/- 4.7 SD) at 2 months, 7.3 (+/- 5.5 SD) at 4 months, and 6.1 (+/- 5.2 SD) at 6 months of treatment (P <.001 with trend). The mean RFS for laryngologist no. 1 was 10.8 (+/- 4.1 SD) at the initial screening and 10.8 (+/- 4.0 SD) at the repeat evaluation (r = 0.95, P <.001). The mean RFS for laryngologist no. 2 was 11.1 (+/- 3.8 SD) at the initial screening and 10.9 (+/- 3.7 SD) at the repeat evaluation (r = 0.95, P <.001). The correlation coefficient for interobserver variability was 0.90 (P <.001). CONCLUSIONS: The RFS accurately documents treatment efficacy in patients with LPR. It demonstrates excellent inter- and intraobserver reproducibility.

Adult↗
PubMed2001

Ambulatory 24-hour double-probe pH monitoring: the importance of manometry.

OBJECTIVE: Historically, manometry has been used for sphincter localization before ambulatory 24-hour double-probe pH monitoring to ensure accurate placement of the probes. Recently, direct-vision placement (DVP), using transnasal fiberoptic laryngoscopy (TFL), has been offered as an alternative technique. Presumably, DVP might be used to precisely place the proximal (pharyngeal) pH probe; however, using DVP, there appears to be no way to accurately position the distal (esophageal) probe. The purpose of this study was to evaluate the accuracy of DVP for pH probe placement using manometric measurement as the gold standard. METHODS: Thirty patients undergoing pH monitoring participated in this prospective study. Each subject underwent manometric examination of the esophagus to determine the precise location of the upper and lower esophageal sphincters (UES and LES). In addition, external anatomic landmarks were used to estimate interprobe distances. A physician blinded to the manometry results then placed a pH catheter using DVP so that the proximal probe was located just above the UES. The results were recorded and compared with those obtained by manometry. RESULTS: Accurate DVP of the proximal pH probe was achieved in 70% (23 of 30) of the subjects. The use of external anatomic landmarks to estimate interprobe distance resulted in accurate positioning of the distal probe in only 40% (12 of 30) of the subjects. Using fixed interprobe distances of 15 cm and 20 cm, distal probe position accuracy was 3% (1 of 30) and 40% (12 of 30), respectively. Therefore, using DVP, the distal esophageal probe was in an incorrect position in 60% to 97% of subjects. CONCLUSION: For double-probe pH monitoring, the proximal probe can be accurately positioned by DVP; however, there is no precise way to determine the interprobe distance required to correctly position the distal pH probe. Failure to accurately position the distal probe results in grossly inaccurate esophageal acid-exposure times. Thus, manometry is needed to ensure valid double-probe pH monitoring data.

Esophagus↗
PubMed2001

Hemicricoidectomy for voice rehabilitation following hemilaryngectomy with ipsilateral arytenoid removal.

The purpose of this article is to describe an approach to reconstruction of the larynx after vertical partial laryngectomy with removal of the ipsilateral arytenoid cartilage. This method addresses the problem of postoperative posterior glottal incompetence (aphonia with or without aspiration). The technique involves resection of the ipsilateral half of the cricoid cartilage, use of an inferiorly based strap muscle flap for vocal fold reconstruction, and placement of a customized stent. This technique may be used at the time of the primary cancer extirpation or as a secondary rehabilitative procedure. Generally, patients who have undergone this procedure have had minimal postoperative breathiness with good phonatory and airway function. We recommend this reconstructive technique for patients with large posterior defects following hemilaryngectomy.

Adult↗
PubMed2001

Laryngospasm and diaphragmatic arrest in immature dogs after laryngeal acid exposure: a possible model for sudden infant death syndrome.

Laryngopharyngeal reflux has been proposed as a possible cause of sudden infant death syndrome (SIDS). We investigated the efferent laryngeal and diaphragmatic responses to acid exposure on the laryngeal mucosa using a neonatal canine model. Electromyographic (EMG) recordings from the thyroarytenoid muscle and the diaphragm were measured with hooked-wire electrodes. Reproducible laryngospasm responses occurred in all animals after laryngeal exposure to hydrochloric acid at pH 2.0 or less. Laryngospasm occurred in combination with tachypnea and increased diaphragmatic activity in most of the animals. Laryngospasm was associated with prolonged apnea and total cessation of diaphragmatic EMG activity in 1 animal, and in another, initial tachypnea was followed by erratic diaphragmatic activity and brief apnea. Laryngeal acid exposure (below pH 2.0) causes laryngospasm and may result in paradoxical apneic events in neonatal dogs. Acid-induced, laryngospasm-associated apnea may represent a potential cause of SIDS, and the immature dog appears to be an excellent model for further investigations.

