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Endoscopic management of adult, benign laryngotracheal stenosis
OtolaryngologyHead and Neck Surgery
Scientific Sessions--Wednesday
Volume 121 Number 2
healthy mother, was noted to have a hearing loss right after birth. He underwent 3 BSERs on different occasions, TOAEs on 2 different occasions, and extensive imaging of the internal auditory canals and inner ears. The child has no other congenital abnormalities. On examination, normal otoscopy was found on both sides, and no other ENT or head and neck abnormalities were found. There was no response to sound stimuli, but balance was normal. Results: All BSERs showed no response bilaterally. TOAEs at age 2 years were present but, when repeated on several other occasions, were consistently absent. A C T scan revealed an absent IAC on the right and a severely malformed IAC on the left, where only the fallopian canals for the facial nerves were present. The inner and middle ear structures were present and apparently normal. Conclusions: It is very unusual to see a congenitally absent IAC with a normally formed inner ear. We will discuss the embiology and restricted treatment options in such cases. The boy is still under investigation.
9:35 to 10:15 AM MCC Rooms 265-268 9
Paparella Award for Distinguished Contributions in Clinical Otology Otology in the 21st Century: Promises and Challenges (With Spanish translation) DAVID J LIM MD
] 0:30 AM to 12:00 NOON MCC 271 9
General Otolaryngology Session (With Spanish translation) TONI M GANZEL MD; RICHARD W WAGUESPACK MD (moderators)
] 0:30 AM
Digital Subtraction versus Magnetic Resonance Sialography: Comparison MARKUSJUNGEHUELSINGMD (presenter); ROMAN FISCHBACH MD; CHRISTIANSIT[ELMD; HANSEDMUNDECKELMD; Cologne Germany
Objectives: Prospective evaluation of magnetic resonance sialography (MRS) versus conventional digital subtraction sialography (CDSS). Methods: MRS as well as CDSS were performed in 30 patients with various lesions of the parotid gland duct system. Investigations were interpreted by 2 independent observers and a score system. Results: The main parotid duct was reliably depicted in all patients by both methods. CDSS delineated secondary and tertiary branches in 28 of 30 patients; MRS allowed high-quality
P191
depiction of secondary branches in 23 of 30 patients and of tertiary branches in 18 of 30 patients. In 2 patients, obstruction of the main parotid duct prevented retrograde filling of the parotid gland duct system and thus performance of CDSS, whereas MRS depicted the whole duct system and the obstruction. Intraductal calculi were reliably depicted in 4 patients by both methods. In 2 patients with Sicca syndrome, MRS imaging quality was poor, whereas CDSS allowed excellent duct system depiction. In 10 patients with chronic sialadenitis, MRS showed very typical cystic tissue lesions. Conclusion: MRS can be successfully applied to investigate the parotid gland duct system, and MRS imaging quality is comparable with that of CDSS. Being completely noninvasive, MRS can also be applied in patients with acute sialadenitis and in children. Subtle secondary and tertiary duct lesions are better demonstrated by CDSS, whereas complete duct obstruction is better visualized by MRS. 10:38 AM
Endoscopic Management of Adult, Benign Laryngotracheal Stenosis F CHRISTOPHERHOLSINGERMD (presenter); MICHAELG STEWART MD MPH; ROBERTB PARKEJR MD MBA; DONALDT DONOVAN MD FACS;HoustonTX
Objectives: Adult, benign laryngotracheal stenosis (LTS) can arise from a diverse spectrum of disease, from postintubation injury to autoimmune disorders. There are effective options to treat these patients, including endoscopic laser ablation, open surgical procedures, and tracheotomy. Successful endoscopic management depends on proper patient selection. Patients with thin, weblike stenosis less than 1 cm in the vertical dimension and without tracheomalacia can be treated effectively using endoscopic techniques. We have identified another subset of patients who also may benefit from primary endoscopic management. These include patients with recurrent stenosis after previous open procedure(s), patients with poorly controlled systemic diseases, and patients who decline an open procedure. Methods: We retrospectively reviewed a series of 25 patients with LTS, treated primarily with endoscopic laser ablation and dilation over a 10-year period. Results: Twenty-five patients (20 female, 5 male) underwent a total of 68 procedures. Average age of patients was 49 years (range 21-86 years). The cause of LTS was postintubation injury in 56% of patients, autoimmune disease in 28%, and idiopathic in 16%. On average, 2.7 endoscopic procedures were performed per patient. Seventeen patients (68%) underwent serial endoscopic procedures, at an average interval of 15 months (range 2-72 months). Minimum follow-up was 13 months, and 64% (16 patients) required 2 or fewer procedures to control symptoms. Of these, nearly half (7 patients) required only 1 procedure and remain asymptomatic. Conclusion: For patients with significant comorbidity, pri-
P192
OtolaryngologyHead and NeckSurgery August 1999
Scientific Sessions--Wednesday
mary endoscopic management of adult, benign laryngotracheal stenosis offers a safe, effective treatment with low morbidity and no mortality. 10:46 AM
Prevalence of Occult Vocal Pathology in a CommunityBased Cohort TODD R REULBACH MD (presenter); JAMES A KOUFMAN MD; GREGORY N POSTMA MD; P DAVID BLALOCK MA; Lewisville NC; Winston Salem NC; Lewisville NC; Winston-Salem NC
