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Here, we describe a multiplexed immunohistochemical platform with computational image processing workflows, including image cytometry, enabling simultaneous evaluation of 12 biomarkers in one formalin-fixed paraffin-embedded tissue section. To validate this platform, we used tissue microarrays containing 38 archival head and neck squamous cell carcinomas and revealed differential immune profiles based on lymphoid and myeloid cell densities, correlating with human papilloma virus status and prognosis. Based on these results, we investigated 24 pancreatic ductal adenocarcinomas from patients who received neoadjuvant GVAX vaccination and revealed that response to therapy correlated with degree of mono-myelocytic cell density and percentages of CD8 + T cells expressing T cell exhaustion markers. These data highlight the utility of in situ immune monitoring for patient stratification and provide digital image processing pipelines to the community for examining immune complexity in precious tissue sections, where phenotype and tissue architecture are preserved to improve biomarker discovery and assessment., (Copyright © 2017 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging., Methods: We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge., Results: Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART's teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which >200 providers were trained., Conclusions: DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.

Objectives: We sought to analyze the outcomes of vocal process granulomas treated with proton pump inhibitors and inhaled triamcinolone acetonide., Methods: We reviewed the medical records of patients with a diagnosis of contact granuloma or vocal process granuloma between 1995 and 2008. Data included age, gender, intubation history, reflux history, lesion location, previous treatment methods, treatment course, and recurrence. All patients were treated with daily or twice-daily protein pump inhibitors and inhaled triamcinolone acetonide (300 microg 3 times a day)., Results: Sixty-seven granulomas were diagnosed in 54 patients: 13 bilateral and 41 unilateral. Twenty patients, including all 11 women, had a recent history of intubation. Sixty-two granulomas in 50 patients were treated with triamcinolone and a proton pump inhibitor. Of the 57 granulomas that completed treatment, 5 (9%) did not respond (mean follow-up, 50 weeks; range, 30.3 to 78.3 weeks), 13 (22%) partially responded (mean follow-up, 11 weeks; range, 3 to 30 weeks), and 40 (69%) completely responded (mean follow-up, 21 weeks; range, 5.9 to 84.6 weeks). Three cases had recurrence: 2 nonresponders and 1 complete responder. One patient developed oral thrush., Conclusions: In this study, vocal process granulomas occurred more frequently in men, whereas women developed granulomas only after intubation. The anti-inflammatory action of inhaled triamcinolone combined with antireflux proton pump inhibitors successfully treats most vocal process granulomas with low rates of side effects and recurrence.

Objectives/hypothesis: Human papillomavirus (HPV) types 6 and 11 are associated with recurrent respiratory papillomatosis (RRP). Although a prophylactic vaccine has been developed that protects against HPV infection, a therapeutic vaccine is still needed for those patients infected with and/or suffering from persistent disease. Therefore, we developed a novel, therapeutic DNA vaccine targeting HPV-11 and characterized the in vivo immunologic responses generated against HPV-11 E6 and E7 after DNA vaccination in a preclinical model., Methods: We generated a DNA vaccine that encodes the HPV-11 E6 and E7 genes in a pcDNA3 backbone plasmid. We then vaccinated C57BL/6 mice with the pcDNA3-HPV11-E6E7 DNA plasmid. Splenocytes were harvested from these vaccinated animals and were incubated with overlapping peptides spanning either the HPV-11 E6 or E7 protein. The frequency of interferon-gamma-releasing CD8(+) T cell responses was then analyzed by flow cytometry., Results: Vaccinated mice with the HPV11-E6E7 DNA generated strong CD8(+) T cell responses against the E6(aa44-51) peptide. We determined that the epitope is presented by the MHC class I H2-K(b) molecule. No significant E7 peptide-specific T cell responses were observed., Conclusions: We developed a novel DNA vaccine that targets the E6 gene of HPV-11. Characterization of the immunologic responses elicited by this DNA vaccine reveals that the E6(aa44-51) peptide contains the most immunogenic region for the HPV-11 viral type. Knowledge of this specific T cell epitope and generation of a RRP preclinical model will allow for the development and evaluation of novel vaccine strategies targeting the RRP patient population.

Background: Inability to intubate and ventilate patients with respiratory failure is associated with significant morbidity and mortality. A patient is considered to have a difficult airway if an anesthesiologist or other health care provider experienced in airway management is unable to ventilate the patient's lungs using bag-mask ventilation and/or is unable to intubate the trachea using direct laryngoscopy., Methods: We performed a retrospective review of a departmental database to determine whether a comprehensive program to manage difficult airways was associated with a reduced need to secure the airway surgically via cricothyrotomy or tracheostomy. The annual number of unplanned, emergency surgical airway procedures for inability to intubate and ventilate reported for the 4 yr before the program (January 1992 through December 1995) was compared with the annual number reported for the 11 yr after the program was initiated (January 1996 through December 2006)., Results: The number of emergency surgical airways decreased from 6.5 +/- 0.5 per year for 4 yr before program initiation to 2.2 +/- 0.89 per year for the 11-yr period after program initiation (P < 0.0001). During the 4-yr period from January 1992 through December 1995, 26 surgical airways were reported, whereas only 24 surgical airways were performed in the subsequent 11-yr period (January 1996 through December 2006)., Conclusions: A comprehensive difficult airway program was associated with a reduction in the number of emergency surgical airway procedures performed for the inability of an anesthesiologist to intubate and ventilate, a reduction that was sustained over an 11-yr period. This decrease occurred despite an increase in the number of patients reported to have a difficult airway and an overall increase in the total number of patients receiving anesthesia per year.

Objective: To assess the effect of primary treatment on tracheoesophageal voice prosthesis (TEP) complications., Design: Retrospective cohort study., Setting: The Johns Hopkins Medical Institutions, Baltimore, Maryland., Patients: Patients who underwent total laryngectomy and TEP between January 1, 1998, and December 31, 2008, were divided into 3 subgroups according to primary treatment: surgery (n = 81), radiotherapy (n = 61), and chemoradiotherapy (n = 32)., Main Outcome Measures: Number of weeks before leakage through the TEP, occurrence of leakage around the TEP, TEP dislodgement, and size changes 6 months or longer after laryngectomy., Results: A total of 174 patients met the study criteria. Of the 81 patients who underwent primary surgery, 81% (n = 66) underwent adjuvant therapy with postoperative radiotherapy or chemoradiotherapy. The incidence of leakage around the prosthesis, prosthesis dislodgement, and size changes 6 months or longer after laryngectomy were significantly higher for patients who required salvage total laryngectomy after chemoradiotherapy or radiotherapy (P < .05). In addition, significantly more patients who underwent salvage total laryngectomy required extended laryngectomy or free tissue reconstruction., Conclusions: Voice prosthesis complications are more frequently encountered in those who require salvage laryngectomy. Understanding the potential for such complications reinforces the need for close communication and follow-up with these patients by the speech language pathologist.

