Biomedical subjects
Publications and source records attributed to J A Koufman.
This report reviews laryngoplastic techniques for correction of bowing of the vocal cords, with special consideration to the anatomic details of the anterior commissure. I present a new technique in which the glottic gap is closed by bilateral medialization. This technique may be superior to those described previously, since the correction achieved at the time of surgery is maintained by the placement of Silastic.
Gastroesophageal reflux (GER) has been implicated in otolaryngologic problems, particularly chronic hoarseness that cannot be attributed to other causes. To study this relationship, we used 24-h ambulatory intraesophageal or dual pharyngoesophageal pH monitoring in 33 patients with chronic hoarseness and laryngeal lesions suggestive of acid irritation. Twenty-six of the patients (78.8%) had pH evidence of severe GER, being at least three times greater than the upper limit of normal. In contrast to 19 patients with proven esophagitis, this GER was worse in the upright position. Of 15 patients with both pharyngeal and esophageal probes, three had esophagopharyngeal reflux, and two had atypical unexplained pharyngeal decreases in pH to below 4.0. Less than half of the 33 patients had the typical symptoms of GER, and standard esophageal tests usually yielded normal findings. Occult GER, predominantly in the upright position, appears to be common and severe in patients with chronic hoarseness, who have laryngeal lesions suggestive of GER. The causative mechanisms are not clear. The 24-h esophageal pH monitor is useful in screening this potentially treatable problem.
Over the past 5 years, the authors have treated 67 adult professional voice users with a musculoskeletal tension disorder involving the larynx and supporting structures and leading to vocal dysfunction. Common clinical features in both sexes were muscle tension in the neck, poor control of the breath stream, and an abnormally low-pitched speaking voice. Most of the men sounded like Humphrey Bogart and the women like Lauren Bacall. These cases represent a discrete clinical vocal fatigue syndrome, the treatment of which is patient education and voice therapy.
In a previously defined canine model of subglottic stenosis, two different wavelength lasers--the carbon dioxide (CO2) and the neodymium-yttrium aluminum garnet (Nd:YAG)--were used as the principal surgical therapy, and the results were compared. Two lathyrogenic agents, colchicine and penicillamine, were also used in a subset of each treatment group in order to determine their effect as an adjunct to laser therapy in the treatment of subglottic stenosis. The CO2 laser treatment group showed an overall improvement; the Nd:YAG laser treatment group showed a worsening of subglottic stenosis. The dogs treated with the lathyrogenic agents had no added benefit from the use of these agents.
The carbon dioxide surgical laser has made many open upper airway operations obsolete. However, new laser-related hazards have been encountered, the most serious of which is fire in the airway. Venturi jet ventilation removes that risk and provides an unobstructed surgical field. Indications and techniques for the use of jet ventilation with carbon dioxide laser surgery remain controversial, particularly whether jet ventilation should be used in papillomatosis or in the severely obstructed airway, and whether proximal and distal catheter techniques are equally safe and effective. We report the successful use of proximal large-bore Venturi jet ventilation in 327 consecutive patients undergoing microlaryngeal laser surgery. The technique is ideal for pediatric patients with subglottic stenosis or recurrent respiratory papillomas and has not caused distal seeding in the latter group. We recommend the use of low-pressure ventilation, even in relatively obstructed airways. The experimental evidence reported here corroborates the clinical viewpoint expressed; the technique is safe, simple, and uncomplicated if used with care.
Thirty-three patients with newly diagnosed laryngeal carcinoma underwent endoscopic treatment with the carbon dioxide laser under microscopic control and venturi jet ventilation. Ten of these patients underwent emergency tumor debulking to relieve airway obstruction and to avoid emergency tracheotomy for airway control, and 23 had definitive treatment of superficial or frankly invasive carcinoma. Among the first group, all had an adequate airway after tumor debulking and could be treated with elective laryngectomy with or without radical neck dissection once their metabolic conditions had improved and they had been appropriately evaluated. Among the second group, two died of lung carcinoma but were free of laryngeal disease and two were lost to follow-up at one year. With a minimal three-year follow-up, six of the remaining 19 patients underwent additional laser procedures. None have required external laryngeal surgery or radiation therapy. Endoscopic laser therapy appears preferable to a more radical approach for carcinoma in situ, microinvasive carcinoma, or superficially invasive carcinoma of the larynx.
Explore the source record for details and available documents.
Sixteen patients with T1 vocal cord squamous cell carcinoma were treated with endoscopic laser excision during a 4-year period. Laser excision was the initial treatment in 11 patients, and it was used to treat 5 patients who had recurrence after radiotherapy. Postoperatively, 13 (81%) of the 16 patients had normal voices. Two patients with persistent postoperative hoarseness had had anterior commissure lesions and previous radiotherapy; the other patient had a subtotal cordectomy. One patient developed a subsequent new lesion 27 months after the initial laser treatment; he was successfully managed with a second endoscopic laser excision. Involvement of the anterior commissure or involvement of the vocal process with minimally invasive disease proved not to be a contraindication to laser excision. The overall results in this small series suggest that laser excision of T1 vocal cord carcinoma is an excellent method of treatment.
Laryngeal framework surgery, using a Silastic implant placed between the thyroid cartilage and inner thyroid perichondrium for vocal cord medialization, offers an exciting new surgical option to intracordal Teflon injection for the relief of symptomatic unilateral vocal cord paralysis. A series of 11 patients who have undergone medialization laryngoplasty is presented. The advantages, technical details, and results of surgery are discussed.