Objectives: Previously, it has been estimated that 12% of the elderly suffer from some degree of vocal dysfunction. However, minimal information is available regarding the true prevalence of vocal pathology within this group. This study was done to determine the prevalence of vocal pathology in a community-based, asymptomatic adult population, which represents a reasonable estimate of the "normal" population. Methods: Ninety-eight volunteer aduk subjects (mean age 60.9 years) completed a questionnaire detailing individual demographic, medical, and laryngeal symptom-related information. All 98 subjects then underwent a complete head and neck examination, as well as transnasal fiberoptic laryngoscopy to assess the larynx for structural or dynamic abnormalities. Results: Presbylaryngis was present in 84% of males and 60% of females. There was a correlation between age and degree of bowing in females. Muscle tension dysphonia was present in 73% of subjects. Presence of muscle tension dysphonia was 97% sensitive in predicting presbylaryngis. Laryngopharyngeal reflux findings were present in 64% of subjects. In addition, other laryngeal pathology was identified in 21 subjects. Conclusion: Presbylaryngis is very common, and the majority of people with this condition use hyperfunctional muscle tension patterns for compensation. Laryngopharyngoal reflux findings are present in a large percentage of people as well. 11:00 AM The Quality of Life (QOL) Impact of Dysphonia KENNETH MACKENZIE MB CHB FRCS (presenter); I J DEARY PHD; AUDREY MILLAR BSC MPHilj JANET A WILSON MD FRCS; Glasgow United Kingdom; Edinburgh United Kingdom; Glasgow United Kingdom; Newcastle Upon Tyne United Kingdom
Objectives: Dysphonia may cause social, lifestyle, and employment quality-of-life (QOL) difficulties. This study is, we believe, the first to document systematically the general health status of patients with dysphonia. It also compares the QOL impact of dysphonia with that of other ORL conditions and chronic illnesses. Methods: The SF-36--an extensively validated questionnaire, scored according to published algorithms and with 8 subscales of general healS---was given to 163 dysphonic out-
patients (38 males, 125 females; mean age 50, SD 14) in a UK voice clinic. Subjects' raw scores were normalized on a 0 to 100 scale and compared with data from healthy controls and with a published series of North American patients with chronic sinusitis. Results: Dysphonia patients had significantly lower scores (indicating poorer health status) than age-matched healthy controls on all 8 subscales of the SF-36. Differences were largest in pain, physical role, and social functioning subscales. Dysphonia patients differed from sinusitis patients on a number of scales. Sinusitis patients appear to have as good QOL in general health perception, social functioning, and mental health subscales. Conclusion: These results emphasize the need to include generic QOL measures in assessing ORL health status and treatment outcomes. The results support health economic case for continued investment and treatment of dysphonia, which has a major QOL impact.
11:08 AM Image Quantification Comparison of Normal and Abnormal Laryngeal Function GREGORY A GRILLONE MD FACS (presenter); GEORGE L CHARPIED CCC MS; Boston MA
Objectives: The advent of powerful and inexpensive PC computers has made it possible to capture videolaryngostroboscopic images and convert typically subjective assessment of laryngeal function into a quasiquantitative assessment that allows for improved diagnosis. Our objective was to demonstrate the clinical feasibility of using a simple technique to capture high-quality video images for determination of arytenoid movement as a reflection of muscular effort. Methods: A 133-MHz pentium computer equipped with video capture and audio cards, Windows 95 OS, and a CRT monitor viewed videolaryngostroboscopic images with an overlaid grid of nondimensionalunits; vector mapping of arytenoid apical position changes over time was documented. The vector maps were orthogonally decomposed for direction and magnitude. Video images of 22 spasmodic dysphonia patients and 20 subjects without abnormality were analyzed in this study. Arytenoid apical movements were also examined before and after botulinum toxin injection in spasmodic dysphonia patients. Results: Spasmodic dysphonia subjects fell into 3 groups of arytenoid apical movement and were identified as anteriorand posterior-going and cross-over of the orthogonal. These movements were larger in both magnitude of movement and bilateral asymmetry in direction when compared with controis. Patients after botulinum toxin injection showed a significant reduction in magnitude of apical movement but retained bilateral symmetry. Conclusion: These data appear to show that the method and the derived mapping of videolaryngostroboscopic images
Scientific Sessions--Wednesday
Volume 121 Number 2
healthy mother, was noted to have a hearing loss right after birth. He underwent 3 BSERs on different occasions, TOAEs on 2 different occasions, and extensive imaging of the internal auditory canals and inner ears. The child has no other congenital abnormalities. On examination, normal otoscopy was found on both sides, and no other ENT or head and neck abnormalities were found. There was no response to sound stimuli, but balance was normal. Results: All BSERs showed no response bilaterally. TOAEs at age 2 years were present but, when repeated on several other occasions, were consistently absent. A C T scan revealed an absent IAC on the right and a severely malformed IAC on the left, where only the fallopian canals for the facial nerves were present. The inner and middle ear structures were present and apparently normal. Conclusions: It is very unusual to see a congenitally absent IAC with a normally formed inner ear. We will discuss the embiology and restricted treatment options in such cases. The boy is still under investigation.
