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Dysplasia in Adult Recurrent Respiratory Papillomatosis
P80
Otolaryngology-Head and Neck Surgery, Vol 143, No 2S2, August 2010
Computerized Biomechanical Model Applied in Canine Larynges Guilherme Marques (presenter); Francisco Zampirolli, PhD; Paulo Pontes, MD OBJECTIVE: The objective of this paper is to develop Computerized Biomechanics model applied to canines larynx to simulate experimentally the movements of posterior cricoarytenoid, lateral cricoarytenoid and, cricothyroid muscles. METHOD: By adapting the Lego Mindstorm NXT technology and development of computer program for its handling, a computerized biomechanical model was developed applying micro engines that track the vocal process of the arytenoid cartilage and the cricothyroid articulation, considering the physiological vectorial forces, simulating the action of the intrinsic muscles of the canine larynx. The biomechanics model was evaluated in 6 canine larynges (4 complete larynges and 2 hemilarynges) by applying dynamic tasks (bilateral adduction of the vocal folds, bilateral abduction of the vocal folds, bilateral adduction with stretching of the vocal folds, and bilateral abduction with stretching of the vocal folds) and tests with sound production. RESULTS: The developed model accomplished all the requested tasks to simulate the intrinsic muscles in the dynamic experiment and during the sound production of the canine larynx. CONCLUSION: The computerized biodynamic model developed and applied in the canine larynges simulated movements produced by the posterior cricoarytenoid, lateral cricoarytenoid, and cricothyroid muscles. Cutting Balloon Treatment of Tracheobronchial Stenosis Colin Butler, MBBS (presenter); Jeremy George, MD; Guri Sandhu, MB, FRCS OBJECTIVE: 1) To describe the use of cutting balloon tracheobronchoplasty via suspension laryngoscopy for treating distal tracheal and bronchial stenosis. 2) To present the efficacy and durability of cutting balloon bronchoplasty for treating tracheobronchial stenosis. METHOD: A prospective study of 12 patients with bronchial stenosis who were treated in a national referral airway centre between 2005 and 2008 with a new balloon device that simultaneously cuts and dilates bronchial lesions. Treatment efficacy was assessed using pre- and postoperative lung function data compared with paired t-test, and treatment durability was determined using actuarial analysis. RESULTS: There were seven females and five males and the average age at presentation was 58 years. Eight bronchial lesions were caused by Wegener’s Granulomatosis, two by post-tuberculosis bronchial stricture, and two were caused by photodynamic therapy. All patients had suspension laryngoscopy and supraglottic jet ventilation and had intralesional ste-
roid injection followed by cutting-balloon bronchoplasty. Following the procedure, forced expiratory volume in 1 second (FEV1) changed from an average of 1.6 to 2.1 (p⬍0.001) and FEV increased from 2.85 to 3.18 (p⬍0.001). None of the patients underwent a lobectomy or a pneumonectomy, and at a minimum of six months follow-up (range 6.5-28), 83% of patients were free of the need to re-intervene. CONCLUSION: Cutting balloon bronchoplasty delivered via suspension laryngoscopy is a safe and effective treatment for distal tracheal and bronchial strictures whose treatment may otherwise require open thoracic surgery and pulmonary resection. Delayed Laryngeal Reinnervation for Unilateral VFP Hong-Liang Zheng, MD (presenter) OBJECTIVE: To determine if ansa cervicalis transfer procedure can serve as a suitable donor for human laryngeal reinnervation. METHOD: The present study included 309 patients with unilateral traumatic RLN injuries, including 208 patients who had a course from 6 to 12 months (group A), 62 patients who had a course from 1 to 2 years (group B), and 39 cases with a course from 2 to 3 years (group C). All patients had undergone ansa cervicalis anastomosis to recurrent laryngeal nerve and were followed by preoperative and monthly postoperative perceptual, acoustic analysis, aerodynamic, stroboscopy, and electromyography, and were followed up at least one year. RESULTS: Voice testing indicated that perceptual, acoustic, and aerodynamic values were significantly improved postoperatively, as compared with preoperative data in 3 groups, regardless of different courses (P0.05). When compared with normative values, group A or B exhibited no significant difference. However, the postoperative parameters of voice in group C were significantly higher than those in group A or B, respectively (P⬍0.05). Perceptual, acoustic, and aerodynamic values of the patients in groups A, B, and C achieved a steady state at a average of [??] 12.74.3, 17.25.7 and 25.411.8 weeks after ansa graft procedure, and there were significant differences between them (P⬍0.05). The procedure recovered the tone and mass of paralyzed vocal folds due to reinnervation of the adductor muscles as demonstrated by laryngeal electromyography and strobscopy. CONCLUSION: Ansa cervicalis graft procedure raises satisfactory phonatory quality for unilateral vocal fold paralysis. Dysplasia in Adult Recurrent Respiratory Papillomatosis Joseph Hall, MD (presenter); Karen Chen, BS; Kenneth Fletcher, MD; Theresa Scott, MS; Robert Ossoff, DMD, MD OBJECTIVE: To characterize the natural progression of dysplasia in adult recurrent respiratory papillomatosis (RRP) and to determine what factors influence this progression.
