Faculty Bibliography

Concurrent manometry and videofluoroscopy were utilized to examine tongue base function during swallowing in 3 patients with head and neck cancer. Subjects were instructed in four voluntary swallow maneuvers, including the supersupraglottic swallow, effortful swallow, Mendelsohn maneuver, and tongue-hold maneuver. Peak catheter pressures (mm Hg) at the tongue base-pharyngeal wall level were recorded and duration of tongue base to pharyngeal wall contact was measured for each swallow. This pilot study revealed that tongue base-pharyngeal wall pressures and contact duration increased with use of maneuvers. Preliminary data are provided to support the use of swallow maneuvers to improve tongue base posterior motion and pressures generated at the tongue base-pharyngeal wall level during swallowing in patients who exhibit this disorder

BACKGROUND: The relationship between subjective complaints of dysphagia and objective measures of swallow function in patients with cancers of the oral cavity, pharynx, or larynx, treated with radiotherapy +/- chemotherapy has not been well documented in the literature. METHODS: Swallowing function in 132 patients with various lesions was evaluated using videofluoroscopy and analyzed by patient complaint of dysphagia grouping. RESULTS: Patients with complaints of dysphagia demonstrated significantly worse swallow function as indicated by lower oropharyngeal swallow efficiency (OPSE), longer transit times, larger residues, and more swallows with aspiration. Patients with complaints of dysphagia also tended to take less of their nutrition by mouth and less variety of food consistencies in their diet compared with those without complaint. CONCLUSIONS: Patients were able to perceive decrements in their swallowing function as dysphagia and may have limited their oral intake in response to that perception. The ability to accurately perceive swallowing function may be useful for self-monitoring changes in dysphagia status during a course of swallow therapy

OBJECTIVE: To determine the reliability of the assessment of laryngoscopic findings potentially associated with laryngopharyngeal reflux disease (LPRD). STUDY DESIGN: Prospective randomized blinded study. METHODS: One hundred twenty video segments of rigid fiberoptic laryngeal examinations were prospectively analyzed by five otolaryngologists blinded to patient information and were scored according to several variables potentially associated with LPRD. Separate assessments of the degree of erythema and degree of edema were scored on a five-point scale for the anterior commissure, membranous vocal fold, and interarytenoid region. Similarly, interarytenoid pachydermia, likelihood of LPRD involvement, and severity of LPRD findings were assessed. For each of these scored physical findings, inter-rater and intrarater reliabilities were determined. RESULTS: The inter-rater reliabilities of the laryngoscopic findings associated with LPRD were poor. Intraclass correlation coefficients were 0.161 and 0.461 for edema of the arytenoids and membranous vocal folds, respectively (P <.001). Intraclass correlation coefficients were 0.181 and 0.369 for erythema of the arytenoids and membranous vocal folds, respectively (P <.001). Raters demonstrated poor agreement as to the severity of LPRD findings (intraclass correlation coefficient, 0.265) and the likelihood of an LPRD component for dysphonia (intraclass correlation coefficient, 0.248). Similarly, intrarater reliability was extremely variable for the various physical findings, with Kendall correlation coefficients ranging from -0.121 to 0.837. CONCLUSIONS: Accurate clinical assessment of laryngeal involvement with LPRD is likely to be difficult because laryngeal physical findings cannot be reliably determined from clinician to clinician. Such variability makes the precise laryngoscopic diagnosis of LPRD highly subjective

