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OBJECTIVES/HYPOTHESIS Applying the principles of misdirected nerve regeneration to the larynx, Roger Crumley in 1989 coined the term laryngeal synkinesis (LS) which he later (2000) classified into 4 types (type I - good voice, type II - involuntary twitches and poor voice, type III - adduction during inspiration, type IV - abduction during phonation). Neurophysiological data were not available for all LS patients at that time. The current study was undertaken to utilize and test the Crumley classification for a clinical interrater comparison and, secondly, compare predicted with actual laryngeal electromyography (LEMG) results. STUDY DESIGN Descriptive study. METHODS Laryngoscopic and LEMG data of patients with unilateral vocal fold paralysis (VFP) of 6 months duration or longer were combined for retrospective evaluation. Forty-five data sets were available for laryngoscopic classification by two local laryngologists and by Roger Crumley. Twenty-three data sets with complete thyroarytenoid (TA) and posterior cricoarytenoid (PCA) - EMG data were used to compare predicted with actual LEMG results. RESULTS Local laryngologists were able to classify 24 of 45, Crumley 30 of 45 cases into one of the 4 synkinesis types. There was substantial agreement between examiners (Cohens Kappa 0.66 [P

There is no universally accepted quantitative metric that defines the ideal nasal tip rotation and projection.To identify the ideal nasal tip projection (NTP) and rotation by using 3 classic NTP methods (Crumley 1, Crumley 2, and Goode).Lateral facial portraits of normal-appearing white women aged 18 to 25 years were selected from a previously validated and attractiveness-scored database of images. Each image was digitally modified to fit the NTP ideals outlined by the Crumley 1, Crumley 2, and Goode methods with columellar facial angles (rotation metric) of 96°, 101°, 106°, 111°, and 116° (15 modified images per portrait). These variants were incorporated into electronic surveys that were distributed to traditional focus-group and online social-network participants. Analysis was performed using paired comparison analysis, a consumer preference research analytic. The traditional focus-group participants were undergraduate students at the University of California, Irvine, whose online social-network contacts were also used.Mean ranks.There were no significant differences in preference between the traditional focus-group (n = 106) and online participants (n = 3872) (P .05). The most preferred rotation variant for all 3 NTP methods was 106° (Crumley 1: mean rank, 2.11 [95% CI, 2.07-2.16]; Crumley 2: mean rank, 2.07 [95% CI, 2.02-2.12]; and Goode: mean rank, 2.05 [95% CI, 1.99-2.11]; P .001). Crumley 1 was considered to be the most attractive NTP method (mean rank, 1.84 [95% CI, 1.82-1.85]; P .001) overall and was the most preferred NTP method for faces of above-average attractiveness (mean rank, 1.78 [95% CI, 1.76-1.80]; P .001). No significantly preferred NTP method was found for faces of average attractiveness (P .05). The most aesthetic combination of tip rotation and projection was a columellar facial angle of 106° with the Crumley 1 tip projection.To our knowledge, this is the first population-based study to attempt to simultaneously determine the ideal NTP and rotation. Each classic NTP method uses measurements dependent on both projection and rotation; thus, ideal rotation for each NTP method must be determined before comparison of the ideals. A rotation of 106° (columellar facial angle) was found to be the most aesthetic. The Crumley 1 method was determined to be the most attractive nasal tip variant overall.NA.

Objectives/Hypothesis The Triological Society requires thesis submission for full membership. Accepted theses (AT) may be recognized with designations of: Mosher Awards (MA), Fowler Awards (FA), Honorable Mention for Basic Science (HMBS), and Honorable Mention for Clinical Science (HMCS). We sought to determine and compare the scholarly impact of Triological Society theses, their authors, and whether differences exist between AT and those that receive special recognition. Study Design Retrospective analysis of awards and theses compiled by The Triological Society home office from 1998 to 2011. Methods Thomson Reuters' Integrated Search Interface (ISI) Web of Knowledge and Google Scholar and were used to determine citations and the author's h-index. Trend and statistical analysis was performed. Results Of the 307 Triological Society theses examined, 275 were published and had record of citation. H-indices and number of citations were found to be nonparametric; thus, median and quartile (1st−3rd quartiles) values were found to be the following: AT 11 (4–26), MA 18 (9–25), FA 6 (1–28), HMBS 11 (4–26), and HMCS 16 (1–28) for number of citations per published thesis. H-indices of authors with accepted theses were AT 15 (10–19), MA 16 (15–23), FA 18 (10–23), HMBS 16 (11–19), and HMCS 15 (11–21). When comparing all groupings of theses and award winners with bibliometric indices, no statistical significance was found (P >0.5). Conclusions The Triological Society cultivates a competitive pool of applicants as membership is highly regarded. Negligible difference in citations and author h-index were observed between AT, MA, and FA theses indicated that the level of excellence is uniform, and thesis submission remains influential and prestigious. Level of Evidence N/A. Laryngoscope, 123:2654–2657, 2013

