Biomedical subjects
Publications and source records attributed to M Remacle.
Initial management of a neck mass in adults is a frequently encountered problem in ENT practice. The differential diagnosis with regards to clinical presentation, localization, imaging studies and cytology and/or histology is reviewed. An algorithm is provided to help the practioner.
OBJECTIVES: The voice handicap index by Jacobson et al doesn't render the difficulties experienced by singers. The aim of this study is to adapt the V.H.I. to the singing voice and evaluate it's reliability and coherence. In order to obtain this first scale, we went through three stages. MATERIAL ET METHOD: The first consisted in the modification of the existing items and the creation of new ones. The second was to measure the stability by a test - retest and the coherence of the adapted and the new items. This was done on groups of dysodic singers and professional voice users. The third stage consisted in evaluating the reliability and the coherence of 31 items on a homogeneous population of 132 classical singers with and without vocal impairment. The subjects were divided in three groups. The first group was composed of 95 normophonic singers, the second included 37 dysphonic singers and the third group was the control group, composed of 20 non singers without vocal complaints. RESULTS: The statistical results show a good stability of the test - retest (ICC=0.949; Rho: 0.912; Bland et Altman [-010.19, +13.23]). The internal coherence of each sub scale (Cronbach's alpha) is good (>0.70). The correlations between the three sub scales are moderate between the functional and the emotional sub scale: 0.58; between the emotional and the physical: 0.64; and between the functional and the physical: 0.78). Each sub scale is measuring a specific dimension; still they are homogeneous between one another. Four variables have a significative influence on the results: the pathology (p<0.001), being a professional singer (p<0.001), the repetition (p=0.003), being a chorister (p=0.002). CONCLUSION: The VH.I adapted to the singers, appears to be reliable, valid and adapted to the population of dysodic classical singers.
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OBJECTIVES: 93 patients with various kinds of organic benign voice pathology (vocal fold nodules, polyp, Reinke's oedema, unilateral paralysis, sulcus/scar) and/or with muscle tension dysphonia, were evaluated before and after their voice treatment (phonosurgery with voice therapy, antireflux medication, or voice therapy alone) in order to check the clinical relevance of a basic multidimensional protocol for assessing functional results of voice treatments, as developed by the Committee on Phoniatrics of the ELS. MATERIAL AND METHOD: The protocol has been used in different university voice clinics. It comprises 5 dimensions: Perception: Grade, Breathiness and Roughness from the GRBAS-scale, rated by two experienced judges: a phoniatrician/laryngologist and a speech therapist. Acoustics: Jitter % and Shimmer % computed on a /a:/, at comfortable loudness and pitch. Also Fo-range and softest possible intensity. Videostroboscopy: Glottal closure, regularity, mucosal wave and symmetry, rated separately. Phonation quotient: computed by dividing the vital capacity (ml) by the maximum phonation time (s) (best value of 2x3 trials). Self rating by the patient: voice quality in itself and general social/occupational handicap due to the voice problem rated separately. RESULTS: Results show that, at group level, the overall effects for each parameter indicate a significant improvement after treatment. However, the correlations between the pre/post changes for the different parameters are weak (low redundancy). CONCLUSION: The assessment of voice pathology needs to be multidimensional, as these multidimensional informations about voice changes lead to a better understanding of the actual way in which a treatment works.
