Laryngeal and esophageal histoplasmosis.
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Esophageal Diseases↗
Biomedical subjects
J A Koufman
Publications and source records attributed to J A Koufman.
Replacement of a failed tracheoesophageal puncture prosthesis under direct vision.
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Carcinoma, Squamous Cell↗
Laryngeal carcinoma and a lower esophageal web.
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Barrett Esophagus↗
Vocal fold paresis.
Vocal fold paresis (VFP) is a relatively common and often overlooked condition that can be difficult to diagnose based on the laryngeal examination alone. A retrospective review of the records of 50 consecutive adult patients with VFP was performed. In each case, the diagnosis of VFP was confirmed by laryngeal electromyography. The presenting symptoms were dysphonia (100%), vocal fatigue (76%), diplophonia (40%), and odynophonia (12%), and the findings were unilateral vocal fold hypomobility (50%), unilateral bowing (36%), and bilateral bowing (22%). Laryngoplasty and/or lipoinjection was performed in 54% of the subjects, and significant vocal improvement was achieved in 85%. VFP appears to be underdiagnosed because many VFP patients have compensatory hyperkinetic disorders at presentation. Although the diagnosis of VFP may be suspected based on the patient's symptoms and findings, the diagnostic sine qua non is laryngeal electromyography. In addition, surgical treatment for VFP appears to be safe and effective.
Adult↗
Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders.
OBJECTIVES: The goal was to estimate the prevalence of laryngopharyngeal reflux (LPR) in patients with laryngeal and voice disorders. STUDY DESIGN AND SETTING: This was a prospective study of 113 unselected, new patients with laryngeal and voice disorders. Patients completed an extensive medical history form including a reflux symptom profile. A comprehensive otolaryngologic examination was performed with photographic transnasal fiberoptic laryngoscopy. Patients with both symptoms and findings of LPR (78/133, 69%) underwent ambulatory 24-hour double-probe pH monitoring. RESULTS: Seventy-three percent (57/78) of patients undergoing pH testing had abnormal studies. Thus 50% (57/113) of the entire the study population had pH-documented reflux. Of the diagnostic sub-groups studied, the highest incidence of reflux was found in patients with vocal cord neoplastic lesions (88%) and patients with muscle tension dysphonias (70%). LPR was infrequently found in patients with neuromuscular disorders. CONCLUSION: LPR occurs in at least 50% of all patients at our center with laryngeal and voice disorders at presentation.
Adult↗
Correlation of laryngeal and pharyngeal carcinomas and 24-hour pH monitoring of the esophagus and pharynx.
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Retraction Notice↗
Reflux in infants with laryngomalacia: results of 24-hour double-probe pH monitoring.
Laryngomalacia is the most common cause of stridor in children. Previous studies using barium esophagrams or single-probe esophageal pH testing have indicated that 68% to 80% of infants with laryngomalacia have reflux. A recent study in a large series of pediatric patients has shown that these 2 testing modalities are relatively insensitive in detecting reflux when compared with 24-hour double-probe pH testing. This study was undertaken to determine the incidence and frequency of reflux in children with laryngomalacia by use of 24-hour double-probe pH monitoring. Twenty-four children with endoscopically diagnosed laryngomalacia underwent 24-hour double-probe pH testing. The distal probe was placed in the lower esophagus, and the proximal probe was placed just above the cricopharyngeus immediately posterior to the larynx. All 24 (100%) children had pharyngeal acid exposure as judged by the proximal pH probe. These children had a mean of 15.21 episodes of reflux to the level of the pharynx during the 24-hour study period. In contrast, only 16 (66%) children had abnormal acid exposure as measured by the distal esophageal probe. These results indicate that essentially all children with laryngomalacia have reflux of gastric acid to the pharyngeal level. Multiple authors have documented the detrimental effects of acid and the accompanying pepsin in the larynx and tracheobronchial tree. Persistent laryngeal edema is an almost universal finding in patients with reflux to the pharyngeal level and is a common finding in children with laryngomalacia. In some patients with laryngomalacia, reflux may be the primary cause of their airway compromise, whereas in others it may be a significant cofactor exacerbating a preexisting neurologic or anatomic abnormality.
Female↗
Bilateral medialization laryngoplasty.