Background: One of the greatest challenges facing both practitioners and risk managers is the identification of previously unknown clinical hazards and defects. With the rapid proliferation of new health care services, unknown hazards may propagate as new therapies are integrated into the existing health care system. The main goal of risk analysis is to make these hazards visible by proactively searching and probing the system. Yet, a comprehensive approach by which to safely integrate new therapies into the existing clinical environment has yet to be clearly articulated. Patient care teams can use the proposed framework when introducing new therapies., A Practical Framework: The framework includes a background investigation and literature search; an in situ simulation (in the actual clinical setting used for patients); a Failure Mode and Effects Analysis to determine the severity, probability, and risk of the potential hazards; and a multidisciplinary protocol and safety checklist to standardize practice and ensure provider accountability., Case Examples: Application of this framework to three operative scenarios--intraoperative radiation therapy (IORT), hyperthermic intraperitoneal chemotherapy (HIPEC), and an interventional pulmonology program--demonstrates its flexibility. Its use prospectively identified and mitigated 20 IORT, 5 HIPEC, and 18 interventional pulmonology hazards/defects. Subsequent patient cases were largely uneventful. All cases and patient safety reporting systems are monitored to identify any new defects in an effort to continuously improve patient care., Conclusion: The use of a comprehensive framework to identify and mitigate hazards in an on-site simulated environment promotes safer care for target patient populations; results in familiarity with procedures, amelioration of staff concerns, and standardization of practice; and facilitates teamwork and communication.

Zenker's diverticulum is a rare anatomic defect that physicians have confronted for almost 250 years. Its location at the interface of the pharynx, neck, and mediastinum makes surgical access difficult and risks severe morbidity. Minimally invasive endoscopic surgical repair of Zenker's diverticulum has been attempted for more than a century as an alternative to reduce morbidity of an open transcervical approach. However, limitations due to available antibiotics, instrumentation, and laryngoscopes, as well as a general discomfort with a sutureless closure of the mucosal excision, have delayed widespread adoption of minimally invasive repair until the last 10 to 15 years. This manuscript will detail the historical evolution of endoscopic surgical therapy for Zenker's diverticulum and highlight the work of two otolaryngologists, Chevalier Jackson and Gosta Dohlman, who were critical in advancing the surgical technique and reducing morbidity. Lastly, this manuscript will analyze the delay in widespread application of endoscopic surgical repair of Zenker's diverticulum.

Objective: To report the oncologic and functional results from our experience in performing supracricoid laryngectomy (SCL) for selected patients with laryngeal cancer., Study Design: Retrospective chart review., Methods: Twenty-four consecutive patients who underwent SCL for laryngeal cancer in our institution from December 2000 to March 2006 have been reviewed. Reports of the site and extent of tumor, type of reconstruction, preoperative or postoperative radiotherapy, and the final histopathologic examination were reviewed. In addition, the reports of the preoperative examination, inpatient course, and postoperative follow-up were reviewed., Results: A total of 24 patients were involved in the study; 19 had tumors involving the glottic region, and 5 patients had tumors involving both the glottic and supraglottic regions (transglottic). Ten patients had their SCL for postradiotherapy recurrence/persistence of disease. Eighteen patients underwent reconstruction through cricohyoidoepiglottopexy (CHEP), whereas six patients had cricohyoidopexy (CHP). Eleven patients had an arytenoid cartilage resected; 8 of 11 had CHEP, and 3 of 11 had CHP. All patients had a tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement performed at the same time as the SCL. The median hospital stay period was 6 days. Twenty-three of 24 had successful tracheostomy tube decannulation, with a median time to decannulation of 37 days. The median time to removal of the PEG tube was 70 days. The complications with SCL were postoperative wound infection in two patients (SCL/CHP) and the need for completion total laryngectomy secondary to intractable aspiration in one patient with SCL/CHP. One patient with SCL/CHEP had a ruptured pexy and subsequently underwent a second reconstruction with successful tracheostomy and PEG tube removal. One of 24 patients is still PEG tube dependant, and he had postoperative radiotherapy. Fifteen patients underwent concurrent neck dissection. None of the patients had any local or regional recurrence, with a median follow-up period of 3 years. All final surgical margins were negative for tumor invasion. Three patients had postoperative radiotherapy, two patients because of nodal metastases in the excised lymph nodes and one because of perineural invasion on final histopathologic examination of the SCL specimen. There were no perioperative deaths., Conclusion: SCL with CHEP or CHP represents an effective technique that can be taught and effectively used to avoid a total laryngectomy while maintaining physiologic speech and swallowing in selected patients with advanced stage primary laryngeal cancer or recurrent/persistent laryngeal cancer after radiotherapy. There is a good functional recovery with acceptable morbidity and an excellent oncologic outcome when strict selection criteria are applied and a formal swallowing rehabilitation program is followed.

The myosin heavy chain (MHC) composition of a given muscle determines the contractile properties and, therefore, the fiber type distribution of the muscle. MHC isoform expression in the laryngeal muscle is modulated by neural input and function, and it represents the cellular level changes that occur with denervation and reinnervation of skeletal muscle. The objective of this study was to evaluate the pattern of MHC isoform expression in laryngeal muscle harvested from normal cadavers and cadavers with naturally occurring left laryngeal hemiplegia secondary to recurrent laryngeal neuropathy. Left and right thyroarytenoideus (TA) and cricoarytenoideus dorsalis (CAD) were obtained from 7 horses affected with left-sided intrinsic laryngeal muscle atrophy and from 2 normal horses. Frozen sections were evaluated histologically for degree of atrophy and fiber type composition. MHC isoform expression was determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) of muscle protein. Histologic atrophy was seen in all atrophic muscles and some right-sided muscles of 3 affected horses, as well as the left TA of 1 normal horse. Fiber type grouping or loss of type I muscle fibers was observed in the left-sided laryngeal muscles in all but 1 affected horse, as well as in the right muscles of 2 affected horses, and the left TA of 1 normal horse. SDS-PAGE showed 2 bands corresponding to the type I and type IIB myosin isoforms in the CAD and TA of the 2 normal horses. Affected horses demonstrated a trend toward increased expression of the type IIB isoform and decreased expression of the type I isoform in atrophic muscles. This study confirmed the presence of histologic abnormalities in grossly normal equine laryngeal muscle, and it demonstrated an increased expression of type IIB MHC with a concurrent decreased expression of type I MHC in affected muscles. Evaluation of muscle fiber changes at the cellular level under denervated and reinnervated conditions may aid in assessing future strategies for reinnervation or regeneration of atrophic laryngeal muscle.