9:35 to 10:15 AM MCC Rooms 265-268 9
Paparella Award for Distinguished Contributions in Clinical Otology Otology in the 21st Century: Promises and Challenges (With Spanish translation) DAVID J LIM MD
] 0:30 AM to 12:00 NOON MCC 271 9
General Otolaryngology Session (With Spanish translation) TONI M GANZEL MD; RICHARD W WAGUESPACK MD (moderators)
] 0:30 AM
Digital Subtraction versus Magnetic Resonance Sialography: Comparison MARKUSJUNGEHUELSINGMD (presenter); ROMAN FISCHBACH MD; CHRISTIANSIT[ELMD; HANSEDMUNDECKELMD; Cologne Germany
Objectives: Prospective evaluation of magnetic resonance sialography (MRS) versus conventional digital subtraction sialography (CDSS). Methods: MRS as well as CDSS were performed in 30 patients with various lesions of the parotid gland duct system. Investigations were interpreted by 2 independent observers and a score system. Results: The main parotid duct was reliably depicted in all patients by both methods. CDSS delineated secondary and tertiary branches in 28 of 30 patients; MRS allowed high-quality
P191
depiction of secondary branches in 23 of 30 patients and of tertiary branches in 18 of 30 patients. In 2 patients, obstruction of the main parotid duct prevented retrograde filling of the parotid gland duct system and thus performance of CDSS, whereas MRS depicted the whole duct system and the obstruction. Intraductal calculi were reliably depicted in 4 patients by both methods. In 2 patients with Sicca syndrome, MRS imaging quality was poor, whereas CDSS allowed excellent duct system depiction. In 10 patients with chronic sialadenitis, MRS showed very typical cystic tissue lesions. Conclusion: MRS can be successfully applied to investigate the parotid gland duct system, and MRS imaging quality is comparable with that of CDSS. Being completely noninvasive, MRS can also be applied in patients with acute sialadenitis and in children. Subtle secondary and tertiary duct lesions are better demonstrated by CDSS, whereas complete duct obstruction is better visualized by MRS. 10:38 AM
Endoscopic Management of Adult, Benign Laryngotracheal Stenosis F CHRISTOPHERHOLSINGERMD (presenter); MICHAELG STEWART MD MPH; ROBERTB PARKEJR MD MBA; DONALDT DONOVAN MD FACS;HoustonTX
Objectives: Adult, benign laryngotracheal stenosis (LTS) can arise from a diverse spectrum of disease, from postintubation injury to autoimmune disorders. There are effective options to treat these patients, including endoscopic laser ablation, open surgical procedures, and tracheotomy. Successful endoscopic management depends on proper patient selection. Patients with thin, weblike stenosis less than 1 cm in the vertical dimension and without tracheomalacia can be treated effectively using endoscopic techniques. We have identified another subset of patients who also may benefit from primary endoscopic management. These include patients with recurrent stenosis after previous open procedure(s), patients with poorly controlled systemic diseases, and patients who decline an open procedure. Methods: We retrospectively reviewed a series of 25 patients with LTS, treated primarily with endoscopic laser ablation and dilation over a 10-year period. Results: Twenty-five patients (20 female, 5 male) underwent a total of 68 procedures. Average age of patients was 49 years (range 21-86 years). The cause of LTS was postintubation injury in 56% of patients, autoimmune disease in 28%, and idiopathic in 16%. On average, 2.7 endoscopic procedures were performed per patient. Seventeen patients (68%) underwent serial endoscopic procedures, at an average interval of 15 months (range 2-72 months). Minimum follow-up was 13 months, and 64% (16 patients) required 2 or fewer procedures to control symptoms. Of these, nearly half (7 patients) required only 1 procedure and remain asymptomatic. Conclusion: For patients with significant comorbidity, pri-
P192
OtolaryngologyHead and NeckSurgery August 1999
Scientific Sessions--Wednesday
mary endoscopic management of adult, benign laryngotracheal stenosis offers a safe, effective treatment with low morbidity and no mortality. 10:46 AM
Prevalence of Occult Vocal Pathology in a CommunityBased Cohort TODD R REULBACH MD (presenter); JAMES A KOUFMAN MD; GREGORY N POSTMA MD; P DAVID BLALOCK MA; Lewisville NC; Winston Salem NC; Lewisville NC; Winston-Salem NC
