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PubMed2006

Current status of fine needle aspiration for thyroid nodules.

When not to perform fine needle aspiration of a thyroid nodule In summary, FNA of thyroid nodules has become one of the most useful, safe, and accurate tools in the diagnosis of thyroid pathology. Thyroid nodules that should be considered for FNA include any firm, palpable, solitary nodule or nodule associated with worrisome clinical features (rapid growth, attachment to adjacent tissues, new hoarseness, or palpable lymphadenopathy). FNA should also be performed on nodules with suspicious ultrasonographic features (microcalcifications, rounded shape, predominantly solid composition); dominant or atypical nodules in multinodular goiter; complex or recurrent cystic nodules; or any nodule associated with palpable or ultrasonographically abnormal cervical lymph nodes. Finally, FNA should be performed on any abnormal-appearing or palpable cervical lymph nodes. The management of thyroid nodules based on FNA findings is summarized in Table 2. It can be argued that in certain circumstances the results of thyroid FNA do not change the surgical management of a thyroid nodule, and thus preoperative FNA may be unnecessary. These cases include solitary nodules in patients who have a strong family history of thyroid cancer, multiple endocrine neoplasia type II, or radiation to the head and neck. These patients when they have thyroid nodules have at least a 40% risk for thyroid cancer and frequent multifocal or bilateral disease and should undergo total thyroidectomy with or without central neck lymph node dissection. Patients who have multinodular goiter and compressive symptoms, patients who have Graves disease and a thyroid nodule, or patients who have large (greater than 4 cm) or symptomatic unilateral thyroid nodules could also be considered for total thyroidectomy or lobectomy as indicated without preoperative FNA. Finally, patients who have a solitary hyperfunctioning nodule on radioiodine scan and a suppressed TSH have an extremely low incidence of malignancy and may be considered for therapeutic thyroid lobectomy or radioiodine ablation as indicated without undergoing FNA biopsy.

Adenoma, Oxyphilic↗
PubMed1995

Laser ablation of recurrent laryngeal papillomas in children.

Papillomas are the most common laryngeal tumors in childhood, and their etiology is thought to be viral. Papillomatosis (ie, widespread, multiple papillomas) may involve a child's airway from the epiglottis to the bronchi. Hoarseness is an early sign of juvenile laryngeal papillomas (JLP), and airway obstruction is a later, life-threatening sign. The recurrence and spread of JLP is common. An otorhinolaryngologist may perform a tracheostomy on a child with JLP; however, this procedure is avoided if possible, because a tracheostomy predisposes the trachea to papilloma seeding. Laser ablation of papillomas through the use of rigid endoscopic equipment and a carbon dioxide laser is the mainstay of therapy.

Adolescent↗
PubMed2003

[Laryngeal sarcoidosis: a case report].

Sarcoidosis is a chronic multisystemic granulomatosis of unknown etiology that affects mainly young adults. It characterized by bilateral hiliar adenopathies interstitial pulmonary infiltrate, and cutaneous and ocular lesions. Localization in upper respiratory tract is infrequent. In the present report we describe a 26-year-old male with a three-month history of a globus sensation, hoarse voice, loud snoring and obstructive sleep apnoea, because of a laryngeal noncaseating granulomatous infiltration. The diagnosis is made through the history, the radiology and the pathological examination. Treatment is symptomatic, due to its tendency to a spontaneous regression. The treatment is based on corticosteroids by systemic or aerosol routes. Micro surgical excision and tracheotomy may be useful in selected patients.

Adult↗
PubMedDate not supplied

[Treatment of laryngeal granuloma with anti-extraesophageal reflux medication].

OBJECTIVE: To asses the role of Gastroesophageal reflux in the genesis of laryngeal granulomas. PATIENTS AND METHODS: Prospective series of 7 patients diagnosed of posterior laryngeal granuloma, 5 were male, and 2 female, ages ranging between 46 and 65 years, (only three with symptoms of gastroesophageal reflux), who followed an antireflux protocol (recommendations, omeprazol 20 mg, cisapride 20 mg, almagato 4000 mg daily). RESULTS: All cases did well, showing complete healing of the larynx 60 days after the beginning of treatment. CONCLUSIONS: Gastroesophageal reflux is an important factor in the genesis of posterior laryngeal granulomas. It seems appropriate to start an antireflux regimen before surgery, which can be chosen for non responders or cases with severe respiratory symptoms, hoarseness, or for definitive diagnosis.

Aged↗
PubMed2006

[Amyloidosis in the ORL field].

