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PubMed1995

A randomized controlled trial of chronic vagus nerve stimulation for treatment of medically intractable seizures. The Vagus Nerve Stimulation Study Group.

Preliminary reports have suggested that chronic, intermittent stimulation of the vagus nerve (VNS) is an alternative treatment for patients with medically refractory seizures. We performed a multicenter, randomized, controlled trial to evaluate the efficacy and safety of adjunctive VNS in patients with poorly controlled partial seizures. An implanted, programmable pacemaker-like device was connected to two stimulating electrodes wrapped around the left vagus nerve. One hundred fourteen patients were randomized to receive 14 weeks of high-level stimulation (presumed therapeutic dose) or low-level stimulation (presumed subtherapeutic dose) using a blinded, parallel study design. Seizure frequency was compared with a 12-week baseline. Mean reduction in seizure frequency was 24.5% for the "high" stimulation group versus 6.1% for the "low" stimulation group (p = 0.01). Thirty-one percent of patients receiving high stimulation had a seizure frequency reduction of > or = 50%, versus 13% of patients in the low group (p = 0.02). Treatment emergent side effects were largely limited to a transient hoarseness occurring during the stimulation train. One patient with no previous history of cardiac disease experienced a myocardial infarction during the third month of vagal stimulation. VNS may be an effective alternative treatment for patients who have failed antiepileptic drug therapy and are not optimal candidates for epilepsy surgery.

Adult↗
PubMed2000

Effects of vagus nerve stimulation on respiration during sleep: a pilot study.

BACKGROUND: Vagus nerve stimulation (VNS) is associated with respiratory effects such as hoarseness, dyspnea, and laryngeal irritation. The effects of VNS on sleep-related breathing in humans have not been reported previously. METHODS: Four epilepsy patients underwent polysomnography (PSG) before and after 3 months of treatment with VNS. Two of the four patients also underwent follow-up PSG to assess the effects of changing stimulus parameters on sleep-related breathing. RESULTS: All patients showed consistent sleep-related decreases in airflow and effort coinciding with VNS activation, although most events did not meet laboratory criteria for apneas or hypopneas. Apneas and hypopneas were more frequent during VNS activation than during nonactivation. Apnea-hypopnea index (AHI) for three subjects during VNS treatment PSG was <5 apneas and hypopneas/hour. In one patient with obstructive sleep apnea (OSA) before VNS treatment, AHI rose from 4 (pretreatment) to 11.3 (treatment). In this patient and in another patient without clinically significant OSA, lowering stimulus frequency, but not stimulus intensity, pulse width, or on-time, ameliorated VNS-related apneas and hypopneas. CONCLUSIONS: VNS is associated with adverse changes in respiration during sleep. In patients without preexisting OSA, this VNS effect is probably not clinically significant. In patients with preexisting OSA, VNS should be administered with care. Lowering VNS stimulus frequency or prolonging off-time may prevent exacerbation of OSA.

Adult↗
PubMed2001

Vagal nerve stimulation: adjustments to reduce painful side effects.

Vagal nerve stimulation is an approved adjunctive treatment for medically intractable epilepsy. Although it is generally well tolerated, some patients experience pain, coughing, or hoarseness during stimulation. Lowering the pulse width in these patients alleviates pain and reduces voice alteration without loss of efficacy. This allows more optimal programming of stimulation intensities.

Adult↗
PubMed2005

Conventional tracheal tubes for intubation through the intubating laryngeal mask airway.