BACKGROUND: Thirty-five patients using tracheoesophageal voice with a 3- to 16-year follow-up were investigated. We analyzed functional voice outcome, voice prosthesis (VP) lifespan, and VP-related complications. METHODS: Between 1987 and 2001, 81 patients underwent total laryngectomy (TL). The 35 currently surviving patients (31 men, 4 women) were studied for VP lifespan and VP-related complications encountered up to 16 years after surgery. For voice rehabilitation, the 35 laryngectomies of our study required 178 prostheses. Short- and long-term voice results of 22 patients were compared by objective voice examination: maximum phonation time (MPT), intensity range (Int.), fundamental frequency (F0), frequency analysis (FA), and voice handicap index (VHI). RESULTS: Long-term results are: F0=131 (range: 30-250); Int=22.5 dB (range: 17-35 dB); MPT=4 sec (range: 2-12 sec); FA=3 (range: 1-4); VHI=38/120 (range: 8-73). Short- vs long-term outcome comparison shows the following values: F0: 93 vs 135 Hz; Int: 25 vs 24 dB; FA: 1 vs 3; and MPT: 21 vs 4 sec. The mean VP lifespan is 165.5 days for Provox (range: 2 days-30 months); 143.5 days for Blom-Singer (range: 10 days-24 months); and 195 days for VoiceMaster (6-7 months). Postoperative complications involved 12 cases of periprosthetic leakage (6.74%); 31 granulomas (17.4%); 3 partial stenoses of the tracheoesophageal tract (1.6%); and 1 temporarily removed VP (0.5%). CONCLUSIONS: Complications are generally resolved during standard office-setting examination. The commercially available VPs are complementary, used according to the diverse characteristics of each VP.
OBJECTIVES: In certain instances medialization thyroplasty under local anesthesia is awkward for the patient and complicates surgery. Moreover, for certain operations such as for sulcus vergeture or presbyphonia, subjective auditory appreciation of vocal improvement under operating room conditions is not efficient. In those various instances, we therefore perform thyroplasty under general anaesthesia using a laryngeal mask, and under fibrerscopic control. MATERIAL AND METHOD: A joint connecting the laryngeal mask to the ventilation tube is angled and comprises a small valve through which a fiberscope is slipped. We have used this method since April 99 for 11 surgery procedures. RESULTS AND CONCLUSION: To date, we have not encountered intraoperative complications that have required intubating the patient in order to continue surgery. It can, however, occur that a change in head posture during surgery displaces the mask. In that event, surgery must be momentarily interrupted in order to re-position the mask. The vocal results met expectations.
The Phonosurgery Committee of the European Laryngological Society (ELS) has examined the definition and technical description of phonosurgical procedures. Based on this review, the committee has proposed a working classification. The current presentation is restricted to vocal fold surgery (VFS) with phonosurgical intent. Both the pathology and the therapeutic aim define VFS: (1). vocal fold lesions that impair vibratory movements require excision (e.g., vocal fold nodule), incision and suction (e.g., Reinke's edema), dissection and/or augmentation (e.g., sulcus-vergeture), coagulation or vaporization (e.g., varicosity) and incision and stenting (e.g., glottal web); (2.vocal fold movement disorders require position and/or tension correction by augmentation (e.g., vocal fold paresis), injection (e.g., botulinum toxin for spasmodic dysphonia) and excision (e.g., dysphonia plicae ventricularis). This presentation excludes surgical instrumentation, implants or injectable materials. Being essentially surgeon-dependent, usage may vary over time and with experience.
OBJECTIVES: The objective of the present study was to review the technique of endoscopic laser-assisted esophagodiverticulostomy (ELAED) for the treatment of Zenker's diverticulum. METHODS: We reviewed 83 cases of ELAED performed for the treatment of Zenker's diverticuli during the past decade. RESULTS: ELAED-treated patients had a reduced hospital stay and were able to start an oral diet earlier than were patients who underwent other surgical procedures. Two (2.4%) of our patients developed small fistulas, which closed spontaneously. An additional 2 (2.4%) of our patients required conversion to an open approach due to inadequate endoscopic exposure, and 5 (6%) required a revision endoscopic procedure for persistent symptoms. CONCLUSIONS: Our series of 83 patients treated at 2 large academic centers during the past decade with an average follow-up of 4 years demonstrates that ELAED is a safe and effective procedure for the management of Zenker's diverticulum.