OBJECTIVES: To review the clinical and pathological characteristics of upper aerodigestive tract amyloidosis with particular attention to laryngeal amyloidosis. Amyloidosis of the upper aerodigestive tract is relatively rare. The larynx is the most common site of involvement in head and neck isolated amyloidosis and the supraglottic region represents the major site of involvement. MATERIAL AND METHODS: Retrospective review of 6 patients diagnosed with upper aerodigestive tract amyloidosis. Hoarseness and airway compromise were the main presenting symptoms. RESULTS: Laryngeal CO2 laser microsurgery was performed and then we refered the patients to the Medical Deparment seeking for systemic involvement and ENT Clinic follow up. CONCLUSIONS: In our experience, laryngeal CO2 laser microsurgery is a succesfull way to treat isolated laryngeal amyloidosis with clinical improvement and low recurrence rates.

Adult↗
PubMed2005

[Lipoid proteinosis].

Lipoid proteinosis is an infrequent disease characterized by the deposition of a PAS-positive diastase-resistant hyaline material in the skin and respiratory tract, although it can also be deposited in internal organs, in a generally asymptomatic manner. The earliest clinical manifestation is hoarseness. Clinical cutaneous manifestations come later, in the form of hyperkeratotic lesions located on the trunk, elbows, axillae, groins, backs of hands, palms and soles. A lesion typical of the disease is moniliform blepharosis, which consists of beaded papules along the eyelid margins. Also characteristic is the presence of comma-shaped intracranial calcifications in the temporal lobes. The course of the disease is progressive, with a normal life expectancy. It affects men and women equally, with worldwide distribution. The diagnosis is based on the clinical symptoms and the histology. At this time, there is no effective treatment for the disease. We present a case of lipoid proteinosis in a 23-year-old woman, with typical clinical and histological characteristics.

Adult↗
PubMed2003

Vocal cord paralysis after transcatheter coil embolization of patent ductus arteriosus.

BACKGROUND: In patients with patent ductus arteriosus (PDA) after Gianturco coil embolization, vocal cord paralysis (VCP) had not been previously described. This study investigates the risk factors of coil embolization associated with VCP. METHODS: We reviewed the medical records of all patients who had undergone transcatheter closure of PDA with a Gianturco coil between March 1998 and May 2001, and 75 patients (age range, 6 months to 55 years; mean age, 5.5 years) were identified. The procedure was performed with local anesthesia and with sedation in some young children. No patient required general anesthesia or endotracheal intubation. RESULTS: Three of the 75 patients had hoarseness caused by VCP after coil embolization. Patients with VCP had a longer ductus length (P <.01) and a smaller ductus diameter (P <.01) than patients without VCP. The pathogenesis of VCP may be caused by tense stretching and angulation of the ductus arteriosus induced by the implanted coil, which leads to compression injury of the adjacent left recurrent laryngeal nerve. CONCLUSIONS: A long ductus length (> or =12 mm) and a small ductus diameter (<1 mm) are significant risk factors of VCP after coil embolization in children <1 year of age. We recommend that coil embolization be performed very carefully in patients with PDA.

Adolescent↗
PubMed2001

Laparoscopic antireflux surgery for supraesophageal complications of gastroesophageal reflux disease.

Gastroesophageal reflux disease can result in such supraesophageal complications as hoarseness, sore throat, cough, bronchitis, asthma, recurrent pneumonia, intermittent choking, chest pain, and ear pain. Appropriate patient care involves careful evaluation to decide on medical or surgical therapy. Preoperative testing must include endoscopy, 24-hour esophageal pH monitoring, and esophageal manometry. Additional evaluations, such as barium swallow, chest x-ray, bronchoscopy, and sinus radiographs, may be required. Medical treatment improves gastroesophageal reflux and supraesophageal symptoms. However, surgical therapy seems to provide better long-term results. A profile that predicts the best response to medical therapy has not been identified, although the best results with surgery are achieved in patients with nocturnal asthma, onset of reflux before pulmonary symptoms, laryngeal inflammation, and a good response to medical treatment.

Fundoplication↗
PubMed2001

Pharyngeal pH measurements in patients with respiratory symptoms before and during proton pump inhibitor therapy.

