Transoral Laser Surgery: The Learning Curve

The Validity of the Pharyngeal Squeeze Maneuver Scott C. Fuller, MD (presenter); Peter C Belafsky, MD, PhD, MPH; Shervin Aminpour, MD; Rebecca Leonard, PhD; Catherine J Rees, MD OBJECTIVE: Pharyngeal strength is essential for safe bolus transit during deglutition. The pharyngeal squeeze maneuver (PSM) is a surrogate measure of pharyngeal strength determined on endoscopic swallow evaluation (FEES). Although several investigations have utilized the PSM, the validity of this diagnostic assessment has never been tested. The purpose of this investigation was to evaluate the clinical validity of the PSM. METHODS: Simultaneous FEES and fluoroscopic swallow evaluations were prospectively performed on 30 consecutive patients being evaluated for dysphagia. The PSM was assessed on all patients and compared to a validated measure of pharyngeal strength on fluoroscopy, the pharyngeal constriction ratio (PCR). As pharyngeal strength diminishes, the PCR increases. The PCR in patients with an intact PSM was compared to the PCR in persons with an absent PSM, with the independent samples t-test and confirmed with the non-parametric Mann-Whitney test. RESULTS: 29 simultaneous FEES-fluoroscpic swallow studies were performed. 75% (22/29) had an intact PSM and 25% (7/9) had an absent PSM. The mean PRC for the group with an intact PSM was 0.06 (⫾ 0.08), compared to a mean PCR of 0.31 (⫾ 0.20) for individuals with an absent PSM. The PCR was significantly higher, indicating a weaker pharynx, in persons with an absent PSM (p ⬍ 0.001). CONCLUSIONS: Pharyngeal strength, as assessed with the PCR, is significantly weaker in persons with an absent PSM. These data suggest that the PSM is a valid surrogate measure of pharyngeal motor integrity. Transnasal Esophagoscopy Findings: Interspecialty Comparison Michael T Falcone, MD (presenter); C Gaelyn Garrett, MD; Michael Fredrick Vaezi, MD, PhD, MSc(Epi); Robert H Ossoff, DMD, MD; James Christopher Slaughter PhD; Dale C. Ekbom, MD; I-Fan Theodore Mau, MD, PhD OBJECTIVE: Otolaryngologists implement transnasal esophagoscopy (TNE) to assess esophageal pathology. Previous studies using TNE to evaluate esophageal pathology have been limited in various ways. These are largely retrospective and deal with select patient populations. There are currently no data on the prevalence of esophageal pathology in “all comers” to an otolaryngology voice center. The objectives are to assess the prevalence of esophageal pathology in this population and

P51 determine the inter-observer variability of the findings reviewed by an otolaryngologist and a gastroenterologist. METHODS: Consecutive patients with throat symptoms presenting to the voice center were asked to undergo TNE. The findings were videotaped and reviewed by an otolaryngologist and a gastroesophagologist blinded to the patients’ presenting complaint. RESULTS: 50 patients were selected prospectively to undergo TNE. Hoarseness was the most common presenting symptom (68%). According to the gastroesophagologist, the prevalence of esophageal findings was: Barrett’s esophagus (12%), esophagitis (10%), hiatal hernia (32%), and esophageal stricture (10%). The percent agreement for a normal study was 72% (kappa 0.44). The percent agreement (kappa value) for various pathologic findings are as follows: Barrett’s esophagus, 86% (0.45); esophagitis, 88% (0.43); hiatal hernia, 76% (0.39); and esophageal stricture, 96% (0.73). The frequency of an exact agreement between raters was 54%. For an abnormal study, the percent agreement was 80%. The reviewers were 7.11 times more likely to agree than disagree (p ⫽ 0.002). CONCLUSIONS: Esophageal abnormalities are common in patients presenting to a voice subspecialty clinic. An interdisciplinary approach can provide this population with complementary patient care. Transoral Laser Surgery: The Learning Curve Manuel S Bernal-Sprekelsen, MD, PhD (presenter); Isabel Vilaseca MD, PhD; Jose Luis Blanch Alejandro OBJECTIVE: To assess the learning curve in transoral laser surgery for malignant tumors of the larynx and hypopharynx. METHODS: Prospective data collection in a SPSS data base from 1998 to 2004. Inclusion criteria: Patients with untreated malignant tumors of the aerodigestive tract treated with curative intent. Patients were divided into consecutive subgroups of n⫽ 50 depending on the experience of the surgeons. Outcome assessment was prformed specifically for number of surgeries per patient, complications, recurrence rates and adjusted survival. RESULTS: 680 patients met the inclusion criteria. Up to 4 groups of increasing consecutive experience could be formed. The number of operations per patients (1,87 operation for group #1 compared to 1.36 for group #4) and the complication rates were significantly reduced with increased experience. Complication rates were linked with a statistical significance to larger tumors (p⬍ 0.0001). Free tumor margins were not related to experience (p⫽0.307), neither the recurrence rates (the lowest Chi-square achieved a p⫽0.088 for the first group of 50 compared to the fourth group of 50). Adjusted survival rates showed a trend of improvement with larger experience when studied individually, but no significant statistical difference was observed (p ⬎0.05). CONCLUSIONS: Assessing surgical experience for new