Patients with penetrating laryngeal trauma can present a wide spectrum of signs and symptoms. Severe trauma frequently leads to life-threatening airway compromise, whereas lesser injuries are often overlooked because of the subtlety of physical and roentgenographic findings or the severity of vascular and neurologic injuries. Increased suspicion should accompany the examination of patients who have sustained a penetrating neck injury, and such injuries demand examination by an experienced laryngoscopist. Early surgical repair is mandatory to avoid delayed complications, which can permanently impair airway, speech, and deglutition. In a series of 19 patients presented here, diagnosis was delayed in seven (37%). The most relevant factor determining return to normal voice appeared to be the presence or absence of vocal cord paralysis.
Explore the source record for details and available documents.
Subglottic stenosis secondary to endotracheal intubation is a distinct clinical entity. Prolonged intubation is an important causative factor, but even short-term endotracheal intubation with too large a tube can damage the cricoid sufficient to cause delayed subglottic stenosis. After studying cricoid size and other factors in 130 adult laryngectomy and autopsy specimens, the following conclusions were reached: (1) The subglottic cricoid is the smallest, fixed cross section in the upper airway. (2) Even if height is comparable, women have smaller cricoid diameters than men. (3) Height is the best predictor of cricoid size. (4) Weight and race are not accurate predictors. (5) Third finger length and cricoid size correlate well, particularly in men. (6) Thus height and third finger length can be used to choose the proper endotracheal tube for adults.
A prospective panendoscopic study (bronchoscopy, laryngoscopy, esophagoscopy) was carried out in 81 consecutively seen, untreated patients newly diagnosed as having a mucosal neoplasm in the upper aerodigestive tract, to determine how many had a synchronous second primary lesion of the aerodigestive tract. Fourteen patients (17%) proved to have multiple primary lesions (14 second-primary and two third-primary lesions). Three lesions were hypopharyngeal, six esophageal, three pulmonary, two laryngeal, and two oropharyngeal. Two of the additional lesions were found during routine head and neck examination, nine lesions would have been found with a single routine symptom- or roentgenogram-directed endoscopic examination; five, because of their location or small size, would not have been found without panendoscopy, even after chest roentgenography, indirect laryngoscopy, and barium esophagography had been done. The most productive endoscopic examinations for detecting second primary lesions were esophagoscopy and laryngoscopy, the former detecting six lesions, the latter five lesions. The yield of chest roentgenograms was low (1/79). No complications resulted from this prospective panendoscopic protocol study. THese findings should reinforce the belief that head and neck cancer is a panmucosal disease of the aerodigestive tract, that silent second synchronous primary lesions are not uncommon, and that every effort should be made to find all primary sites before treatment of the index tumor is begun.
Inflammatory polyps that arise in the maxillary antra may extend into the nasal cavity and result in nasal obstruction. In some instances a combination of roentgenographic findings is helpful in diagnosis. This combination includes diminished aeration of the involved maxillary antrum, expansion of the antrum, and a soft tissue mass within but not arising from the nasopharynx.
An unusual case of hypercalcemia associated with an ameloblastoma occurred. The sequence of recurring ameloblastoma, increased serum calcium levels and urinary cyclic adenosine monophosphate (cAMP) levels, removal of the tumor, and decrease of those levels to normal suggests that the ameloblastoma was secreting a parathormone-like substance that, in turn, was stimulating the production of nephrogenous cAMP and elevating the serum calcium level.
Endoesophageal prostheses are sometimes used in palliative therapy of esophageal carcinoma. Placement or subsequent manipulation of these devices may require general anesthesia, and these anesthetics are fraught with potential complications, both from the patient's illness and from the prosthesis itself. The two patients in our report presented anesthetic challenges, including acute upper airway obstruction occurring outside the operating theater and management of malignant tracheoesophageal fistula.
PURPOSE: To describe a condition that occurs following an upper respiratory illness, which represents injury to various branches of the vagus nerve. Patients with this condition may present with breathy dysphonia, vocal fatigue, effortful phonation, odynophonia, cough, globus, and/or dysphagia, lasting long after resolution of the acute viral illness. The patterns of symptoms and findings in this condition are consistent with the hypothesis that viral infection causes or triggers vagal dysfunction. This so-called postviral vagal neuropathy (PVVN) appears to have similarities with other postviral neuropathic disorders, such as glossopharyngeal neuralgia and Bell's palsy. MATERIALS AND METHODS: Five patients were identified with PVVN. Each patient's chart was reviewed, and elements of the history were recorded. RESULTS: Each of the 5 patients showed different features of PVVN. CONCLUSIONS: Respiratory infection can trigger or cause vocal fold paresis, laryngopharyngeal reflux, and neuropathic pain.
Functional voice disorders result from vocal misuse or abuse; they are more easily recognized than other psychosomatic disorders because the clinician is able to visualize the laryngeal structure and function. If those structures appear normal, then an aberration of voice quality can be assumed to be functional. Functional dysphonia with prolonged aberrant vocal usage may lead to development of secondary pathological lesions of the larynx, which, although true pathological entities, must be recognized as resulting from the underlying and preceding functional disorder. In this report, we present a classification of and an approach to the diagnosis and treatment of functional voice disorders. On the basis of our clinical experience with 52 patients, we distinguished five types of functional voice disorders: type 1, hysterical aphonia/dysphonia; type 2, habituated hoarseness; type 3, falsetto voice, type 4, vocal abuse; and type 5, postoperative dysphonia. Forty-eight of the 52 patients (92%) were followed for a median period of 16 months (range 2-51 months). Therapy yielded excellent results in patients with types 1, 2 and 3; good results with types 4 and 5.