Sleep disordered breathing (SDB) patients usually undergo an ENT clinical examination before any therapeutic decision. This clinical examination would be predictive about the occurrence of Obstructive Sleep Apnea Syndrome, cost effective, reproducible and would determine the sites of obstruction in the upper airways. To achieve this, ENT specialists from Belgium, representatives of academic hospitals in the country, have tried to establish an updated work-up in the clinical evaluation of the SDB patients. History, risk factors evaluation, excessive daytime sleepiness, static and dynamic evaluation of the upper airways (velopharynx aspect, tonsils grading, Mallampati score, Müller's maneuver, fiberoptic evaluation) have been standardized in a consensus report easily accessible to the vast majority of ENT specialists. This consensus must be understood as a clinical work-up to perform before the monitoring of breathing during sleep.
Our study encompasses 61 patients (49 men--80.3%; 12 women--19.7%) treated from September 1998 through August 2001. Mean follow-up covers 25 months (range: 7-43 months). Our CO2-LAUP technique involves vaporizing the palatine mucosa along a rectangular surface from the palatal dimple to the base of the uvula; trimming the palatine arches under the velum; and resecting the uvula. For 22 patients, we employed intravelar diode laser coagulation in the expectation of reducing the postoperative pain whilst achieving the same therapeutic effectiveness. There is no pain difference between the CO2-LAUP technique versus that combining intravelar diode laser coagulation with CO2 laser uvula resection and trimming of the palatine arches. Mean maximal pain reaches 6.93 +/- 3.55 with CO2 laser and 6.95 +/- 3.64 with CO2 laser plus diode laser. Similarly, both techniques involve the same mean algesic period of 22 days with the day of maximal pain at 1 week after surgery. Associating base of tongue vaporization significantly increases the algesic period (p = 0.042). No long-term complications were observed in relation to intravelar coagulation or LAUP, whether combined or not with base of tongue vaporization. In terms of patients satisfaction, no significant difference exists between the various surgical techniques of the velum alone. The satisfaction rate reaches 5.26 +/- 3.92 with CO2 laser and 5.82 +/- 2.67 with the CO2 laser plus diode laser. Satisfaction is statistically identical when base of tongue vaporization is included in the procedure.
Sleep disordered breathing patients may undergo surgical treatment after history, clinical examination and polysomnographic study if they demonstrate upper airway obstruction. This article focus on the surgical treatment designed for these patients. Sino-nasal surgery, rhinopharyngeal procedure, velopharyngeal procedures (Uvulopalato-pharyngoplasty, Laser assisted uvulopalatoplasty, Radiofrequency tissue volume reduction) as well as base of the tongue procedures were discussed among a panel of Belgian ENT specialists offering their experience in this field. Algorithm on corrective surgery as well as guidelines for postoperative management are proposed in the management of sleep disordered breathing patients.
BACKGROUND: The goal of reconstructive laryngectomy addressing glottic carcinoma, as described by Tucker, is twofold: achieve local control and preserve as much as possible the physiological laryngeal function. METHODS: The study consisted of long-term assessment of oncological, deglutitory, and vocal outcome in 34 patients following Tucker's reconstructive laryngectomy. Postoperative follow-up included fiberscopic examination, videoradiography, and voice assessment after speech rehabilitation. RESULTS: The 5-year overall survival rate was 92% +/- 5%. Fiberscopic examination and videoradiography contributed to observing and understanding the rehabilitation process and impairment to its progress. Two main compensatory movements were identified: the anticipatory backward movement of the tongue base (50%) and the anticipatory upward laryngeal motion (15%). Both movements occurred simultaneously at the beginning of the pharyngeal stage of the swallow (35%). The median duration prior to tracheostomy tube removal was 14 days. Swallowing of solids resumed on day 9 (median), and liquid intake (water and soup) resumed on day 12 (median). The median duration of hospitalization was 16 days. Following speech rehabilitation, the latest follow-up visit measured as follows: the mean conversational voice intensity at 64 dB (range, 57-79 dB); the mean maximum intensity at 87 dB (range, 78-96 dB); the minimum intensity at 54 dB (range, 45-65 dB); the mean maximum phonation time at 16 seconds (range, 10-29 seconds); and the mean phonation quotient at 284 mL/second (range, 205-341 mL/second). According to our classification, voice spectral analysis revealed 19 class-III patients, 12 class-II patients, and three class-I patients. CONCLUSION: Tucker's reconstructive laryngectomy is reliable in terms of both the oncological and functional outcome. Fiberscopic examination and videoradiography are two complementary methods for assessing postoperative deglutition.
