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Establish the feasibility of a predictive validity study in sinus surgery simulation training and demonstrate the effectiveness of the Endoscopic Sinus Surgery Simulator (ES3) as a training device.Prospective, multi-institutional controlled trial.Four tertiary academic centers with accredited otolaryngology-head and neck surgery residency programs.Twelve ES3-trained novice residents were compared with 13 control novice residents.Subjects were assessed on the performance of basic sinus surgery tasks. Their first in vivo procedure was video recorded and submitted to a blinded panel of independent experts after the panel established a minimum inter-rater reliability of 80 percent. The recordings were reviewed by using a standardized computer-assisted method and customized metrics. Results were analyzed with the Mann-Whitney U test. Internal rater consistency was verified with Pearson moment correlation.Completion time was significantly shorter in the experimental group (injection P = 0.003, dissection P0.001), which, according to the rater panel, also demonstrated higher confidence (P = 0.009), demonstrated skill during instrument manipulation (P = 0.011), and made fewer technical mistakes during the injection task (P = 0.048) compared with the control group. The raters' post hoc internal consistency was deemed adequate (r0.5 between serial measurements).The validity of the ES3 as an effective surgical trainer was verified in multiple instances, including those not depending on subjective rater evaluations. The ES3 is one of the few virtual reality simulators with a comprehensive validation record. Advanced simulation technologies need more rapid implementation in otolaryngology training, as they present noteworthy potential for high-quality surgical education while meeting the necessity of patient safety.

Objective Stroke is the third leading cause of death in the United States, behind heart disease and cancer. It affects as many as 5% of the population over 65 years old, and this number is growing annually due to the aging population. A significant portion of stroke patients that initially survive are faced with the risk of aspiration, as well as quality-of-life issues relating to impaired communication. The goal of this paper is to define the scope of practice in otolaryngology for these patients, and to review pertinent background literature. Study Design Consensus report and retrospective literature review. Results Otolaryngology involvement in these patients is critical to their rehabilitation, which often requires an interdisciplinary team of specialists. This committee presentation explores epidemiological data regarding the impact of stroke and its complications on hospitalizations. A pertinent review of neuroanatomy as it relates to laryngeal function is also discussed. State-of-the-art diagnostic and therapeutic procedures are presented. Conclusion There is a well-defined set of diagnostic and therapeutic options for laryngeal dysfunction in the stroke patient. Significance Otolaryngologists play a critical role in the interdisciplinary rehabilitation team.

Biomarkers for thyroid cancer (TCa) lack specificity. To develop TCa specific biomarkers, SELDI-TOF-MS was used to examine the proteomic profile of biopsies obtained from papillary TCa along with adjacent normal tissue. Sixty-three potential biomarkers were categorized by univariate analysis into single biomarker candidates and segregated by multivariate analysis into normal and cancerous groups. Our studies demonstrate the sensitivity and reproducibility of this approach to detect biomarkers for TCa.

Objective To evaluate the efficacy and safety of a combined endoscopic and transconjunctival orbital decompression in patients with thyroid-related orbitopathy with orbital apex compression. Study Design Retrospective review. Methods A sequential series of patients with thyroid-related orbitopathy presenting with orbital apex compressive myopathy with and without optic neuropathy who were undergoing combined endoscopic and transconjunctival decompression by the same surgeons from 1992 to 2001 was reviewed. Patients were regularly evaluated preoperatively and postoperatively over a 3- to 55-month period to record the effects of this approach on visual acuity, Hertel exophthalmometry, and diplopia. Complications and secondary ophthalmological procedures were reviewed. Results Between 1992 and 2001, 72 combined endoscopic and transconjunctival decompressions were performed on 41 patients with orbital apex compression. Visual acuity improved in 89.3% of the patients with compressive optic neuropathy (P