The Neurolaryngology Study Group convened a multidisciplinary panel of experts in neuromuscular physiology, electromyography, physical medicine and rehabilitation, neurology, and laryngology to meet with interested members from the American Academy of Otolaryngology Head and Neck Surgery, the Neurolaryngology Subcommittee and the Neurolaryngology Study Group to address the use of laryngeal electromyography (LEMG) for electrodiagnosis of laryngeal disorders. The panel addressed the use of LEMG for: 1) diagnosis of vocal fold paresis, 2) best practice application of equipment and techniques for LEMG, 3) estimation of time of injury and prediction of recovery of neural injuries, 4) diagnosis of neuromuscular diseases of the laryngeal muscles, and, 5) differentiation between central nervous system and behaviorally based laryngeal disorders. The panel also addressed establishing standardized techniques and methods for future assessment of LEMG sensitivity, specificity and reliability for identification, assessment and prognosis of neurolaryngeal disorders. Previously an evidence-based review of the clinical utility of LEMG published in 2004 only found evidence supported that LEMG was possibly useful for guiding injections of botulinum toxin into the laryngeal muscles. An updated traditional/narrative literature review and expert opinions were used to direct discussion and format conclusions. In current clinical practice, LEMG is a qualitative and not a quantitative examination. Specific recommendations were made to standardize electrode types, muscles to be sampled, sampling techniques, and reporting requirements. Prospective studies are needed to determine the clinical utility of LEMG. Use of the standardized methods and reporting will support future studies correlating electro-diagnostic findings with voice and upper airway function.

Objectives: Optical coherence tomography (OCT) is a high-resolution optical imaging technique that produces cross-sectional images of living tissues using light in a manner similar to ultrasound. This prospective study evaluated the ability of OCT to identify the characteristics of laryngeal cancer and measure changes in the basement membrane, tissue microstructure, and the transition zone at the edge of tumors. Materials and Methods: One hundred thirtythree patients underwent OCT examination during surgical endoscopy of the head and neck. Twenty-two patients with laryngeal cancer or a history of laryngeal cancer were imaged with a fiberoptic OCT system. Tumor and adjacent transition zones were imaged along with uninvolved subsites. OCT images were correlated with histopathology. Results: Twenty-six OCT examinations were performed in 22 patients. Basement membrane disruption was seen in 18 subjects, all of whom had histology showing classic features of cancer. A transition zone to uninvolved epithelium at the tumor periphery was also often observed. In six studies, benign or premalignant processes were histologically confirmed. In three thin, superficial lesions, an intact basement membrane was observed. The basement membrane could not be identified in three other bulky exophytic, premalignant lesions, primarily because of increased superficial signal backscattering observed in pathologic tissues. Conclusions: OCT clearly identifies basement membrane violation from laryngeal cancer and can identify transition zones at the cancer margin. In bulky exophytic lesions, OCT signal may not penetrate deeply enough to show the basement membrane, but for many suspicious lesions that require exclusion of cancer, OCT shows potential for assisting in diagnostic assessment. Key Words: Optical coherence tomography, larynx, vocal cord, laryngeal cancer, endoscopy, optical biopsy, laryngology. Laryngoscope, 116:1107–1113, 2006

Background Optical coherence tomography (OCT) is an emerging imaging modality that uses light to produce in vivo high-resolution cross-sectional images (7 μm) of tissues to depths of up to 3 mm. OCT is analogous to ultrasound, but relies on interferometry and low-coherence optical sources to produce images of tissue structure at the histological level. Methods In this study, OCT was used to image the mucosa overlying structures in the nasal cavity to obtain information regarding normative in vivo tissue microstructure. An OCT system using a Michaelson interferometer and a 1.3-μm broadband light source was incorporated into a fiber-optic imaging device that was inserted into the nasal cavity. Cross-sectional tomographic images of the anterior and posterior nasal septum, turbinates, and vestibule were acquired in 44 patients in either the office or the operating room during surgical endoscopy. Results OCT images of the nasal mucosa identified the distinct boundaries between the epithelium, lamina propria, and underlying bone/cartilaginous tissue. Within the lamina propria, features consistent with glands, ducts, and blood vessels were clearly identified. In patients who underwent decongestant therapy, before and after images showed distinct morphological changes in the mucosa. The thickness of the epithelium was tabulated, as well. Conclusion This study establishes the potential of using OCT to produce high-resolution images of the nasal mucosa. As an in vivo tissue microstructural imaging modality, OCT may be valuable in studying the impact of allergic and infectious disease on the nasal mucosa and monitoring its response to pharmacologic therapy.

