Biomedical subjects

S M Zeitels

Publications and source records attributed to S M Zeitels.

At least 19 recordsLinked to original sources

PubMed1998

Chevalier Jackson's contributions to direct laryngoscopy.

Chevalier Jackson championed rigid endoscopy of the upper aerodigestive tract and facilitated its development and popularity at the beginning of the 20th century. He realized that endoscopy and open surgery are inextricably linked for effective management of diseases of the upper air and food passages. Toward this end, Jackson contributed a number of important innovations to direct laryngoscopy, while developing a unique mastery of the technique. Ultimately, he combined this endoscopic proficiency with open surgical techniques.

History, 19th Century↗

PubMed1998

Infrapetiole exploration of the supraglottis for exposure of the anterior glottal commissure.

Effective microlaryngoscopic surgery of the anterior glottal commissure depends on adequate exposure of this region. Despite the use of elevated vector suspension and external laryngeal counter-pressure, there are some individuals in whom inadequate exposure precludes execution of the planned surgery. To solve this problem, a procedure was designed in which the anterior vestibular folds and the infrapetiole region of the supraglottis are resected to facilitate complete exposure of the Broyle's ligament. The microspot carbon-dioxide laser is used with cold instruments to resect the anterior vestibular folds and thyroepiglottic ligament in continuity. After this tissue is removed, external counter-pressure then provides clear visualization of the anterior-superior thyroid lamina as well as the superior surface of the anterior commissure of the glottis. This procedure was used in ten cases in which the pathology included carcinoma, keratosis with atypia, and papillomatosis. This approach allows for a clear determination about whether early glottic cancer has invaded the thyroid lamina (T1 versus T4) without altering the structural integrity of Broyle's ligament, which avoids significant impairment of the voice. The exposure also allowed for en-block endoscopic resection of two anterior commissure carcinomas. Endoscopic resection of the infrapetiole region and anterior vestibular folds provides a gateway to the superior surface of the anterior glottal commissure. Furthermore, the procedure establishes an effective means to assess the depth of invasion of epithelial neoplasia to the underlying cartilage framework, as well as to facilitate en-block resection of carcinoma if it is appropriate.

Carcinoma, Squamous Cell↗

PubMed1998

Soft-palate reconstruction with a "SCARF" superior-constrictor advancement-rotation flap.

Reconstruction of hemi-soft-palate defects after tumor resection is usually done by means of a regional flap, free-tissue transfer or a prosthesis. These options vary in complexity and have a number of shortcomings. A local myomucosal flap was designed that employs a superior-constrictor advancement-rotation flap (SCARF) to achieve circumferential closure of the velopharynx and to re-establish its valvular sphincteric function. Ten patients underwent a SCARF reconstruction of the velopharynx after 35% to 65% of the soft palate was resected. All patients re-established normal velopharyngeal function without significant phonatory or deglutitive disability. Two patients did require a second-stage reinforcement of the suture line after partial dehiscence. The SCARF reconstruction of the soft palate is simple, fast, and reliable and there is no significant donor site morbidity. Patients resume oral intake earlier than standard reconstructive approaches. The SCARF can be done transorally, which allows for primary resection and discontinuous neck dissection. These factors facilitate short hospitalization and effective use of resources.

Humans↗

PubMed1998

Assessment of vocal function using simultaneous aerodynamic and calibrated videostroboscopic measures.

Despite many attempts to model how vocal fold movements relate to the aerodynamic forces acting on them during phonation, there have been few simultaneous measurements of glottal area and transglottal air pressures and flows. A novel system is described that combines endoscopic measurement of glottal area with aerodynamic flow and pressure measures made during phonation. Results from bench top model tests and from one human subject are presented. For both tests, an aerodynamic model of airflow through a constriction was used to predict the area of the constriction (glottis), and these predictions were compared with endoscopic measurements. The results showed good correlation between predicted and observed areas; however, for small constrictions (<0.025 cm2), whether artificial or glottal, the errors in estimating areas with either optical or aerodynamic methods increase significantly. These results suggest that this measurement system has the potential to enhance the assessment of vocal function.

Adult↗

PubMed1998

Outcomes of atypical symptoms attributed to gastroesophageal reflux treated by laparoscopic fundoplication.

