Faculty Bibliography

The symptom of cough may result from a multitude of etiologies involving different parts of the aerodigestive tract. This article focuses on the association of cough and swallowing dysfunction in the sense that cough may be an indicator of swallow dysfunction and in the importance of cough in preventing aspiration and aspiration-related disorders. Whereas these associations have been known for a long time, research is starting to connect the dots, allowing targeting of strategies aimed at diagnosing and preventing illness in certain dysphagic patients

OBJECTIVES/HYPOTHESIS: To identify contemporary indications, treatment principles, technique, injection materials, complications, and success rates of vocal fold injection augmentation. STUDY DESIGN: Multi-institutional retrospective review. METHODS: Records of patients undergoing injection augmentation at seven university medical centers from July 2007 through June 2008 were reviewed for information regarding diagnosis, unilateral or bilateral injection, route of injection, anesthesia, treatment site (office or operating room), material used, reason for technique selected, and technical success. RESULTS: In 12 months, 460 injections were performed, 236 (51%) in awake, unsedated patients, and 224 (49%) under general anesthesia. Indications included vocal fold paralysis (248; 54%), paresis (97; 21%), atrophy (68; 15%) and scar (47; 10%). Scar was more likely to be treated in the operating room (P = .000052). In awake patients, 112 (47%) injections were performed by transcricothyroid approach, 55 (23%) by peroral approach, 49 (21%) by transthyrohyoid membrane approach, and 20 (8%) by transthyroid cartilage approach. Neither technical success rate (99% vs. 97%) nor complication rate (3% vs. 2%) differed between awake and asleep techniques. The most common materials in the clinic setting were methylcellulose (35%), bovine collagen (28%), and calcium hydroxylapatite (26%); in the operating room these were calcium hydroxylapatite (36%) and methylcellulose (35%). Calcium hydroxylapatite was more likely to be used under general anesthesia (P = .019). Five-year data show that the use of injection in the awake patient rose from 11% to 43% from 2003 to 2008. CONCLUSIONS: Injection augmentation remains a safe, effective, and clinically practical treatment with a high rate of success, whether performed in the awake or asleep patient. The rapid adoption of awake injection over the past 5 years speaks to its clinical utility. Complication rates are low and equivalent to those under general anesthesia. Otolaryngologists continue to use a variety of techniques and materials to treat a range of conditions of glottic insufficiency.

Patients or Programs: A 15-year-old boy with multiple injuries after a bicycle accident. Program Description: The patient was admitted to an acute care hospital after a bicycle accident resulting in diffuse axonal injury with callosal tear and T10 vertebral fracture. He self extubated and required reintubation and later for right lower lobe pneumonia (PNA). He presented to rehabilitation (rehab) with waxing and waning alertness and decreased short-term memory. He required maximum assistance (A) for activities of daily living (ADL). He ambulated with minimal A with a widened base of support. Soon after admission, he became tachypneic and hypoxemic, was transferred to acute care and treated for PNA. During his second rehab stay, he had 2 days of worsening stridor, thought to be related to upgrading his diet with possible aspiration. A 3-cm subglottic narrowing was seen on neck CT and was considered secondary to trauma from intubation. He had a balloon dilation of the trachea but had continued stridor. He required tracheal reconstruction with subsequent prolonged bedrest with his chin sewn to his chest. He was later readmitted to rehab. His rehab course was greatly prolonged by medical problems and extended bedrest. Setting: Acute pediatric rehabilitation unit. Results: Upon discharge, he was modified independent (I) to I in his ADLs and ambulated with modified I. His higher executive functioning appeared to be normal but he continued to have difficulties with problem solving and math skills. Discussion: As with all rehab patients, close physiatric care is required to monitor for medical issues that arise during therapy. If a patient presents with dyspnea or stridor during therapy, a broad differential diagnosis should be suspected, including aspiration PNA, asthma exacerbation and tracheal stenosis. Tracheal stenosis is a potential postintubation complication and may be fatal if not recognized. This typically does not manifest until 4-6 weeks post injury; thus it may not be seen in an acute care setting. It is likely to be seen in acute rehabilitation and needs to be acted upon in that setting. Conclusions: Many rehab patients are admitted post intubation. Postintubation tracheal stenosis should be suspected in those who present with dyspnea, stridor or wheezing