Background The objectives of this pilot study were to (1) determine whether bipolar radiofrequency plasma-mediated ablation (PMA) can efficiently remove nasal septal cartilage and (2) calculate the ablation rate as a function of device power, probe force, and translation velocity using ex vivo porcine tissue. Methods Specimens were secured to a linear translation stage and were subjected to varying translation velocities (4, 7, and 12 cm/s), probe forces (140, 200, and 225 g), and bipolar radiofrequency generator (Coblator ENTec power settings, 38–58, 77–115, and 129–193 Watts root mean squared. Specimen mass loss and depth of ablation were measured using an analytic balance and dissection microscope, respectively. Results Visual and microscopic inspection revealed little char. Mass loss increased with decreasing translation velocity and increasing generator setting. Increasing probe force also influenced mass loss and increased crater depth. Depth of ablation did not correlate with translation velocity or generator setting. Conclusion PMA effectively ablates nasal septal cartilage and may be able to reduce or contour cartilaginous deformities and framework structures in the head and neck.

Objective To evaluate and optimize the design of a removable and inexpensive internal stabilization device to reduce the effect of intention tremor during laryngeal microsurgery. Study design and setting In this laboratory investigation, stabilizers were designed and constructed to allow a nonobstructing view of the surgical field, permit simple insertion and removal, and accommodate microsurgical instruments. Prototype stabilizers were tested by using a Dedo laryngoscope, a measurement grid, and video recording equipment, which recorded instrument tremor within the magnified operative field for later analysis. Physicians also rated instrument stability, mobility, visualization, and ease of use on a survey form. Results Instrument tremor was reduced approximately 90%, with little obstruction of view of the surgical field. Instrument range of motion was reduced but improved rapidly as the stabilizer bar was moved further from the tip of the laryngoscope. Conclusions Use of a stabilization device in the laryngoscope lumen reduces instrument tremor and has the potential to improve surgical performance during laryngeal microsurgery. EBM rating: B-3.

To assess the feasibility of reshaping cartilage using radiofrequency (RF) heating, and to examine the effects of this process on tissue biophysical properties (optical and thermal) and cellular viability.Mechanically deformed porcine septal cartilage was reshaped using 2 RF-generating devices. We performed dynamic measurements of tissue thermal and optical properties while heating cartilage with one of these devices. Cellular viability was assessed immediately and 7 days after treatment.A characteristic change in the diffuse transmittance of light through the cartilage occurred during heating. Change in transmittance has been shown to accompany the onset of stress relaxation in cartilage. Peak radiometric surface temperature during heating was 88.6 degrees C. Specimens retained their user-specified curved shape for the observed period of 14 days. Chondrocyte viability in RF-heated tissue was 19% and 14% of that in untreated control specimens at days 0 and 7 after treatment, respectively.Radiofrequency heating has been shown to effectively reshape cartilage while maintaining cellular viability, illustrating a novel application for a widely used technology.

First described in 1982, laryngeal synkinesis continues to play an important diagnostic and therapeutic role following recurrent laryngeal nerve (rln) injury. Vocal fold motion impairment (formerly called “vocal cord paralysis”), hyperadducted and hyperabducted vocal folds, and certain laryngeal spasmodic and tremor disorders are often best explained by synkinesis. A closer look at these mechanisms confirms that following rln injury, immobile vocal folds may be nearly normally functional (favorable), or spastic, hyperadducted, or hyperabducted (unfavorable). This has resulted in a functional classification of laryngeal synkinesis as follows: type I laryngeal synkinesis, with satisfactory voice and airway (vocal fold poorly mobile, or immobile); type II synkinesis, with spasmodic vocal folds and an unsatisfactory voice and/or airway; type III synkinesis, with hyperadducted vocal folds and airway compromise; and type IV synkinesis, with hyperabducted vocal folds, poor voice, and possible aspiration. This classification facilitates the understanding of laryngeal pathophysiology following RLN injuries and promotes a more scientific basis for management.

Bilateral vocal cord immobility can be life threatening for some patients. Others, who have an open glottic chink, may have a breathy dysphonia, intermittent dyspnea, and stridor. These signs and symptoms may also be found in a number of other conditions that cause weakness or paradoxical motion of the vocal cords that mimics paralysis. These other conditions include central nervous system diseases, neuromuscular disorders, laryngospasm, and psychogenic disorders. In addition, patients with cricoarytenoid joint immobility or interarytenoid scar can also have similar symptoms at presentation. It is critical to consider the differential diagnosis of an assumed bilateral vocal cord paralysis and understand the management of paradoxical movement, weakness, joint fixation, interarytenoid scar, laryngospasm, and psychogenic disorders. The treatment for bilateral immobility should proceed only after a thorough evaluation, which might include electromyography and/or examination during general anesthesia under dense anesthetic paralysis. Reconstructive procedures are the treatments of choice, and destructive procedures should be chosen only as a last resort.