Objectives: To determine the incidence and presentation of synchronous thyroid lesions in a patient population undergoing open partial laryngectomy (OPL), and to determine whether routine preoperative evaluation of the thyroid gland prior to OPL is useful to identify synchronous thyroid lesions in order to reduce the need for reoperation in this complex patient population., Design: Retrospective medical chart review., Setting: Academic institution., Patients: Sixty-seven consecutive patients with laryngeal tumors who had undergone OPL from 1996 to 2005., Interventions: Charts of 67 consecutive patients with laryngeal tumors who underwent OPL in 1996 to 2005 have been reviewed for synchronous thyroid lesions. For all patients, reports of (1) complete preoperative examination findings, (2) inpatient course, (3) postoperative follow-up, and (4) postoperative final histopathologic findings were reviewed. For patients with synchronous thyroid lesions, reports of (1) thyroid evaluation and imaging and (2) preoperative (fine-needle aspiration), (3) intraoperative (frozen section), and (4) postoperative (final) histopathologic results for the thyroid lesions were reviewed., Main Outcome Measures: Incidence of synchronous thyroid lesions and laryngeal cancer in patients undergoing OPL., Results: Eight (11.9%) of 67 (95% confidence interval, 5.3%-22.2%) patients with laryngeal tumors who underwent OPL had evidence of synchronous thyroid lesions. All 8 patients had squamous cell carcinoma of the larynx and underwent either supracricoid or supraglottic laryngectomy. In these 8 patients, synchronous thyroid lesions were incidentally detected. Four patients had papillary thyroid carcinoma, 1 had squamous metaplasia, and 3 had follicular thyroid tissue that was negative for malignancy on final pathologic examination. In 2 patients, the thyroid lesions were detected preoperatively (prior to OPL); in another 2 patients, thyroid masses were detected intraoperatively; and in 4 patients, the thyroid disease was identified postoperatively on histopathologic examination of excised cervical lymph nodes. In 2 patients, thyroidectomy was performed as a second operation after the OPL, and 1 of them had transient vocal fold paralysis for 2 months. Thyroid ultrasonography was performed in 4 patients. In 3 patients, the ultrasonography was performed after the OPL final pathologic findings indicated the presence of metastatic thyroid disease in cervical lymph nodes. Ultrasonography revealed intrathyroidal lesions in all 3 patients., Conclusions: Patients with laryngeal tumors who will be undergoing OPL might have occult synchronous thyroid lesions. Thyroid surgery in patients with previous OPL may have an increased potential for complication owing to postsurgical changes in the central neck region. Routine preoperative evaluation of the thyroid gland, especially with ultrasonography, to screen for occult synchronous thyroid lesions is recommended for all patients with laryngeal tumors who will be undergoing OPL. Eradication of any thyroid cancer detected preoperatively by fine-needle aspiration should be performed at the same time as OPL. Pros and cons of total thyroidectomy for indeterminate thyroid nodules should be discussed with this patient population.

Objective: To determine a plan for the management of cervical lymph nodes in patients undergoing salvage laryngeal surgery (SLS) for recurrent/persistent laryngeal cancer after primary radiotherapy (RT)., Study Design: : Retrospective chart review., Methods: Charts of 51 consecutive patients who had salvage total or supracricoid laryngectomy with or without neck dissection for recurrent/persistent laryngeal squamous cell carcinoma after primary RT from 1988 to 2005 in our institution were reviewed. No patients received concomitant or neo-adjuvant chemotherapy. Thirty-four patients underwent SLS along with unilateral or bilateral neck dissection, whereas 17 patients underwent the SLS without neck dissection. Reports of preRT and preSLS staging of the primary tumor and the neck, recorded using the TNM system, were reviewed. Reports of the final histopathologic examination for the excised laryngeal cancer and cervical lymph nodes were reviewed., Results: Thirty-four patients underwent SLS with unilateral or bilateral neck dissection. The preRT staging of the primary tumor for those 34 patients showed that 32 (94%) were staged T-1 (14) and T-2 (18), whereas the preSLS staging of the primary tumor for those 34 patients showed that 29 (85%) were staged T-3 and T-4. The postSLS final histopathologic examination of the excised lymph nodes in those 34 patients demonstrated that 30 (88%) did not have any evidence of nodal metastasis. On comparing patients with and without nodal metastasis (on their postSLS final histopathology), we found that the preSLS neck staging, based on computed tomographic (CT) scanning of the neck, was significantly associated with the negative/positive postSLS status of nodal metastasis (P = .006). Of 29 patients staged preSLS as N-0, 28 (97%) patients did not have nodal metastasis on their postSLS final pathology (negative predictive value = 97%, confidence interval, 82.2-99.9). PreRT neck staging, preRT and preSLS staging of the primary tumor, along with laryngeal subsite involvement (supraglottis, glottis, subglottis) did not significantly correlate with the status of neck metastasis on final postSLS histopathology (P = .68, 0.78, 0.49, and 0.42, respectively). None of the 34 patients had any neck tumor recurrence in the postSLS follow-up period (median, 3 yr). In addition, all 17 patients who underwent SLS without neck dissection were staged N-0 both before RT as well as preSLS, and none developed neck disease in the postSLS follow-up period (median, 2.5 yr)., Conclusion: Management of the neck in patients undergoing salvage total or supracricoid laryngectomy for laryngeal cancer recurrence/persistence after primary RT should be based on the preSLS CT staging of the neck. Patients staged N-0 preSLS are not likely to harbor occult nodal metastasis and therefore may not require elective neck dissection.

Objective: The impact of polarity change on the efficiency of in vivo electroporative (EP) gene transfection was assessed in rat laryngeal muscle., Study Design and Setting: High (HV) and low field voltage (LV) were combined with polarity changes to determine transfection in 5 different conditions: 1) without EP (EP[-]), 2) HV+LV (HL), 3) HV+LV followed by HV+LV with no change in polarity (HLHL unidirectional), 4) HV+LV followed by HV+LV with opposite polarity (HLHL bidirectional), 5) HV+LV followed by LV with opposite polarity (HLL bidirectional)., Results: HLL bidirectional sequence showed the best result with less interindividual variability and extended expression period. With the exception of repeated high voltage sequences, EP parameters were not likely to induce cell injury or inflammation., Conclusion: HLL bidirectional electroporative gene delivery produces high transfection rates with limited tissue trauma., Significance: Bidirectional EP provides a safe and highly efficient method for therapeutic gene delivery into skeletal muscle.

Objective: To evaluate the role of positron emission tomography and computed tomography (PET-CT) fusion in the management of early-stage and advanced-stage primary head and neck squamous cell cancer., Design: Retrospective analysis, with a blinded evaluation of clinical data and formation of a treatment plan., Setting: Single tertiary academic medical institution. Patients Thirty-six patients with previously untreated head and neck squamous cell carcinoma who underwent staging CT or magnetic resonance imaging of the neck prior to undergoing PET-CT as part of their initial diagnostic evaluation between July 2000 and January 2005., Main Outcome Measures: Confirmation or alteration of the treatment plan with the addition of the PET-CT information compared with traditional clinical and radiological data alone for early-stage and advanced-stage disease. When available, histopathological results were correlated with the PET-CT findings., Results: Among the 36 patients, PET-CT provided additional information that confirmed the treatment plan in 25 patients (69%) and altered the treatment plan in 11 patients (31%). Six of 11 patients in the altered-treatment group had their tumors upstaged. Four of 8 patients with early-stage tumors had their treatment plan altered, compared with 7 of 28 patients with advanced-stage disease. Among 18 patients who underwent a surgical intervention for their primary tumor, PET-CT identified the primary tumor in all 18 patients and, based on histopathological findings, correctly staged the regional nodal disease in 9 of 16 patients who had their nodal disease addressed., Conclusion: The use of PET-CT is important in the initial treatment planning of early-stage and advanced-stage head and neck squamous cell carcinoma.