BACKGROUND: The introduction of laparoscopic fundoplication (LF) has lowered the threshold for operation in patients with symptoms attributed to gastroesophageal reflux. We sought to determine whether the outcomes in patients referred for atypical symptoms (pulmonary, pharyngolaryngeal, and pain syndromes) were as good as those referred for correction of heartburn and regurgitation (typical symptoms). METHODS: Thirty-five of 150 consecutive patients undergoing LF with a minimum of 12 months of follow-up were referred primarily for correction of atypical symptoms. A standard preoperative evaluation included endoscopy, manometry, upper gastrointestinal contrast radiography, and 24-hour pH probe testing (33 of 35 patients with atypical symptoms). Patients completed a symptom questionnaire administered by a study nurse before the operation and 3 and 12 months after the operation. Symptoms were scored from 0 to 10. RESULTS: Heartburn was relieved by LF in 93% of patients, whereas only 56% of patients had relief of atypical symptoms. Furthermore, the degree of improvement in typical symptoms was greater than that seen for atypical symptoms as measured by the 0 to 10-symptom rating score (improvement in typical symptoms = 6.2 vs improvement in atypical symptoms = 4.4 [p = 0.01]). The response rate for laryngeal, pulmonary, and epigastric/chest pain symptoms was 78%, 58%, and 48%, respectively. Analysis of factors associated with relief of atypical symptoms revealed that response to a preoperative trial of omeprazole or H2-blockers was significantly associated with successful surgical outcome (p = 0.03). Six of seven patients with laryngeal symptoms who had acid reflux above the cricopharyngeal level shown by dual-probe pH testing had relief of the symptoms after LF. Manometric findings (amplitude of esophageal body contractions, propagation of contractions, and lower esophageal sphincter resting pressure) neither predicted nor correlated with relief of atypical symptoms after the operation. CONCLUSIONS: Relief of atypical symptoms attributed to gastroesophageal reflux by LF is less satisfactory and more difficult to predict than relief of heartburn and regurgitation. The only useful preoperative predictors of relief of atypical symptoms in this study were the response to pharmacologic acid suppression and dual-probe pH testing (only in patients with laryngeal symptoms).

Adult↗

PubMed1998

Adduction arytenopexy: a new procedure for paralytic dysphonia with implications for implant medialization.

Arytenoid adduction was designed to enhance posterior glottal closure in patients with paralytic dysphonia by reproducing lateral cricoarytenoid muscle function. However this procedure can exaggerate normal medial rotation of the vocal process, because the agonist-antagonist function of the interarytenoid, lateral thyroarytenoid, and posterior cricoarytenoid muscles is not simulated. Therefore, a new adduction procedure (adduction arytenopexy) was devised to affix the arytenoid on the cricoid facet in a more optimal position for glottal sound production. The adduction arytenopexy procedure was designed on fresh cadavers. In this technique, the lateral aspect of the cricoarytenoid joint is opened widely and the body of the arytenoid is manually medialized along the cricoid facet. A specially designed single suture is then placed through the posterior cricoid and the body or the muscular process of the arytenoid to achieve 2-point fixation. This draws the arytenoid posteriorly, superiorly, and medially for precise positioning. The arytenoid is rocked internally on the cricoid facet, and suture tension is adjusted appropriately to simulate normal cricoarytenoid adduction. In the first study, the adduction arytenopexy was compared with the classic arytenoid adduction in 10 fresh cadaver larynges. The new arytenopexy procedure resulted in an average increase of 2.1 mm (p < .01) in the length of the musculomembranous vocal fold, whereas the classic arytenoid adduction did not reveal a significant change in length. Additionally, the adduction arytenopexy resulted in a consistently higher vocal fold and a more normally contoured arytenoid than the classic adduction procedure. The second study consisted of a clinical trial in which 12 patients, who presented with a widely patent posterior glottis, underwent adduction arytenopexy in conjunction with implant medialization. The procedure was successful in all patients, and there were minimal complications. In the third study, preoperative and postoperative vocal assessment measures (stroboscopic, aerodynamic, acoustic, and perceptual) were analyzed in 9 of the 12 patients. The most striking preoperative stroboscopic observation was that 8 of the 9 patients presented with an aperiodic vibrational flutter during phonation due to severe valvular incompetence. Postoperatively, all patients developed complete closure of the glottal chink and effective entrained oscillation of the vocal folds. This visual improvement in function was commensurate with comparable changes in most of the other objective and subjective measures of vocal function. The new adduction arytenopexy procedure closely simulates the biomechanics underlying normal glottal closure and cricoarytenoid adduction. In turn, complex implant design shapes are not necessary to achieve proper alignment of the arytenoid and the vocal fold. Because the arytenoid is properly positioned prior to the medialization, implants can be sized more precisely and are unencumbered by an anterior thyroid lamina suture. These procedural innovations resulted in enhanced entrained oscillation of the glottal valve and, in turn, improved laryngeal sound production.