The purpose of this article is to review our current approach to selective modification of laryngeal neuromuscular function. Dissection of the distal branches of the recurrent laryngeal nerve allows for selective modification of laryngeal adductory and abductory function. The surgical techniques for identification of recurrent laryngeal nerve branches to the posterior cricoarytenoid muscle, the lateral cricoarytenoid muscle, and the vocalis muscle are described. Reinnervation is achieved while using motor branches of the ansa hypoglossi nerve or the superior laryngeal nerve. The techniques described are useful for the treatment of spasmodic dysphonia and laryngeal paralysis.

This article describes the mechanisms of peripheral nerve healing and the efforts to achieve an optimal healing outcome. The mainstay of treatment has been adherence to good surgical technique and the use of microsurgical equipment. Despite advances in microsurgery, complete structural and functional recovery is uncommon. Research focused on adjunctive methods for nerve repair is also reviewed in this article.

A survey of fellowship-trained otolaryngologists was undertaken. Seven hundred forty-four questionnaires were mailed, and 344 were returned. The survey respondents were asked questions regarding their fellowship training, location of practice, attitudes regarding certification, relevancy of fellowship to practice, and quality of fellowship training, among others. Results of this survey provide some information regarding the ongoing proliferation of fellowships in Otolaryngology--Head and Neck Surgery and the philosophies of those having taken fellowships. Generally, this survey indicates that fellowship-trained specialists feel that there are enough fellowships currently, and suggestions are made to improve the quality of fellowship training. Almost 70% of this survey's respondents prefer a Certificate of Added Qualifications from the American Board of Otolaryngology for credentialing and validation of their fellowship training.

A retrospective review of 45 children with mucopolysaccharidoses was performed to determine the frequency of complications related to the head and neck. In this series, every patient had at least one complication involving the head and neck region, and in over half, operative intervention by the otolaryngologist was required. Upper airway obstruction occurred in 17 (38%) and necessitated a tracheostomy in 7 (16%). Cervical spine instability occurred in 8 (18%), making airway management difficult. Recurrent respiratory infections occurred in 17 (38%), and chronic recurrent middle ear effusions were noted in 33 (73%). This review demonstrates that children afflicted with the mucopolysaccharidoses frequently have otolaryngologic-related complications that are common throughout their life span and often the primary management issue in their continuing care. The otolaryngologic management of these patients is outlined based on the results of this study and review of the relevant literature.

Silvadene cream and Sulfamylon make up the treatment regimen for one contributor (Dr. Crumley). No systemic antibiotics would be given. Any areas of obvious third-degree burns would be debrided and grafted. The tympanic membrane perforation would be treated with antibiotic/steroid drops. The second author concurs with use of Silvadene cream and would avoid any pressure on the area (Dr. Abemayor). While he agrees that systemic antibiotics should be avoided, he also would not prescribe ear drops. He recommends evaluation for a pulmonary or ophthalmologic injury. There is a disagreement regarding imaging studies. One expert would order a CT scan to rule out facial fractures (Dr. Crumley). His counterpart would not order a CT but would check a baseline chest x-ray if there were any sign of pulmonary compromise (Dr. Abemayor). Both experts would obtain an audiogram after the acute problems are treated. In the case of foul drainage, burn reconstruction would be delayed. In addition to treating the otorrhea with ear drops, one physician would add oral antibiotics (Dr. Abemayor). The other author believes tympanoplasty should be performed prior to reconstruction (Dr. Crumley). There were several procedures suggested for the reconstruction. Both authors discuss a method of creating a postauricular pocket, burying the ear pedicle, and using costal cartilage for an inlay helical graft. Another approach involves minimal debridement of the cartilage and letting the wound mature for 6 to 8 months. At that time the area would be debrided and the postauricular skin used for external coverage (Dr. Crumley). If the facial scar is a cosmetic problem 1 year after the injury, triamcinolone injections and local massage should be considered.(ABSTRACT TRUNCATED AT 250 WORDS)

Summary Vocal perturbation, harmonics-to-noise, and intensity measures were obtained for 10 subjects during three experimental tasks: (a) prolonged /a/, (b) /pa/ with vowel prolonged, and (c) same as (b) with subjects wearing a pneumotachographic mask and oral pressure tube inserted between the lips. There were no statistically significant differences among the experimental conditions for any of the measures. The findings suggest that a single task may be used to obtain airflow, oral pressure, and acoustic measures of vocal performance. Observed differences in jitter and harmonic-to-noise means for the male and female speakers are discussed.

