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The need for multidisciplinary and multiprofessional management of dysphagia is constantly increasing and creating a major challenge for healthcare professionals and society, especially in terms of professional expertise and human resources. The distribution of tasks among the dysphagia team members, which includes phoniatricians, otolaryngologists, and speech-language therapists, is flexible and overlapping. For assessing dysphagia, the (fibreoptic) flexible endoscopic evaluation of swallowing (FEES), with or without videofluoroscopy, is a pivotal diagnostic tool. This position paper aims to illustrate the phoniatrician's role in performing a FEES, which is an indispensable component of the diagnostic workup of patients suffering from oropharyngeal dysphagia. It is based on the current collaborative expert view of the Swallowing Committee of the Union of European Phoniatricians and a literature review. A FEES is one of the core competences of phoniatricians due to their endoscopic expertise and experience in the field of dysphagia and diseases of the upper aerodigestive tract. Therefore, the phoniatrician is an important member of the dysphagia team, for the medical diagnostics of the aerodigestive tract and dysphagia as well as for FEES. Phoniatric competence is especially important for head and neck cancer patients, infants, and complex cases., (© 2022. The Author(s).)

Practitioners in the field of voice are often faced with patients who are 'dysphonic', but who do not have identifiable abnormalities of the vocal tract structures or any neural or hormonal alteration affecting the phonatory function. For lack of better nomenclature describing the origin of the disorder, this group of patients has been labeled as having 'non-organic' or 'functional' dysphonia. 'Non-organic' only states what the dysphonia is not, and 'functional' does not have any etiological implication. Hence 'functional disorder' as a determination of the origin is at best vague, imprecise and often misleading. In truth, the terms "functional" and 'non-organic' are by now so muddled and confused in everyday clinical usage and parlance that it is unclear what they mean in any given clinical setting or for any particular clinical case. Thus, the UEP Voice Committee (VC) has come to the conclusion that it is best to adopt a new term that is clearly defined, universally agreed to, and indicative of a different and more useful perspective. We have reviewed the literature relating to terminology of these phonatory disorders. We now propose replacement of the phrase 'functional dysphonia' with 'malregulative dysphonia', since the indication of faulty regulation represents an etiological connotation. We also propose a restructuring of the etiological terminology of phonation disorders. We believe this to be a biologically clearer framework for the labeling of 'non-organic' phonatory disorders, and hope that its routine use will allow for more clarity of presentation and discussion in the future., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background: A professional singer produced various vowels on a comfortable loudness and pitch in an inspiratory and expiratory phonation manner. The present study investigates the morphological differences and tries to find a link with the acoustical characteristics., Objectives/hypothesis: We hypothesize that features, constantly present over all vowels, characterize inhaling phonation and that the formant frequencies reflect the morphological findings., Study Design: A prospective case study was carried out., Methods: A female singer uttered the vowels /a/, /e/, /i/, /o/, and /u/ in a supine position under magnetic resonance imaging, on a comfortable loudness and pitch, in both inhaling and exhaling manner. The exact same parameters as in previous reports were measured (1-3). Acoustical analysis was performed with Praat., Results: Wilcoxon directional testing demonstrates a statistically significant difference in (1) the distance between the lips, (2) the antero-posterior tongue diameter, (3) the distance between the lips and the tip of the tongue, (4) the distance between the epiglottis and the posterior pharyngeal wall, (5) the narrowing of the subglottic space, and (6) the oropharyngeal and the hypopharyngeal areas. Acoustical analysis reveals slightly more noise and irregularity during reverse phonation. The central frequency of F0 and F1 is identical, whereas that of F2 and F3 increases, and that of F4 varies., Conclusions: A smaller mouth opening, a narrowing of the subglottic space, a larger supralaryngeal inlet, and a smaller antero-posterior tongue diameter can be considered as morphological characteristics for reverse phonation. Acoustically, reverse phonation discretely contains more noise and perturbation. The formant frequency distribution concurs with a mouth narrowing and pharyngeal widening during inhaling., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Harmful effects of diesel emissions can be investigated via exposures of human epithelial cells, but most of previous studies have largely focused on the use of diesel particles or emission sources that are poorly representative of engines used in current traffic. We studied the cellular response of primary bronchial epithelial cells (PBECs) at the air-liquid interface (ALI) to the exposure to whole diesel exhaust (DE) generated by a Euro V bus engine, followed by treatment with UV-inactivated non-typeable Haemophilus influenzae (NTHi) bacteria to mimic microbial exposure. The effect of prolonged exposures was investigated, as well as the difference in the responses of cells from COPD and control donors and the effect of emissions generated during a cold start. HMOX1 and NQO1 expression was transiently induced after DE exposure. DE inhibited the NTHi-induced expression of human beta-defensin-2 (DEFB4A) and of the chaperone HSPA5/BiP. In contrast, expression of the stress-induced PPP1R15A/GADD34 and the chemokine CXCL8 was increased in cells exposed to DE and NTHi. HMOX1 induction was significant in both COPD and controls, while inhibition of DEFB4A expression by DE was significant only in COPD cells. No significant differences were observed when comparing cellular responses to cold engine start and prewarmed engine emissions., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Inspiratory phonation (IP) means phonating with inspiratory airflow. Some vocalists remarkably master this technique, to such an extent that it offers new dramatic, aesthetic, and functional possibilities in singing specific contemporary music. The present study aims to a better understanding of the physiological backgrounds of IP., Material and Methods: A total of 51 inhaling utterances were compared with 61 exhaling utterances in a professional soprano highly skilled in inhaling singing, by means of high-speed single-line scanning and advanced acoustic analysis. Ranges of intensity and Fo were kept similar., Results: The main differences are: (1) an inversion of the mucosal wave, (2) a smaller closed quotient in IP, (3) a larger opening/closing quotient in IP with the additional difference that in IP, the quotient is larger than 1 (opening slower than closing), whereas it is less than 1 in expiratory mode (opening faster than closing), (4) a larger vocal-fold excursion in IP, (5) higher values of adaptive normalized noise energy in IP, and (6) a steeper slope of harmonic peaks in IP. However, jitter values are similar (within normal range), as well as damping ratios and central formant frequencies. The two voicing modes cannot be differentiated by blind listening., Conclusion: The basic physiological mechanisms are comparable in both voicing modes, although with specific differences. IP is actually to be considered as an "extended vocal technique," a term applied to vocalization in art music, which falls outside of traditional classical singing styles, but with remarkable possibilities in skilled vocalists., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Inhaling singing is a recently developed singing technique explored by the soprano singer Françoise Vanhecke. It is based on an inspiratory airflow instead of an expiratory airflow. This article describes the anatomical structural differences of the vocal tract between inhaling and exhaling singing. We hypothesize that the vocal tract alters significantly in inhaling singing, especially concerning the configuration of the anatomical structures in the oral cavity and the subglottal region., Study Design: This is a prospective study., Methods: A professional singer (F.V.) performed sustained tones from F5 chromatically rising up to Bb5 on the vowel /a/. Vocal tract anatomy is assessed by magnetic resonance imaging., Results: Wilcoxon directional testing demonstrates (1) that the vocal tract volume above the glottal region does not differ statistically in contrast to the subglottal region and (2) significant changes in the configuration of the tongue, the upright position of the epiglottis, the length of the floor of mouth, and the distance between the teeth., Conclusions: The narrowing of the subglottis is considered to be secondary to suction forces used in the inhaling singing technique. The changes in the anatomical structures above the vocal folds possibly suggest a valve-like function controlling the air inlet together with the regulator function of the resonator capacities of the vocal tract., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