The laryngeal mask airway (LMA)-Fastrach silicone wire-reinforced tracheal tube (FTST) was specially designed for tracheal intubation through the intubating LMA (ILMA). However, conventional tracheal tubes have been successfully used to accomplish tracheal intubation. We designed this study to evaluate the success rate of blind tracheal intubation through the ILMA by using the FTST, the Rusch polyvinyl chloride tube (PVCT), and the Rusch latex armored tube (LAT). One-hundred-fifty healthy adults of ASA physical status I and II who were undergoing elective surgery under general anesthesia were randomly allocated into three groups. FTST (n=50), prewarmed PVCT (n=50), and LAT (n=50) were used for tracheal intubation. Ease of tracheal intubation was assessed by the time taken, the number of attempts, and the number of maneuvers required for success. In addition, numbers of failed intubation attempts and times taken for ILMA removal were also recorded. After surgery, the incidence of trauma, sore throat, and hoarseness was noted. Significantly more frequent success in tracheal intubation was achieved with the PVCT and FTST (96%) compared with the LAT (82%) (P <0.05). Tracheal intubation on the first attempt was similar with the PVCT and FTST (86%) and was significantly more frequent than with the LAT (52%) (P <0.05). Esophageal placement was significantly more frequent with the LAT (29.7%) when compared with the PVCT and FTST (1.8% and 7.4%, respectively) (P <0.05). The authors conclude that a prewarmed PVCT can be used as successfully as the FTST for blind tracheal intubation through the ILMA, whereas the LAT is associated with more frequent failure and esophageal intubation.

Adult↗
PubMed2005

Alkalinization of intracuff lidocaine: efficacy and safety.

When alkalinized lidocaine instead of air is used to fill the endotracheal tube (ETT) cuff, coughing, and bucking are decreased during extubation when ventilation is controlled with N2O. However, sodium bicarbonate (NaHCO3) used to transform lidocaine hydrochloride (L-HCl) to lidocaine base induces a pH increase that could be irritating for mucosa in the case of cuff rupture. Therefore, we determined, in a randomized controlled study with controlled patient ventilation without N2O, whether the smallest concentrations of NaHCO3 (1.4% versus 8.4%) reduced diffusion (in vitro evaluation) and other secondary clinical benefits. After pH determination of different solutions (2 mL of 2% L-HCl and 2 to 6 mL of 8.4%, or 1.4% NaHCO3), an in vitro lidocaine diffusion through the ETT cuffs was evaluated (2 mL of 2% L-HCl and 3 mL of 8.4% or 1.4% NaHCO3). Then, adult patients scheduled for total thyroidectomy surgery were consecutively enrolled (n = 20 for each group). The ETT cuff was filled with air (group air) or with alkalinized lidocaine (2 mL of 2% L-HCl) using 8.4% (group large dose) or 1.4% (group small dose) of NaHCO3. After tracheal extubation, sore throat was evaluated by visual analog scale as the main end-point of the study. Hoarseness, bucking, dysphonia, dysphagia, cough, restlessness, and postoperative nausea and vomiting were also evaluated. There was a slight tendency toward a slower release when a small concentration of NaHCO3 was used (i.e., 1.4%). Compared with group air, the alkalinized-lidocaine groups had a significant reduction in sore throat during the 24-h postoperative period (P < 0.0001). The difference was not significant between the two alkalinized lidocaine groups. This increase in ETT tolerance was confirmed by the analysis of secondary end-points. No laryngospasm, rupture of ETT cuff, or depression of the swallowing reflex were recorded. A decrease in sore throat during the postoperative period was recorded when the cuff was inflated with a small dose of alkalinized lidocaine (i.e., 40 mg of L-HCl and 1.4% of NaHCO3) rather than with air when ventilation was controlled without N2O.

Adult↗
PubMed2006

Does the timing of tracheal intubation based on neuromuscular monitoring decrease laryngeal injury? A randomized, prospective, controlled trial.

