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Gore-Tex medialization laryngoplasty for dysphagia
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Otolaryngology-Head and Neck Surgery, Vol 141, No 3S1, September 2009
Gore-Tex medialization laryngoplasty for dysphagia Ryan Hendricker, MD (presenter); Brad deSilva; Arick Forrest, MD OBJECTIVES: To describe our experience with Gore-Tex medialization laryngoplasty and the treatment of dysphagia as well as examine the anatomy of Gore-Tex and silastic medialization laryngoplasty in two fresh cadaver larynges. METHODS: Retrospective case review/anatomic cadaver dissection. Tertiary referral center. Between April 2000 and September 2008, 189 Gore-Tex medialization laryngoplasties were performed on 180 patients by the senior author. Complete records and analyses were available and performed on 121 procedures for 113 patients. In addition, two fresh cadaver larynges were dissected for anatomic analysis. Main outcome measures were discontinuation of g-tube use or avoidance of g-tube, as well as clinical subjective improvement in swallowing function. Cadaver dissection measurements were made to assess true vocal fold lengthening following silastic and GoreTex medialization laryngoplasty, as well as photodocumentation of implant location. RESULTS: 57/113 (50%) of patients had complaints of dysphagia at presentation with 47/57 (82%) having an objective swallowing evaluation. 32/47 (68%) documented penetration and/or aspiration. 20/57 (35%) patients with dysphagia required g-tubes for alimentation. 11/20 (55%) patients were able to discontinue g-tube use following Gore-Tex medialization laryngoplasty and an additional 5 patients with aspiration were able to avoid g-tubes with Gore-Tex medialization laryngoplasty and swallowing therapy. Cadaver dissection demonstrated increased true vocal cord lengthening with Gore-Tex and a more posterior position than can be achieved with silastic medialization. CONCLUSIONS: Gore-Tex medialization laryngoplasty is a well tolerated and described treatment for the management of glottal incompetence. The procedure is an appropriate adjunct in dysphagia management for the appropriate patient population. Laryngopharyngeal reflux and the flora of the larynx Stuart D S Gillett, MBBS, MRCS (presenter); Martin A Birchall, FRCS; Tristan Cogan; Kate Birchenall; Louisa Rees OBJECTIVES: Laryngopharyngeal reflux (LPR) is present in nearly all non-smokers diagnosed with laryngeal carcinoma. The effects of LPR on the human laryngeal mucosa or its bacterial population are relatively undetermined. We set out to examine the bacterial flora, and in particular the presence of Helicobacter Pylori, in laryngeal mucosa affected by LPR. METHODS: Laryngeal mucosal biopsies were taken from patients diagnosed LPR- positive or LPR- negative, none of whom had laryngeal disease. Presence of bacteria and epithe-
lial integrity were determined by fluorescence in situ hybridization, using probes to eubacteria, and H. pylori, real time PCR specific to H. pylori and all bacteria and immunofluorescence, using an antibody to occludin. RESULTS: H. pylori DNA was identified in biopsies from patients with and without laryngopharyngeal reflux. This was present on the mucosal surface, but also localized to epithelial cells within the laryngeal mucosa. It was not associated with CD-45 positive cells, suggesting that its presence in the tissues was due to an active process of bacterial invasion, rather than phagocytosis. An increase in the total number of eubacteria present in the laryngeal mucosa was found to be significantly associated with LPR (p⬍0.05). CONCLUSIONS: The association between LPR and an increase in total eubacteria in the laryngeal mucosa presents a possible aetiology for pathological symptoms associated with LPR. The fact that H. pylori was present in all of the laryngeal mucosal biopsies indicates that the larynx is an important site of extra gastric colonisation. Long-term laryngeal allograft survival using everolimus David G Lott, MD (presenter); Olivia Dan; Lina Lu, MD; Marshall Strome, MD OBJECTIVES: 1) Determine mouse laryngeal allograft viability after single agent immunosuppressive therapy with everolimus (immunosuppressive for solid organ transplantation shown to increase radiosensitivity and decrease solid tumor burden in late stage cancers). 2) Analyze everolimusinduced immune system modulation and correlate to histological findings. 3) Define the role of everolimus in laryngeal transplantation after laryngectomy for malignancy. METHODS: The study was conducted January 2008 through June 2008. Fifteen recipient mice (five per group) were injected with everolimus (1 mg/kg/day) until sacrifice at 15, 30, and 60 days post-transplantation. Larynges were histologically graded for rejection severity. Draining lymph nodes and spleens were evaluated by flow cytometry to assess the systemic immunologic environment. RESULTS: Each time group demonstrated minor allograft rejection (rejection severity scores: 2.51, 2.46, 2.78; No rejection - 1, Severe - 6). This was not significantly different between groups. Flow cytometry showed a blunted cytotoxic T cell response, differentiation favoring regulatory T cells, and decreased number and function of dendritic cells. CONCLUSIONS: Everolimus successfully prevents laryngeal allograft rejection up to 60 days post-transplantation. Studies performed in our laboratory have previously demonstrated a suppressive effect on squamous cell cancer. Everolimus alone or in combination with other immunosuppressants may enable laryngeal transplantation to become a viable reconstructive option following laryngectomy for malignancy.