This article is a compilation of own research performed during the European COoperation in Science and Technology (COST) action 2103: 'Advance Voice Function Assessment', an initiative of voice and speech processing teams consisting of physicists, engineers, and clinicians. This manuscript concerns analyzing largely irregular voicing types, namely substitution voicing (SV) and adductor spasmodic dysphonia (AdSD). A specific perceptual rating scale (IINFVo) was developed, and the Auditory Model Based Pitch Extractor (AMPEX), a piece of software that automatically analyses running speech and generates pitch values in background noise, was applied. The IINFVo perceptual rating scale has been shown to be useful in evaluating SV. The analysis of strongly irregular voices stimulated a modification of the European Laryngological Society's assessment protocol which was originally designed for the common types of (less severe) dysphonia. Acoustic analysis with AMPEX demonstrates that the most informative features are, for SV, the voicing-related acoustic features and, for AdSD, the perturbation measures. Poor correlations between self-assessment and acoustic and perceptual dimensions in the assessment of highly irregular voices argue for a multidimensional approach.

Introduction: This explorative study examines personal and neighbourhood characteristics associated with short-distance trips made by car, bicycle or walking in order to identify target groups for future interventions., Methods: Data were derived from 'Mobility Research Netherlands (2004-2009; MON)', a dataset including information regarding trips made by household members (n = ±53,000 respondents annually). Using postal codes of household addresses, MON data were enriched with data on neighbourhood typologies. Multilevel logistic modelling was used to calculate odds ratio (OR) of active transport versus car use associated with four different trip purposes (shopping (reference), commuting, taking or bringing persons or sports). A total of 277,292 short distance trips made by 102,885 persons were included in analyses., Results: Compared to women shopping, women less often take active transport to sports clubs (OR = 0.88) and men less often take active transport for shopping (OR = 0.92), or for bringing or taking persons (OR = 0.76). Those aged 25-34 years (OR = 0.83) and 35-44 years (OR = 0.96) were more likely to use active transport for taking or bringing persons than persons belonging to the other age groups (relative to trips made for shopping by those 65 years or over). A higher use of active transport modes by persons with an university or college degree was found and particularly persons living in urban-centre neighbourhoods were likely to use active transport modes., Conclusion: IN DEVELOPING POLICIES PROMOTING A MODE SHIFT SPECIAL ATTENTION SHOULD BE GIVEN TO THE FOLLOWING GROUPS: a) men making short distance trips for taking or bringing persons, b) women making short distance trips to sport facilities, c) persons belonging to the age groups of 25-44 years of age, d) Persons with a primary school or lower general secondary education degree and persons with a high school or secondary school degree and e) persons living in rural or urban-green neighbourhoods.