Vocal cord injuries (VCI) and postoperative hoarseness (PH) are common complications after general anesthesia. Poor muscle relaxation at the moment of tracheal intubation may result in VCI. There is a large interindividual variation in neuromuscular depression after administration of neuromuscular blocking drugs. Therefore, the optimal individual timing of tracheal intubation based on neuromuscular monitoring (monitoring) may decrease VCI. In this prospective trial, 60 patients were randomized into 2 groups: Monitoring group: tracheal intubation at maximum block based on monitoring after atracurium 0.5 mg/kg and 2-min group: tracheal intubation 2 min after injection of atracurium 0.5 mg/kg. Intubating conditions were evaluated with the Copenhagen score. VCI were examined by stroboscopy before and 24 and 72 h after surgery. PH was assessed at 24, 48, and 72 h after surgery by a standardized interview. Excellent intubating conditions were significantly increased in the monitoring group compared with the 2-min group: 8 versus 2 patients, respectively (P = 0.036). The incidence of PH between the study groups was comparable: 7 (monitoring) versus 8 patients (2-min) (P = 0.860). Similar findings were observed for VCI: 9 versus 5 patients; respectively (P = 0.268); type of VCI: thickening of the vocal cords: 8 (monitoring) versus 5 (2-min) patients (P = 0.423), hematomas: 2 patients in each group (not significant). The present study demonstrated that neuromuscular monitoring improved endotracheal intubating conditions. However, tracheal intubation at maximum intensity of neuromuscular block was not associated with a decrease in vocal cord injuries.

Adult↗
PubMed1994

Intracranial vertebral artery dissections: clinical, radiological features, and surgical considerations.

We reviewed 24 patients with intracranial vertebral artery dissections treated during the last 12 years. Sixteen patients were admitted with subarachnoid hemorrhage (SAH) and 8 did not have SAH. The mean age at the time of onset was 50.0 years. Male preponderance was noted. Among 21 patients with acute onset, 6 (29%) experienced prodromal neck pain and 3 (60%) of 5 SAH patients showed nuchal stiffness when examined within 6 hours of onset. The preoperative angiographical findings were uniform in SAH cases in contrast to the varied angiographical findings seen in non-SAH cases. So-called pearl and string sign was observed in most SAH cases, but the "string" was often so short and wide that the term "constriction" appeared more suitable. From intraoperative observations, the angiographical point of constriction seemed to represent the proximal or distal end of dissection. As for treatment, 19 patients underwent 20 surgeries. Trapping was performed in eight surgeries, base clipping was performed in five, and proximal clipping was performed in seven. Both trapping and base clipping prevented further bleeding, but trapping was associated with a high rate of postoperative lower cranial nerve palsy. Postoperative neurological complications were less frequent after proximal clipping, but subsequent postoperative bleeding occurred in one patient treated by this technique. The overall long-term outcome in the surgically treated cases in our series was favorable, but most patients suffered from various degrees of uncomfortable dysphagia or hoarseness for some period after surgery. It was also noted that, in half of the disabled cases, the major disability was attributable to lower cranial nerve palsy and respiratory troubles that developed postoperatively.

Adult↗
PubMed2004

Microvascular decompression for glossopharyngeal neuralgia: long-term effectiveness and complication avoidance.

OBJECTIVE: To establish the long-term safety, efficacy, and durability of microvascular decompression (MVD) for the treatment of glossopharyngeal neuralgia, this study presents the immediate (<6 mo) postoperative and long-term results of a large series of 47 patients with treated with MVD. METHODS: Operative reports and hospital charts were analyzed to collect demographic information, clinical presentation, and surgical findings. Surgical results and complications were ascertained by direct patient contact or by contact with the patient's family or physician if the patient was dead. Long-term (>10 yr) personal follow-up was available for 29 of 47 patients. RESULTS: Forty-six (98%) of 47 patients experienced complete relief of pain immediately after MVD. Long-term follow-up was available for 29 of these 47 patients (range, 125-211 mo; median, 152 mo, or 12.7 yr), and 28 of these 29 patients continued to be pain-free. Permanent neurological deficits (>6 mo) attributed to the surgery were observed in 5 (11%) of 47 patients. Of these patients, 4 of 5 had mild hoarseness or dysphagia or both, and one had a Grade II/VI facial nerve paresis. CONCLUSION: This study demonstrates that MVD is a safe, effective, and durable surgical procedure for producing prolonged pain relief in patients with medically intractable glossopharyngeal neuralgia.