Animals↗
PubMed2001

Cell biology of laryngeal epithelial defenses in health and disease: preliminary studies.

Esophageal epithelium has intrinsic antireflux defenses, including carbonic anhydrases (CAs I to IV) that appear to be protective against gastric reflux. This study aimed to investigate the expression and distribution of CA isoenzymes in laryngeal epithelium. Laryngeal biopsy specimens collected from the vocal fold and interarytenoid regions were analyzed by Western blotting and immunofluorescence. Carbonic anhydrases I and II were expressed by the majority of samples analyzed. In contrast, CA III was differentially expressed in the interarytenoid samples and was not detected in any vocal fold samples. The expression of CA III was increased in esophagitis as compared to normal esophageal tissue. Carbonic anhydrase I and III isoenzymes were distributed cytoplasmically in the basal and lower prickle cell layers. The laryngeal epithelium expresses some CA isoenzymes and has the potential to protect itself against laryngopharyngeal reflux. Laryngeal tissue may be more sensitive to injury due to reflux damage than the esophageal mucosa because of different responses of CA isoenzymes.

Acid-Base Equilibrium↗
PubMed2001

Esophageal motor function in laryngopharyngeal reflux is superior to that in classic gastroesophageal reflux disease.

Laryngopharyngeal reflux (LPR) in otolaryngology patients appears to be different from classic gastroesophageal reflux disease (GERD). In particular, esophagitis and its principal symptom, heartburn, considered the diagnostic sine qua non of GERD, are often absent in LPR. It has therefore been postulated that LPR patients have superior esophageal function. Esophageal acid clearance (EAC) is a measure of the ability of the esophagus to restore neutral pH after reflux events have occurred. It is considered an excellent overall measure of esophageal function. The mean EAC can be calculated from 24-hour pH monitoring data. A comparison of EAC in patients with GERD and LPR has not been previously reported. To compare the EAC of 1) patients with LPR alone, 2) patients with GERD alone, 3) patients with both LPR and GERD, and 4) patients without either LPR or GERD, we studied 200 otolaryngological patients who had undergone 24-hour double-probe (simultaneous pharyngeal and distal esophageal) pH monitoring, 50 in each group. The subgrouping of each patient was determined by previously established pH monitoring criteria. We defined GERD as abnormal esophageal reflux and LPR as abnormal pharyngeal reflux. The patients with GERD had a mean (+/-SD) EAC of 1.44 +/- 1.2 minutes, and those with LPR had a mean EAC of 1.00 +/- 1.00 minutes (p < .05). The patients with both GERD and LPR had a mean EAC of 1.53 +/- 1.01 minutes. The patients without reflux had a mean EAC of 0.53 +/- 0.38 minutes. We conclude that patients with LPR have significantly better EAC than those with GERD. These data suggest that patients with LPR have superior esophageal function. This finding may clarify our understanding of the differences in mechanisms, symptoms, and incidence of esophagitis in patients with LPR and GERD.

Acid-Base Equilibrium↗
PubMed2001

Effects of gum chewing on pharyngeal and esophageal pH.

We investigated the effects of gum chewing on pharyngeal and esophageal pH levels in patients with laryngopharyngeal reflux (LPR) who were undergoing reflux testing. Forty consecutive, unselected, adult patients who were undergoing ambulatory double-probe (simultaneous pharyngeal and esophageal) pH monitoring for diagnosis of LPR were asked to chew 2 sticks of gum 4 times during their pH studies. Twenty subjects chewed regular sugarless gum, and 20 subjects chewed a sugarless gum containing bicarbonate. The subjects recorded the beginning and end of each gum-chewing period. The mean pH values for the gum-chewing intervals and for comparable pre-gum-chewing intervals were analyzed statistically for both the pharyngeal and esophageal probe data. The regular gum group and the bicarbonate gum group were analyzed separately. In addition, the gum-chewing pH data were compared to controls, ie, normal postcibal buffering effects. The data show that gum chewing consistently increases esophageal and pharyngeal pH, and that bicarbonate gum causes greater increases than regular gum. For patients with LPR, gum chewing appears to be a useful adjunctive antireflux therapy.

Acid-Base Equilibrium↗