CONTEXT: Primary salivary clear cell tumors comprise an uncommonly encountered subgroup of salivary neoplasia. We hypothesize that clear cell carcinoma does not represent a 'monomorphic' variant of epithelial-myoepithelial carcinoma, but is distinct in terms of histogenesis and tumor biology. OBJECTIVES: To compare the clinicopathologic features of 20 cases of salivary primary clear cell tumors, including 12 clear cell carcinomas (CCCs), 7 epithelial-myoepithelial carcinomas (EMECs), and 1 clear cell myoepithelial carcinoma (CCMEC); to investigate their interrelationship with regard to myoepithelial differentiation; and to offer a diagnostic approach for distinguishing between these entities. DESIGN: Retrospective and prospective identification and review of patients diagnosed with primary salivary clear cell neoplasia and review of the English language literature. SETTING: Three academic tertiary-care hospitals. PATIENTS: We identified 12 patients with CCC, 7 with EMEC, and 1 with CCMEC. Patients included 11 men and 9 women, aged 30 to 88 years (median 72.5 years). MAIN OUTCOME MEASURES: Immunohistochemical reactivity for S100, muscle-specific actin, and calponin; ultrastructural examination when feasible; review of patient charts; and telephone interviews to establish clinical outcome. RESULTS: Clear cell carcinoma has a predilection for intraoral sites, whereas EMEC has a predilection for the parotid. All 3 of the tumor types studied have a propensity for locoregional recurrence, which can manifest decades after initial surgery. There were no mortalities among patients with CCC, even after pulmonary metastasis in 2 patients, confirming the indolent nature of this group of clear cell tumors. A meta-analysis of reported cases of CCC, EMEC, and CCMEC confirmed that EMEC and CCMEC have a much greater propensity for locoregional recurrence than CCC, despite the predilection of both for a more surgically accessible site (parotid). We found no definitive evidence of myoepithelial differentiation in CCC, indicating that it is probably morphogenetically distinct from EMEC and CCMEC, both tumors with diagnostically requisite myoepithelial differentiation. CONCLUSIONS: The initial treatment of choice for CCC, CCMEC, and EMEC is surgical resection with negative margins. Locoregional recurrence should be treated aggressively, as it is still consistent with long disease-free intervals. The lack of myoepithelial differentiation in CCC is consistent with the concept that this tumor is histomorphogenically distinct from EMEC and that it is not merely a monomorphic variant

OBJECTIVES: To report the preliminary data of voice and quality-of-life improvement after micronized AlloDerm injection laryngoplasty in patients with unilateral vocal cord paralysis. STUDY DESIGN: A prospective study was conducted in patients with unilateral vocal cord paralysis who underwent injection laryngoplasty with micronized AlloDerm. METHODS: Preoperative and postoperative patient evaluation consisted of videostrobolaryngoscopy, computer voice analysis, airflow, and voice handicap index (VHI) assessment. All injections were conducted with the patient under general anesthesia using the Storz injector system and a 22-gauge spinal needle. RESULTS: Fourteen patients received injection with an average amount of 0.641 mL. Twelve patients were available for evaluation. Initial results at 4 weeks (n = 12) showed significant increase in habitual phonation time from 3.84 to 6.72 seconds (P <.01) and a decrease in airflow from 0.616 to 0.295 I's (P <.01). The VHI rating improved from 62.8 to 37.5 (P <.01). Jitter and shimmer also improved significantly (P <.05). Stroboscopic findings showed complete closure of glottic gap in 10 patients with excellent return of mucosal wave on the injected side. The mucosal wave return after injection was rapid with little evidence of tissue reaction. Postoperative follow-up at 3 months (n = 8) demonstrated slight resorption of the material, but sustained excellent voice was noted in 87.5%. Minimal morbidity and tissue reaction were noted. CONCLUSIONS: Micronized AlloDerm appears to be a safe new material that is suitable for injection laryngoplasty. Long-term results are pending.

PURPOSE: This article describes the use of the temporoparietal osteofascial flap (TOF) for reconstruction of bony defects in the midface and mandible. PATIENTS AND METHODS: We reviewed the demographics, etiology, indications, surgical technique, radiographic evaluation, and final outcome of 11 patients with upper or lower jaw defects who underwent reconstruction using the TOF between 1994 and 1999. RESULTS: The TOF was used to reconstruct a defect of the mandible in 7 patients, the hard palate in 2 patients, the maxilla in 1 patient, and the zygoma in 1 patient. The defect was a result of tumor resection in 9 patients and of trauma in 2 patients. The defect size ranged from 3 to 6 cm. Ten flaps (91%) were successful and 1 flap failed. There was 1 donor site complication (small dural tear) that was repaired immediately without sequelae. One patient had osseointegrated dental implants placed in the bone with good results. Exploration of the construction area was performed in 1 patient 13 months after surgery because of recurrent tumor. It showed a fully integrated bone flap. CONCLUSION: This vascularized calvarial bone flap can be used for the reconstruction of small to medium-sized defects of the maxilla and lateral mandible with good functional and cosmetic results. It can be performed without special microvascular expertise and with minimal donor site morbidity. A full-thickness bone flap can support osseointegrated dental implants