Optical coherence tomography (OCT) is a new imaging modality analogous to ultrasound, with the exception that light from low-coherence sources rather than sound is used to create cross-sectional images of tissue,1 with an axial resolution approaching that of light microscopy (approximately 7 μm). This technology is already in clinical use by ophthalmologists for examination of both retina and cornea.2 Applications in the areas of cardiology, dermatology, urology, gastroenterology, and dentistry are in development.3–7 In otolaryngology, OCT has been used to image the mucosa of the upper aerodigestive tract, the middle ear, the cochlea, and the thyroid gland.8–11 OCT imaging is becoming increasingly important technology for the upper airway, especially in the larynx, where perhaps is the most promising application of this technology within the upper aerodigestive tract, because OCT can identify key structural features such as the basement membrane.8,12–14 This is particularly appealing for the management of early laryngeal cancers, as distinguishing between benign lesions and early carcinoma can be difficult without biopsy. Laryngeal microsurgery carries numerous risks including scarring and permanent vocal quality changes, and these concerns combined with the difficulty of diagnosing cancer on clinical examination alone have made the decision to pursue surgery often a considerable undertaking. Unlike advanced solid tumors of the head and neck whose boundaries and extension to other structures can be determined or estimated using CT or MR imaging, there are no imaging techniques in clinical use that can provide surgeons with the resolution needed to identify the axial spread of early cancer through the basement membrane and into the lamina propria. At present this information on tumor behavior at the tissue structural level requires a biopsy. OCT has potential to provide a means to image with high resolution (~7 μm) the vertical extension of early cancers and other neoplasms through the basement membrane of the delicate laryngeal mucosa. The potential clinical utility of OCT in the larynx has already been demonstrated in several publications. 8,12,14 However, while detailed OCT images of both benign and malignant laryngeal disease continue to be acquired and published, little is known about the normative microstructure of the laryngeal mucosa. This is important because the dimensions of the epithelium are generally thicker in early T1 cancers, dysplastic lesions, and benign disease, which may mimic cancer on clinical examination.8 If OCT is to evolve into a viable in vivo imaging modality to provide valuable information on the cross-sectional anatomy of the larynx, then it is absolutely necessary to know the dimensions of the tissue layers in the normal larynx. Just as in previous decades when CT and MRI images were compared with gross anatomy dissections and large whole body cross-sectional slices,15 with OCT the thickness of the different layers of the laryngeal mucosa measured in vivo using OCT must be compared with measurements made in ex-vivo histological specimens. The purpose of this study is to accomplish this basic task. It is important to emphasise that although the ideal study would be to correlate the in vivo OCT images with in vivo laryngeal histological specimens, but this is unethical, because it requires performing total laryngectomies on healthy patients after in vivo OCT images were taken.

Objectives: To determine the feasibility and accuracy of the Niris Optical Coherence Tomography (OCT) system in imaging of the mucosal abnormalities of the head and neck. The Niris system is the first commercially available OCT device for applications outside ophthalmology. Methods: We obtained OCT images of benign, premalignant and malignant lesions throughout the head and neck, using the Niris OCT imaging system (Imalux, Cleveland, OH). This imaging system has a tissue penetration depth of approximately 1-2mm, a scanning range of 2mm and a spatial depth resolution of approximately 10-20μm. Imaging was performed in the outpatient setting and in the operating room using a flexible probe. Results: High-resolution cross-sectional images from the oral cavity, nasal cavity, ears and larynx showed distinct layers and structures such as mucosa layer, basal membrane and lamina propria, were clearly identified. In the pathology images disruption of the basal membrane was clearly shown. Device set-up took approximately 5 minutes and the image acquisition was rapid. The system can be operated by the person performing the exam. Conclusions: The Niris system is non invasive and easy to incorporate into the operating room and the clinic. It requires minimal set-up and requires only one person to operate. The unique ability of the OCT offers high-resolution images showing the microanatomy of different sites. OCT imaging with the Niris device potentially offers an efficient, quick and reliable imaging modality in guiding surgical biopsies, intra-operative decision making, and therapeutic options for different otolaryngologic pathologies and premalignant disease.

• The treatment of keloids remains difficult. In experimental studies, lathyrogenic agents and colchicine have been shown to be effective in keloid prevention. Recently, a study was published of a new animal model utilizing human keloids implanted in athymic mice. We used the same model to compare the effects of penicillamine, acetylcysteine, colchicine, and triamcinolone acetonide. Unexpectedly, all keloids implanted showed a growth peak at 4 weeks and then regression in size. Histologic sections of the implanted keloids revealed peripheral vascularity, collagen bundles similar to the parent keloids, and no evidence of implant rejection. After 8 weeks, the mice treated with the lathyrogenic agents exhibited a higher rate of regression when compared with the control mice. While triamcinolone acetonide may have prevented keloid implant growth, drug toxic reaction may have been a factor. ( Arch Otolaryngol Head Neck Surg . 1991;117:1177-1181)

