Faculty Bibliography

OBJECTIVES: The differential diagnosis and treatment of patients with chronic cough, paradoxical vocal fold motion, and disordered breathing can be a challenge to most practicing otolaryngologists. Tracheobronchial (ie, asthma, bronchitis, and tracheal stenosis), laryngeal (ie, vocal fold paralysis and neoplasms), and rhinologic (ie, allergies and rhinosinusitis) etiologies are commonly diagnosed and treated effectively. However, occasionally one is faced with patients who are refractory to medical treatment and have no obvious rhinologic, laryngeal or pulmonary cause. STUDY DESIGN AND SETTING: We conducted a review of the literature. METHODS: We present a thorough review of the current medical literature exploring the complex neurologic mechanisms involved in the production of cough and the relationship between gastroesophageal reflux disease, vagal neurapathy, and paradoxical vocal fold motion. RESULTS: The diagnosis and successful treatment of chronic cough can be complex. It requires a thorough understanding of the neurologic mechanisms behind cough excitation and suppression. Successful treatment strategies include aggressive management of the patient's reactive airway disease, gastroesophageal reflux disease, and, in select cases, paradoxical vocal fold motion. This may involve a well-coordinated effort among pulmonologists, otolaryngologists, gastroenterologists, and speech pathologists. CONCLUSION: Gastroesophageal reflux disease, vagal neuropathy, and paradoxical vocal fold motion are additional causes of chronic cough and disordered breathing that need to be considered, in the absence of obvious laryngotracheal and/or rhinologic pathology. A high index of suspicion is essential in making the diagnosis and formulating an effective multidisciplinary treatment plan for these patients

Even though the symptoms and findings of laryngopharyngeal reflux (LPR) have been described, the clinical diagnosis is sometimes elusive. Symptoms can occur in the absence of conclusive laryngeal physical findings, and they can be nonspecific. For example, dysphonia can be caused not only by LPR, but also by neoplasia and by geriatric, neurologic, and behavioral disorders. The clinician must realize that the diagnosis of LPR is based on a combination of factors, including symptoms, laryngeal findings, and diagnostic test results

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

OBJECTIVE: To determine the relationship between coin size, coin location, patient age, and patient weight and likelihood of coin passage through the esophagus following pediatric coin ingestion. A secondary objective is to test the hypothesis that coin denomination can be determined based on radiographic appearance. METHODS: A retrospective review was performed of all children seen and evaluated for coin ingestion at a single institution over a 25-month period. Outcome measures included the number of coins that were retained in the esophagus, and the number that passed. Various factors were assessed for their predictive value in judging outcome in coin ingestion cases. RESULTS: Nineteen percent of patients (15/79) in the study passed their ingested coins. Coin denomination could be accurately determined on every patient that had a standard AP or lateral X-ray film. These findings were marked when compared with the lack of reliability of history in determining coin denomination. Patients who passed coins were as a group older (4.6 vs. 3.2 year, P=0.04), but did not differ significantly by weight (19.5 vs. 15.4 kg, P=0.07) from those that retained the coins. Coins located at the gastroesophageal junction had a significantly higher passage rate than coins located elsewhere in the esophagus (89 vs. 8.2%, P<0.01). Coin size was not predictive of coin passage (P=0.7 by chi(2)). CONCLUSIONS: Radiographic assessment of coin denomination is reliable, but in this study could not be used to predict coin passage. Patient age and coin location at the gastroesophageal junction, however, do correlate with this event

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

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