Otolaryngology-Head and Neck Surgery, Vol 141, No 3S1, September 2009
Gore-Tex medialization laryngoplasty for dysphagia Ryan Hendricker, MD (presenter); Brad deSilva; Arick Forrest, MD OBJECTIVES: To describe our experience with Gore-Tex medialization laryngoplasty and the treatment of dysphagia as well as examine the anatomy of Gore-Tex and silastic medialization laryngoplasty in two fresh cadaver larynges. METHODS: Retrospective case review/anatomic cadaver dissection. Tertiary referral center. Between April 2000 and September 2008, 189 Gore-Tex medialization laryngoplasties were performed on 180 patients by the senior author. Complete records and analyses were available and performed on 121 procedures for 113 patients. In addition, two fresh cadaver larynges were dissected for anatomic analysis. Main outcome measures were discontinuation of g-tube use or avoidance of g-tube, as well as clinical subjective improvement in swallowing function. Cadaver dissection measurements were made to assess true vocal fold lengthening following silastic and GoreTex medialization laryngoplasty, as well as photodocumentation of implant location. RESULTS: 57/113 (50%) of patients had complaints of dysphagia at presentation with 47/57 (82%) having an objective swallowing evaluation. 32/47 (68%) documented penetration and/or aspiration. 20/57 (35%) patients with dysphagia required g-tubes for alimentation. 11/20 (55%) patients were able to discontinue g-tube use following Gore-Tex medialization laryngoplasty and an additional 5 patients with aspiration were able to avoid g-tubes with Gore-Tex medialization laryngoplasty and swallowing therapy. Cadaver dissection demonstrated increased true vocal cord lengthening with Gore-Tex and a more posterior position than can be achieved with silastic medialization. CONCLUSIONS: Gore-Tex medialization laryngoplasty is a well tolerated and described treatment for the management of glottal incompetence. The procedure is an appropriate adjunct in dysphagia management for the appropriate patient population. Laryngopharyngeal reflux and the flora of the larynx Stuart D S Gillett, MBBS, MRCS (presenter); Martin A Birchall, FRCS; Tristan Cogan; Kate Birchenall; Louisa Rees OBJECTIVES: Laryngopharyngeal reflux (LPR) is present in nearly all non-smokers diagnosed with laryngeal carcinoma. The effects of LPR on the human laryngeal mucosa or its bacterial population are relatively undetermined. We set out to examine the bacterial flora, and in particular the presence of Helicobacter Pylori, in laryngeal mucosa affected by LPR. METHODS: Laryngeal mucosal biopsies were taken from patients diagnosed LPR- positive or LPR- negative, none of whom had laryngeal disease. Presence of bacteria and epithe-
lial integrity were determined by fluorescence in situ hybridization, using probes to eubacteria, and H. pylori, real time PCR specific to H. pylori and all bacteria and immunofluorescence, using an antibody to occludin. RESULTS: H. pylori DNA was identified in biopsies from patients with and without laryngopharyngeal reflux. This was present on the mucosal surface, but also localized to epithelial cells within the laryngeal mucosa. It was not associated with CD-45 positive cells, suggesting that its presence in the tissues was due to an active process of bacterial invasion, rather than phagocytosis. An increase in the total number of eubacteria present in the laryngeal mucosa was found to be significantly associated with LPR (p⬍0.05). CONCLUSIONS: The association between LPR and an increase in total eubacteria in the laryngeal mucosa presents a possible aetiology for pathological symptoms associated with LPR. The fact that H. pylori was present in all of the laryngeal mucosal biopsies indicates that the larynx is an important site of extra gastric colonisation. Long-term laryngeal allograft survival using everolimus David G Lott, MD (presenter); Olivia Dan; Lina Lu, MD; Marshall Strome, MD OBJECTIVES: 1) Determine mouse laryngeal allograft viability after single agent immunosuppressive therapy with everolimus (immunosuppressive for solid organ transplantation shown to increase radiosensitivity and decrease solid tumor burden in late stage cancers). 2) Analyze everolimusinduced immune system modulation and correlate to histological findings. 3) Define the role of everolimus in laryngeal transplantation after laryngectomy for malignancy. METHODS: The study was conducted January 2008 through June 2008. Fifteen recipient mice (five per group) were injected with everolimus (1 mg/kg/day) until sacrifice at 15, 30, and 60 days post-transplantation. Larynges were histologically graded for rejection severity. Draining lymph nodes and spleens were evaluated by flow cytometry to assess the systemic immunologic environment. RESULTS: Each time group demonstrated minor allograft rejection (rejection severity scores: 2.51, 2.46, 2.78; No rejection - 1, Severe - 6). This was not significantly different between groups. Flow cytometry showed a blunted cytotoxic T cell response, differentiation favoring regulatory T cells, and decreased number and function of dendritic cells. CONCLUSIONS: Everolimus successfully prevents laryngeal allograft rejection up to 60 days post-transplantation. Studies performed in our laboratory have previously demonstrated a suppressive effect on squamous cell cancer. Everolimus alone or in combination with other immunosuppressants may enable laryngeal transplantation to become a viable reconstructive option following laryngectomy for malignancy.