Tracheobronchomalacia due to amyloidosis in a patient with rheumatoid arthritis

In this case report, we describe a patient with longstanding rheumatoid arthritis who developed tracheobronchomalacia with fatal outcome. Despite negative antemortem biopsies of abdominal fat and tongue, amyloid was found postmortem in the trachea and appeared to be associated with tracheobronchomalacia

Relationship between videofluoroscopic and subjective (physician- and patient- rated) assessment of late swallowing dysfunction after (chemo) radiation:Results of a prospective observational study

BACKGROUND AND PURPOSE: Primary (chemo)radiation (CHRT) for HNC may lead to late dysphagia. The purpose of this study was to assess the pattern of swallowing disorders based on prospectively collected objective videofluoroscopic (VF) assessment and to assess the correlations between VF findings and subjective (physician- and patient-rated) swallowing measures. MATERIAL AND METHODS: 189 consecutive HNC patients receiving (CH)RT were included. Swallowing evaluation at baseline and 6 months after treatment (T6) encompassed: CTCAE v.4.0 scores (aspiration/dysphagia), PROMs: SWAL QOL/ EORTC QLQ-H&N35 (swallowing domain) questionnaires and VF evaluation: Penetration Aspiration Scale, semi-quantitative swallowing pathophysiology evaluation, temporal measures and oral/pharyngeal residue quantification. Aspiration specific PROMs (aPROMs) were selected. Correlations between late penetration/aspiration (PA_T6) and: clinical factors, CTCAE and aPROMs were assessed using uni- and multivariable analysis. RESULTS: Prevalence of PA increased from 20% at baseline to 43% after treatment (p<0.001).The most relevant baseline predictors for PA_T6 were: PA_T0, age, disease stage III-IV, bilateral RT and baseline aPROM 'Choking when drinking' (AUC: 0.84). In general aPROMs correlated better with VF-based PA than CTCAE scores. The most of physiological swallowing components significantly correlated and predictive for PA (i.e. Laryngeal Vestibular Closure, Laryngeal Elevation and Pharyngeal Contraction) were prone to radiation damage. CONCLUSION: The risk of RT-induced PA is substantial. Presented prediction models for late penetration/aspiration may support patient selection for baseline and follow-up VF examination. Furthermore, all aspiration related OARs involved in aforementioned swallowing components should be addressed in swallowing sparing strategies. The dose to these structures as well as baseline PROMs should be included in future NTCP models for aspiration

The influence of closure technique in total laryngectomy on the development of a pseudo-diverticulum and dysphagia

OBJECTIVE: In total laryngectomy, the neopharynx can be closed in several ways. It is suggested that a pseudo-diverticulum is seen more frequently in patients closed with vertical closure than with "T"-shaped closure, causing postoperative dysphagia. We report the results of patients treated with vertical closure and "T"-shaped closure with regard to the formation of a pseudo-diverticulum and postoperative dysphagia. METHODS: In our retrospective cohort study, we identified 117 consecutive laryngectomized patients treated in the VU University Medical Center of Amsterdam between March 2009 and December 2013. Evaluations with statistical analysis of postoperative outcome measures (the formation of a pseudo-diverticulum and dysphagia), qualitative and quantitative variables were conducted. RESULTS: Patient demographics were similar between the vertical-shaped closure and the "T"-shaped closure groups. In 84.6% of patients with vertical closure, a pseudo-diverticulum was seen compared to 18.5% with "T"-shaped closure (p < 0.001). Dysphagia was increasingly seen in patients with a pseudo-diverticulum (60.5%) compared to patients without a pseudo-diverticulum (39.5%) (p = 0.090). CONCLUSION: Formation of a pseudo-diverticulum is more frequently seen in laryngectomy patients closed with vertical closure than in patients closed with "T"-shaped closure of the neopharynx. It is favorable to implement "T"-shaped closure in laryngectomy

Bevacizumab as treatment option for recurrent respiratory papillomatosis: a systematic review

PURPOSE: To this day, there is no cure for recurrent respiratory papillomatosis (RRP). Multiple surgical procedures are performed to achieve symptom relief and prevention of airway obstruction. A promising drug for RRP is the vascular endothelial growth factor (VEGF) binding antibody bevacizumab. This chemotherapeutic agent has an angiogenesis-inhibiting effect which inhibits tumor growth. The objective of this review was to investigate the efficacy of bevacizumab as treatment option for RRP, and to explore the difference of its effects between intralesional and systemic treatment. METHODS: A systematic search was conducted in Cochrane, PubMed, and Embase. Articles were included if bevacizumab treatment was given intralesionally and/or systemically. The methodological quality of the studies was assessed using the CAse REport (CARE) guidelines. RESULTS: Of 585 unique articles screened by title and abstract, 15 studies were included, yielding a total of 64 patients. In 95% of the patients treated with systemic bevacizumab, the post-bevacizumab surgical interval was considerably prolonged. More than half of them did not need any surgical intervention during mean follow-up of 21.6 months. Treatment with intralesional bevacizumab showed a lower efficacy: in 62% of the patients, the post-bevacizumab surgical interval (mean, 1.8 months follow-up) was extended when compared to the interval before the treatment. CONCLUSION: Systemically and intralesionally administered bevacizumab are effective treatment options for severe RRP. A systemic administration might be the treatment of first choice. Further prospective research with long term follow-up is advocated to elucidate this important topic