Laryngeal muscle atrophy induced by nerve injury is a major factor contributing to the disabling symptoms associated with laryngeal paralysis. Alterations of global proteins in rat laryngeal muscle following denervation were, therefore, studied using proteomic techniques. Twenty-eight adult Sprague-Dawley rats were divided into normal control and denervated groups. The thyroarytenoid (TA) muscle was excised 60 days after right recurrent laryngeal nerve was resected. Protein separation and identification were preformed using 2-DE and MALDI-MS with database search. Forty-four proteins were found to have significant alteration in expression level after denervation. The majority of these proteins (57%), most of them associated with energy metabolism, cellular proliferation and differentiation, signal transduction and stress reaction, were decreased levels of expression in denervated TA muscle. The remaining 43% of the proteins, most of them involved with protein degradation, immunoreactivity, injury repair, contraction, and microtubular formation, were found to have increased levels of expression. The protein modification sites by phosphorylation were detected in 22% of the identified proteins that presented multiple-spot patterns on 2-D gel. Significant changes in protein expression in denervated laryngeal muscle may provide potential therapeutic strategies for the treatment of laryngeal paralysis.

Objectives: The ultimate goal of this study is to improve the efficiency of gene transfer in mammalian muscle by developing targeted adenoviral vectors. Altering the tropism of viral vectors to recognize tissue specific antigens is one method to achieve this goal. This approach requires identification of cell-surface receptors and the insertion of target peptide sequences into the adenoviral fiber protein. In this study, phage biopanning was performed on cultured rat skeletal and laryngeal muscle to identify cell-surface receptors., Study Design: In vitro cell culture and in vivo animal model., Methods: M-13 Phage biopanning was used for muscle cell-surface receptor analysis on cultured rat skeletal and laryngeal muscle. Nonbinding and binding phage to cultured skeletal and laryngeal muscle were screened for muscle specific surface peptides. In vivo studies were then performed using muscle specific phage., Results: Skeletal muscle specific binding by the YASTNPM phage was observed by in vivo immunostaining. Phage titering demonstrated a 10(9)-fold increase in skeletal muscle binding compared with nontarget tissue. A peptide sequence (NPSQVKH) specific for laryngeal muscle yielded a 10(7)-fold increase in laryngeal muscle phage titer compared with nontarget tissue., Conclusions: These results identify muscle cell-surface receptors that may be used as potential targets for genetic modification of adenovirus tropism. Moreover, phage specificity for skeletal and laryngeal muscle indicates specific muscle groups may be targeted.

Two-dimensional gel electrophoresis (2-DE) is currently the best method for separating complex mixtures of proteins, and its use is gradually becoming more common in cardiac proteome analysis. A number of variations in basic 2-DE have emerged, but their usefulness in analyzing cardiac tissue has not been evaluated. The purpose of the present study was to systematically evaluate the capabilities and limitations of several 2-DE techniques for separating proteins from rat heart tissue. Immobilized pH gradient strips of various pH ranges, parameters of protein loading and staining, subcellular fractionation, and detection of phosphorylated proteins were studied. The results provide guidance for proteome analysis of cardiac and other tissues in terms of selection of the isoelectric point separating window for cardiac proteins, accurate quantitation of cardiac protein abundance, stabilization of technical variation, reduction of sample complexity, enrichment of low-abundant proteins, and detection of phosphorylated proteins.

Objectives: To establish a sound objective model for assessing the effects of neurotrophic factors on facial nerve function after injury and to compare the effects of brain-derived neurotrophic factor (BDNF) with its neutralizing antibody on facial nerve function after injury., Design: Prospective electrophysiologic analysis of recovery of function 4 weeks after axotomy involving facial nerve transection and primary end-to-end reanastomosis in adult rats and blind comparison with randomized intramuscular injection of either BDNF, monoclonal antibody to BDNF in neutralizing concentration, or control solution., Results: There were no statistically significant differences between groups in latencies, duration, amplitude, area, or conduction velocity before axotomy, and recorded conduction velocities were consistent with previously reported values, which suggests that the recordings were reliable and reproducible. After transection, there was a mean increase in latency 1 and decreases in latency 2, integrated average area, muscle action potential duration, amplitude, and conduction velocity for all 3 groups. When the groups were compared after transection, the anti-BDNF group showed a significant decrease in conduction velocity and muscle action potential duration (Kruskal-Wallis P = .01 and P = .008, respectively) compared with the other groups. There were no statistically significant differences in latencies, amplitude, or area among the groups., Conclusions: We have established an electrophysiologic model for objective assessment of facial nerve function in the rat. Future studies should combine functional electrophysiologic assessment and histologic examination to provide a more robust model for studying the effects of neurotrophic factors on facial nerve reinnervation and synkinesis.

Objectives/hypothesis: The authors have designed a rat laryngeal paralysis model to study gene transfer strategies using a muscle-specific expression system to enhance local delivery of human insulin-like growth factor-1 (hIGF-1). In preliminary studies, a nonviral vector containing the alpha-actin promoter and human hIGF-1 sequence produced both neurotrophic and myotrophic effects 1 month after single injection of plasmid formulation into paralyzed rat thyroarytenoid muscle in vivo. Based on these findings, it is hypothesized that the effects of hIGF-1 will enhance the results of laryngeal muscle innervation procedures. The timing of gene delivery relative to nerve repair is likely to be important, to optimize the results., Study Design: Prospective analysis., Methods: The effects of nonviral gene transfer for the delivery of hIGF-1 were evaluated in rats treated immediately following recurrent laryngeal nerve transection and repair and in rats receiving a delayed treatment schedule, 30 days after nerve transection and repair. Gene transfer efficiency was determined using polymerase chain reaction and reverse transcriptase-polymerase chain reaction techniques. Muscle fiber diameter, motor endplate length, and percentage of motor endplates with nerve contact were examined to assess hIGF-1 trophic effects., Results: Compared with reinnervated untreated control samples, both early and delayed hIGF-1 transfer resulted in significant increase in muscle fiber diameter. Motor endplate length was significantly decreased and nerve/motor endplate contact was significantly increased following delayed gene transfer, but not after early treatment., Conclusion: We infer from results of the study that delayed hIGF-1 gene transfer delivered by a single intramuscular injection will enhance the process of muscle reinnervation. The clinical relevance of these findings supports the future application of gene therapy using nonviral vectors for management of laryngeal paralysis and other peripheral nerve injuries.