The study of paranasal sinus diseases spans a 2000-year history from the earliest known investigators to the present. After an exhaustive historical review of the classification for each sinus, an operational definition of the anatomical status of the paranasal sinus system is presented from a developmental perspective. A comprehensive examination of nomenclature is undertaken to clarify discrepancies and vagaries in anatomical terminology, which have been a major source of confusion among those studying or operating upon the nasal complex – nose and paranasal sinuses. Primary original sources of nomenclature were consulted to clarify persistent confusions encountered in the literature, which will permit better communication in addition to eliminating redundant terminology. Morphological entities such as the agger nasi versus agger nasi cells, frontal cell, frontal recess, lateral recess, ethmoid infundibulum, hiatus semilunaris, “nasofrontal duct,” and nasolacrimal duct are examined from an embryologic, comparative anatomical, and evolutionary frame of reference in order to identify their importance in sinus disease processes. Multiple approaches are used to describe the anatomy of the nasal complex utilizing the diverse backgrounds of the authors, who are comparative evolutionary anatomists, radiologist, and ENT surgeons from France and the USA with a combined clinical experience of 120 years of surgical practice. Methods used for this chapter include CT and endoscopic nasal imaging of living humans, examination of dry cranial material, fresh tissue anatomical dissections, and three-dimensional volume-rendering methods that allow for digitization of spaces within the nasal complex for graphical examination. Given the great complexity and extreme variability of the paranasal sinus system, otolaryngology is arguably among the most challenging of surgical fields. Indeed, when afflicted with a viral or bacterial infection, or presenting with one of many types of carcinomas, their formidable clinical manifestations challenge the depth of the ENT surgeon’s knowledge and experience. As such, a dizzying array of anatomical terms has been applied to these densely clustered, disease-prone spaces and their associated structures. It is thus the charge of the otolaryngologist to master the anatomy of the paranasal sinuses and greater nasal complex, which clinically may be considered the last frontier in craniofacial biology.

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.

Objectives/Hypothesis Improve the care of acute external laryngeal trauma by reviewing controversies and the evolution of treatment. Data Source Internet-based search engines, civilian and military databases, and manual search of references from these sources over the past 90 years. Review Methods Utilizing the above-mentioned sources, electronic and manual searches of primary topics such as laryngeal trauma or injury, emergency tracheotomy, airway trauma, intubation versus tracheotomy, cricothyrotomy, esophageal trauma, and emergent management of airway injuries in civilian and combat zones. Citations were reviewed, selected reports analyzed, and the most relevant articles referenced. Results Optimal treatment of acute laryngeal trauma includes early identification of injuries utilizing a directed history and physical examination. Timely management of the wounded airway is essential. The choice of intubation, tracheotomy, or cricothyrotomy must be individualized. Computed tomography (CT) may assist in differentiating patients who can be observed versus those who require surgical exploration. In selected patients, laryngeal electromyography and stroboscopy may also be useful. Surgery should begin with direct laryngoscopy and rigid esophagoscopy to evaluate the hard and soft tissues of the larynx, and to visualize the pharynx and esophagus. Minor endolaryngeal lacerations and abrasions may be observed, whereas more significant injuries require primary closure via a thyrotomy. Laryngeal skeletal fractures should be reduced and fixated. Endolaryngeal stenting is reversed for massive mucosal trauma, comminuted fractures, and traumatic anterior commissure disruption. Conclusions Acute external injury to the larynx is both life threatening and a potential long-term management challenge. Although a rare injury, sufficient experience now exists to recommend specific treatments, and to preserve voice and airway function. Laryngoscope, 124:233–244, 2014

In this article, case studies from four separate clinicians are presented along with comments. These cases offer unusual examples of problems that occur with endoscopic sinus surgery.

Objective To determine if comorbid dysphagia in all hospitalized patients has the potential to prolong hospital stay and increase morbidity. Dysphagia is increasingly prevalent with age and comorbid medical conditions. Our research group has previously shown that dysphagia is a bad prognostic indicator in patients with stroke. Design Analysis of national database. Main Outcome Measures The National Hospital Discharge Survey (NHDS), 2005-2006, was evaluated for presence of dysphagia and the most common comorbid medical conditions. Patient demographics, associated disease, length of hospital stay, morbidity and mortality were also evaluated. Results There were over 77 million estimated hospital admissions in the period evaluated, of which 271 983 were associated with dysphagia. Dysphagia was most commonly associated with fluid or electrolyte disorder, esophageal disease, stroke, aspiration pneumonia, urinary tract infection, and congestive heart failure. The median number of hospitalization days for all patients with dysphagia was 4.04 compared with 2.40 days for those patients without dysphagia. Mortality increased substantially in patients with dysphagia associated with rehabilitation, intervertebral disk disorders, and heart diseases. Conclusions Dysphagia has a significant impact on hospital length of stay and is a bad prognostic indicator. Early recognition of dysphagia and intervention in the hospitalized patient is advised to reduce morbidity and length of hospital stay.

Spasmodic dysphonia is primarily a disorder of vocalization. Increasing evidence, however, suggests that individuals with this disorder comprise a heterogeneous population characterized by abnormal motor control throughout the vocal tract. Multichannel simultaneous electromyography was performed on 11 spasmodic dysphonia patients and 10 normal awake subjects to investigate both the distribution of neuromotor abnormality within the vocal tract (eg, intrinsic and extrinsic laryngeal muscles, tongue, and palate) and the contribution of activation of higher central nervous system centers to observed abnormality. Experimental tasks ranged from vegetative (quiet breathing) to simple linguistic (short sentences). Digitized electromyographic signals were analyzed to compute the amplitude envelope and extract a set of parameters that represent amplitude characteristics. Electrode insertions were cross-validated by quantitative analysis of patterns of activation across selected reference tasks and by traditional qualitative methods. Between-group differences were found for measures of normalized median and peak token amplitudes. These differences are both task- and measure-dependent. Results highlight the complex and interactive effects of muscle, task, and quantitative measures on between-group differences.