OBJECTIVES: To present indications, techniques, and results of bilateral medialization laryngoplasty (BML). STUDY DESIGN: Retrospective review of 39 consecutive patients who had BML for correction of glottal insufficiency attributable to presbylaryngis (n = 16), bilateral vocal fold paresis (n = 13), unilateral paralysis with contralateral bowing (n = 4), and other miscellaneous neurologic diseases (n = 6). METHODS: Complete preoperative and postoperative clinical and acoustical data were analyzed for 74% (29/39) of the subjects. All 39 subjects completed a patient survey to assess their long-term outcomes. RESULTS: Overall, 90% (35/39) of the patients who had BML experienced significant improvement in voice and swallowing function. Subsequently, 36% (14/39) of the patients underwent adjunctive lipoinjection for closure of small residual glottal gaps (vocal "fine-tuning"). Of the BML patients (with or without lipoinjection) who had complete preoperative and postoperative voice data, 83% (24/29) had complete glottal closure after surgery, resulting in normal or near-normal voices. Eighty-five percent (33/39) of the patients responded that they "would have surgery again." Of the six patients who said that they would not have surgery again, three had good results and one had progressive neurologic disease. The mean duration of follow-up was 17 months. CONCLUSIONS: BML is an effective rehabilitative surgical treatment for symptomatic vocal fold bowing. In addition, lipoinjection is useful as an adjunct to BML to enhance the voice outcome in selected cases.
Female↗
Correlation of laryngeal and pharyngeal carcinomas and 24-hour pH monitoring of the esophagus and pharynx.
The cause of laryngeal and pharyngeal carcinomas is likely multifactorial. Smoking is an important factor, but mucosal damage from gastroesophageal reflux may also contribute. The purpose of this study was to determine whether gastroesophageal reflux is more common in patients with laryngeal or pharyngeal carcinomas than in those without these malignancies. Over an 8-year period, we correlated the results of clinical and radiographic examinations of the pharynx and esophagus to pH monitoring results in 798 patients with a variety of upper aerodigestive tract symptoms and who underwent both pH monitoring and barium esophagography. In this group, 63 patients (52 men, 11 women) had laryngeal or pharyngeal carcinomas, and 735 patients (319 men, 416 women) had neither malignancy. Abnormal pH findings were defined as a total percentage of esophageal acid exposure time of 6% or more as determined with the esophageal probe, or any reflux event detected with the pharyngeal probe. Thirty-four of 63 patients with carcinomas (54%) had abnormal pH-monitoring results: Esophageal acid exposure was abnormal in 10 patients, pharyngeal acid exposure was abnormal in 7 patients, and acid exposure was abnormal in both areas in 17 patients. Of the 735 patients without malignancies, 365 (50%) had abnormal pH-monitoring results (p > 0.05). In this population of patients, abnormal results of pH monitoring were common, occurring in 399 (50%) of 798 patients, but no significant difference was found between results in those with and without laryngeal or pharyngeal carcinomas. Therefore, our study found that gastroesophageal reflux as shown by pH monitoring was not more common in patients with these malignancies.
Adult↗
Sensitive assay for measurement of antibodies to Clostridium botulinum neurotoxins A, B, and E: use of hapten-labeled-antibody elution to isolate specific complexes.
The measurement of chicken and human antibodies to Clostridium botulinum neurotoxins A, B, and E was accomplished by affinity isolation of complexes containing these antibodies. By this approach, a mixture of toxin with the test antibody, fluoresceinated antibody, and enzyme (Russell's viper venom factor X activator)-labeled antibody is allowed to form a complex in solution phase. This complex is then bound to a matrix containing antifluorescein antibody. All components not bound to the matrix are washed off, and the complex is isolated intact by elution with fluorescein, which competes with the complex for binding to the antifluorescein matrix. The eluted complex is then bound to a matrix which specifically binds the test antibody (anti-chicken immunoglobulin Y [IgY] or anti-human IgG), and the bound complex is measured by using the enzyme label. Using this approach, we were able to measure as little as 1 ng of specific antibody per ml from affinity-isolated, monospecific chicken antibody preparations and to measure antibody specifically from IgY fractions of monospecific chicken antibody preparations. Human antibodies from subjects immunized with pentavalent toxoid preparations were detectable at dilutions as great as 24,300-fold, and undiluted serum from most control subjects showed no measurable antibody. Antibody was also measured in 65 subjects who were receiving preparations of neurotoxin A (BOTOX) for the treatment of spastic disorders. Eighteen of them had toxin-specific antibody reactive with toxin B, and two of them had toxin-specific antibody reactive with toxin A. The two patients having antibody to toxin A were refractory to treatment with this toxin. This approach of isolation of hapten-labeled immune complexes under nondenaturing conditions with hapten is broadly applicable to the specific measurement of antibodies present at very low concentrations in serum.
Animals↗
The etiology and pathogenesis of laryngeal carcinoma.
Epidemiologic data suggest that the etiology and pathogenesis of laryngeal carcinoma are influenced by environmental and lifestyle-related factors, such as tobacco use, ethanol consumption, and exposure to toxic substances. In addition, dietary factors, irradiation, papilloma virus infection, and laryngopharyngeal reflux seem to be significant carcinogenic cofactors. This article presents a multi-factorial model of laryngeal mucosal carcinogenesis.