The goal of this study was to test 2 hypotheses about language development in pediatric cochlear implant (CI) users. The 'language instinct' hypothesis states that children with CIs will develop language in the same sequence as children with normal hearing, but in a delayed fashion. In other words, noun plurals will develop first, and the use of the uncontractible copula and regular past tense will follow. An alternative hypothesis (the 'perceptual prominence' hypothesis) is that the pattern of language development in CI users will be strongly affected by the perceptual prominence of the relevant morphological markers. This hypothesis predicts that the uncontractible copula will develop first, followed by noun plurals, and then by regular past tense. A sentence completion task was used to measure the performance of 9 pediatric CI users and compare it to that of several groups of children with normal hearing. The results from the CI users were consistent with the perceptual prominence hypothesis. In particular, the scores for the copula probe were higher than those for the noun plural probe for 8 of the 9 CI users. This result represents a rather striking inversion with respect to the usual development pattern in children with normal hearing and even in children with specific language impairment. If the perceptual prominence hypothesis receives further support in future studies, clinicians who work in language rehabilitation of CI users may choose to target those aspects of grammar that are less acoustically prominent to these children. In addition, and from a theoretical standpoint, these results suggest that although there may well be an innate language acquisition mechanism, patterns of language development can be strongly affected by the acoustic input. $$:

BACKGROUND: Paragangliomas are highly vascular tumors of neural crest origin that involve the walls of blood vessels or specific nerves within the head and neck. They may be multicentric, and they are rarely malignant. Surgery is the preferred treatment, and these tumors frequently extend to the skull base. There has been controversy concerning the role of preoperative angiography and embolization of these tumors and the benefits that these procedures offer in the evaluation and management of paragangliomas. METHODS: Forty-seven patients with 53 paragangliomas were treated from the period of 1990-2000. Initial evaluation usually included CT and/or MRI. All patients underwent bilateral carotid angiography, embolization of the tumor nidus, and cerebral angiography to define the patency of the circle of Willis. Carotid occlusion studies were performed with the patient under neuroleptic anesthesia when indicated. The tumors were excised within 48 hours of embolization. RESULTS: Carotid body tumors represented the most common paraganglioma, accounting for 28 tumors (53%). All patients underwent angiography and embolization with six patients (13%), demonstrating complications (three of these patients had embolized tumor involving the affected nerves). Cerebral angiography was performed in 28 patients, and 5 of these patients underwent and tolerated carotid occlusion studies. The range of mean blood loss according to tumor type was 450 to 517 mL. Postoperative cranial nerve dysfunction depended on the tumor type resected. Carotid body tumor surgery frequently required sympathetic chain resection (21%), with jugular and vagal paraganglioma removal frequently resulting in lower cranial nerve resection. These patients required various modes of postoperative rehabilitation, especially vocal cord medialization and swallowing therapy. CONCLUSIONS: The combined endovascular and surgical treatment of paragangliomas is acceptably safe and effective for treating these highly vascular neoplasms. Adequate resection may often require sacrifice of one or more cranial nerves, and appropriate rehabilitation is important in the treatment regimen.

PURPOSE: Adenosquamous carcinoma is an uncommon, controversial neoplasm. To further comprehend its natural history, the clinical and pathological features of 12 new cases were reviewed and analyzed collectively with those described in the English literature. MATERIALS AND METHODS: Twelve cases of adenosquamous carcinoma of the upper aerodigestive tract with adequate follow-up and available microscopic slides and paraffin tissue blocks were identified in the anatomic pathology files of Presbyterian Hospital of the University of Pittsburgh Medical Center over the period 1983-2001. RESULTS: The 8 men and 4 women ranged in age from 34 to 81 years (mean, 62.8 years). The larynx (5 cases) and the floor of the mouth (4 cases) were the most common sites of origin. Nine patients had cervical lymph nodes positive for carcinoma (8 at diagnosis), 7 experienced local recurrences, and 2 developed distant metastases. Four of 10 (40%) patients with follow-up died of disease. Combining our cases with those in the literature (total of 58 cases) revealed similar findings: 64.7% were associated with positive cervical lymph nodes, 46.7% experienced local recurrences, 23.1% developed distant metastases, and 42.9% died of their disease at a mean follow-up period of 24.7 months. CONCLUSIONS: Adenosquamous carcinoma is an aggressive neoplasm with a tendency for early lymph node metastasis, frequent local recurrence, occasional distant metastasis, and death from disease, usually within 2-3 years. Surgery with neck dissection is the treatment of choice