BACKGROUND: Pharyngeal pH monitoring is a diagnostic tool used to identify Gastroesophageal reflux disease (GERD) as an etiology of respiratory symptoms. We performed pharyngeal pH monitoring on 14 patients with respiratory symptoms thought to be induced by GERD. METHODS: Symptoms and pH monitoring (esophageal and pharyngeal) were assessed prior to and 3 months after the initiation of double-dose proton pump inhibitor therapy. RESULTS: Symptoms included cough, hoarseness, and throat clearing. Ten patients had at least one episode of pharyngeal reflux (PR+) and 4 patients had no pharyngeal reflux (PR-). Pharyngeal reflux episodes in PR+ patients decreased from 3.5 to 0.9 (P <0.05) per day with 8 of 10 (80%) patients having elimination or reduction of such episodes. Eight of 9 PR+ patients (89%) with suppressed pharyngeal reflux on medical therapy had resolution of respiratory symptoms. Three of 4 PR- patients (75%) had persistent symptoms on medical therapy. CONCLUSIONS: Proton pump inhibitor therapy improves clinical symptoms and decreases pharyngeal reflux episodes in patients with respiratory symptoms related to GERD. Direct measurement of pharyngeal pH is helpful in the identification of patients likely to respond to antireflux therapy.

Anti-Ulcer Agents↗
PubMed2002

Effects of antireflux procedures on respiratory symptoms.

BACKGROUND: Antireflux surgery can reduce respiratory symptoms associated with gastroesophageal reflux. However, there is a paucity of data on the durability of this benefit. To evaluate the long-term effects of antireflux surgery on respiratory complaints associated with gastroesophageal reflux, we reviewed our experience. METHODS: Retrospective review of 2,123 antireflux procedures completed between 1986 and 1998 identified 65 patients (3.1%) with associated respiratory symptoms. There were 32 men and 33 women, ranging in age from 20 to 80 years (median 59 years). Respiratory symptoms included wheezing in 43 patients, sputum production in 37, cough in 30, choking episodes in 24, and hoarseness in 17. Preoperative medication use included steroids in 23 patients and bronchodilators in 18. RESULTS: Antireflux operations included the uncut Collis-Nissen fundoplication in 29 patients, Belsy Mark IV repair in 13, open Nissen fundoplication in 13, and laparoscopic Nissen fundoplication in 10. Perioperative complications occurred in 19 patients who underwent open procedures and in none who had laparoscopic procedures. There was one death in the open-operation group and none in the laparoscopic group. Median follow-up was 65 months (range 1 to 174 months) and was complete in 62 patients (96.9%). Improvement in respiratory symptoms (83%) and reduction in-respiratory medication use (78%) were significant as compared to a calculated 33% placebo-effect improvement (p < 0.05). CONCLUSIONS: Antireflux operations significantly reduce respiratory complaints associated with gastroesophageal reflux. This benefit appears to be long term.

Adult↗
PubMed1982

Esophagectomy: definitive treatment for esophageal neuromotor dysfunction.

Twenty-two patients with a history of between one and four (average of two) unsuccessful prior esophageal operations for neuromotor dysfunction were treated with esophageal resection and replacement. Eleven (50%) had recurred reflux esophagitis in association with various disorders of motility: esophageal spasm in 4, achalasia in 3, scleroderma in 2, and esophageal atresia in 2. Eight (36%) had primary esophageal spasm and 3 (14%) had achalasia. Esophageal obstruction, regurgitation, and severe spasm were the most common manifestations of the inability to swallow normally. Transthoracic or transhiatal (blunt) esophagectomies were performed in 5 and 17 patients, respectively. The stomach, with a cervical esophagogastric anastomosis, was used for esophageal substitution in 15 patients. Six patients underwent a long-segment colonic interposition, and 1 patient with achalasia underwent a distal esophagectomy and short-segment colonic interposition. One patient undergoing transthoracic esophagectomy for achalasia died from unrecognized intraoperative bleeding into the opposite chest. There were no other operative deaths. Additional complications included transient hoarseness in 8 patients, chylothorax in 1, and anastomotic leak in 1. After an average follow-up of 25 months for the 21 surviving patients, ability to eat is regarded as good in 18 (85%), fair in 1 (5%), and poor in 2 (10%). In patients with incapacitating esophageal neuromotor disease, a more radical operative approach-esophagectomy--may be safer and more reliable than attempting another procedure and risking another failure. Esophagectomy ensures definitive elimination of the esophageal problem and as optimal an ability to eat as possible. Our experience suggests that the stomach, with a cervical esophagogastric anastomosis, offers a better functional esophageal substitute than does a colonic interposition.

Adult↗
PubMed1997

Mediastinal parathyroid cysts.