Background: Hemodialysis (HD) tunneled cuffed catheters may be fitted with neutral-valve closed-system connectors. Such connectors, which are flushed with saline solution and used for 3 consecutive HD sessions, provide a mechanically closed positive-pressure barrier and potentially may be useful to prevent catheter-related bacteremia and dysfunction., Study Design: Single-center randomized controlled trial., Setting & Participants: 66 adult HD patients with a tunneled cuffed catheter., Intervention: Neutral-valve closed-system connector (Tego Needlefree Hemodialysis Connector) versus trisodium citrate, 46.7%, locking solution (Citra-Lock; control group)., Outcomes: Primary composite outcome was the incidence rate of catheter-related dysfunction or bacteremia. Secondary outcomes were the separate incidence rates of catheter-related dysfunction and bacteremia and the cost of both procedures., Measurements: Catheter dysfunction was defined as the requirement of urokinase and/or a mean blood flow ≤250 mL/min during 2 consecutive HD sessions. Catheter-related bacteremia was defined as ≥2 positive blood cultures. Time of catheter use was calculated and the incidence rate of complications was expressed per 100 person-years., Results: 66 patients were followed up for a median of 86 (IQR, 29-200) days. The composite primary outcome was not significantly reduced in the closed-system-connector intervention group versus the citrate-locking-solution control group (63.56 vs 71.51 per 100 person-years; P = 0.3). Catheter dysfunction in the intervention group was not decreased versus controls (59.59 vs 51.64 per 100-person-years; P = 0.9). Only 6 catheter-related bacteremia events were identified, one in the intervention group (3.97 vs 19.86 per 100 person-years; P = 0.06)., Limitations: Small size of the patient population and single-center study., Conclusions: Superiority of the closed-system connector in terms of prevention of the primary efficacy end point compared to the standard locking solution was not observed. Further evaluation in a larger study is suggested., (Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study is to assess the efficacy of UES's dysfunction treatments with the DHI (Deglutition Handicap Index)., Material and Method: 24 patients suffering of UES's dysfunction were included prospectively between 2008 and 2009 in 2 centers (France and Netherlands). Patients completed DHI before and after treatment. For statistics, Wilcoxon two-sample tests were used., Results: The mean score was 57 +/- 17 in the preoperative and 26 +/- 19 in the post operative time. The statistical difference was significant p < 0.0001. The difference is also significant for the 3 subscales (symptoms, functional, emotional)., Conclusion: The DHI has been validated in terms of content, concurrent, construct validity and temporal reliability. It can be used for assessing efficacy of treatments used for dysphagia.

In this article, we investigate whether (1) the IINFVo (Impression, Intelligibility, Noise, Fluency and Voicing) perceptual rating scale and (2) the AMPEX (Auditory Model Based Pitch Extractor) acoustical analysis are suitable for evaluating adductor spasmodic dysphonia (AdSD). Voice recordings of 12 patients were analysed. The inter-rater and intra-rater consistency showed highly significant correlations for the IINFVo rating scale, with the exception of the parameter Noise. AMPEX reliably analyses vowels (correlation between PUVF (percentage of frames with unreliable F0/voicing 0.748), running speech (correlation between PVF (percentage of voiced frames)/voicing 0.699) and syllables. Correlations between IINFVo and AMPEX range from 0.608 to 0.818, except for noise. This study indicates that IINFVo and AMPEX could be robust and complementary assessment tools for the evaluation of AdSD. Both the tools provide us with the valuable information about voice quality, stability of F0 (fundamental frequency) and specific dimensions controlling the transitions between voiced and unvoiced segments.

After osteosarcoma, chondrosarcoma is the second most common primary bone tumor accounting for 26% of all malignancies. In the laryngeal region however, chondrosarcomas are rather rare. Only 300 cases are reported in literature. Considering laryngeal chondrosarcoma, about 75% occur in the cricoid cartilage, whereas 20% occur in the thyroid cartilage. In this paper we report a case of thyroidal chondrosarcoma, and based on a thorough literature search we suggest some practical guidelines concerning diagnosis and therapy.

In this paper, an experimental study of inter-judge consistency for the different dimensions of a recently proposed new scale for the rating of substitution voices is presented. The IINFVo rating scale tries to score five parameters, namely impression, intelligibility, noise, fluency and voicing. Each parameter is scored between 0 (very good substitution voicing) and 10 (very deviant substitution voicing) on a visual analogue scale. Inter-judge consistencies were measured among semi-professional as well as among professional jury members. The consistencies among semi-professionals, expressed as Pearson correlation coefficients, ranged from moderate to good (0.57-0.68), whereas those among professionals were good to excellent (0.82-0.87) and compared favourably to consistency figures published for traditional perceptual evaluation scales such as the GRBAS scale for laryngeal dysphonia. Since there is a strong correlation between the scores of impression and intelligibility, and since intelligibility is hard to score by non-native listeners, we suggest taking the mean of the two scores as the "impression" of a modified dimensional INFVo rating scale. Our experiments demonstrate that the INFVo rating scale has good potential to become a routine perceptual evaluation method in a multidimensional assessment protocol for substitution voicing.