Objectives: Botulinum toxin (BTX) injection is currently the primary and most common treatment for adductor spasmodic dysphonia (ADSD). A variety of injection strategies and dosage regimens have been described. This study reports on our experience with the dosage schedule and dosing consistency of BTX for the treatment of ADSD. Methods: We retrospectively reviewed our laryngeal BTX database for the period 1991 to 2005. Our strict inclusion requirements limited our selection to 13 patients who had received a minimum of 6 injections (average, 11.5; range, 6 to 19) of BTX for ADSD. Results: The average total dose of BTX to the larynx for each treatment episode was 3.9 units (range, 1.5 to 7.5). The total dose administered tended to trend downward among patients who began treatment from 1991 to 1998, indicating that the initial dose (usually 2.5 units per side) may have been high. Those patients who began from 1999 onward had a more stable dose, indicating that the initial dose (usually 1.5 units per side) was more suitable. The subjects underwent an average of 2.2 injections (range, 1 to 5) before reaching their optimal BTX dose. The total number of treatments performed in this group of patients was 150, of which 145 were successful (96.7%). Conclusions: The BTX dose for the optimal treatment of ADSD usually remains consistent over time, as does the treatment interval. An initial dose of 1.5 units per side or less appears to improve dosing stability, indicating that the initial dosing of 2.5 units per side in our study was often greater than required. The optimal BTX dose was usually ascertained by the second or third injection. In our patient population, the long-term dosing consistency of BTX confirmed that neither tachyphylaxis nor increasing sensitivity to BTX occurred during the course of treatment for ADSD.

Surgical rehabilitation of the paralyzed larynx is currently performed by Teflon injection, thyroplasty, and reinnervation techniques. Proponents of the two newer techniques maintain that they are preferred to Teflon injection because superior phonatory quality is achievable. This paper was written in an attempt to dissect the issues regarding this question. Teflon remains the quickest and least expensive procedure, but further experience with stroboscopic and other voice analyses reveals that the other procedures demonstrate some superiority in phonatory quality over Teflon. In this author's hands, the nerve transfer offers the best opportunity to achieve a normal phonatory voice. In addition, it is the only one of the three procedures that leaves the vocal cord entirely undisturbed — Important in the event one of the other two procedures becomes necessary.

Surgical repair and reconstruction of the injured recurrent laryngeal nerve are discussed. Tips to avoid inadvertent nerve injury are noted, as are aspects of non-recurring recurrent laryngeal nerves. The controversy regarding recurrent laryngeal nerve anastomosis is updated, and a protocol for management of the injured recurrent laryngeal nerve is presented.

To describe the novel use of a delayed chondrofascial flap to increase auricular projection in microtia reconstruction.Retrospective survey analysis. Ten consecutive children with unilateral microtia without other craniofacial abnormalities were followed up for a period ranging from 6 months to 5 years after microtia reconstruction was performed with the newly described delayed flap. Individual patient reconstructed auricular projection measurements were compared with contralateral (control) auricular projection values.The auricular projection measurements taken at the superior helix and the lobule approximated those of the control side as confirmed by t test.The newly described delayed chondrofascial flap buttresses auricular projection in microtia repair to approximate the projection values of the normal side.

Objectives: Optical coherence tomography (OCT) is an emerging imaging modality that combines lowcoherence light with interferometry to produce crosssectional images of tissue with resolution about 10 m. Patients undergoing surgical head and neck endoscopy were examined using a fiberoptic OCT imaging probe to study and characterize microstructural anatomy and features of the larynx and benign laryngeal pathology in vivo. Study Design: Prospective clinical trial. Materials and Methods: OCT imaging of the larynx was performed in 82 of 115 patients who underwent surgical endoscopy for various head and neck pathologies. The OCT device employs a 1.3 m broadband light source (FWHM, 80 nm). The frame rate is 1 Hz. Imaging was performed using a handheld probe placed in near contact with the target site. The maximum axial and lateral dimensions for the region of interest imaged were 2.5 mm 6 mm, with resolutions of 10 m. Simultaneously, conventional endoscopic images were obtained to provide anatomic correlation with OCT images and histology. Optical micrometry was performed to measure the epithelium thickness. Results: Systematic OCT imaging of laryngeal structures and subsites provided information on the thickness of the epithelium, integrity of the basement membrane, and structure of the lamina propria. Microstructural features identified included glands, ducts, blood vessels, fluid collection/edema, and the transitions between pseudostratified columnar and stratified squamous epithelium. The mean epithelial thickness of laryngeal subsites was calculated: true vocal cord (129 m), false vocal cords (124 m), aryepiglottic fold (177 m), subglottis (98 m), and epiglottis (185 m). True vocal cord pathology imaged included Reinke’s edema, papillomatosis, polyps, mucous cysts, and granulation tissue. Subglottic imaging identified boundaries between epithelium, lamina propria, and cartilage. The OCT images compared favorably with conventional histopathology. Conclusion: OCT has the unique ability to image laryngeal tissue microstructure and can detail microanatomic changes in benign, premalignant, and malignant laryngeal pathologies. OCT holds the potential to guide surgical biopsies, direct therapy, and monitor disease, particularly when office-based systems are developed. This is a promising imaging modality to study the larynx. Key Words: Optical coherence tomography, larynx, vocal cord, vocal cord polyps, laryngeal cancer, Reinke’s edema, endoscopy, optical biopsy, respiratory papillomas, hyperkeratosis, laryngology. Laryngoscope, 115:1904–1911, 2005