Adult↗
PubMed2005

Use of "bonnet" bypass with radial artery interposition graft in a patient with recurrent cranial base carcinoma: technical report of two cases and review of the literature.

OBJECTIVE AND IMPORTANCE: Two patients with recurrent cranial base carcinomas involving the carotid artery received a "bonnet" bypass using the contralateral superficial temporal artery as the donor vessel because the ipsilateral common and external carotid arteries were unavailable. The radial artery was used as the graft. CLINICAL PRESENTATION: A 58-year-old man with ear pain and an enlarging mass involving the left cranial base and neck had undergone a right partial glossectomy and modified neck dissection followed by radiotherapy for squamous cell carcinoma. Recurrent carcinoma extensively involved the left internal carotid artery. A 46-year-old man with jaw pain and hoarseness had undergone multiple resections and radiation therapy for medullary thyroid carcinoma. Magnetic resonance imaging showed recurrent tumor on the right. INTERVENTION: Both patients underwent a pterional craniotomy. The supraclinoid internal carotid artery was exposed. The radial artery was harvested. The contralateral superficial temporal artery was dissected at its bifurcation into the frontal and parietal branches. The radial artery graft was anastomosed to the superficial temporal artery and a recipient ipsilateral branch of the middle cerebral artery. The internal carotid artery was clip-ligated. After surgery, both patients remained neurologically stable. Angiography confirmed that the bypasses were patent and that the middle cerebral artery territory filled. The patients' carcinomas were resected aggressively. CONCLUSION: When aggressive resection of cranial base tumors is needed and the ipsilateral carotid artery is unavailable as a donor vessel, a "bonnet" bypass with carotid artery sacrifice may be performed. Compared with vein grafts, microsurgical anastomosis is easier and the patency rate is higher with a radial artery graft.

Cerebral Revascularization↗
PubMed2006

Internal jugular venous thrombosis as a complication after an elective anterior cervical discectomy: case report.

OBJECTIVE: Anterior cervical discectomy is one of the most common spine procedures in neurosurgery. Various complications, including hoarseness, hematoma, and dysphagia, have been reported in the literature. We report the first case of internal jugular venous thrombosis after an elective anterior cervical discectomy. CLINICAL PRESENTATION: A 35-year-old woman with past medical history significant only for hypercholesterolemia and cholecystectomy underwent an anterior cervical discectomy with fusion for a symptomatic cervical disc at the C5-C6 level. Intraoperatively, the patient had venous bleeding, which was adequately controlled. The procedure was completed with good hemostasis before closure. The patient was discharged home 1 day after the surgery. She was readmitted 5 days later with a 2-day history of a swollen right neck. The patient had no respiratory symptoms, but did report mild dysphagia. A hematoma was suspected. INTERVENTION: A computed tomographic scan of the neck was performed when the patient presented with cervical swelling. This was suggestive of a right internal jugular venous thrombosis. This diagnosis was confirmed with cervical ultrasound. The patient was seen by the vascular surgery department. The hospital course was otherwise uneventful and the patient was discharged 3 days later on oral anticoagulation with warfarin. CONCLUSION: This is the first report of internal jugular venous thrombosis after an elective anterior cervical discectomy. Internal jugular venous thrombosis should be considered in the differential diagnosis of a patient presenting with cervical swelling after an anterior cervical discectomy.

Adult↗
PubMed2006

Minimally invasive video-assisted thyroidectomy for follicular neoplasm: is there an advantage over conventional thyroidectomy?