Objective: This study examines the differential expression of myosin heavy chain (MyHC) components in human laryngeal muscle groups., Study Design: A battery of monospecific monoclonal antibodies in Western blots was used to determine expression of IIX, extraocular-specific (EOM), and IIB MyHCs for the thyroarytenoid (TA), vocalis (VOC), lateral cricoarytenoid (LCA), cricothyroid (CT), and posterior cricoarytenoid (PCA) muscles obtained from fresh cadaver specimens., Results: Fast IIX MyHC was only expressed in the TA, VOC, and LCA muscles. Fast IIA and slow MyHCs were expressed in all laryngeal muscles including the CT and PCA. The CT with mixed phonatory and respiratory function and the PCA with respiratory function did not express IIX MyHC. The 2 MyHC isoforms associated with the highest speeds of contraction in rat laryngeal muscle, namely, the EOM MyHC and IIB MyHC, were not detected in human laryngeal muscles. Novel MyHC bands were not detected in SDS-PAGE gels or Western blots using a broad specificity MyHC antibody., Conclusion: The profile of MyHC expression in human laryngeal muscles differs from that observed in human extraocular and masticator muscles, and other mammalian species. Our data demonstrate that IIX MyHC expression is associated primarily with muscles affecting glottic closure and is absent in CT and PCA., Significance: A higher percentage of IIX MyHC is expected to impart a high speed of shortening to the TA and LCA muscles. The absence of IIX MyHC in muscles with respiratory (PCA) and mixed respiratory/phonatory function (CT) further supports the inference that the physiologic difference between laryngeal muscles is reflected in the molecular composition of contractile protein.

Objectives/hypothesis: To determine whether the myotrophic activity of human insulin-like growth factor (hIGF)-1 promotes restoration of normal myosin heavy chain (MHC) composition after nerve injury, MHC composition was analyzed after hIGF-1 gene transfer in denervated rat laryngeal muscle., Study Design: Animal model to study effects of gene transfer on laryngeal paralysis., Methods: In anesthetized rats, the left recurrent and superior laryngeal nerves are cut and suture ligated. A midline thyrotomy is performed, and the thyroarytenoid muscle is injected with a polyvinyl-based formulation containing a muscle specific expression system and hIGF-1 DNA (treatment group) or saline (control group). After 30 days, animals were killed, and the thyroarytenoid muscle was removed and processed for sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). Densitometric measurements were obtained to determine composition of MHCs., Results: As previously described, MHC composition in denervated laryngeal muscle was characterized by a decrease in type IIB and IIL and up-regulation of IIA/IIX. Compared with controls, hIGF-1 treated animals demonstrated a significant increase in expression of type IIB and IIL and a significant decrease in expression of type IIA/X., Conclusions: These findings suggest that the myotrophic effect of hIGF-1 gene transfer results in normalization of MHC composition in denervated muscle, with suppression of type IIA/X MHC and promotion of type IIL expression.

Proteomic analysis was performed to construct a protein database for human laryngeal muscle. Thyroarytenoid (TA) muscle specimens were obtained from six post mortem cases within 24 h of death. Isoelectric focusing was performed by using immobilized pH gradient strips followed by 12% sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Silver stained gels were then analyzed using PDQuest software to locate, quantify and match spots. Proteins were identified by matrix-assisted laser desorption/ionization-mass spectrometry on the basis of peptide mass fingerprinting following in-gel digestion with trypsin. Comparison of protein distribution between broad and narrow pH range gels demonstrated that 75% of all protein spots from human TA muscle were located within the pH range 5-8, and between mass 15-120 kDa. Based on peptide mass fingerprinting, 75 proteins were identified and classified into six functional groups. These include membrane proteins (8.5%), cytoskeletal and myofibrillar proteins (14.6%), energy production proteins (28%), proteins associated with stress responses (8.5%), and protein associated with transcription regulation (10.9%). Approximately one-third (29%) were categorized as "other proteins". This data provides an initial reference map for comparative studies of protein expression in human and laryngeal muscle. Further development of this database will provide a valuable resource for molecular analysis of normal and pathologic conditions affecting human striated muscle.

Giant fibrovascular polyp of the esophagus is a rare but dramatic entity. These large polyps arise in the proximal esophagus and can cause airway obstruction secondary to mechanical pressure on the larynx, or they can present as a mass that is regurgitated into the oral cavity. We present a 66-year-old man who complained of nausea and vomiting that were associated with a fibrovascular polyp protruding into the mouth. He had also experienced several episodes of syncope resulting from intermittent airway obstruction. He underwent an open resection of an 11.8-cm fibrovascular polyp and an endoscopic resection of a second fibrovascular polyp 2 days later. Histopathologically, both masses were composed of a mixture of mature adipose tissue lobules and fibrovascular tissue, lined by reactive squamous epithelium. Despite their large size, giant fibrovascular polyps should be recognized radiologically and pathologically as benign lesions. However, they can result in significant morbidity.

This article reviews management of early laryngeal squamous cell carcinoma with respect to current standards of practice and recent advances in minimally invasive endoscopic surgery, specifically highlighting powered instrumentation as an alternative to transoral laser resection of early glottic lesions. Limitations of the current staging system, controversy regarding management of lesions involving the anterior commissure, and the role of radiation therapy versus surgical management are also discussed with reference to current outcomes literature.

Objectives: To test the hypothesis that myosin heavy chain (MHC) composition is a biological marker indicative of appropriate and functional reinnervation., Study Design: Age-matched adult rats were randomized for prospective study under three experimental conditions., Methods: In adult rats, three experimental conditions were surgically created, including transient recurrent laryngeal nerve (RLN) crush injury, RLN transection and repair, and cricoarytenoid joint fixation with intact RLN. Animals were survived for 30, 90, and 180 days. At each interval, vocal fold mobility was assessed by rigid microlaryngoscopy. Laryngeal electromyography (EMG) was performed before euthanasia. The thyroarytenoid and posterior cricoarytenoid muscles were then excised, each muscle was processed for sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and MHC composition was determined., Results: Thirty days after nerve crush injury, three of six animals regained vocal fold mobility and normal MHC composition. Impaired vocal fold motion in three of six animals was associated with MHC composition characteristic of denervation. At 90 and 180 days, normal vocal fold motion and normal MHC composition were observed in all animals. Following nerve transection and repair, impaired vocal fold motion and MHC composition characteristic of denervation were observed in all animals, despite evidence of reinnervation on EMG. Following joint fixation, alteration in MHC composition consistent with denervation was observed only at 30 days, as was evident in the nerve crush model., Conclusion: Temporary injury and vocal fold immobilization result in transient shifts in MHC composition. Nerve transection and repair result in persistent alteration of MHC composition and vocal fold dysfunction. The expression of normal MHC composition is dependent on the condition of appropriate neural contact and functional reinnervation.