Objectives: Evaluation of a perceptual specific rating scale for specific severe non laryngeral dysphonia., Material and Method: 113 speech samples from substitution voices were scored perceptually according to the IINFVo scale: overall quality impression (I), impression of Intelligibility (I), additive and unnecessary noise (N), speech fluency (F) and presence of voiced segments (Vo). Each parameter was scored on a visual analogue scale from 0 (minimally deviant) to 10 (maximally deviant substitution voicing). These samples were presented to semi-professional jury-members (second grade speech therapy students) and professional jury-members (phoniatricians and speech therapists, specialised in the oncological field)., Results: Interindividual agreement between semi-professionals was moderate (0.57-0.68). Interindividual agreement between professionals was higher (0.82-0.86). These figures are similar or even better compared to the classical perceptual evaluation scale for laryngeal speech (GRBAS)., Conclusion: Our study suggests that the I(I)NFVo rating scale is suitable for perceptual evaluation of substitution voicing and consistency results are comparable with the classical perceptual rating scale (GRBAS).

This paper describes our first attempts to develop a method for the objective assessment of quality in substitution voices. The objective analysis deals with acoustic parameters characterising short voice and speech samples like a sequence of isolated vowels, a sequence of VCV and CVCVCV syllables, a short sentence, etc. A database of 113 registrations from 68 patients (53 total laryngectomy patients with tracheo-esophageal speech, 14 total laryngectomy patients with esophageal speech and 5 patients with partial frontolateral laryngectomy) and 6 registrations from healthy control persons was collected. Each registration consisted of seven speech utterances and was subjected to an acoustic analysis as well as to a perceptual evaluation, the latter involving eight parameters like "overall impression", "tonicity", etc. Since the goal of our work is to find out the best acoustical measurement for supporting perception and making it precise, it seemed logical to strive for a perceptually based acoustic analysis. We therefore performed the analysis by means of a peripheral auditory model with a built-in fundamental frequency (pitch) extractor. From the frame-level outputs (a frame is 10 ms) of the analyser, global objective parameters, such as (1) the percentage of voiced frames, (2) the average voicing evidence, (3) the voicing length distribution and (4) the fundamental frequency jitter, were computed for the different speech utterances. So as to reduce the parameter variability arising from the nature of the speech utterances (e.g., the presence of pauses in the signal, errors caused by the pitch extractor, etc.), the objective parameters were computed using non-standard averaging schemes involving energy weighting and frame selection. A statistical analysis of the objective parameters confirms that the quality of tracheo-esophageal speech is superior to that of esophageal speech, but inferior to that of normal speech and speech with the preservation of one vocal fold. Correlations between the objective parameters and the perceptual parameters are moderate.

We tested the Voice Handicap Index (VHI) in 45 patients with substitution voicing (that is, without the use of two vocal folds), the majority of them using tracheo-oesophageal speech. We introduced a corrected VHI score (VHI(corr)) whose values are in the range from 0 to 100 and which can be expressed as a percentage. As such, the VHI(corr) is a handy and transparent tool, and it seems to be suited for representing the handicap caused by the voice disorder when some items are unanswered as experienced in patients with substitution voicing. Interestingly, our data reveal that the voice handicap severity of this particular category of patients is (1) moderate and in the range of "common" dysphonia and (2) not affected by additional radiotherapy. It seems that the E domain is overstated due to the number of problematic items in the P and F domains.

Placement of a voice device in a tracheoesophageal fistula provides successful speech rehabilitation after total laryngectomy. However, in the long term, removal of the voice device and permanent closure of the fistula is sometimes necessary. This paper presents and evaluates a simple surgical technique for primary closure of tracheo-esophageal fistulae. We retrospectively review 12 laryngectomees who received this technique of primary closure from 1997 to 2000. In 58% of the patients, permanent fistula closure could be obtained. Six patients (50%) healed primarily; in one patient (8%) the residual fistula opening healed secondarily. Four patients (33%) needed a second surgical procedure, and in one patient (8%) inserting a new speech prosthesis obliterated the residual fistula. Radiotherapy seems to compromise wound healing and therefore may be considered as a contraindication. Complications such as tracheal stenosis, tissue necrosis and pneumonia, etc., did not occur.

Background: Wide resection of oropharyngeal malignancies implicates the risk of velopharyngeal insufficiency, which can cause nasal regurgitation and hypernasality. A meticulous reconstruction is necessary to avoid impairment and handicap in deglutition and speech. In the classic reconstructive techniques for large oropharyngeal defects, functional outcome only regards deglutition. We also focus on nasality, because hypernasality often occurs as a consequence in this type of reconstruction., Methods: In four patients, the surgical defect is closed with a free radial forearm flap sutured to the posterior side of the hard palate, thus imitating a caudally based pharyngeal flap. Speech is assessed by an independent speech pathologist, perceptually and acoustically. Deglutition is evaluated by a questionnaire and videofluoroscopy., Results: All patients had normal food intake. They did not report alterations in speech quality or verbal communication. Perceptual evaluation of articulation, voice, and nasality was optimal. Objective measurements with acoustical analysis and nasality scores confirmed the excellent functional outcome. Videofluoroscopy showed an unimpaired bolus transport with a complete velopharyngeal closure and optimal oral and pharyngeal clearance times., Conclusions: This meticulous reconstructive technique ensures an excellent functional outcome. The absence of nasality, in particular, proves the value of this refinement. The technique allows wide surgical margins and complete velopharyngeal closure., (Copyright 2003 Wiley Periodicals, Inc. Head Neck 25: 772-777, 2003)