Objectives: Previously, it has been estimated that 12% of the elderly suffer from some degree of vocal dysfunction. However, minimal information is available regarding the true prevalence of vocal pathology within this group. This study was done to determine the prevalence of vocal pathology in a community-based, asymptomatic adult population, which represents a reasonable estimate of the "normal" population. Methods: Ninety-eight volunteer aduk subjects (mean age 60.9 years) completed a questionnaire detailing individual demographic, medical, and laryngeal symptom-related information. All 98 subjects then underwent a complete head and neck examination, as well as transnasal fiberoptic laryngoscopy to assess the larynx for structural or dynamic abnormalities. Results: Presbylaryngis was present in 84% of males and 60% of females. There was a correlation between age and degree of bowing in females. Muscle tension dysphonia was present in 73% of subjects. Presence of muscle tension dysphonia was 97% sensitive in predicting presbylaryngis. Laryngopharyngeal reflux findings were present in 64% of subjects. In addition, other laryngeal pathology was identified in 21 subjects. Conclusion: Presbylaryngis is very common, and the majority of people with this condition use hyperfunctional muscle tension patterns for compensation. Laryngopharyngoal reflux findings are present in a large percentage of people as well. 11:00 AM The Quality of Life (QOL) Impact of Dysphonia KENNETH MACKENZIE MB CHB FRCS (presenter); I J DEARY PHD; AUDREY MILLAR BSC MPHilj JANET A WILSON MD FRCS; Glasgow United Kingdom; Edinburgh United Kingdom; Glasgow United Kingdom; Newcastle Upon Tyne United Kingdom
Objectives: Dysphonia may cause social, lifestyle, and employment quality-of-life (QOL) difficulties. This study is, we believe, the first to document systematically the general health status of patients with dysphonia. It also compares the QOL impact of dysphonia with that of other ORL conditions and chronic illnesses. Methods: The SF-36--an extensively validated questionnaire, scored according to published algorithms and with 8 subscales of general healS---was given to 163 dysphonic out-
patients (38 males, 125 females; mean age 50, SD 14) in a UK voice clinic. Subjects' raw scores were normalized on a 0 to 100 scale and compared with data from healthy controls and with a published series of North American patients with chronic sinusitis. Results: Dysphonia patients had significantly lower scores (indicating poorer health status) than age-matched healthy controls on all 8 subscales of the SF-36. Differences were largest in pain, physical role, and social functioning subscales. Dysphonia patients differed from sinusitis patients on a number of scales. Sinusitis patients appear to have as good QOL in general health perception, social functioning, and mental health subscales. Conclusion: These results emphasize the need to include generic QOL measures in assessing ORL health status and treatment outcomes. The results support health economic case for continued investment and treatment of dysphonia, which has a major QOL impact.
11:08 AM Image Quantification Comparison of Normal and Abnormal Laryngeal Function GREGORY A GRILLONE MD FACS (presenter); GEORGE L CHARPIED CCC MS; Boston MA
Objectives: The advent of powerful and inexpensive PC computers has made it possible to capture videolaryngostroboscopic images and convert typically subjective assessment of laryngeal function into a quasiquantitative assessment that allows for improved diagnosis. Our objective was to demonstrate the clinical feasibility of using a simple technique to capture high-quality video images for determination of arytenoid movement as a reflection of muscular effort. Methods: A 133-MHz pentium computer equipped with video capture and audio cards, Windows 95 OS, and a CRT monitor viewed videolaryngostroboscopic images with an overlaid grid of nondimensionalunits; vector mapping of arytenoid apical position changes over time was documented. The vector maps were orthogonally decomposed for direction and magnitude. Video images of 22 spasmodic dysphonia patients and 20 subjects without abnormality were analyzed in this study. Arytenoid apical movements were also examined before and after botulinum toxin injection in spasmodic dysphonia patients. Results: Spasmodic dysphonia subjects fell into 3 groups of arytenoid apical movement and were identified as anteriorand posterior-going and cross-over of the orthogonal. These movements were larger in both magnitude of movement and bilateral asymmetry in direction when compared with controis. Patients after botulinum toxin injection showed a significant reduction in magnitude of apical movement but retained bilateral symmetry. Conclusion: These data appear to show that the method and the derived mapping of videolaryngostroboscopic images