Cadaver↗

PubMed1997

Jacob Da Silva Solis-Cohen: America's first head and neck surgeon.

Jacob Da Silva Solis-Cohen was a Renaissance physician and healer, who possessed great technical and intellectual skills. He was a self-made specialist in aerodigestive tract disease at a time when this was generally perceived as charlatanism. Unlike his contemporaries in laryngology, he was a trained surgeon, and he believed strongly that the laryngologist should be capable of doing his own surgery. Solis-Cohen was not a general surgeon who did work in the head and neck, but rather the first general surgeon who became a specialist in diseases of the upper air and food passages. His educational development is the model by which today's conventional paradigm in the training of Head and Neck Surgeons is designed. He fathered a medical and surgical specialty in America from its infancy in the 19th century until it was firmly grounded in the beginnings of this century. Just as Mosher was known as the "Chief" in the first half of this century, Jacob Da Silva Solis-Cohen had been designated the "Nestor" and "Chief" in laryngology many decades earlier. He died 2 months shy of 90 years on December 22, 1927.

History, 19th Century↗

PubMed1997

Reinke's edema: phonatory mechanisms and management strategies.

Reinke's edema (RE) has been associated typically with smoking and sometimes with vocal abuse, but aspects of the pathophysiology of RE remain unclear. To gain new insights into phonatory mechanisms associated with RE pathophysiology, we used an integrated battery of objective vocal function tests to analyze 20 patients (19 women) who underwent phonomicrosurgical resection. Preoperative stroboscopic examinations demonstrated that the superficial lamina propria is distended primarily on the superior vocal fold surface. Acoustically, these individuals have an abnormally low average speaking fundamental frequency (123 Hz), and they generate abnormally high average subglottal pressures (9.7 cm H2O). The presence of elevated aerodynamic driving pressures reflects difficulties in producing vocal fold vibration that are most likely the result of mass loading associated with RE, and possibly vocal hyperfunction. Furthermore, it is hypothesized that in the environment of chronic glottal mucositis secondary to smoking and reflux, the cephalad force on the vocal folds by the subglottal driving pressure contributes to the superior distention of the superficial lamina propria. Surgical reduction of the volume of the superficial lamina propria resulted in a significant elevation in fundamental frequency (154 Hz) and improvement in perturbation measures. In almost all instances, both the clinician and the patient perceived the voice as improved. However, these patients continued to generate elevated subglottal pressure (probably a sign of persistent hyperfunction) that was accompanied by visually observed supraglottal strain despite the normal-sized vocal folds. This finding suggests that persistent hyperfunctional vocal behaviors may contribute to postsurgical RE recurrence if therapeutic strategies are not instituted to modify such behavior.

Edema↗

PubMed1997

Surgical management of early supraglottic cancer.

Surgical management of early supraglottic cancer has evolved over the last half of the century from total laryngectomy to inclusion of conservation approaches. The development and fundamental principles underlying open supraglottic laryngectomy and endoscopic supraglottic resections are reviewed. In doing so, a rational approach for the application of these surgical techniques is provided for management of both the primary site and the neck.

Combined Modality Therapy↗

PubMed1996

Phonomicrosurgical treatment of early glottic cancer and carcinoma in situ.