METHOD: Retrospective study at a tertiary care hospital between 2004 and 2009 in patients over 18 years with RRP. RESULTS: Eighty-seven patients were identified. Sixty (69%) were male and 27 (31%) were female (mean age 48 years). Eighty of the 87 patients (92%) had biopsy data. Dysplasia was identified in 53.7% (43/80). The mean number of operations for patients with dysplasia was 5 and without was 3. Of the 80 patients, 46.3% had no dysplasia, 31.2% had mild dysplasia (grade 1), 10.0% had moderate dysplasia (grade 2), 2.5% had severe dysplasia (grade 3), 5.0% had carcinoma in situ, and 5.0% had squamous cell carcinoma as the highest noted degree of dysplasia. Twenty-seven patients (27/80, 34%) developed a higher dysplastic grade with 8/80 (10.0%) developing carcinoma in situ or squamous cell carcinoma. Most patients who developed dysplasia progression were older (mean age 50 vs. 47 in non-progressors) and male (15/27), while only nine (9/27) had a history of smoking. HPV 6 was the most common subtype found with dysplasia progression (15/27, 56%). Cidofovir was utilized in 24/80 patients (30%). Twelve patients (12/24, 50%) had progression of dysplasia despite cidofovir usage. CONCLUSION: This study delineates the natural progression of dysplasia in adult RRP. Progression of dysplasia was associated with older age, male gender, and HPV 6. These data reveal the significance of dysplasia progression in adult RRP and the necessity of accurate monitoring. Early Office-Based Injection for Vocal Cord Paralysis Matthew Broadhurst, BMBS, FRACS (presenter) OBJECTIVE: 1) Assess the efficacy of early intervention for unilateral vocal cord paralysis using office-based trans-oral injection with hyaluronic acid(HA). 2) Assess patient tolerance of this injection technique, given the alternative is general anesthetic and hospital admission with other techniques. METHOD: A prospective study was conducted using consecutive patients presenting with acute unilateral vocal cord paralysis of less than 6 month duration. Etiology of the paralysis, voice handicap index(VHI), acoustic measurements and videostrobolaryngoscopy data were collected and analyzed both prior to and after the injection laryngoplasty procedure. Transoral injection laryngoplasty with hyaluronic acid was used to augment the unilateral paraglottic space. Patient satisfaction data was also collected and analyzed. RESULTS: Over 18 months, 23 patients completed the study and all tolerated the procedure. The minimum follow-up was 6 months. The glottal defect was successfully closed and the VHI improved in all patients. These findings were supported by videostrobolaryngoscopy data. After the study period, patients who had not recovered vocal cord motion were offered permanent vocal cord reconstruction. CONCLUSION: For the immediate management of unilateral vocal cord paralysis, an office-based trans-oral injection laryn-
P81 goplasty of HA can provide significant improvement in voice and swallowing. Patients can resume work and social activities while waiting to see if the vocal cord regains motion. Patients can also avoid hospital admission and general anesthetic by undergoing this technique. Etiology-Related Results of Vocal Fold Lipoinjection Giovanna Cantarella, MD (presenter); Giovanna Baracca, MD; Stella Forti, BMath; Michele Gaffuri; Riccardo Mazzola, MD OBJECTIVE: The aim of this study was to make a multidimensional evaluation of the results obtained by vocal fold lipoinjection in the treatment of glottal insufficiency (GI) due to unilateral vocal fold paralysis (UVFP) in comparison to congenital or acquired soft tissue