The objectives of this pilot study were to (1) determine whether bipolar radiofrequency plasma-mediated ablation (PMA) can efficiently remove nasal septal cartilage and (2) calculate the ablation rate as a function of device power, probe force, and translation velocity using ex vivo porcine tissue.Specimens were secured to a linear translation stage and were subjected to varying translation velocities (4, 7, and 12 cm/s), probe forces (140, 200, and 225 g), and bipolar radiofrequency generator (Coblator ENTec power settings, 38-58, 77-115, and 129-193 Watts root mean squared. Specimen mass loss and depth of ablation were measured using an analytic balance and dissection microscope, respectively.Visual and microscopic inspection revealed little char. Mass loss increased with decreasing translation velocity and increasing generator setting. Increasing probe force also influenced mass loss and increased crater depth. Depth of ablation did not correlate with translation velocity or generator setting.PMA effectively ablates nasal septal cartilage and may be able to reduce or contour cartilaginous deformities and framework structures in the head and neck.

Denervation of skeletal muscle is thought to lead to an accelerated proliferation of myogenic stem cells known as satellite cells. The transition of these cells from a quiescent to a proliferative state is thought to require satellite cells to enter the cell cycle and replicate. Little is known about the expression of genes associated with cell cycle control, and so the objective of this study was to examine the effects of denervation and reinnervation of the posterior cricoarytenoid (PCA) muscle on key cell cycle genes. Female Sprague-Dawley rats were assigned to control, denervated, or reinnervated groups. Animals were killed at 7, 14, and 30 days after ligation of the recurrent laryngeal nerve. The PCA muscle was then analyzed for changes in the messenger RNA levels of key genes associated with cell cycle control, differentiation, and proliferation. Cyclin D1 is a key gene responsible for initiating progression of the cell cycle from G1 to S phase. Interestingly, neither denervation nor reinnervation affected the expression of this gene. In contrast, we found large increases in key cell cycle inhibitors (p21 and the growth arrest and DNA destruction 45 [GADD45] gene) in both the denervated and reinnervated groups. We interpret the increases in these cell cycle inhibitors to reflect (1) an inhibition of satellite cell proliferation and/or (2) a special form of apoptosis that results in the loss of myonuclei known to occur under atrophic conditions. To our knowledge, this is the first study to examine the effects of denervation on cell cycle regulation.

Background and Objectives The smaller anatomy and limited access to instrumentation pose a challenge to the pediatric airway surgeon. The enhanced precision and ability to photocoagulate tissue while operating with the laser enhances the surgeon's ability to successfully treat unique pediatric conditions. Study Design/Materials and Methods A comprehensive literature review was performed using the Medline (1995–2004) database. Results Due to its shallow tissue penetration and thermal effect, the carbon dioxide (CO2) laser is generally considered the laser of choice for pediatric airway applications. The potential for increased scarring and damage to underlying tissue caused by the greater penetration depth and thermal effect of the Nd:YAG and potassium-titanyl-phosphate (KTP) lasers preclude their widespread use in this population. Conclusions In this review, we will discuss the clinical applications of lasers in pediatric airway surgery, the current state of the art, where the current technology is deficient, and the potential applications of novel laser systems. Lasers Surg. Med. 35:128–134, 2004. © 2004 Wiley-Liss, Inc.

Problem: While it is known that denervation of skeletal muscle can induce atrophy, the effect of denervation on muscle cell cycle genes is unclear. Further, while attempted reinnervation of laryngeal muscle has thus far been unsuccessful in restoring function, cell cycle gene expression might be utilized to predict reinnervation success. The objective of this study was to examine the effects of denervation and reinnervation of the posterior cricoarytenoid (PCA) muscle on key genes involved in the cell cycle. Methods: Female Sprague-Dawley rats were assigned to 1 of 3 groups: control (CON, n = 24); denervation (DEN, n = 24); or reinnervation (REIN, n = 24). DEN and REIN animals had their left recurrent laryngeal nerves transected and ligated at the fourth tracheal ring while REIN animals subsequently had their nerves repaired using 10–0 suture. Animals were then euthanized after 7, 14, and 30 days, and mRNA expression examined using RT-PCR. If significant group differences were seen using one-way ANOVA (P < 0.05), Tukey post-hoc tests were employed. Results: Expression of p21, p53, GADD45 alpha, GADD45 beta, GADD45 gamma, and cyclin D1 genes were compared. At all time points, cyclin D1 and p53 gene expressions were unchanged with DEN or REIN. However, DEN muscles were found to express significantly higher levels of p21, GADD45 alpha, and GADD45 beta than CON at all time points. Conclusion: Interestingly, while REIN p21, GADD45 alpha, and GADD45 beta expressions were found to be elevated at 7 and 14 days, GADD45 alpha and GADD45 beta levels at 30 days were not significantly different from CON, threreby suggesting a recovery of REIN muscle gene expression at later time points. Significance: Paradoxically, while the restoration of some cell cycle genes to normal levels in REIN muscles might be seen as an indication of successful reinnervation of the PCA, no significant functional recovery was associated. Support: None reported.

