Pneumomediastinum: a rare complication of anorexia nervosa in children and adolescents. A case study and review of the literature

Spontaneous pneumomediastinum is uncommon in paediatric practice. We describe two cases of spontaneous pneumomediastinum in a child and an adolescent with anorexia nervosa. Thorough investigation failed to reveal any underlying cause for secondary pneumomediastinum. Pneumomediastinum in anorexia nervosa can be caused by not only elevated intrathoracic pressures, but also by the poor quality of the alveolar walls due to malnutrition. The incidence of spontaneous pneumomediastinum in anorexia nervosa is probably higher than that recorded, since it resolves spontaneously and, therefore, it can remain undetected. We conclude that it is our considered opinion that malnutrition associated with anorexia nervosa predisposes for spontaneous pneumomediastinum due to weakness of the alveolar wall and the loss of connective tissue

Long-Term Results of External Upper Esophageal Sphincter Myotomy for Oropharyngeal Dysphagia

The aim of this work was to assess the efficacy of external myotomy of the upper esophageal sphincter (UES) for oropharyngeal dysphagia. In the period 1991–2006, 28 patients with longstanding dysphagia and/or aspiration problems of different etiologies underwent UES myotomy as a single surgical treatment. The main symptoms were difficulties in swallowing of a solid-food bolus, aspiration, and recurrent incidents of solid-food blockages. Pre- and postoperative manometry and videofluoroscopy were used to assess deglutition and aspiration. Outcome was defined as success in the case of complete relief or marked improvement of dysphagia and aspiration and as failure in the case of partial improvement or no improvement. Initial results showed success in 21 and failure in 7 patients. The best outcomes were observed in patients with dysphagia of unknown origin, noncancer-related iatrogenic etiology, and neuromuscular disease. No correlation was found between preoperative constrictor pharyngeal muscle activity and success rate. After follow-up of more than 1 year, 20 patients were marked as success and 3 as failure. All successful patients had full oral intake with a normal bolus consistency without clinically significant aspiration. We conclude that in select cases of oropharyngeal dysphagia success may be achieved by UES myotomy with restoration of oral intake of normal bolus consistency

Prospective evaluation of voice outcome during the first two years in male patients treated by radiotherapy or laser surgery for T1a glottic carcinoma

In this prospective cohort study, we assessed voice outcome in patients before and up to 2 years after treatment for early glottic cancer either by radiotherapy or by laser surgery; 106 male patients, treated for T1aN0M0 glottic cancer either by endoscopic laser surgery (n = 67) or by radiotherapy (n = 39), participated in the study. Patients’ voices were recorded and analysed pre-treatment and 3, 6, 12 and 24 months post-treatment at their routine visit at the outpatient clinic. Average fundamental frequency (F0), percent jitter, percent shimmer and normalized noise energy (NNE) were determined. After 2 years, local control rate was 95% in the radiotherapy group and 97% in the laser surgery group. Larynx preservation rate was 95% after radiotherapy and 100% after laser surgery. Voice outcome recovers more quickly in patients treated with laser surgery in comparison to radiotherapy: 3 months after laser surgery there is no longer a difference with regard to normal voices except for the fundamental frequency, which remains higher pitched, even in the longer term. For patients treated with radiotherapy it takes longer for jitter, shimmer and NNE to become normal, where jitter remains significantly different from normal voices even after 2 years. According to these results, we believe that laser surgery is the first treatment of choice in the treatment of selected cases of T1a glottic carcinomas with good functional and oncological results

Laryngeal suspension and upper esophageal sphincter myotomy as a surgical option for treatment of severe aspiration

Severe aspiration remains a difficult condition to treat without sacrificing the laryngeal functions of respiration and phonation. Upper esophageal sphincter (UES) myotomy as a sole treatment proves to be insufficient in many cases. Deglutative laryngeal elevation can be considered the most important factor responsible for opening of the esophageal inlet during deglutition. Therefore, a combination of laryngeal suspension procedure and a UES myotomy may be an alternative for treatment of severe aspiration without separating the airway and alimentary tract. Laryngeal suspension has in the past been proposed as a reconstructive procedure in major ablative surgery involving the floor of the mouth and the hyoid. Ten patients with severe aspiration and insufficient laryngeal elevation and constrictor pharyngeal muscle activity during deglutition were surgically treated with a laryngeal suspension procedure and upper esophageal sphincter myotomy. Five of the 10 patients had a good result, enabling them to have an oral intake sufficient to fulfill their nutritional needs. Two other patients have improved after the procedure, but are still dependent on gastrostomy feeding. Three patients eventually underwent a total laryngectomy, 2 of them after initial successful prevention of aspiration. In these 2 cases, aspiration recurred as a result of progression of the muscular disease. Life-threatening aspiration can often successfully be corrected by UES myotomy and laryngeal suspension. After a high initial success rate, long-term overall success can be anticipated in approximately 50% of the cases because of relapses in some patients caused by progression of underlying diseases

Cervical necrotizing fasciitis with thoracic extension after total laryngectomy

Cervical necrotizing fasciitis (CNF) with thoracic extension is rare. It has never been reported in laryngectomized patients. A case of fatal CNF in a laryngectomized patient equipped with a voice prosthesis is presented. Diagnosis and treatment are discussed. CNF with thoracic extension was diagnosed on clinical picture, computed tomography (CT) and biopsies were taken just above the tracheostoma. Antibiotic treatment was started and extensive debridement of the affected tissues performed. A minor extension to the left pleura was considered irresectable. Irradical debridement and the impossibility of administering hyperbaric oxygen therapy caused death within two day after presentation. CNF is a rare disease and to our knowledge, has never been reported after total laryngectomy. This case emphasizes the need for early antibiotic treatment and radical surgical resection of the affected tissues

Health status and voice outcome after treatment for T1a glottic carcinoma.

Radiotherapy as well as endoscopic laser surgery as the most widely used treatment modalities for T1a glottic carcinoma cause minor morbidity and negligible mortality and result in more or less comparable, excellent cure and larynx preservation rates. Therefore, other outcome measures such as voice-related problems and health status are important factors in the choice of treatment for T1a glottic cancer. The present study focuses on voice-related problems in the daily life of patients treated by radiotherapy or endoscopic laser surgery for T1a glottic cancer. Self ratings on health status assessed by means of COOP/WONCA health status charts and voice problems evaluated with a validated voice-specific questionnaire (the Voice Handicap Index) and overall judgment on voice quality were obtained. A total of 102 patients (56 treated by endoscopic laser surgery and 46 treated by radiotherapy) with at least 1-year follow-up were included. Response scores were high: 52 (93%) patients after endoscopic laser surgery versus 40 (87%) patients after radiation therapy completed and returned the questionnaires. A high percentage of patients reported voice problems in daily life: 58% of the patients following radiotherapy and 40% of the patients following endoscopic treatment had abnormal VHI scores. The difference between both treatment modalities proved to be significant. No significant differences were found concerning health status or overall judgment of voice quality. Moderate correlations were found between total VHI score and voice quality judgment and the COOP/WONCA social activities chart. This study reveals that treatment for T1a glottic cancer often does result in voice problems in daily life, negatively influencing patients social activities. Patients selected for endoscopic laser surgery on average report fewer voice-related problems than those who underwent radiotherapy