It is known that heat and moisture exchangers have a positive effect on the respiratory system in patients after total laryngectomy. The ATOS and INHEALTH devices are most frequently used in Belgium. However, recently a new device, the HME filter Cyranose, has become available. As a pilot study, this device has been applied to a total of 12 patients in three different centres. The temperature of the inspired air was considered as good or excellent in 90% of our patients at the 1st week and up to 100% at the 3rd month. The air humidification was considered as good or excellent in 100% of the patient population, and the HME filter positively influenced the phlegm production in 78% of our laryngectomy population. Our study stresses the benefits of a HME filter in general and seems promising for the Cyranose HME filter.

Our study compares deglutition between a group who had undergone total esophagopharyngolaryngectomy and a group who had esophagectomy and partial pharyngectomy with preserved larynx, after reconstruction of the upper digestive tract with pedicled colon interposition. In four patients the laryngeal structures could be preserved (three caustic burns and one proximal esophageal tumor). Six patients underwent a total laryngopharyngectomy for large pharyngeal tumors. Swallowing was assessed by a questionnaire, clinical examination, and videofluoroscopy. All patients had normal intake of semisolid foods and fluids. All patients but three experienced some feeling of "narrowing" of the tract: four at the level of the hypopharynx, two at the oropharyngeal level, one at the oral level. In the laryngectomy group, solid food caused some degree of delayed swallowing in three patients. Dumping occurred in one case out of the nonlaryngectomy group. On clinical examination a tense motility in all laryngectomy patients appeared, food remnants in five and repeated swallowing movements in four. The videofluoroscopy confirmed repeated swallowing movements and presence of residual food in the oral cavity. Temporal stagnation occurred at the anastomosis site in all patients and in two patients at a place of colon redundancy. Colon interposition is a reliable reconstruction and gives the possibility of a good functional outcome. Although preservation of the larynx facilitates swallowing even in this reconstructive procedure, it may be better to perform a total laryngopharyngectomy and colon interposition in oncological cases where the pharyngeal remnant is borderline for primary closure.

Objectives: 93 patients with various kinds of organic benign voice pathology (vocal fold nodules, polyp, Reinke's oedema, unilateral paralysis, sulcus/scar) and/or with muscle tension dysphonia, were evaluated before and after their voice treatment (phonosurgery with voice therapy, antireflux medication, or voice therapy alone) in order to check the clinical relevance of a basic multidimensional protocol for assessing functional results of voice treatments, as developed by the Committee on Phoniatrics of the ELS., Material and Method: The protocol has been used in different university voice clinics. It comprises 5 dimensions: Perception: Grade, Breathiness and Roughness from the GRBAS-scale, rated by two experienced judges: a phoniatrician/laryngologist and a speech therapist. Acoustics: Jitter % and Shimmer % computed on a /a:/, at comfortable loudness and pitch. Also Fo-range and softest possible intensity. Videostroboscopy: Glottal closure, regularity, mucosal wave and symmetry, rated separately. Phonation quotient: computed by dividing the vital capacity (ml) by the maximum phonation time (s) (best value of 2x3 trials). Self rating by the patient: voice quality in itself and general social/occupational handicap due to the voice problem rated separately., Results: Results show that, at group level, the overall effects for each parameter indicate a significant improvement after treatment. However, the correlations between the pre/post changes for the different parameters are weak (low redundancy)., Conclusion: The assessment of voice pathology needs to be multidimensional, as these multidimensional informations about voice changes lead to a better understanding of the actual way in which a treatment works.

We present a patient treated by a total pharyngolaryngoesophagectomy and postoperative radiotherapy for a hypopharyngeal T4N2bM0 squamous cell carcinoma. The upper digestive tract was reconstructed with a pedicled left colon interposition through the posterior mediastinum. A voice prosthesis was placed 9 months after the initial treatment, following measurement of the tracheo-neopharyngeal wall thickness by sonography. Fifteen months after the total pharyngolaryngectomy, the patient remains free of recurrent disease and has successfully resumed speaking with the voice prosthesis.