BACKGROUND: In recent years, transoral resection of early glottic cancer has developed into a phonomicrosurgical approach that resulted from the convergence of microlaryngoscopic surgical technique theory with body cover mucosal wave theory of voice production. The vocal outcome from these procedures has improved by minimizing the deep resection margin and thereby maximizing the preservation of the vocal folds' normal layered microstructure (laminae propria and epithelium). Recurrence and cure rates from this narrow-margin approach were examined. METHODS: The phonomicrosurgical resection approach is composed of four basic procedures in which there is an increasing depth of resection to accommodate a narrow-field deep cancer margin. This approach was employed to treat 13 T1 cancers and 7 with carcinoma in situ (CIS). RESULTS: No patients who underwent a cancer resection developed a recurrence. Minimum follow-up on these patients was 2 years and the mean follow-up was 42 months. In the group with CIS, 2 patients developed microinvasive carcinoma despite en bloc excision of the CIS. Both were successfully treated; 1 was resected transorally and the other underwent radiation therapy. CONCLUSIONS: This study indicates that the phonomicrosurgical approach, which incorporates a narrow deep cancer margin to enhance the postoperative vocal outcome, resulted in standard control and cure of early glottic neoplasia.

Carcinoma in Situ↗

PubMed1996

Laser versus cold instruments for microlaryngoscopic surgery.

Controversy has arisen concerning the merits of the CO2 laser in microlaryngoscopic surgery because of the potentially harmful effects that the injudicious application of the laser could have on voice production. In an effort to develop a logical approach to instrument selection, the author examined the use of both cold instruments and the CO2 laser in the treatment of various benign and malignant lesions. A retrospective review of 307 microlaryngeal procedures performed over a 3-year period revealed that 263 (86%) were glottal and 44 (14%) were supraglottal. Of the 263 glottal procedures, 203 (77%) employed cold instruments alone and 60 (23%) used both cold instruments and the CO2 laser. The laser was used to assist in all 44 supraglottal procedures. Therefore, 203 (66%) of 307 procedures were done with cold instruments alone, and 104 (34%) of 307 procedures were performed using the CO2 laser with cold instruments. Lesions were stratified on the basis of pathology and size, as well as surgical approach. A primary phonomicrosurgical principle in glottal surgery is to maximally preserve the vocal fold's layered microstructure (laminae propria and epithelium). Precise tangential dissection was necessary for achieving this goal. For limited lesions, this dissection was best accomplished with cold instruments alone. The CO2 laser facilitated hemostatic surgical dissection for all supraglottal lesions and for selected larger glottal lesions in which bleeding would obscure visualization of the microanatomy of the musculomembranous vocal fold.

Algorithms↗

PubMed1996

Vocal fold submucosal infusion technique in phonomicrosurgery.

Phonomicrosurgery is optimized by maximally preserving the vocal fold's layered microstructure (laminae propriae). The technique of submucosal infusion of saline and epinephrine into the superficial lamina propria (SLP) was examined to delineate how, when, and why it was helpful toward this surgical goal. A retrospective review revealed that the submucosal infusion technique was used to enhance the surgery in 75 of 152 vocal fold procedures that were performed over the last 2 years. The vocal fold epithelium was noted to be adherent to the vocal ligament in 29 of the 75 cases: 19 from previous surgical scarring, 4 from cancer, 3 from sulcus vocalis, 2 from chronic hemorrhage, and 1 from radiotherapy. The submucosal infusion technique was most helpful when the vocal fold epithelium required resection and/or when extensive dissection in the SLP was necessary. The infusion enhanced the surgery by vasoconstriction of the microvasculature in the SLP, which improved visualization during cold-instrument tangential dissection. Improved visualization facilitated maximal preservation of the SLP, which is necessary for optimal pliability of the overlying epithelium. The infusion also improved the placement of incisions at the perimeter of benign, premalignant, and malignant lesions, and thereby helped preserve epithelium uninvolved by the disorder.

Epinephrine↗

PubMed1996

Phonosurgery.

Phonosurgery is composed of procedures that are intended to maintain or improve the quality of the voice by correcting defects in laryngeal sound production. These procedures are rooted in a rich medical history that dates back to the early 19th century. There has been a recent convergence of physiologic principles of voice production with surgical technique theory. Recognition of this interdependence has provided a catalyst for collaboration among surgeons, scientists, speech pathologists, vocal pedagogists, and performing artists. We live in a society that is linked to effective communication, and there is a growing population of individuals who have professional voice responsibilities as part of everyday life. This has created a need for the recent developments in phonosurgery and its emergence as a subspecialty of otolaryngology.