The proposal of this basic protocol is an attempt to reach better agreement and uniformity concerning the methodology for functional assessment of pathologic voices. The purpose is to allow relevant comparisons with the literature when presenting/publishing the results of voice treatment, e.g. a phonosurgical technique, or a new/improved instrument or procedure for investigating the pathological voice. Meta-analyses of the results of voice treatments are generally limited and may even be impossible owing to the major diversity in the ways functional outcomes are assessed. A multidimensional set of minimal basic measurements suitable for all "common" dysphonias is proposed. It includes five different approaches: perception (grade, roughness, breathiness), videostroboscopy (closure, regularity, mucosal wave and symmetry), acoustics (jitter, shimmer, Fo-range and softest intensity), aerodynamics (phonation quotient), and subjective rating by the patient. The protocol is elaborated on the basis of an exhaustive review of the literature, of the experience of the Committee members, and of plenary discussions within the European Laryngological Society. Instrumentation is kept to a minimum, but it is considered essential for professionals performing phonosurgery.
OBJECTIVE: To use the CO2 laser-assisted tympanic membrane fenestration in office settings, under local anesthesia, as the sole treatment for patients with chronic otitis media with effusion (OME). BACKGROUND DATA: This new treatment ensures artificial ventilation of the middle ear for several weeks, and provides an intermediate solution between ordinary lancet-made tympanocentesis and transtympanic ventilation tube insertion. The operative technique is already well codified, and preliminary studies have demonstrated that tympanic membrane fenestration does not expose patients to any major hazard. METHODS: We treated 30 ears in 21 children and 29 ears in 24 adults. All patients had presented with OME persistent for more than 3 months. The laser tympanostomy was performed under local anesthesia, as an outpatient procedure, using a CO2 flash-scanning laser in conjunction with a handpiece (OTOLAM). Using a power of 12 W to 17 W, a single laser pulse usually sufficed to create a 2-mm-diameter circular perforation in the anteroinferior quadrant of the eardrum. RESULTS: The tympanic membrane fenestration allows avoiding ventilation tube insertion in 63% of children and 75% of adults. CONCLUSIONS: The CO2 laser-assisted tympanic membrane fenestration seems a valid therapeutic option addressing OME. This study should be pursued on a larger scale to define more precisely the indications of the laser tympanostomy.
This article reports six patients with severe laryngotracheal stenosis. The causes of stenosis were tracheotomy (two cases); prolonged endotracheal intubation (one case); laryngeal trauma (two cases); and surgery with postoperative chemo- and radiotherapy, addressing a thyroid gland follicular adenocarcinoma (one case). Two patients were already tracheotomized. The main postoperative complication was necrosis of the graft in a female patient who had previously undergone treatment for thyroid follicular adenocarcinoma. All patients were decannulated 6 months postoperatively. Five patients were then regularly followed up, but we lost contact with one patient. Comparison between pre- and postoperative pulmonary function testing revealed an increased maximum inspiratory flow (Vi max50) in five cases between 0.57 l/s and 2.18 l/s. A helical scan with 3-dimensional reconstruction of the cervical area in four patients confirmed the presence and preservation of the hyoid bone graft. Four patients remained satisfied with their postoperative voice quality, one patient was dissatisfied, and one patient was not followed up. This technique is effective in adults with severe laryngotracheal stenosis, restricted to the first tracheal rings, providing one takes into consideration the main contraindications of the procedure: past history of radiotherapy and thyroid surgery.