BACKGROUND: Minimally invasive video-assisted thyroidectomy (MIVAT) is safe and effective for selected patients, but its advantages are not clearly defined. Results of MIVAT for follicular neoplasms at a single institution were retrospectively evaluated to define its advantages or disadvantages. METHODS: Between October 2002 and May 2004, 22 patients underwent MIVAT. Twenty-six patients who underwent conventional thyroidectomy during the same time period served as matched controls. Operative times, pathologic findings, complications, analgesic requirements, and incision lengths were retrospectively evaluated. RESULTS: Four MIVAT and three conventional surgery patients underwent total thyroidectomy. Eighteen MIVAT and 23 conventional patients underwent hemithyroidectomy. The operative time (mean +/- SEM) for hemithyroidectomy was 102 +/- 4 minutes for MIVAT and 86 +/- 3 minutes for conventional surgery (P < .05). In subgroup analysis that excluded patients with thyroiditis, operative times were not significantly different: MIVAT, 99 +/- 4 minutes; conventional, 88 +/- 4 minutes. The mean incision length was 2.3 +/- .5 cm in the MIVAT group. Conventional thyroidectomy was performed through a 4- to 5-cm incision. The average amount of narcotic used was not significantly different (intravenous, 9.9 +/- 3.1 mg [MIVAT] vs. 12.4 +/- 3.8 mg; oral, 10.3 +/- 4.2 mg [MIVAT] vs. 3.5 +/- 2.0 mg). The conventional group received more cyclooxygenase 2 inhibitor (527 +/- 9 mg vs. 187 +/- 84 mg; P < .05). One patient in each group experienced transient hoarseness. There were no cases of permanent hypoparathyroidism or recurrent laryngeal nerve injury in either group. CONCLUSIONS: MIVAT is as safe and effective as conventional thyroidectomy and is associated with similar narcotic analgesic requirements, but it can be performed through smaller incisions. Operative times were significantly longer for MIVAT, but when patients with thyroiditis were excluded, operative times were not significantly different.

Adenocarcinoma, Follicular↗
PubMed2006

Influence of mouth washing procedures on the removal of drug residues following inhalation of corticosteroids.

Mouth washing after inhalation of corticosteroids is effective for prevention of local adverse effects such as hoarseness and oropharyngeal candidiasis. To establish an optimal procedure for such mouth washing, we investigated the removal rates of drug residues remaining on the oropharyngeal mucosa using various mouth washing methods following inhalation. A beclomethasone dipropionate metered dose inhaler (BDP-MDI) (100 microg) and a fluticasone propionate dry powder inhaler (FP-DPI) (100 microg) were used. The effects of different mouth washing methods were evaluated by quantification of drugs in the expectorated rinse solution using an HPLC method. The amounts of BDP recovered in the rinse after gargling and rinsing for 5 s each were 47.1+/-13.6 microg, while they were 42.9+/-9.4 microg after rinsing alone for 10 s and 38.7+/-9.2 microg after gargling alone for 10 s. Under the same conditions, FP amounts were 32.9+/-7.3 microg, 28.9+/-2.4 microg, and 27.1+/-7.9 microg, respectively. In a comparison of washing time, the amounts of BDP recovered were 49.8+/-9.7 microg after gargling and rinsing for 2 s each, 53.5+/-10.2 microg after those for 3 s each, and 47.1+/-13.6 microg after those for 5 s each, while the amounts of FP under the same conditions were 36.4+/-2.4 microg, 33.3+/-6.4 microg, and 32.9+/-7.4 microg, respectively. As for the effect of time lag before mouth washing, the amount of BDP recovered decreased by 65.7% with a lag time of 1 min and by 5.6% after 10 min, while that of FP decreased by 51.1% with a lag time of 1 min and by 7.7% after 10 min. Our results suggest that the amount of drugs removed by mouth washing is significantly associated with the time lag between inhalation and mouth washing. We concluded that immediate gargling and rinsing after inhalation is most useful for the removal of drugs following inhalation of corticosteroids.

Administration, Inhalation↗
PubMed2000

The management of dysphasia in skeletal hyperostosis.

Diffuse idiopathic skeletal hyperostosis (DISH), or Forestier's disease, is an ossifying condition frequently encountered in otolaryngology as it affects 12-28 per cent of the adult population. This form of hyperostosis can manifest clinically with dysphagia, food impaction, hoarseness, stridor, myelopathies and other neurological problems. Judicious management of severe dysphagia proves challenging. The failure of conservative care often leaves surgery as the only option. In this report an anterolateral transcervical surgical approach to the confluent osteophytes is discussed and the value of videofluoroscopic swallow highlighted.