Objectives: We will present clinical and pathologic findings of the recurrent laryngeal nerve of a 54-year-old man with apparent idiopathic vocal fold paralysis and discuss clinical and scientific implications of these findings. Study Design: Our design is in the format of a case report with emphasis on the clinical, intraoperative, histologic, and neuropathologic findings, followed by a discussion of contemporary theories of idiopathic unilateral vocal fold immobility and the implications of our findings. Methods: A 54-year-old man presented with a 2-year history of unilateral vocal fold motion impairment (VFMI) after an upper respiratory infection. Radiographic and laboratory data revealed no organic cause. The patient clinically appeared to have a classical unilateral vocal fold paralysis and had previously undergone collagen injection and medialization thyroplasty, each with only temporary improvement of voice. We performed ansa cervicalis-recurrent laryngeal nerve anastomosis. Results: Intraoperative dissection revealed an indurated and thickened section of nerve approximately 15 mm in length, located at the beginning of the intralaryngeal segment, near the cricothyroid joint. Segments of this nerve were submitted for histologic evaluation, revealing necrosis with granulomatous inflammation. Postoperative electromyography and videostrobolaryngoscopy were consistent with successful reinnervation from the ansa procedure. Conclusions: The diagnosis of “idiopathic VFMI” likely represents a number of distinct pathologic entities. This case highlights our lack of understanding of idiopathic VFMI and raises many important questions regarding our current theories of this diagnosis. The clinical and pathologic implications are discussed, and continued investigation is recommended.

Dystonia has been described in various diseases affecting mitochondrial function but spasmodic dysphonia, a form of focal dystonia, has not. We present a patient with action myoclonus affecting the hands and arms who carried the most common mutation in mitochondrial DNA causing the myoclonic epilepsy and ragged red fibers (MERRF) syndrome (the AG substitution at nucleotide 8344 in the tRNALys gene). This patient also had spasmodic dysphonia that was responsive to treatment with intralaryngeal botulinum toxin. © 2003 Movement Disorder Society

Background The canine lateral cricoarytenoid muscle contains a large proportion of muscle fibers that coexpress various combinations of myosin heavy-chain isoforms (ie, so-called hybrid fibers). Objective To test the hypothesis that hybrid fibers are a common motif throughout laryngeal muscles. Design The posterior cricoarytenoid, canine cricothyroid, and thyroarytenoid muscles were removed from 5 beagle dogs. The posterior cricoarytenoid and canine cricothyroid muscles were each dissected into horizontal, oblique, and rectus regions. The thyroarytenoid was separated into medial and lateral regions. Approximately 40 single fibers were microdissected from each region (≈1800 total fibers were sampled) and placed into a denaturing sample buffer. Sodium dodecyl sulfate–polyacrylamide gel electrophoresis was then used to separate the individual myosin heavy-chain isoforms. Results Each laryngeal muscle contained hybrid fibers; however, the types and proportions of hybrid fibers were clearly muscle specific. Within a given muscle, there were relatively minor regional differences in the types and proportions of hybrid fibers. Conclusion If the myosin heavy-chain isoform composition of a single fiber can be used as a "physiological marker," then the extent of hybridism may reveal the diversity of activity required of a given laryngeal muscle.

This report describes the first known investigation of canine laryngeal muscle in which single fibers were dissected and their myosin heavy chain (MHC) isoform content was analyzed. Both SDS-polyacrylamide gel electrophoresis (SDS-PAGE) and western blot techniques were used. The data from single fiber SDS-PAGE indicate that the lateral cricoarytenoid (LCA) is predominantly a fast muscle composed of the following MHC isoforms: Type I, 16.3%; Type IIA, 71.3%; Type IIX, 10.4%; and Type IIB, 2.0%. The results reveal a phenomenon that, to our knowledge, has not been previously described for laryngeal muscle: the presence of two or more MHC isoforms in a single canine LCA muscle fiber. A large number (41%) of muscle fibers coexpressed two or more MHC isoforms. The three most common patterns of coexpression were Type IIA/IIX (72%), Type IIA/I (16%), and Type IIA/IIX/I (8%). Interestingly, the fast Type IIX MHC isoform was typically present with other isoforms and rarely found by itself in individual fibers. Additional experiments are underway to determine whether other laryngeal muscles exhibit such an unusually high ratio of MHC isoform polymorphism.