defects. METHOD: Of the 65 patients prospectively studied at our university hospital, 41 had GI due to UVFP (age 16-79), and 24 GI due to vocal fold scarring or sulcus glottidis (age 16-67). The lipoaspirate was centrifuged at 1200 g for 3’ to separate and remove blood, cell debris and the oily layer, and injected under direct microlaryngoscopy. The outcome measures considered preoperatively and three months after lipoinjection were GRBAS perceptual evaluation, maximal phonation time (MPT), self-assessed Voice Handicap Index (VHI), and voice acoustic analysis by MDVP. RESULTS: Before surgery, the G, B, and A scores and MPT were worse in the UVFP group (p⬍ 0.05). All of the variables were significantly improved by surgery in both groups (p⬍ 0.05) except for the voice instability indices in patients with soft tissue defects. A General Linear Model for repeated measures showed a greater reduction in G, B, and VHI (total, functional and emotional subscales) in the UVFP patients (p⬍0.05); MPT and MDVP similarly improved in both groups. CONCLUSION: Vocal fold lipoinjection is significantly effective in treating GI due to UVFP or soft tissue defects, although better results can be expected in the perceptual evaluation and self-assessment of dysphonia-related disability in UVFP patients. Fatigue and Hoarseness: A New Link Janet Wilson, MD, FRCSEd, FRCSEng (presenter); James O’Hara, FRCS; Paul Carding, PhD, FRCSSLT; Tracy Miller, MSc; Vincent Deary, MSc OBJECTIVE: 1) To assess the possible relationship between fatigue and functional dysphonia (hoarseness). 2) To explore a further relationship between perfectionism and fatigue in hoarseness. METHOD: Setting: The speech therapy department of a major UK otolaryngology department. Case control design. Patients with substantial vocal cord abnormality/paresis were excluded.
ORALS
Oral Presentations
Otolaryngology-Head and Neck Surgery, Vol 143, No 2S2, August 2010
Computerized Biomechanical Model Applied in Canine Larynges Guilherme Marques (presenter); Francisco Zampirolli, PhD; Paulo Pontes, MD OBJECTIVE: The objective of this paper is to develop Computerized Biomechanics model applied to canines larynx to simulate experimentally the movements of posterior cricoarytenoid, lateral cricoarytenoid and, cricothyroid muscles. METHOD: By adapting the Lego Mindstorm NXT technology and development of computer program for its handling, a computerized biomechanical model was developed applying micro engines that track the vocal process of the arytenoid cartilage and the cricothyroid articulation, considering the physiological vectorial forces, simulating the action of the intrinsic muscles of the canine larynx. The biomechanics model was evaluated in 6 canine larynges (4 complete larynges and 2 hemilarynges) by applying dynamic tasks (bilateral adduction of the vocal folds, bilateral abduction of the vocal folds, bilateral adduction with stretching of the vocal folds, and bilateral abduction with stretching of the vocal folds) and tests with sound production. RESULTS: The developed model accomplished all the requested tasks to simulate the intrinsic muscles in the dynamic experiment and during the sound production of the canine larynx. CONCLUSION: The computerized biodynamic model developed and applied in the canine larynges simulated movements produced by the posterior cricoarytenoid, lateral cricoarytenoid, and cricothyroid muscles. Cutting Balloon Treatment of Tracheobronchial Stenosis Colin Butler, MBBS (presenter); Jeremy George, MD; Guri Sandhu, MB, FRCS OBJECTIVE: 1) To describe the use of cutting balloon tracheobronchoplasty via suspension laryngoscopy for treating distal tracheal and bronchial stenosis. 