Alcohol Drinking↗
Extraesophageal pediatric reflux: 24-hour double-probe pH monitoring of 222 children.
Although extraesophageal gastric reflux has been implicated as a cause of many pediatric airway and respiratory diseases, its prevalence in these conditions remains unknown due to the relative lack of sensitivity and/or specificity of traditional reflux testing methods. A prospective study of 222 children (ages 1 day to 16 years) was performed with 24-hour double-probe (simultaneous esophageal and pharyngeal) pH monitoring. Seventy-six percent (168/222) of the study population had abnormal findings in either one or both of the pH probes. Of those, 46% (78/168) had pharyngeal reflux (extraesophageal gastric acid documented by the pharyngeal probe), despite having normal esophageal acid exposure times according to the esophageal probe. Thus, had the pharyngeal probe not been used, 46% of the children with documented extraesophageal (pharyngeal) reflux would have been falsely presumed to have normal reflux parameters. Patients with laryngeal abnormalities, pulmonary abnormalities, and emesis had significantly more pharyngeal acid reflux (p < .001) than patients with nonrespiratory symptoms. These data suggest that extraesophageal reflux may be underestimated by single-probe intraesophageal monitoring alone, and that laryngopharyngeal reflux may play a role in the pathogenesis of the conditions studied.
Adolescent↗
Laryngeal biomechanics of the singing voice.
By transnasal fiberoptic laryngoscopy, patients with functional voice often demonstrate abnormal laryngeal biomechanics, commonly supraglottic contraction. Appropriately, such conditions are sometimes termed muscle tension dysphonias. Singers working at the limits of their voice may also transiently demonstrate comparable tension patterns. However, the biomechanics of normal singing, particularly for different singing styles, have not been previously well characterized. We used transnasal fiberoptic laryngoscopy to study 100 healthy singers to assess patterns of laryngeal tension during normal singing and to determine whether factors such as sex, occupation, and style of singing influence laryngeal muscle tension. Thirty-nine male and 61 female singers were studied; 48 were professional singers, and 52 were amateurs. Examinations of study subjects performing standardized and nonstandardized singing tasks were recorded on a laser disk and subsequently analyzed in a frame-by-frame fashion by a blinded otolaryngologist. Each vocal task was graded for muscle tension by previously established criteria, and objective muscle tension scores were computed. The muscle tension score was expressed as a percentage of frames for each task with one of the laryngeal muscle tension patterns shown. The lowest muscle tension scores were seen in female professional singers, and the highest muscle tension scores were seen in amateur female singers. Male singers (professional and amateur) had intermediate muscle tension scores. Classical singers had lower muscle tension scores than nonclassical singers, with the lowest muscle tension scores being seen in those singing choral music (41%), art song (47%), and opera (57%), and the highest being seen in those singing jazz/pop (65%), musical theater (74%), bluegrass/country and western (86%), and rock/gospel (94%). Analyzed also were the influences of vocal nodules, prior vocal training, number of performance and practice hours per week, warm-up before singing, race, smoking, and alcohol consumption.
Adult↗
Paroxysmal laryngospasm secondary to gastroesophageal reflux.
Over a 2-year period (1992 to 1994), 12 consecutive adult patients with paroxysmal laryngospasm were prospectively studied. All had had other symptoms of gastroesophageal reflux (GER); however, only 4 (33%) experienced symptoms of heartburn. Each patient underwent fiberoptic laryngeal examination, barium swallow/esophagography, and ambulatory, 24-hour, double-probe pH monitoring (pH-metry). Eleven (92%) of the 12 patients had evidence of GER on examination, and 10 (83%) had abnormal pH-metry, including 3 who demonstrated pharyngeal reflux while having normal total acid exposure times in the esophageal probe. All the patients responded to antireflux treatment, using dietary and lifestyle modifications and omeprazole, with complete cessation of the laryngospastic episodes. This study documents the role of GER in the etiology of paroxysmal laryngospasm, it highlights the advantages of double-probe pH-metry in diagnosing this extraesophageal manifestation of GER, and it demonstrates that antireflux therapy with omeprazole is effective in controlling GER-induced laryngospasm.
Adult↗
Acid-induced laryngospasm in a canine model.