Aged↗
PubMed2000

Presumed laryngo-pharyngeal reflux: investigate or treat?

A review of a combined gastroenterology and laryngology clinic was conducted to determine the effectiveness of treatment and the predictive value of clinical findings and investigations. Data were collected prospectively. Investigations were performed according to clinical criteria. Patients with symptoms suspected to be due to laryngopharyngeal reflux (based on a positive oesophageal pH test and/or changes on videolaryngoscopy consistent with posterior laryngitis) were treated with omeprazole for at least two to three months. There were 87 patients; the most common symptoms were cough (38 per cent) and hoarseness (36 per cent); 77 per cent had some symptoms suggestive of gastro-oesophageal reflux. Sixty-seven patients were given omeprazole. A good response to laryngo-pharyngeal symptoms was seen in 37 patients (55 per cent). The presence of reflux symptoms was not a predictor of a good response. Increasing severity of oesophageal acid exposure over the 24 hours of pH testing was associated with a better symptom response (Spearman rank correlation, p = 0.01). Posterior laryngitis was not associated with the response to treatment, although there was a trend towards an association between improvement in laryngitis (after treatment) and improvement in symptoms (p = 0.08). The response to proton pump inhibitors was lower than other published results. Oesophageal pH monitoring may have a role in predicting which patients will respond to proton pump inhibitors. This study does not support the decision to treat with anti-secretory therapy, based only on the presence of posterior laryngitis.

Anti-Ulcer Agents↗
PubMed2000

Isolated extramedullary plasmacytoma of the true vocal fold.

We report a rare case of isolated extramedullary plasmacytoma (EMP) of the right true vocal fold in a 38-year-old male with a one-year history of hoarseness. Immunohistochemical staining of plasma cells in the tumour, showed over 90 per cent of them to be positive for kappa light chains. After two attempts at local surgical excision and recurrence within 10 months, the tumour was irradiated. Only seven reported cases of isolated EMP of the true vocal fold are reported in the literature. The therapeutic options are discussed.

Adult↗
PubMed2001

Deliberate removal of incisor teeth to allow access for laryngoscopy.

This paper describes a clinical situation where it was impossible to obtain a biopsy of a lesion at the anterior commissure in a patient with progressive hoarseness of voice using standard microlaryngoscopy techniques. Due to anatomical difficulties and a histological suggestion of laryngeal papillomatosis the incisor teeth were deliberately removed to allow an adequate view of the larynx and to facilitate further access.

Humans↗
PubMed2001

Cervical osteophytes presenting as unilateral vocal fold paralysis and dysphagia.

Any process involving either the vagus nerve, its recurrent laryngeal branch or the external branch of the superior laryngeal nerve may cause paralysis of the vocal fold. The most common cause is neoplasm. Clinically, the patients often present with a hoarse, breathy voice as well as symptoms of aspiration. The following represents a unique case of unilateral vocal fold paralysis and dysphagia caused by a degenerative disease of the cervical spine, resluting in extrinsic compression of the recurrent laryngeal nerve.

Aged↗
PubMed2002

Laryngeal gout.

A review of the literature reveals only 12 reported cases of laryngeal gout. We describe three further cases of laryngeal gout, the largest series ever published. The first case is previously undescribed acute gouty cricoarytenoiditis resulting in acute airway embarrassment requiring tracheotomy, and then we describe two cases of chronic tophaceous involvement of the thyroid lamina with computed tomography (CT) images of this process. The paucity of literature on this subject may not only be due to rarity but also lack of clinical awareness. Gouty involvement of the larynx must be considered in any patient with a history of gout who presents with hoarseness, odynophagia, dysphagia, stridor or neck lump. Acute airway compromise may require tracheotomy, whereas chronic airway problems may necessitate endoscopic tophi removal, lateralization procedures or even permanent tracheostomy.

Aged↗