2) To present the efficacy and durability of cutting balloon bronchoplasty for treating tracheobronchial stenosis. METHOD: A prospective study of 12 patients with bronchial stenosis who were treated in a national referral airway centre between 2005 and 2008 with a new balloon device that simultaneously cuts and dilates bronchial lesions. Treatment efficacy was assessed using pre- and postoperative lung function data compared with paired t-test, and treatment durability was determined using actuarial analysis. RESULTS: There were seven females and five males and the average age at presentation was 58 years. Eight bronchial lesions were caused by Wegener’s Granulomatosis, two by post-tuberculosis bronchial stricture, and two were caused by photodynamic therapy. All patients had suspension laryngoscopy and supraglottic jet ventilation and had intralesional ste-
roid injection followed by cutting-balloon bronchoplasty. Following the procedure, forced expiratory volume in 1 second (FEV1) changed from an average of 1.6 to 2.1 (p⬍0.001) and FEV increased from 2.85 to 3.18 (p⬍0.001). None of the patients underwent a lobectomy or a pneumonectomy, and at a minimum of six months follow-up (range 6.5-28), 83% of patients were free of the need to re-intervene. CONCLUSION: Cutting balloon bronchoplasty delivered via suspension laryngoscopy is a safe and effective treatment for distal tracheal and bronchial strictures whose treatment may otherwise require open thoracic surgery and pulmonary resection. Delayed Laryngeal Reinnervation for Unilateral VFP Hong-Liang Zheng, MD (presenter) OBJECTIVE: To determine if ansa cervicalis transfer procedure can serve as a suitable donor for human laryngeal reinnervation. METHOD: The present study included 309 patients with unilateral traumatic RLN injuries, including 208 patients who had a course from 6 to 12 months (group A), 62 patients who had a course from 1 to 2 years (group B), and 39 cases with a course from 2 to 3 years (group C). All patients had undergone ansa cervicalis anastomosis to recurrent laryngeal nerve and were followed by preoperative and monthly postoperative perceptual, acoustic analysis, aerodynamic, stroboscopy, and electromyography, and were followed up at least one year. RESULTS: Voice testing indicated that perceptual, acoustic, and aerodynamic values were significantly improved postoperatively, as compared with preoperative data in 3 groups, regardless of different courses (P0.05). When compared with normative values, group A or B exhibited no significant difference. However, the postoperative parameters of voice in group C were significantly higher than those in group A or B, respectively (P⬍0.05). Perceptual, acoustic, and aerodynamic values of the patients in groups A, B, and C achieved a steady state at a average of [??] 12.74.3, 17.25.7 and 25.411.8 weeks after ansa graft procedure, and there were significant differences between them (P⬍0.05). The procedure recovered the tone and mass of paralyzed vocal folds due to reinnervation of the adductor muscles as demonstrated by laryngeal electromyography and strobscopy. CONCLUSION: Ansa cervicalis graft procedure raises satisfactory phonatory quality for unilateral vocal fold paralysis. Dysplasia in Adult Recurrent Respiratory Papillomatosis Joseph Hall, MD (presenter); Karen Chen, BS; Kenneth Fletcher, MD; Theresa Scott, MS; Robert Ossoff, DMD, MD OBJECTIVE: To characterize the natural progression of dysplasia in adult recurrent respiratory papillomatosis (RRP) and to determine what factors influence this progression.