SCI. ORALS

Scientific Oral Presentations

P52

Otolaryngology-Head and Neck Surgery, Vol 139, No 2S1, August 2008

technologies is not as simple, as new joining surgeons profit from experienced colleagues. The complication rate clearly seems to depend on experience; however, patient adjusted survival rates do not. Vox-Implants Injection after Partial Laryngectomy Angelo Ghidini (presenter); Giuseppe Bergamini; Matteo Alicandri-Ciufelli; Gabriele Molteni, MD; Francesco Mattioli; Livio Presutti, MD; Daniele Marchioni OBJECTIVE: To illustrate a surgical technique for swallowing rehabilitation of patients after partial laryngectomy and to evaluate quality of life after treatment. METHODS: A longitudinal prospective study. 11 patients with persistent swallowing impairment after partial laryngectomy were included in the study. Swallowing disorders were diagnosed with videofluoroscopy and FEES (fiberoptic endoscopic evaluation of swallowing), and were quantified by 2 scales (a dysphagia score and a modified Penetration-Aspiration scale). A self-evaluation questionnaire about quality of life after polydimethylsiloxane (PDMS) injection was submitted to each patient (EORTC-QLQ 30). After identification of site of inhalation of bolus, PDMS was injected into the neoglottis to fill the neoglottic gap in order to obtain a better continence of the neolarynx. Aerodynamics and acoustic analysis were assessed before and after treatment. RESULTS: Average follow-up was 25 months (range 5-39). All patients showed an improvement both in the dysphagia score and in the modified Penetration-Aspiration scale. Average improvement was 2.6 points in the dysphagia score (p⫽0.0042) and 2.1 in the modified Penetration-Aspiration scale (p⫽0.0043). MPT showed an average improvement of 5 sec (p⫽0,037). The quality of life assessment showed a subjective improvement in each patient. CONCLUSIONS: PDMS injection can be a useful technique in surgical rehabilitation of swallowing in patients who underwent partial laryngectomy. FEES is a very important tool in identifying anatomical alterations that can cause incorrect passage of bolus in the airways during deglutition. Filling these regions with PDMS can avoid passage of food into the airways, thus improving deglutition and voice and by consequence, patients’ quality of life.

Otology/Neurotology A New Role of Staged Tympanoplasty for Cholesteatoma Yasuyuki Hinohira, MD, PhD (presenter); Naoaki Yanagihara, MD; Naohito Hato, MD OBJECTIVE: 1) Investigate a correlation between pathological findings at the 2nd stage operation and long-term outcomes

in a staged canal wall-up tympanoplasty (SCUT) for middle ear cholesteatoma. 2) Advocate a new role of the staged manner based on the study. METHODS: SCUT was performed on 90 ears with cholesteatoma involving both the ossicles and the mastoid cavity. The 1st stage operation included scutum plasty and mastoid cortex plasty with bone pate following removal of cholesteatoma and ossicles involved. The 2nd stage operation records were reviewed regarding the pathological findings associated with retraction pocket (RP) and residual cholesteatoma (RC) formation. The scutum defect was revised with auricular cartilage, and the mastoid cortex plasty was again performed after removal of RC. Postoperative follow-up with endoscopic observation and CT was performed for all patients. RESULTS: At the 2nd stage, RP was seen in 15 ears (16.7%) which all showed partial or total absorption of the scutum reconstructed. Aeration grade of the mastoid cavity reconstructed did not correlate with RP or RC formation. RC was found in 28 ears (31.1%) regardless of RP formation. The long-term follow up study revealed that the statistically higher incidence of RP re-formation (26.7%) and RC (3.2%) was seen in ears which had been identified at the 2nd stage, respectively. CONCLUSIONS: The present study showed that the longterm outcomes after SCUT were correlated with RP and RC formation at the 2nd stage. This indicates the 2nd stage operation has a role of the long-term prognosis in addition to exploration of RC. Chorda Tympani in Chronic Inflammatory Middle Ear Disease Arun Goyal (presenter); P P Singh, MD; Gautam Dash, MD OBJECTIVE: To study the effect of chronic inflammatory middle ear disease on gustatory function of chorda tympani nerve. METHODS: A prospective study was performed in 2007 on 85 patients of unilateral chronic inflammatory middle ear disease of both cholesteatomatous and noncholesteatomatous type. Gustatory assessment on both sides of the tongue was performed using dry taste strips. Taste strips were made of filter paper soaked in four different taste solutions of four different concentrations each and dried. The taste score is the number of correctly identified taste strips. Results were analyzed using Analysis of Variance (ANOVA) and t-test. RESULTS: Comparison of mean taste scores on the side of diseased ear with normal ear was done. On the diseased side, the mean taste score was 9.16 and on the normal side, the mean taste score was 13.24. The difference between the two was found to be statistically significant (p⬍0.0001). The results were also analyzed for various other parameters like type, duration, and location of disease. Site of cholesteatoma was found to have a significant effect on the taste score of the