A canine model was used to investigate the efferent laryngeal responses to stimulation by topically applied acid and pepsin. Five adult mongrel dogs were studied. Electromyographic recordings from the thyroarytenoid muscle were measured with hooked-wire electrodes as an acid solution (normal saline/hydrochloric acid at pH 6.0, 5.0, 4.0, 3.0, 2.5, 2.0, 1.5, and 1.0) was sequentially instilled into the larynx. Laryngospasm (tonic, sustained contraction of the thyroarytenoid muscle) occurred in all animals at pH 2.5 to 2.0 or less. Control substances such as neutral pH isotonic saline, hypotonic saline, hypertonic saline, water, and pepsin alone failed to produce laryngospasm. Next, solutions containing both acid (in the same pH range) and pepsin were tested. The laryngeal responses were similar to those of acid alone. The superior laryngeal nerves were sectioned bilaterally and the above experiments repeated. None of the test solutions produced laryngospasm; however, when capsaicin (1%) was instilled into the subglottis, laryngospasm occurred. Thus, chemoreceptors in the subglottis (supplied by the recurrent laryngeal nerves) appear to be responsive to capsaicin stimulation but not to acid stimulation. The data suggest that pH-sensitive chemoreceptors in the canine larynx cause laryngospasm (when the pH of the test solution is 2.5 or less) and that these acid receptors are supplied by the superior laryngeal nerves.
Animals↗
Correlation of lower esophageal mucosal ring and 24-h pH monitoring of the esophagus.
OBJECTIVE: To study the relationship of LEMR and gastroesophageal reflux. The pathogenesis of the lower esophageal mucosal ring (LEMR) is not known. The most likely theory is that the ring results from reflux esophagitis as part of the morphological spectrum of peptic stricture. METHODS: We correlated barium esophagrams and 24-h pH monitoring (pHM) in 343 patients (173 women, 170 men; mean age 52 yr). Patients were categorized into three groups by radiographic findings: 1) normal esophagus (n = 121), 2) hiatal hernia (HH) only (n = 174), and 3) LEMR (n =48). Abnormal pHM was defined as a total percentage of the esophageal acid exposure time of 6% or more; abnormal pHM was also analyzed relative to patient position (supine vs. upright). RESULTS: Findings showed that 21 (17%) of 121 normal patients had abnormal pHM compared with 58 (33%) of 174 patients with HH and 15 (31%) of 48 patients with LEMR. Normal patients had a significantly lower frequency of abnormal pHM (p < 0.01) vs. the other two groups; however, no significant difference in results of pHM was found in the groups with HH and LEMR. No significant relationships of abnormal supine versus upright pHM was observed comparing the three groups. CONCLUSIONS: 1) Most patients in this study had normal pHM, regardless of the anatomic status of the esophagogastric region; 2) patients with HH and LEMR had a higher frequency of abnormal pHM, although the two groups were not significantly different; and 3) an etiological relationship of LEMR and gastroesophageal reflux was not supported, other than its association with HH.
Esophagogastric Junction↗
Fate of liposuctioned and purified autologous fat injections in the canine vocal fold.
Injection of autologous fat obtained by liposuction has been reported as an augmentation technique for vocal fold paralysis. Unfortunately, it is not known whether this technique is associated with long-term graft survival. The purpose of this study, using a canine model, was to determine the volume of viable injected fat grafts when the tissue was harvested and processed by two different methods: 1. by liposuction alone, and 2. by "purification," i.e., excision of adipose tissue, followed by tissue homogenization and centrifugation in a buffering solution. The results of this study confirm that injected fat grafts survive long-term; however, the average volumetric "take" was only about 20%. Surprisingly, significantly more liposuctioned fat survived than grafts prepared by the purification method (P < .05). At 12 weeks, there was relatively little inflammation present in the tissues surrounding the injected fat, suggesting a stable fat graft volume.
Adipose Tissue↗
The cricothyroid muscle does not influence vocal fold position in laryngeal paralysis.
The status of the cricothyroid muscle, which is innervated by the superior laryngeal nerve, is believed to influence the vocal fold position in laryngeal paralysis. It is believed that isolated lesions of the recurrent laryngeal nerve generally result in the paralyzed vocal fold assuming a paramedian position but that with lesions of both the superior and recurrent laryngeal nerves, a more lateral (intermediate or cadaveric) vocal fold position can be expected. Twenty-six consecutive patients with unilateral vocal fold paralysis underwent transnasal fiberoptic laryngoscopy (TFL) and laryngeal electromyography (LEMG). By TFL, the vocal fold positions were paramedian in 8 patients, intermediate in 7, and lateral in 11. By LEMG, 13 patients had isolated recurrent laryngeal nerve lesions and 13 patients had combined (superior and recurrent laryngeal nerve) lesions. There was no correlation between the vocal fold position and the status of the cricothyroid muscle, i.e., the status of the cricothyroid muscle by LEMG did not predict the vocal fold position nor did the vocal fold position by TFL predict the site of lesion. In addition, we investigated the possibility that the degree of thyroarytenoid muscle recruitment (tone) might correlate with vocal fold position, but no relation was found. We conclude that 1. the cricothyroid muscle does not predictably influence the position of the vocal fold in unilateral paralysis; 2. thyroarytenoid muscle recruitment (tone) does not appear to influence vocal fold position; and 3. still unidentified and unknown factors may be responsible for determining vocal fold position in laryngeal paralysis.
Adolescent↗