Botulinum Toxins↗

PubMed1995

Hyoepiglottic ligament in supraglottic cancer.

The hyoepiglottic ligament (HL) is a connective tissue structure that serves as the roof of both the paraglottic and the preepiglottic spaces and thereby anatomically separates the supraglottic larynx from the tongue base. Whole mount serially sectioned larynges with supraglottic cancer were reviewed to help clarify cephalad spread of cancer in this region. The whole mount slides were analyzed from 70 laryngectomy specimens that were resected for supraglottic cancer. The HL was breached by cancer in 13 specimens, and all of these displayed clinical and histopathologic invasion of the preepiglottic and paraglottic spaces. Invasion of the suprahyoid epiglottis was noted in 9 specimens, and invasion of the aryepiglottic fold in 4. There were no instances in which cancer escaped from the deep compartments of the supraglottic larynx to the tongue base without synchronous erosion of the suprahyoid epiglottis (insertion of the medial HL) or the pharyngoepiglottic fold (lateral HL). The HL is a resilient connective tissue barrier to the spread of cancer from the supraglottis to the tongue base. This investigation reinforced the concept that, typically, the HL acts as a deep cephalad surgical boundary in resecting supraglottic cancer that 1) is confined to the laryngeal membranes and 2) does not clinically invade the suprahyoid epiglottis.

Connective Tissue↗

PubMed1995

Premalignant epithelium and microinvasive cancer of the vocal fold: the evolution of phonomicrosurgical management.

Phonomicrosurgical treatment of premalignant vocal fold epithelium and microinvasive cancer combines principles of surgical oncology with advanced laryngoscopic microsurgical-techniques. This treatment is guided by mucosal-wave theory of voice production and strives not only to cure the disease but also to achieve optimal vocal function. Surgical techniques developed during the past two centuries have improved methods for vocal fold visualization, tissue retrieval, and tissue evaluation. Examination of the evolution of these surgical techniques reveals the incomplete convergence of laryngoscopic surgical theory with both the concept of premalignancy and the anatomical-physiological principles of voice production. This historical review, which helps to explain the lack of consensus about current treatment options, led to a series of four investigations. They were conducted with the aim of developing a laryngoscopic (phonomicrosurgical) management approach for improving the treatment of premalignant and microinvasive vocal fold epithelium. In the first of four investigations, 42 patients (each of whom had a significant smoking history) underwent microlaryngoscopic biopsy of 52 vocal fold lesions. These lesions, which were suspicious for atypia or malignancy and were confined to the musculomembranous vocal fold, were mapped according to surface involvement and depth of penetration. Review of the maps revealed that 27 of the 52 lesions involved only the superior/ventricular surface. For these patients, the entire layered vocal fold structure could potentially be preserved on the medial/vocalizing surface. Twenty-five of the 52 lesions involved both the superior/ventricular surface and the medial/vocalizing surface. No lesion involved only the medial surface. These data suggest that (in smokers) geographic localization of keratotic and erythroplastic lesions on the superior/ventricular surface of the musculomembranous vocal fold are likely to contain atypia. This characteristic facilitates the appropriate selection of patients for biopsy and may spare individuals, who have lesions resulting from hyperfunctional dysphonia and/or gastroesophageal reflux, from unnecessary biopsy. These two disorders typically result in pathology on the medial and/or posterior glottal surfaces. In order to determine whether a directed biopsy or an excisional biopsy approach is preferable for obtaining an accurate diagnosis, all specimens underwent whole-mount sectioning for three-dimensional histopathological analysis. Keratosis was noted: without atypia in 14; with atypia in 27; and with carcinoma in 11. The severity of the atypia usually varied throughout each specimen. The surface appearance of the lesion was not a reliable prognosticator of the severity of dysplasia either between patients or in different areas of the same lesion; therefore, excisional biopsy and whole-mount, multiple-section histopathological analysis were necessary for obtaining an accurate diagnosis.(ABSTRACT TRUNCATED AT 400 WORDS)

Biopsy↗

PubMed1994

"External counterpressure" and "internal distention" for optimal laryngoscopic exposure of the anterior glottal commissure.