The European Laryngological Society is proposing a classification of different laryngeal endoscopic cordectomies in order to ensure better definitions of post-operative results. We chose to keep the word "cordectomy" even for partial resections because it is the term most often used in the surgical literature. The classification comprises eight types of cordectomies: a subepithelial cordectomy (type I), which is resection of the epithelium; a subligamental cordectomy (type II), which is a resection of the epithelium, Reinke's space and vocal ligament; transmuscular cordectomy (type III), which proceeds through the vocalis muscle; total cordectomy (type IV); extended cordectomy, which encompasses the contralateral vocal fold and the anterior commissure (type Va); extended cordectomy, which includes the arytenoid (type Vb); extended cordectomy, which encompasses the subglottis (type Vc); and extended cordectomy, which includes the ventricle (type Vd). Indications for performing those cordectomies may vary from surgeon to surgeon. The operations are classified according to the surgical approach used and the degree of resection in order to facilitate use of the classification in daily practice. Each surgical procedure ensures that a specimen is available for histopathological examination.
The vocal quality of a patient is modeled by means of a Dysphonia Severity Index (DSI), which is designed to establish an objective and quantitative correlate of the perceived vocal quality. The DSI is based on the weighted combination of the following selected set of voice measurements: highest frequency (F(0)-High in Hz), lowest intensity (I-Low in dB), maximum phonation time (MPT in s), and jitter (%). The DSI is derived from a multivariate analysis of 387 subjects with the goal of describing, purely based on objective measures, the perceived voice quality. It is constructed as DSI = 0.13 x MPT + 0.0053 x F(0)-High - 0.26 x I-Low - 1.18 x Jitter (%) + 12.4. The DSI for perceptually normal voices equals +5 and for severely dysphonic voices -5. The more negative the patient's index, the worse is his or her vocal quality. As such, the DSI is especially useful to evaluate therapeutic evolution of dysphonic patients. Additionally, there is a high correlation between the DSI and the Voice Handicap Index score.
OBJECTIVE: To analyze the impact of positron emission tomography with fluorodeoxyglucose (FDG-PET) in the treatment of patients suspected of having head and neck cancer recurrence. STUDY DESIGN: Prospective and consecutive inclusion of 44 patients presenting with clinical symptoms suggestive of head and neck tumor recurrence. METHODS: FDG-PET was compared with combined computed tomography (CT) plus magnetic resonance imaging (MRI) procedures for the differential diagnosis between tumor recurrence and benign post-therapeutic changes. For FDG-PET, the potential additional value of semiquantitative indexes was studied. The impact on patient treatment (i.e., their ability to accurately select patients for panendoscopic exploration) was analyzed retrospectively for both CT+MRI and PET workups. RESULTS: The diagnostic accuracy was found higher for PET than for combined CT+MRI: sensitivity ranged from 96% to 73%, specificity from 61% to 50%, and accuracy from 81% to 64% for PET and CT+MRI, respectively. The accuracy of FDG-PET was the highest (94%) in patients included more than 12 weeks after the end of therapy. In 15 discordant cases, PET was correct in 11 and CT+MRI in 4. Patient selection for panendoscopic exploration and biopsy was correct in 79% and 50% of patients with FDG-PET and CT+MRI, respectively. Quantification of FDG uptake had no additional value over visual analysis alone, although we found that a SUVlbm (standardized uptake value corrected for lean body mass) threshold of 3 could be helpful in patients scanned less than 12 weeks after the end of therapy. CONCLUSION: FDG-PET has a major additional diagnostic value to CT+MRI for the evaluation of the symptomatic patient suspected of having head and neck cancer recurrence. PET could have a direct impact on management by correctly selecting patients in whom a panendoscopic exploration with biopsy is indicated.