Objectives: Myosin heavy chain (MHC) composition of human thyroarytenoid (TA), lateral cricoarytenoid (LCA), interarytenoid (IA), vocalis, posterior cricoarytenoid (PCA), and cricothyroid muscles were examined using sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and Western bolt techniques. The presence of superfast MHC was also assessed using antibodies directed against the extraocular MHC., Study Design: MHC protein was analyzed using fresh human laryngeal muscles., Methods: Laryngeal muscles excised from cadavers were processed for SDS-PAGE. The composition of MHC isoforms was determined by densitometry. Western blot was carried out to identify specific bands., Results: MHC types IIA and IIB are the predominant MHC components in human laryngeal muscles. The adductor muscles--TA, LCA, and IA--have a higher percentage of type IIB MHC and a lower percentage of type I when compared with the abductor--PCA. The rank file order for type IIB MHC composition (TA > LCA > or = IA > PCA) is the same in all specimens. A band migrating between type IIA and type I was observed in several specimens. Although similar to type IIL in rats, this atypical band did not react with anti-extraocular MHC antibody on Western blot., Conclusion: Characterization of laryngeal muscles determined by the composition of MHC is correlated with function and neural input. Human laryngeal muscle is characterized by a predominance of fast-type MHCs in laryngeal closing muscle and mixed fast-slow type MHCs in respiratory and phonatory muscle groups. Although an atypical myosin band similar to type IIL (superfast) MHC in rat was identified, it did not react with anti-extraocular MHC antibody.

Despite many operative procedures focused on vocal fold lateralization, none has achieved an acceptable level of dependability. Bilateral vocal fold abductor paralysis is treated by arytenoidectomy, cordotomy, suture lateralization, or partial cordectomy. Tracheotomy remains the gold standard for maximizing the airway and preserving phonatory function. We have developed a device that is minimally invasive, tunable, and reversible, with the potential for lateralization or medialization of the vocal process. The device consists of a polyethylene collar, a Vitallium cam, and a double-helix core for engaging soft tissue. It is introduced through a circular opening in the thyroid cartilage by a modified thyroplasty approach. Both the first and second iterations of this device have been evaluated for clinical effectiveness in 9 sheep by means of photographic and video documentation. Effectiveness in humans is currently being assessed. The results of the animal study permit us to have substantial optimism with respect to the clinical application of this device.

Objective: To compare the biological effects of single vs multiple treatment of rat denervated laryngeal muscle with human insulinlike growth factor 1 (hIGF1) gene therapy. EXPERIMENTAL METHODS OR DESIGN: A muscle-specific nonviral vector containing the alpha-actin promoter and hIGF1 gene formulated with polyvinyl polymers was injected into denervated adult rat thyroarytenoid muscle. The effects on animals given a single injection (n = 16) vs those given multiple injections (n = 14) vs control groups (n = 18) were evaluated. Twenty-eight days after the first injection, gene expression, muscle fiber size, motor endplate length, and nerve-to-motor endplate contact were evaluated., Results: Gene expression, detected by reverse transcriptase polymerase chain reaction for hIGF1 messenger RNA, occurred in 13 (81%) of 16 animals receiving single injections and 14 (100%) of 14 animals receiving multiple injections. Compared with controls, hIGF1-transfected animals in both single- and multiple-injection groups had a significant increase in the lesser diameter of muscle fiber, a significant decrease in motor endplate length, and a significant increase in the percentage of endplates with nerve contact (P <.05 for all). There was no statistical difference between single- and multiple-injection groups., Conclusions: Applied to laryngeal paralysis, hIGF1 gene therapy provides an opportunity to augment surgical treatment modalities by the prevention or reversal of muscle atrophy, and enhancement of nerve sprouting and muscle reinnervation. Although the percentage of denervated muscles demonstrating hIGF1 expression was increased following multiple injections, no difference was observed in the biological response compared with that in the single-injection treatment groups. Further investigation will be conducted to assess long-term benefits and physiological responses and to define the limitations of this potentially valuable therapeutic strategy.

The developmental transitions of myosin heavy chain (MHC) isoforms of rat posterior cricoarytenoid (PCA), thyroarytenoid (TA), cricothyroid (CT), and lateral cricoarytenoid (LCA) muscles were examined by means of sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and Western blot techniques. The muscles were microscopically dissected from animals on postnatal days 0, 3, 7, 10, 14, 21, 28, 35, 45, and 55 and from adult animals. Silver-stained SDS-PAGE gels of each muscle were analyzed densitometrically to measure the composition of MHC isoforms, and Western blot was carried out to identify specific bands. Characterizations of the internal laryngeal muscles determined by the composition of MHCs were correlated with their function in the adult. Temporally, differentiation reflects onset of function. Differentiation of isoforms and transition to adult forms occur first in the TA muscle, followed by the PCA, LCA, and CT muscles. Expression of type IIL was observed only in muscles innervated by the recurrent laryngeal nerve. Postnatally observed developmental differences of myosin phenotypes suggest that regulation of MHC expression is influenced by neural activity or other environmental factors.

Objectives: To demonstrate gene transfer in rat laryngeal muscle using a reporter gene, beta-galactosidase, and a muscle-specific expression system containing the human IGF-1 (hIGF-1) gene sequence and to investigate the myotrophic and neurotrophic effects of hIGF-1 gene transfer in denervated rat laryngeal muscle., Methods: In 8 adult rats, a polyvinyl-based formulation containing beta-galactosidase DNA was injected into denervated thyroarytenoid muscle. Twelve animals were similarly administered a polyvinyl-based formulation containing a muscle-specific expression system and hIGF-1 DNA. Twelve animals were injected with isotonic sodium chloride solution, and all animals survived for 1 month. The production of beta-galactosidase and hIGF-1 was detected using immunohistochemical techniques. The effects of hIGF-1 on motor endplates and nerve sprouting were assessed using cholinesterase or silver staining and immunostaining for growth-associated protein (GAP-43). mals by immunostaining, X-gal histochemical staining, or both. In frozen section specimens, hIGF-1 immunoreactivity was positive in 3 of 8 animals. In sequential sections, GAP-43 was localized to areas of hIGF-1 expression in 2 of the 3 hIGF-1-positive specimens. Increased nerve sprouting and motor endplate contact occurred in 2 of 4 animals treated with hIGF-1., Conclusions: Gene transfer into laryngeal muscle was demonstrated using a polyvinyl-based formulation containing a muscle-specific gene expression system. Preliminary findings indicate a positive effect on motor endplates, nerve sprouting, and the expression of GAP-43 in animals treated with the hIGF-1 vector. This study establishes a foundation for investigating hIGF-1 gene transfer as a novel treatment of laryngeal paralysis. Further studies are necessary to quantify myotrophic and neurotrophic effects and to establish therapeutic benefit.

Larynges taken from normally developing rats ranging from embryos starting at embryonic day 10 to adults were harvested. Sections of the larynges were prepared with the use of immunohistochemical techniques with primary antibodies directed to the neural cell adhesion molecule; selected sections were exposed to antibodies directed against the embryonic polysialated form of the neural cell adhesion molecule and against L1. Cell adhesion molecules were present throughout embryonic development associated with the recurrent laryngeal nerve. Downregulation of expression was observed after postnatal day 14. We conclude that cell adhesion molecules may play a role in the normal neural development of the larynx in rats.