Purpose: Ethmoid sinus cancer is a rare malignancy. Treatment results are mostly reported together with other sinonasal tumors, grouping a wide range of different histologies and treatment approaches. This study reports on the treatment outcome of 47 patients diagnosed with adenocarcinoma of the ethmoid sinuses and treated with surgery and high-dose postoperative radiation therapy., Methods and Materials: Between September 1985 and October 2001, 51 patients with adenocarcinoma of the ethmoid sinuses were referred to the Ghent University Hospital. Four patients were treated with low-dose palliative radiation because of very extended inoperable disease or distant metastasis at the time of diagnosis. They were not included in this analysis. The other 47 patients, all staged as N0M0, were treated with surgery and postoperative high-dose radiation therapy. The median follow-up was 32 months. The T-stages were T1 for 2, T2 for 17, T3 for 11, and T4 for 17 patients. All 47 patients were staged as N0M0., Results: The 3-year, 5-year, and 7-year overall survival are respectively 71%, 60%, and 38%. The 3-year and 5-year disease-free survival are respectively 62% and 36%. The 3-year and 5-year disease-free survival for T1-T2 stages are respectively 87% and 55%, for T3 stages 57% and 28%, and for T4 stages 41% and 25%. The locoregional tumor control was 70% and 59% at respectively 3 and 5 years. Patients presenting with intracranial tumor invasion at the time of diagnosis relapsed within 7 months after the end of radiotherapy. Radiation-induced severe dry eye syndrome and optic neuropathy was observed in respectively 7 and 2 of the 47 cases., Conclusion: Postoperative radiotherapy for adenocarcinoma of the ethmoid sinuses is associated with good local control rates. Crucial for a favorable prognosis is the absence of intracranial invasion. The rarity of these tumors makes it difficult to evaluate new therapeutic advances.

The aim of this study was to present our experience with the clinical characteristics of non-tuberculous mycobacterial (NTM) head and neck lymph node infections, the use of modern diagnostic tools and the appropriate therapeutic measures. We have reviewed the cases of 14 Caucasian children with NTM head and neck lymphadenitis who were treated in our clinic in the last 5 years. Three of the patients were male and 11 were female. Their age ranged from 15 to 98 months (mean age 45.7 +/- 21.76 months). Cervical lymph nodes were involved in all of our cases, while the submandibular region was found to be the area mostly affected. Overlying skin was involved in 7 cases. Diagnosis was based on intradermal skin testing with specific antigens for atypical mycobacteria, histological examination and specimen culture. Skin tests were positive for NTM in all of the patients with a predilection for Mycobacterium avium complex. The diagnosis was confirmed by histological examination in 13 cases. Specimen culture was positive in 9 cases, most of them growing M. avium-intracellulare complex. Treatment included complete surgical excision of the affected lymph nodes and the overlying skin, as well as functional neck dissection when required. A second procedure was performed in 2 patients. Successful evaluation of NTM infections of the head and neck lymph nodes should include a detailed history, thorough physical examination and specific laboratory investigations. The treatment of choice is complete surgical excision of all affected tissue., (Copyright 2002 S. Karger AG, Basel)

Midwave and long-wave infrared propagation were measured in the marine atmosphere close to the surface of the ocean. Data were collected near San Diego Bay for two weeks in November 1996 over a 15-km horizontal path. The data are interpreted in terms of effects expected from molecules, aerosol particles, and refraction. Aerosol particles are a dominant influence in this coastal zone. They induce a diurnal variation in transmission as their character changes with regular changes in wind direction. A refractive propagation factor calculation is introduced, and it is systematically applied to the model and to the data analysis. It is shown that this refractive propagation factor is a necessary component of a complete near-sea-surface infrared transmission model.

Sleep disordered breathing patients may undergo surgical treatment after history, clinical examination and polysomnographic study if they demonstrate upper airway obstruction. This article focus on the surgical treatment designed for these patients. Sino-nasal surgery, rhinopharyngeal procedure, velopharyngeal procedures (Uvulopalato-pharyngoplasty, Laser assisted uvulopalatoplasty, Radiofrequency tissue volume reduction) as well as base of the tongue procedures were discussed among a panel of Belgian ENT specialists offering their experience in this field. Algorithm on corrective surgery as well as guidelines for postoperative management are proposed in the management of sleep disordered breathing patients.

Acoustic analysis of snoring could make patient assessment more accurate, treatment planning more efficient and could provide objective documentation reliable for comparison. However, spectral characteristics are irregular and difficult to analyse. The authors give an overview of the available literature and the various applied methods. These methods differ in purpose and are subject to restrictions. Until now, acoustic analysis of snoring remains controversial. For linking the results of the acoustic analysis with anatomical levels or degree of obstruction, further study is needed to develop a reliable parameter.

Sleep disordered breathing (SDB) patients usually undergo an ENT clinical examination before any therapeutic decision. This clinical examination would be predictive about the occurrence of Obstructive Sleep Apnea Syndrome, cost effective, reproducible and would determine the sites of obstruction in the upper airways. To achieve this, ENT specialists from Belgium, representatives of academic hospitals in the country, have tried to establish an updated work-up in the clinical evaluation of the SDB patients. History, risk factors evaluation, excessive daytime sleepiness, static and dynamic evaluation of the upper airways (velopharynx aspect, tonsils grading, Mallampati score, Müller's maneuver, fiberoptic evaluation) have been standardized in a consensus report easily accessible to the vast majority of ENT specialists. This consensus must be understood as a clinical work-up to perform before the monitoring of breathing during sleep.

Botulinum injection in the cricopharyngeal muscle has not yet been described thoroughly. In reviewing the literature, only 24 cases were found in which botulinum injection was used to treat cricopharyngeal dysfunction. We want to add another four cases and discuss specific indications and necessary pre-treatment examinations. Depending on the patient's history and the clinical findings, botulinum injection may be performed. Manometry and videofluoroscopy are not mandatory. The type of functional pathology defines whether botulinum toxin will be a definite treatment or a temporary relief.