BACKGROUND: Mediastinal parathyroid cysts are a relatively rare clinical entity. The clinical presentation can be quite varied, although most are found incidentally during investigations for esophageal or respiratory symptoms. METHODS: We present a review of the literature and describe two instructive cases showing specific clinical findings. The clinical presentation, radiologic and pathologic findings, and treatment of mediastinal parathyroid cysts are discussed. RESULTS: In the first patient, the presenting symptom was increasing hoarseness resulting from paresis of the right recurrent laryngeal nerve. This case illustrates the rare association of a benign mediastinal parathyroid cyst with unilateral vocal cord palsy. The second patient presented with the more classic findings of progressive dyspnea and stridor related to tracheal compression. CONCLUSIONS: Although mediastinal parathyroid cysts are rare and can have varied presentations, thorough investigation can reveal the underlying cyst. Surgical excision is the treatment of choice and can be expected to produce excellent results.

Aged↗
PubMed1997

Extension of the "elephant trunk" technique in complex aortic pathology: the "bidirectional" option.

BACKGROUND: The "elephant trunk" technique, using a free-floating vascular prosthesis, was originally described to facilitate a subsequent operation on the downstream aorta. We developed an additional refinement of this technique, called the "bidirectional elephant trunk." This option may represent an interesting tool in more complex aortic operations, especially when the descending aorta has to be replaced first in patients with concomitant pathology of the ascending aorta or of the aortic arch. METHODS: The initial operation is performed through a left thoracotomy. The proximal elephant trunk is created by invaginating the future aortic arch graft into the descending aortic graft. The proximal anastomosis between the doubled graft and the proximal descending aorta is performed first. During construction of the distal anastomosis, a distal elephant trunk may be inserted likewise. If the aortic arch and ascending aorta have to be replaced later, this second step is performed through a median sternotomy. The free-floating arch graft is pulled out of the proximal descending aorta with a nerve hook, unfolded, and used for total arch replacement. RESULTS: This technique was used successfully in 3 patients without mortality. No major complications were observed excepted persistent hoarseness in a patient with preoperative paresis of the recurrent nerve. No perfusion problems due to the unfolding of the free-floating graft occurred during the second operation. CONCLUSIONS: The bidirectional elephant trunk technique is an interesting option that may be suitable for patients presenting with a complex pathology of the whole thoracic aorta when the descending segment has to be replaced first.

Anastomosis, Surgical↗
PubMed1997

Dysphagia complications of the Minerva brace.

The effects of cervical bracing on swallowing function have not been evaluated in neurologically intact individuals. An 83-year-old woman fell, striking her head, and suffered C1, odontoid, and C3 fractures. She had no neurologic deficits and was placed in a Minerva brace. Subsequently, she developed coughing during her meals, a low-grade fever, and transient hoarseness, and complained of stiffness in the facial muscles. Aspiration pneumonia in the left lower lobe was diagnosed. In the absence of any neurologic condition, this was attributed to the Minerva brace. Less than 1 week later, the brace was replaced with a halo-vest, and the dysphagia resolved. This case shows that dysphagia and aspiration pneumonia may be caused by wearing a cervical brace and illustrates the importance of assessing swallowing in individuals who wear such braces. Particular attention should be paid to swallowing and cervical bracing in patients with additional risk factors for dysphagia such as advanced age or neurologic deficits.

Aged↗
PubMed1997

Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota.

BACKGROUND & AIMS: Gastroesophageal reflux is considered a common condition, but detailed population-based data on reflux in the United States are lacking. The aim of this study was to determine the prevalence and clinical spectrum of gastroesophageal reflux in Olmsted County, Minnesota. METHODS: A reliable and valid self-report questionnaire was mailed to an age- and sex-stratified random sample of 2200 Olmsted County residents aged 25-74 years. RESULTS: The prevalence per 100 of heartburn and/or acid regurgitation experienced at least weekly was 19.8 (95% confidence interval [95% CI], 17.7-21.9). Heartburn and acid regurgitation were associated with noncardiac chest pain (odds ratio [OR], 4.2; 95% CI, 2.9-6.0), dysphagia (OR, 4.7; 95% CI, 2.9-7.4), dyspepsia (OR, 3.1; 95% CI, 1.9-5.0), and globus sensation (OR, 1.9; 95% CI, 1.0-3.6) but not with asthma, hoarseness, bronchitis, or a history of pneumonia. Among subjects with reflux symptoms, 1.0% reported an episode of hematemesis and 1.3% had a past esophageal dilatation. CONCLUSIONS: Symptoms of reflux are common among white men and women who are 25-74 years of age. Heartburn and acid regurgitation are significantly associated with chest pain, dysphagia, dyspepsia, and globus sensation. The percentage of patients reporting complications is low, but the absolute number is probably considerable given the high prevalence of the condition in the community.