Superfast myosin heavy chain (MHC), which is found in jaw-closing muscle and extraocular muscle (EOM), may also be found in rat laryngeal muscles. Immunostaining and Western blot using anti-EOM antibody were performed to identify and localize EOM MHC in laryngeal muscles. Specific reactivity of laryngeal IIL MHC was confirmed by Western blot and on immunostaining, all fibers in the lateral part of thyroarytenoid muscle reacted with EOM antibody. A scattered pattern of positive fibers was observed in the medial part of the thyroarytenoid, the posterior cricoarytenoid and the lateral cricoarytenoid muscles. EOM MHC was not detected in the cricothyroid muscle. The expression of EOM MHC in rat laryngeal muscle is consistent with the functional demands of the airway protection reflex.

Current surgical strategies for the treatment of laryngeal paralysis are limited by the muscle atrophy associated with denervation. Moreover, attempts at reinnervation have not effected significant change in surgical outcome. To address this clinical problem, we have developed a rat laryngeal paralysis model to study novel gene transfer strategies. Using this model, the human insulin-like growth factor I (hIGF-I) gene was introduced into paralyzed rat laryngeal muscle to assess the benefit of sustained local hIGF-I production. A muscle-specific nonviral vector containing the alpha-actin promoter and hIGF-I gene was used in formulation with a polyvinyl-based delivery system and injected into paralyzed adult rat laryngeal muscle. Twenty-eight days after a single injection, gene transfer efficiency, muscle fiber size, motor endplate length, and nerve-to-motor endplate contact were evaluated. Gene transfer was detected in 100% of injected animals by PCR. Gene transfer with expression, as measured by RT-PCR for hIGF-I mRNA, occurred in 81.3 % of injected animals. When compared with controls, hIGF-I-transfected animals presented a significant increase in muscle fiber diameter [17.56 (+/-0.97 SD) microm versus 14.70 (+/-1.43 SD) microm; p = 0.0002], a significant decrease in motor endplate length [20.88 (+/-1.42 SD) microm versus 25.41 (+/-3.19 SD) microm; p = 0.0025], and a significant increase in percentage of endplates with nerve contact (20.3% (+/-13.9 SD) versus 4.4% (+/-4.2 SD); p = 0.0079). In the context of laryngeal paralysis, gene therapy represents a tremendous opportunity to augment current surgical treatment modalities by preventing or reversing muscle atrophy, and by enhancing nerve sprouting and reinnervation.

Background: Cinnamon aldehydes found in cinnamon-flavored gums can incite mucosal alterations at points of contact with the oral mucosa. These alterations may include inflammation and epithelial proliferation, but as a rule, the changes are reversible and promptly resolve when gum-chewing activity is discontinued., Methods: The authors report a case of a 24-year-old woman who developed a squamous cell carcinoma of the tongue following persistent and prolonged exposure to cinnamon-flavored gum., Results: Several social, clinical, and histopathologic features point to the cinnamon-flavored chewing gum as a possible causal factor in the development of the patient's oral carcinoma., Conclusions: Prompt withdrawal of cinnamon products is encouraged in heavy gum chewers who develop cinnamon-related oral lesions. For those lesions which do not promptly resolve upon cinnamon withdrawal, diagnostic biopsy should be considered to exclude the possibility of a squamous cell carcinoma.

Objectives: The effects of denervation on myosin heavy chain (MHC) expression in specific laryngeal muscles are characterized using gel electrophoresis. Observed temporal changes in MHC composition will then be used as a biologic marker in studies designed to develop strategies for laryngeal reinnervation and gene therapy., Study Design: Animal study using an adult rat model for laryngeal paralysis., Methods: In anesthetized rats the left recurrent and superior laryngeal nerve were divided. Animals were survived for 7, 14, 28, 90, and 180 days. Animals were euthanized and the thyroarytenoid (TA), vocalis (VOC), posterior cricoarytenoid (PCA), lateral cricoarytenoid (LCA), and cricothyroid (CT) muscle excised. Each muscle was processed for sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and densitometric measurements were obtained to determine composition of MHC fiber types., Results: The changes in relative MHC composition are described for each specific laryngeal muscle. In general, a decrease in type IIB and an increase in IIA and IIX are seen after denervation. Expression of IIL in the denervated condition is variable and the relative change in type I is minimal., Conclusion: This study supports previous work using rat soleus muscle in which IIA/IIX expression is favored in conditions with decreased neuromuscular activity, and conversely, IIB expression is activity dependent. Expression of type I appears to be independent of neural activity. Further study will be undertaken to quantify expression of MHC components and to study factors modulating expression.

This study evaluates the soft tissue response in rabbits following laryngeal implantation for medialization using hydroxylapatite prostheses, carved silicone rubber prostheses, and injectable Teflon. Sixteen rabbits underwent left recurrent laryngeal nerve section for denervation and laryngeal implantation with hydroxylapatite. At 1, 3, 6, and 12 months, 4 animals were painlessly sacrificed and processed for histology. Similarly, animals were implanted with carved silicone rubber prostheses or with Teflon injected through a flap in the thyroid lamina for comparison at 1, 3, and 6 months. In animals implanted with hydroxylapatite, histologic findings include limited acute inflammatory response, thin fibrous encapsulation, and osteogenesis in the region of the fenestra, with lamellar bone bridging the space between the implant and thyroid lamina. With silicone rubber prostheses, there is a limited inflammatory response and fibrous encapsulation of the implant without evidence of osteogenesis. Animals implanted with Teflon demonstrated a classic foreign body reaction with multinucleated giant cells, granuloma formation, and migration of Teflon into surrounding muscle. With respect to soft tissue response, both hydroxylapatite and silicone rubber are less reactive than Teflon. The osteogenesis observed in the presence of hydroxylapatite increases implant stability and minimizes the risk of migration. Conversely, the presence of bone growth may limit the reversibility of medialization procedures performed with hydroxylapatite.

Medialization thyroplasty is generally considered a phonosurgical procedure for voice augmentation in patients with glottic insufficiency. This article addresses specifically the issue of dysphagia and aspiration in patients with laryngeal paralysis. A retrospective review of patients undergoing medialization thyroplasty is performed. From 1991 to 1995, 84 patients at The Johns Hopkins Medical Institutions underwent medialization thyroplasty for unilateral vocal fold motion impairment. At presentation 48 patients had isolated recurrent laryngeal nerve injury, 26 with combined superior laryngeal nerve/recurrent laryngeal nerve injury and 10 with idiopathic nerve injury. Sixty-one percent of patients had swallowing difficulties. The severity of symptoms is greater in the superior laryngeal nerve/recurrent laryngeal nerve group. Before surgery 13 patients were dependent on feeding tubes. Nine patients improved to the point at which all alimentation was taken by mouth and tube feedings were discontinued after medialization thyroplasty. One patient was subsequently converted to a full oral diet after cricopharyngeal myotomy. Three patients remained dependent on feeding tubes. The pathophysiology of dysphagia including clinical and experimental observations is reviewed. In addition, the nonsurgical and surgical approaches to treatment of patients with laryngeal paralysis are reviewed.