This phase I pilot study reports on (1) the safety and feasibility of 99Tc(m)-HL91, an amine oxime core radioligand that has shown oxygen dependent binding, and imaging; and (2) its usefulness for the visualization of local tumour recurrence of a biopsy proven squamous cell carcinoma of the head and neck (SCCHN) as compared to spiral computed tomogaphy (CT) and biopsy. Nine men (mean age 33 years, range 34-74 years) were prospectively included. For safety measurements, vital signs were recorded and serum chemical analysis carried out, with a complete blood cell count and urine analysis, and an ECG was performed prior to injection of 99Tc(m)-HL91 and repeated during the investigation. Single photon emission computed tomography (SPECT) scans of the head and neck, and of a standard, were performed at 2 h and 4 h post-injection of 740 MBq 99Tc(m)-HL91. Tumour-to-normal tissue background (T/N) ratios and percentage uptake were measured for all 99Tc(m)-HL91 scans. Spiral CT scans were obtained using a Somaton 4+ Siemens scanner within 1 week from the 99Tc(m)-HL91 scans. Based on CT and the 99Tc(m)-HL91 scan findings guided biopsies were performed. No adverse or subjective side effects were noticed. Vital signs, ECG findings, clinical laboratory, blood and urine assays remained stable in all patients. Spiral CT suggested local recurrence in 5/9 patients accompanied by nodal involvement in three, all of which proved positive on biopsy. 99Tc(m)-HL91 scintigraphy was false positive in one patient and true positive (TP) in 3/5 local recurrences and two out of three sites of lymph node involvement depicted by spiral CT. The mean T/N ratios at 2 h and 4 h in TPs were 1.28 (range 1.1-1.66) and 1.40 (range 1.0-1.6), respectively. The corresponding absolute percentages of 99Tc(m)-HL91 lesional uptake at 2 h and 4 h were mu = 0.05% (SD = 0.03%) and mu = 0.048% (SD = 0.035%). The findings suggest 99Tc(m)-HL91 is a safe radioligand and that metabolic binding in a large fraction but not all of local SCCHN recurrences may be expected. The inference that tumour 99Tc(m)-HL91 avidity could be a non-invasive measure of tumour hypoxia deserves however independent confirmation with needle oximetry.

A mycobacterial strain isolated from a lymph node of a 3-year-old female with cervical lymphadenitis was identified as Mycobacterium interjectum by means of sequencing of the 16S rRNA gene. Analysis of this case and previously published cases demonstrates the importance of M. interjectum as a causative agent of cervical lymphadenitis in young children.

The authors present a case of ectopic cervical thymus in a 4-month-old child. Ectopic cervical thymus is an uncommon etiology of a neck mass in a child. It is often misdiagnosed preoperatively as a possible malignancy. It is usually located along the embryologic course of thymus migration from the angle of the mandible to the superior mediastinum. Its treatment is surgical since malignant transformation and respiratory infection have been described. No case of immune deficit after total thymectomy has been described in the literature.

There are few reports on focal epithelial hyperplasia (FEH) in association with human immunodeficiency virus (HIV) infection; thus the relationship between them has not been completely clarified yet. We present a case of recurrent FEH in an HIV-positive man (the first described in Belgium), which, according to the PCR-DNA testing, was due to human papilloma virus type 13 (HPV13). To our knowledge, based on the accessible literature, this type of HPV has not been detected in any other documented study of FEH in HIV-positive patients before. Our patient experienced three recurrences of FEH in 1 year. It is therefore suggested that immunodeficiency due to HIV infection is responsible for the HPV-related FEH and the subsequent recurrences. In order to support the consideration of FEH as an oral manifestation of an HIV-related opportunistic infection, every new 'HPV-type' oral lesion in HIV-positive patients must be completely documented., (Copyright 2001 S. Karger AG, Basel)

A particular type of phonosurgery is voice change surgery in cases of gender dysphoria. This paper presents a review of the surgical techniques available for raising or lowering speaking fundamental frequency. A cricothyroid approximation to raise the vocal pitch is the most common procedure. This procedure results in an increase of about one octave immediately postoperatively and about half an octave after stabilization of the voice.

Caustic burns of the upper aerodigestive tract continue to be a significant clinical problem. However, the available literature uncommonly mentions changes affecting the larynx. We could find only one publication in which four cases of high hypopharyngeal stenosis were described in detail and where the functional outcome of the laryngeal function was stated as partially saved. We describe here a case of total retrocricoid stenosis in a 28-year-old woman that was caused by lye ingestion. A life-saving gastroesophagectomy was performed by the Department of General Surgery. Reconstruction of the esophagus was carried out with mobilized right colon, which was meticulously sutured circumferentially behind the arytenoids and on the prevertebral fascia. The anatomy of the larynx and its nerve supply were scrupulously maintained intact. We believe that our patient's rehabilitation was due mainly to an intensive 18-month program of care, following which all laryngeal functions recovered with normal voice and swallowing patterns.