Adult↗
PubMedDate not supplied

Acoustic correlates of dysphonia: type and severity.

The purpose of this study was to explore the acoustic discrimination and graded severity of three clinical voice types. Listeners classified 102 samples of dysphonic vowels /a/ and /i/ on the basis of voice types: breathy, hoarse, and strained. The vowels were analyzed acoustically with two measures of perturbation and 2 measures of spectral noise. Discriminant analysis showed that apriori, acoustic classifications of voice type were made with 92% accuracy using four acoustic parameters: (a) cepstral peak prominence (CPP), (b) jitter standard deviation (SD-J), (c) fundamental frequency (F0), and (d) standard deviation of signal-to-noise ratio (SD-SNR). Findings suggest that voice type is associated with the interaction of spectral noise, fundamental frequency, and signal irregularity, and that dysphonic severity is associated with similar parameters, regardless of voice type.

Adolescent↗
PubMed1981

Electrocardiographic changes induced by the stellate ganglion block in normal subjects.

In order to examine the laterality of the sympathetic control of the human heart, electrocardiographic changes induced by a unilateral stellate ganglion block (SGB) were observed. 10ml of 1% lidocaine was used for the block and post-block ECG was recorded just after the appearance of Horner's sign. Patients who developed vocal hoarseness were excluded. 15 recordings of 14 subjects with right SGB and 16 recordings of 12 subjects with left SGB were used for analysis. A significant increase in the P-P interval from 0.90 +/- 0.17 sec to 0.96 +/- 0.16 sec. was observed only with right SGB and the predominance of the right side in the sympathetic nervous control of the human heart was thus demonstrated. The atrioventricular conduction time was not affected by either the right or left SGB. The QTc was slightly but significantly prolonged only by the right SGB, from 0.40 +/- 0.04 sec. to 0.43 +/- 0.04 sec. This prolongation was not large enough to support a definite conclusion and further investigations should be made.

Adult↗
PubMed1997

Instability of voice in adolescence: pathologic condition or normal developmental variation?

OBJECTIVE: Pediatricians often send adolescents with dysphonia to the otorhinolaryngologist's office to find the reason for their hoarseness. The aim of this study was to identify the main characteristics of adolescent voice and to determine which characteristic (variable of voice analysis) can distinguish normal variations of voice development from pathologic disorders. STUDY DESIGN: On the basis of history, indirect laryngoscopy, and stroboscopy, 51 adolescents (22 boys, 29 girls) from age 10 to 17 years were divided into four subgroups: candidates for singing lessons without voice problems, subjects with mutation voice disorders, subjects with functional dysphonia, and subjects with vocal cord nodules. Voice analysis by Multi-Dimensional Voice Program (Kay Elemetrics) evaluated the fundamental frequency, the variability of pitch and amplitude (loudness), and the presence of noise in the analyzed voice sample of each of the subjects. Data were analyzed with the SPSS+/PC Statistical Program. RESULTS: All mean values of variables that describe variability of pitch and amplitude were abnormal in boys and in girls, with greater abnormality among boys. The variability of loudness and specifically the variability of pitch were abnormal in a majority of subjects. A significant negative correlation between age and fundamental frequency was stated in boys only and between age and variability of amplitude in girls only. Variables that express variability of pitch and amplitude correlated positively between themselves. No significant differences were found between the first subgroup (candidates for singing lessons), which represented a normal population, and the other three subgroups (subjects with mutational disorders, functional dysphonia, and vocal cord nodules). In addition, no significant differences were found between the first three subgroups (subjects without voice problems and subjects with functional voice disorders) and the fourth subgroup (subjects with vocal cord nodules: organic lesion of laryngeal mucosa). CONCLUSIONS: According to this study, the main characteristic of adolescent voice is the instability of amplitude (loudness) and specifically the instability of pitch. Female voices appear more stable than male voices. No single variable of performed voice analysis can distinguish normal variation of voice development from pathologic disorders. The reason for this instability can be attributed to more gradual adaptation of the afferent and efferent nervous control to the rapid growth of the phonatory, respiratory, and resonatory organs. In the growing speech apparatus, optimal phonatory patterns can be created; therefore adolescence is an ideal period for treatment of functional voice disorders.

Adolescent↗