External laryngeal counterpressure and internal laryngeal distention produce forces that are helpful for enhancing laryngoscopic exposure of the anterior glottis. These principles were formally described in the early 20th century, but are seldom used today. Hand pressure has been the typical source for external counterpressures. Since this maneuver is unstable if provided by an assistant and wasteful if provided by the surgeon, it is often neglected. Current phonomicrosurgical techniques require wider glottal exposure; therefore, a reexamination of the value of external counterpressure and internal distention is worthwhile. During the last 2 years, 125 microlaryngoscopic procedures were performed for a variety of benign, premalignant, and malignant lesions. All patients were placed in the Boyce-Jackson position and sustained with a modified Killian gallows, with resulting elevated-vector suspension. Internal distention was achieved by placing the largest-lumen glottiscope possible between the endotracheal tube and the infrapetiole region. Exposure was also improved by using silk adhesive tape to apply external counterpressure to the lower laryngeal framework. The use of both external counterpressure and internal distention as an adjunct to microlaryngoscopy was most helpful for the surgical management of lesions located near the anterior commissure. Seemingly, the two resultant forces are in opposition to each other, but in fact they are complementary, both to each other and to the orthodox laryngoscopic principle of elevated-vector suspension.

Glottis↗

PubMed1994

Endoscopic treatment of supraglottic and hypopharynx cancer.

Transoral excision of supraglottic and hypopharynx cancer as a single modality is effective when lesions are selected for small size and endoscopic accessibility. Excisional biopsy with clear margins of larger supraglottic tumors in combination with postoperative radiotherapy provides an excellent treatment alternative for selected lesions in patients who are not candidates for open surgery. In this preliminary report, 45 cases using this minimally invasive approach are reviewed outlining oncologic rationale and functional advantages. A large bore tubed laryngoscope or the adjustable bivalve supraglottiscope was used along with a carbon dioxide laser in all cases. In 22 of the 45 patients (mostly T1), local en bloc excision of the primary cancer was performed as sole treatment on selected lesions of the supraglottis and hypopharynx. There were no local recurrences, however, 1 patient developed a neck recurrence and was salvaged by neck dissection. Twenty-three of the 45 patients had more extensive primaries (mostly T2, T3) and N0 necks. Transoral excisional biopsy was followed by full-course radiation therapy to the primary site and both necks. All 23 were followed a minimum of 2 years, and the median follow-up period was 58 months. Clear margins were obtained in 16 of 23, and there were no recurrences in the larynx. Two of 16 did fail in the neck and died despite neck dissection. Seven of 23 patients had positive margins and, despite full-course radiotherapy to the primary site and both necks, 5 of 7 failed locally or regionally. Two of the 7 died of their disease despite open salvage surgery. Therefore, 4 of 23 patients who underwent transoral excision of larger lesions followed by full-course radiotherapy died of recurrent cancer.

Combined Modality Therapy↗

PubMed1991

Suprahyoid pharyngotomy for oropharynx cancer including the tongue base.

Suprahyoid pharyngotomy has been utilized as the standard approach to tongue base cancer not involving the larynx or mandible for the last 6 years at the Department of Veterans Affairs Medical Center, Boston, Mass. Review of 15 patients revealed that all had advanced disease (stage III and stage IV); 14 cases involved the tongue base, and one was on the posterior pharyngeal wall. By following the hyoepiglottic ligament, precise entry into the vallecula was routine. No injuries of vital neurovascular structures or compromised tumor margins were present; one tracheotomy was performed. Primary closure without the use of flaps was accomplished in 14 of 15 patients. No locoregional recurrences were found, with a median follow-up of 25 months. However, two patients died of another unrelated cancer, and two patients died of a myocardial infarction unrelated to their surgery. Suprahyoid pharyngotomy is a familiar approach often utilized during laryngectomy. In our experience, it provides excellent exposure of the oropharynx, can be combined with a transoral approach to avoid mandibulotomy without precluding this option, allows for simple reconstruction, and has a low complication rate.

Follow-Up Studies↗