OBJECTIVES/HYPOTHESIS: The potassium titanyl phosphate (KTP) laser is emerging as a potentially effective treatment for various vocal fold pathologies. To date, the precise mechanism(s) of action of this wavelength on the layered microarchitecture of the vocal fold remains unknown. The purpose of this study is to develop an in vivo model for the use of the KTP laser in the rat vocal fold and to characterize the potential of this model for future studies. STUDY DESIGN: In vivo survival surgery. METHODS: A model for videoendoscopic visualization and injury to the rat vocal fold was established using a microlaryngoscope and rigid telescope. Unilateral vocal fold injury was induced with the KTP laser at 10 Watts (W) 20 milliseconds (ms) pulse width. Animals were euthanized at 1 day post-treatment. Larynges were subjected to gross visual analysis and histological analyses via hematoxylin and eosin and trichrome staining. RESULTS: Consistent endoscopic visualization and injury was obtained without significant operative morbidity or mortality. The KTP laser caused superficial blanching and minor edema in the vocal fold, which resolved grossly by 24 hours postinjury. A modest inflammatory cell infiltrate was observed 1 day following injury. However, no remarkable alterations to the vocal fold microarchitecture were observed in the acute period. CONCLUSIONS: We propose that this novel model simulates the clinical scenario of laser use for the vocal folds. Use of this model will allow us to further characterize effects, mechanisms, and therapeutic efficacy of this wavelength

OBJECTIVE: To review and summarize the current literature on transnasal esophagoscopy, and to compare information with conventional esophagoscopy. DATA SOURCES: Medline (Ovid), book chapters. REVIEW METHODS: A thorough review of the literature using the Medline database was performed with the following search terms: esophagoscopy, transnasal esophagoscopy, ultrathin endoscopy, and esophagoscope. RESULTS: The literature seems to support the equivalence of transnasal esophagoscopy and conventional esophagoscopy in image quality and diagnostic capability. It also points to some potential advantages of transnasal esophagoscopy. CONCLUSIONS: Transnasal esophagoscopy is a useful tool for accurate diagnosis and can be used in a variety of office procedures

OBJECTIVES: This study compares normal and pathologic voices using a novel voice analysis algorithm that examines pitch deviation during connected speech. The study evaluates the clinical potential of the algorithm as a mechanism to distinguish between normal and pathologic voices using connected speech. METHODS: Adult vocalizations from normal subjects and patients with known benign free-edge vocal fold lesions were analyzed. Recordings had been previously obtained in quiet under controlled conditions. Two phrases and sustained /a/ were recorded per subject. The subject populations consisted of 10 normal and 31 abnormal subjects. The voice analysis algorithm generated 2-dimensional patterns that represent pitch deviation in time and under variable window widths. Measures were collected from these patterns for window widths between 10 and 250 ms. For comparison, jitter and shimmer measures were collected from sustained /a/ by means of the Computerized Speech Lab (CSL). A t-test and tests of sensitivity and specificity assessed discrimination between normal and abnormal populations. RESULTS: More than 58% of the measures collected from connected speech outperformed the CSL jitter and shimmer measures in population discrimination. Twenty-five percent of the experimental measures (including /a/) indicated significantly different populations (p < .01%). CONCLUSIONS: The results demonstrate that the algorithm distinguishes between normal and abnormal populations by use of samples of connected speech

PURPOSE OF REVIEW: The purpose of this article is to review the history of vocal fold injection augmentation and provide a thorough description of the percutaneous thyrohyoid approach to office-based vocal fold injection augmentation for the management of glottic incompetence. RECENT FINDINGS: A number of techniques for vocal fold injection augmentation have been developed since the first procedure was performed. Since vocal fold injection augmentation is performed without an open surgical approach, morbidity is reduced and the technique can be done in the outpatient setting. Accordingly, over the past decade there has been an effort to perfect techniques and to develop new materials and methods to make the procedure more effective and comfortable for the patient. SUMMARY: Recently, office-based vocal fold injection augmentation has gained significant popularity among laryngologists. While there are a variety of in-office injection techniques, the thyrohyoid approach, in the authors' opinion, is the simplest and best tolerated. This technique is effective and eliminates many of the shortcomings of the other approaches. This approach continues to be the 'workhorse' for in-office vocal fold injection augmentation in the senior author's practice. It is important, however, for any practitioner to be familiar with the other approaches, as this technique is not universally effective for all patients