Adult rhabdomyomas of the head and neck are uncommon benign skeletal muscle tumors. Only a few cases occurring in the pharyngeal wall have been described in the world literature. We present a case of recurrent bilateral rhabdomyomas in the pharynx and discuss the clinicopathological features of this lesion, comparing it to those of other neoplasms from which it must be differentiated. To our knowledge, bilaterality of this type of lesion has not been described previously. Although adult rhabdomyomas have a distinct histology, they often are mistaken for a variety of other lesions, particularly granular cell tumor.

Cleft palate is a known pathology but there exists a lot of controversy about the therapy. The aim of this paper is to give a brief overview of the pathology itself and its consequences particularly in speech. At this point the velar and velopharyngeal function are stressed.

Background and Purpose: Concave dose distributions generated by intensity modulated radiotherapy (IMRT) were applied to re-irradiate three patients with pharyngeal cancer., Patients, Materials and Methods: Conventional radiotherapy for oropharyngeal (patients 1 and 3) or nasopharyngeal (patient 2) cancers was followed by relapsing or new tumors in the nasopharynx (patients 1 and 2) and hypopharynx (patient 3). Six non-opposed coplanar intensity modulated beams were generated by combining non-modulated beamparts with intensities (weights) obtained by minimizing a biophysical objective function. Beamparts were delivered by a dynamic MLC (Elekta Oncology Systems, Crawley, UK) forced in step and shoot mode., Results and Conclusions: Median PTV-doses (and ranges) for the three patients were 73 (65-78), 67 (59-72) and 63 (48-68) Gy. Maximum point doses to brain stem and spinal cord were, respectively, 67 Gy (60% of volume below 30 Gy) and 32 Gy (97% below 10 Gy) for patient 1; 60 Gy (69% below 30 Gy) and 34 Gy (92% below 10 Gy) for patient 2 and 21 Gy (96% below 10 Gy) at spinal cord for patient 3. Maximum point doses to the mandible were 69 Gy for patient 1 and 64 Gy for patient 2 with, respectively, 66 and 92% of the volume below 20 Gy. A treatment session, using the dynamic MLC, was finished within a 15-min time slot.

A combined intracranial and transfacial approach for often very malignant lesions of the sino-nasal complex yields the best chance of curation. The operative risk diminishes in a centre with a large turnover after an initial learning curve and it is the only possibility to try to cure the patient from his or her disease. The removal of a rather small malignant lesion in the anterior part of the middle meatus can be safely done through the nostril with correct oncologic margins. In case of inoperability because of local destructions or because of the histological type (malignant melanoma e.g.) freeing up the nasal airway endoscopically can help patients symptomatically and repeatedly.

Background and Purpose: Intensity modulated radiotherapy (IMRT) is used in our department for treatment of paranasal sinuses. We describe the methodology that was developed together with the clinical implementation, illustrated by a case report., Material and Methods: Patient history, treatment and short follow-up are described. An IMRT, obtained by superposition of static beam segments was implemented. Electronic portal images, compared to digitally reconstructed radiographs (DRR) were used to evaluate and adjust patient positioning., Results, Discussion and Conclusion: IMRT is an appropriate and feasible treatment technique for head and neck cancer in anatomical regions that are difficult to treat. A high tumour dose can be combined with a good sparing of the surrounding organs at risk (OAR's).

MRI plays an important and specific role prior to tumor surgery in the head and neck region. It is especially interesting in providing a detailed description of the exact tumor extent close to the skull base and to investigate perineural and perivascular tumor spread. In selected cases this technique can give a presumed histopathological diagnosis for a mass that is clinically detected. This is especially true for some benign masses, such as hemangiomas, cysts and lipomas. The role of MRI with regard to a lymph node imaging survey in the neck is rather limited. MRI is moreover not routinely performed in neck regions where many motion artifacts can be expected, such as in the larynx.

Objective: Determining the results 5 years after surgery for proximal femur fractures., Design: Descriptive, retrospective., Setting: Department of General Medicine, Red Cross Hospital, the Hague, the Netherlands., Method: In 1996, for all patients operated on for proximal femur fractures in 1991, data were collected from the patient records regarding the admission and situation at home, and from the municipal archives, the family physician, the patient or his or her family regarding survival. The 5-year survival was compared with that of a cohort matched for age and sex, according to data from the Central Bureau for Statistics. The level of function after 5 years was evaluated by means of a Broos checklist., Results: Of the 117 patients operated, 69 had medical, 9 lateral and 39 pertrochanteric fractures. The average age of the 20 men and 97 women was 71 and 82 years, respectively. The average duration of hospitalisation was 31 days. Seven patients (6%) died while still in hospital. Of the 110 surviving patients, 61 (55%) returned to the situation in which they lived before. Starting 6 months postoperatively, the 5-year survival curves were parallel to those of the matched cohort. After 5 years, 53 patients (45%) were still alive. Of these, 37 patients (70%) functioned well., Conclusion: Most patients with proximal femur fracture belong to the category of patients in advanced old age. The survival after 5 years was 45%; most of the mortality occurred during the first 6 months after the operation. Of those surviving, 70% functioned well.