Voice in early glottic cancer compared to benign voice pathology

The purpose of this study is to compare (Dutch) Voice Handicap Index (VHIvumc) scores from a selected group of patients with voice problems after treatment for early glottic cancer with patients with benign voice disorders and subjects from the normal population. The study included a group of 35 patients with voice problems after treatment for early glottic cancer and a group of 197 patients with benign voice disorders. Furthermore, VHI scores were collected from 123 subjects randomly chosen from the normal population. VHI reliability was high with high internal consistency and test-retest stability. VHI scores of glottic cancer patients were similar to those of patients with voice problems due to benign lesions. Both groups of patients were clearly deviant from the normal population. Within the normal population, 16% appeared to have not-normal voices. Based on ROC curves a cut-off score of 15 points was defined to identify patients with voice problems in daily life. A clinical relevant difference score of 10 points was defined to be used for individual patients and of 15 points to be used in study designs with groups. Patients with voice problems after treatment for early glottic cancer encounter the same amount of problems in daily life as the other voice-impaired patients. The VHI proved to be an adequate tool for baseline and effectiveness measurement of voice

Associations between voice quality and swallowing function in patients treated for oral or oropharyngeal cancer

<p>The purpose of this study was to investigate associations between voice quality and swallowing function in patients treated for oral or oropharyngeal cancer.</p><p>Recordings of speech and videofluoroscopy of 51 patients after treatment for oral or oropharyngeal cancer were analysed. Acoustic voice parameters (fundamental frequency (F0), perturbation (jitter %, shimmer %), harmonics-to-noise ratio (HNR), and intensity (extracted from the vowels /a/, /i/, and /u/)) were compared to swallowing function parameters as assessed via videofluoroscopy (oral, oropharyngeal, and total transit time; estimated percent of oral, oropharyngeal, and total residue; oropharyngeal swallowing efficiency (OPSE), and the penetration/aspiration (PA-) scale).</p><p>Stepwise multivariate regression analyses revealed that jitter, shimmer, and HNR were not associated with swallowing function. Higher voice intensity in all three vowels /a/, /i/, and /u/ was significantly associated with a higher score on the PA-scale (more penetration and aspiration). Higher voice intensity and F0 were significantly associated with lower OPSE.</p><p>Higher voice intensity was significantly associated with higher amount of penetration/aspiration, and higher voice intensity and fundamental frequency were significantly associated with swallowing inefficiency. Possible explanations may be found in overcompensation by increased laryngeal muscular strength resulting in increased intensity and pitch during phonation. However, the physiology of associated voice and swallowing function is yet unclear, and more research is recommended.</p>

Informed consent for suspension microlaryngoscopy: what should we tell the patient? A consensus statement of the European Laryngological Society

Introduction: Informed consent for any surgical intervention is necessary, as only well-informed patients can actively participate in the decision-making process about their care, and better understand the likely or potential outcomes of their treatment. No consensus exists on informed consent for suspension microlaryngoscopy (SML). Materials and methods: Informed consent procedures in nine countries on five continents were studied. Results: Several risks can be discerned: risks of SML as procedure, anesthesiologic risks of SML, specific risks of phonosurgery, risks of inadequate glottic exposure or unexpected findings, risks of not treating. SML has recognized potential complications, that can be divided in temporary (minor) complications, and lasting (major) complications. Conclusion: SML is a safe procedure with low morbidity, and virtually no mortality. Eleven recommendations are provided

Swallowing after major surgery of the oral cavity or oropharynx: a prospective and longitudinal assessment of patients treated by microvascular soft tissue reconstruction

BACKGROUND: The aim of this study was to analyze swallowing outcome in advanced oral/oropharyngeal cancer patients treated with microvascular reconstructive surgery and adjuvant radiotherapy. METHODS: Eighty patients were included. Patient, tumor, and treatment factors were assessed. Postoperative videofluoroscopic swallowing studies (VFSS) and scintigraphy tests were performed at 6 (n = 54 vs 44) and 12 (n = 32 vs 37) months. Swallowing parameters such as the oropharyngeal swallow efficiency and the Penetration/Aspiration Scale were analyzed. RESULTS: Impaired swallowing status was found at 6 months, which remained stationary at 12 months. Comorbid condition, larger tumors (T3-T4 vs T2), and resections of the base of tongue and soft palate combined (vs defects of other dynamic structures) were associated with most profound swallowing problems (p < .05). CONCLUSIONS: Swallowing difficulties are relatively frequent and can to a large extent be predicted. With the knowledge of this study, better counseling and vigilance as to swallowing difficulties may be possible

Evaluation of vascular features of vocal cords proposed by the European Laryngological Society

A newly proposed classification by the European Laryngological Society (ELS) of glottic lesions by narrow-band imaging (NBI) divides their vascular patterns into longitudinal and perpendicular ones. The latter are further subdivided into the wide and narrow patterns. The longitudinal, wide, and narrow patterns are characteristic of benign disease, papilloma, and malignancy, respectively. The aim of the study was to investigate the diagnostic effectiveness of the classification. Forty patients with glottic lesions underwent microlaryngoscopy. The vascular patterns of all vocal cords were defined with NBI. The affected vocal cords were histologically analysed and comprised the arm (A). Unaffected vocal cords were not histologically analysed but followed-up and comprised the arm (B) and were regarded as true negatives if no suspicious changes appeared during the follow-up. The vocal cords from the arm A were categorised into the benign and malignant group according to the histologic result. The ratio of vascular patterns was determined and the groups were statistically compared using the Chi-square test and Fisher’s exact test. Perpendicular changes were observed in 36.6% (9/26) of benign diseases and in 100% (23/23) of cancer conditions (p OpenSPiltSPi 0.001). Wide perpendicular changes appeared only in papillomas (6/6) while narrow ones mostly in malignancies (23/26) and also in benign conditions (3/26) (p OpenSPiltSPi 0.001). The sensitivity, specificity, positive and negative predictive values, and accuracy were 100, 95, 88, 100 and 96%, respectively. The new ELS classification can be used effectively and safely to differentiate malignant from benign disease