To determine the mechanism for obstructive sleep apnea in two patients with clinical abnormalities of laryngeal function, airflow dynamics during sleep were analyzed. The site of airway obstruction was assessed by examining pressure gradients across specific airway segments. The relation between maximal inspiratory airflow and nasal pressure was analyzed to determine (1) the critical pressure, a measure of the collapsibility of the laryngeal airway, and (2) the effect of nasal continuous positive airway pressure on airflow during sleep. Large inspiratory pressure gradients developed during sleep between the supraglottic and pleural spaces, indicating that collapse had occurred in the larynx. Elevated critical pressures of -6.4 and +1.2 cm H2O, respectively, occurred in the two patients. When the nasal pressure was raised to 10 cm H2O, normal levels of tidal airflow occurred, and obstructive apneas were eliminated. These findings indicate that sleep apnea was caused by laryngeal airflow obstruction that resulted from elevations in the collapsibility of the larynx. The response to nasal continuous positive airway pressure suggested that laryngeal sleep apnea was similar to pharyngeal sleep apnea in pathophysiologic characteristic and response to treatment.

This paper reviews a new technique to develop high-resolution three-dimensional (3-D) images of the larynx using histological sections. Three-dimensional computer-reconstructed histological sections of the cat are used in this study to evaluate the recurrent laryngeal nerve (RLN) in its true anatomic course, with emphasis on its relationship to surrounding structures (laryngeal framework). A cat model was used because of specimen availability and technical ease of tissue preparation. Computer-reconstructed serial histologic sections add a new dimension to the study of laryngeal anatomy, laryngeal trauma, and growth patterns of laryngeal cancer. The technical aspects of three-dimensional reconstruction and future applications are discussed.

Laryngeal implantation for medialization has improved our ability to manage the patient with vocal fold motion impairment. We present preliminary data evaluating the use of preformed hydroxylapatite laryngeal implants and instrumentation for rapid determination of implant size and position. A window in the thyroid ala is created by means of a standard fenestra template. One of 5 prosthesis templates is inserted through the window for determination of correct size and position. The corresponding implant is then inserted and secured with a hydroxylapatite shim. Thirty-five patients have been implanted for vocal fold paralysis, and 4 patients were implanted for soft tissue deficits or bowing. Thirty-one of 35 patients have reported subjective improvement (89%). Improvement was demonstrated in 13 of 15 (87%) patients with complete preoperative and postoperative objective voice function measurements. Complications include 1 implant extrusion and 1 case of airway obstruction secondary to edema. Preliminary results indicate that prefabricated hydroxylapatite implants are effective for medialization thyroplasty. Advantages include a readily available implant selection, rapid determination of correct size and position, and improved implant stabilization with a hydroxylapatite shim.

Twenty patients with vocal fold motion impairment were reviewed to correlate the findings of electromyography (EMG) and stroboscopy. The causes of motion impairment were idiopathic, previous surgery with recurrent laryngeal nerve injury, neck and skull base trauma, and neoplasm. The EMG studies were analyzed to assess the status of innervation of the immobile vocal fold. The presence or absence of the mucosal wave prior to therapeutic intervention was determined with stroboscopic examination. Eight of 10 patients with EMG evidence of reinnervation or partial denervation were found to have mucosal waves, and 3 of 10 patients with EMG evidence of denervation were found to have mucosal waves. Six patients developed mucosal waves after surgical medialization, despite evidence of denervation by EMG criteria. These findings support the premise that tension and subglottic pressure, rather than status of innervation, determine the presence of the mucosal wave.

The use of lidocaine hydrochloride as either a topical or intravenous agent has become a common practice for minimizing laryngospasm and the reflex cardiovascular effects resulting from upper airway manipulation. The efficacy and mechanism of action of lidocaine for this purpose remain unclear. We evaluated the effect of lidocaine on the laryngeal chemoreflex (LCR), mechanoreflex (LMR), and superior laryngeal nerve electrical stimulation adductor reflex (SLN-ESAR) in piglets. Cardiopulmonary responses were used to assess LCR and LMR. Latency following SLN stimulation was used to assess SLN-ESAR. Intravenous lidocaine hydrochloride at 3 mg/kg produced no suppression of the LCR, LMR, or latency (SLN-ESAR onset latency before lidocaine 11.7 +/- 0.7 milliseconds, after lidocaine 12.2 +/- 0.5 milliseconds; peak latency before lidocaine 13.2 +/- 0.2 milliseconds, after lidocaine 13.4 +/- 0.4 milliseconds). Topically applied lidocaine at the same dose eliminated both LCR and LMR responses in all animals, with return of reflex responses 15 minutes after application. No effect on the SLN-ESAR was seen with application of topical lidocaine. This study supports topical lidocaine as a suppressant of laryngeal mucosal neuroreceptors without central neural reflex effects. Intravenous lidocaine did not affect peripheral neuroreceptors, nor did it significantly affect the latency of the SLN-ESAR neural reflex arc. Intravenous and topical lidocaine differ in mechanism of action and efficacy with regard to modulation of reflex effects induced by laryngeal stimulation.

Necrotizing fasciitis is a destructive soft tissue infection that rarely involves the eyelids. Three cases of necrotizing fasciitis of the eyelids are described. Necrotizing fasciitis was preceded by minor forehead soft tissue trauma in two cases and occurred spontaneously in one. In two patients necrotizing fasciitis was bilateral and involved both the upper and lower eyelids. Review of these cases, in addition to 18 cases previously reported in the English literature, reveals a predominance in females, preceding minor local soft tissue trauma, frequent bilateral involvement, and an association with alcohol abuse and diabetes. In all of the patients, group A beta-hemolytic streptococci were cultured from the wound. Early recognition of the disease process, prompt surgical debridement of the necrotic tissue, aggressive antimicrobial therapy, and delayed skin grafting combine to minimize morbidity.

The functional organization of laryngeal motoneurons in the nucleus ambiguous (NA) was evaluated in adult male rats before and after recurrent laryngeal nerve section and reinnervation. Using retrograde double labeling techniques with fluorescent probes, we obtained the number and position of labeled neurons by using the Bioquant 3-D imaging system. Reinnervation was documented by electromyography. In nine control animals vector analysis revealed significant (p less than .05) separation of the posterior cricoarytenoid (PCA) muscle motoneurons and the thyroarytenoid and lateral cricoarytenoid (TA/LCA) muscle motoneurons. The PCA motoneurons were positioned ventromedially in the NA, and TA/LCA motoneurons were found dorsolaterally in the NA. Rostral-caudal separation was not significant. Electromyography revealed phasic electrical activity synchronous with respiration in the PCA, and activity synchronous with deglutition in the TA/LCA. In four animals surviving 15 weeks following recurrent laryngeal nerve section and primary neurorrhaphy, functional organization within the NA was lost and phasic motor unit activity synchronous with respiration was seen in the TA/LCA muscle as well as the PCA. Vector analysis revealed the reinnervating motoneurons for both the PCA and TA/LCA to be positioned dorsolaterally, similar to the control group TA/LCA motoneurons. These findings demonstrate a shift in the topographic organization of laryngeal motoneurons within the NA following reinnervation, with random organization occurring at the neurorrhaphy site.