METHOD: Retrospective study at a tertiary care hospital between 2004 and 2009 in patients over 18 years with RRP. RESULTS: Eighty-seven patients were identified. Sixty (69%) were male and 27 (31%) were female (mean age 48 years). Eighty of the 87 patients (92%) had biopsy data. Dysplasia was identified in 53.7% (43/80). The mean number of operations for patients with dysplasia was 5 and without was 3. Of the 80 patients, 46.3% had no dysplasia, 31.2% had mild dysplasia (grade 1), 10.0% had moderate dysplasia (grade 2), 2.5% had severe dysplasia (grade 3), 5.0% had carcinoma in situ, and 5.0% had squamous cell carcinoma as the highest noted degree of dysplasia. Twenty-seven patients (27/80, 34%) developed a higher dysplastic grade with 8/80 (10.0%) developing carcinoma in situ or squamous cell carcinoma. Most patients who developed dysplasia progression were older (mean age 50 vs. 47 in non-progressors) and male (15/27), while only nine (9/27) had a history of smoking. HPV 6 was the most common subtype found with dysplasia progression (15/27, 56%). Cidofovir was utilized in 24/80 patients (30%). Twelve patients (12/24, 50%) had progression of dysplasia despite cidofovir usage. CONCLUSION: This study delineates the natural progression of dysplasia in adult RRP. Progression of dysplasia was associated with older age, male gender, and HPV 6. These data reveal the significance of dysplasia progression in adult RRP and the necessity of accurate monitoring. Early Office-Based Injection for Vocal Cord Paralysis Matthew Broadhurst, BMBS, FRACS (presenter) OBJECTIVE: 1) Assess the efficacy of early intervention for unilateral vocal cord paralysis using office-based trans-oral injection with hyaluronic acid(HA). 2) Assess patient tolerance of this injection technique, given the alternative is general anesthetic and hospital admission with other techniques. METHOD: A prospective study was conducted using consecutive patients presenting with acute unilateral vocal cord paralysis of less than 6 month duration. Etiology of the paralysis, voice handicap index(VHI), acoustic measurements and videostrobolaryngoscopy data were collected and analyzed both prior to and after the injection laryngoplasty procedure. Transoral injection laryngoplasty with hyaluronic acid was used to augment the unilateral paraglottic space. Patient satisfaction data was also collected and analyzed. RESULTS: Over 18 months, 23 patients completed the study and all tolerated the procedure. The minimum follow-up was 6 months. The glottal defect was successfully closed and the VHI improved in all patients. These findings were supported by videostrobolaryngoscopy data. After the study period, patients who had not recovered vocal cord motion were offered permanent vocal cord reconstruction. CONCLUSION: For the immediate management of unilateral vocal cord paralysis, an office-based trans-oral injection laryn-
P81 goplasty of HA can provide significant improvement in voice and swallowing. Patients can resume work and social activities while waiting to see if the vocal cord regains motion. Patients can also avoid hospital admission and general anesthetic by undergoing this technique. Etiology-Related Results of Vocal Fold Lipoinjection Giovanna Cantarella, MD (presenter); Giovanna Baracca, MD; Stella Forti, BMath; Michele Gaffuri; Riccardo Mazzola, MD OBJECTIVE: The aim of this study was to make a multidimensional evaluation of the results obtained by vocal fold lipoinjection in the treatment of glottal insufficiency (GI) due to unilateral vocal fold paralysis (UVFP) in comparison to congenital or acquired soft tissue defects. METHOD: Of the 65 patients prospectively studied at our university hospital, 41 had GI due to UVFP (age 16-79), and 24 GI due to vocal fold scarring or sulcus glottidis (age 16-67). The lipoaspirate was centrifuged at 1200 g for 3’ to separate and remove blood, cell debris and the oily layer, and injected under direct microlaryngoscopy. The outcome measures considered preoperatively and three months after lipoinjection were GRBAS perceptual evaluation, maximal phonation time (MPT), self-assessed Voice Handicap Index (VHI), and voice acoustic analysis by MDVP. RESULTS: Before surgery, the G, B, and A scores and MPT were worse in the UVFP group (p⬍ 0.05). All of the variables were significantly improved by surgery in both groups (p⬍ 0.05) except for the voice instability indices in patients with soft tissue defects. A General Linear Model for repeated measures showed a greater reduction in G, B, and VHI (total, functional and emotional subscales) in the UVFP patients (p⬍0.05); MPT and MDVP similarly improved in both groups. CONCLUSION: Vocal fold lipoinjection is significantly effective in treating GI due to UVFP or soft tissue defects, although better results can be expected in the perceptual evaluation and self-assessment of dysphonia-related disability in UVFP patients. Fatigue and Hoarseness: A New Link Janet Wilson, MD, FRCSEd, FRCSEng (presenter); James O’Hara, FRCS; Paul Carding, PhD, FRCSSLT; Tracy Miller, MSc; Vincent Deary, MSc OBJECTIVE: 1) To assess the possible relationship between fatigue and functional dysphonia (hoarseness). 2) To explore a further relationship between perfectionism and fatigue in hoarseness. METHOD: Setting: The speech therapy department of a major UK otolaryngology department. Case control design. Patients with substantial vocal cord abnormality/paresis were excluded.
ORALS
Oral Presentations