Objectives/Hypothesis: To evaluate standardized recurrent laryngeal nerve (RLN) injuries using a rat model via minimally invasive transoral electromyography (ToL EMG) and histologic studies. Methods: Forty-two female Sprague Dawley rats weighing 200 g to 250 g underwent crush injury to the right RLN using a calibrated pressure clip (0.61 N or 1.19 N) for 60 seconds. Following injury, serial ToL EMGs were performed on abductor and adductor laryngeal muscles during respiratory cycles and spontaneous vocal fold abduction on day 4 and then weekly for 6 weeks. Vocal fold motion associated with spontaneous respiration was graded from 0 to 4. Rats were sacrificed at different time points for histologic evaluation of injured nerves. Results: EMG signals showed fibrillation potentials on day 4 in all experimental conditions. Crushed RLN, regardless of force, exhibited polyphasic potentials at 2 weeks postinjury. Normal motor unit potentials and recruitment patterns were observed in EMG signals at 4 weeks for all 0.61 N clip animals. Six weeks following crush injury, motor unit potentials having normal appearance were observed in most animals. Synkinetic EMG signals were observed at 5 weeks and 6 weeks in the 1.19 N clip animals. Endoscopic evaluation of vocal fold mobility was consistently normal at 6 weeks only following 0.61 N crush injury. Conclusions: This model is useful to simulate intraoperative RLN injuries and to better understand the electrophysiologic events during nerve recovery. The severity of injury to the RLN dictates histologic, neurologic and functional recovery of the laryngeal motor system. This model is useful to evaluate the efficacy of systemic and local neurotropic agents in the treatment of RLN injury.

An update regarding the selective application of CT scanning in acute laryngeal trauma is presented for a period encompassing 9 years. A study group of 16 patients from a larger population of 52 patients was identified as having undergone CT scanning as part of their clinical management. A rationale is presented for the use of scanning in certain injuries, and the outcome of medical and surgical treatment is discussed.

Objectives: We developed a standardized method of minimally invasive transoral laryngeal (ToL) bipolar electromyography (EMG) for evaluation of recurrent laryngeal nerve (RLN) recovery after a controlled crush injury in a rat model. Methods: Ten 200- to 250-g Sprague-Dawley rats underwent a controlled crush injury to the left RLN performed with 60 seconds of use of a calibrated aneurysm clamp with a closing force of 0.61 N. Serial ToL bipolar EMG was performed on adductor muscles and the posterior criocoarytenoid muscle during spontaneous vocal fold motion under anesthesia. Each animal underwent ToL EMG immediately after surgery and 1, 3, and 6 weeks after surgery. Results: The EMG signals showed normal motor unit potentials and recruitment patterns 3 weeks after crush injury. Endoscopic evaluation of vocal fold mobility yielded consistently normal findings 6 weeks after crush injury. Conclusions: We have developed a standardized method of crush injury to the rat RLN model and a minimally invasive transoral bipolar spontaneous EMG technique to serially evaluate and follow nerve injury and recovery in rats. This model is intended to simulate intraoperative RLN injury, to elucidate the electrophysiological events that occur during nerve recovery, and to form the basis for studying agents to enhance such recovery.

Cortical function was evaluated in 26 subjects with spasmodic dysphonia. Quantitative topographic electrophysiologic mapping (QTE) was employed to provide quantitative analyses of EEG spectra and auditory and visual long-latency evoked potentials. Single-photon emission computed tomography (SPECT) of the cerebral transit of Xenon-133 was used to evaluate regional cerebral blood flow. Left hemispheric abnormalities in cortical function were found by both techniques in 10 subjects and by at least one technique in 18 subjects. Right hemispheric abnormalities were observed by both techniques in 8 subjects and by at least one technique in 18 subjects. Most patients with cortical dysfunction in one hemisphere had cortical dysfunction in the other, while only 4 subjects had unilateral lesions as found by one of the two techniques. Eight subjects were normal by all measurements. Underlying structural abnormalities were detected by magnetic resonance imaging in 5/24 subjects. However, functional abnormalities (SPECT or QTE) were not observed at sites of structural abnormalities. SPECT and QTE were significantly related in identification of left hemispheric dysfunction (p = .037) with a trend in the right hemisphere (p = .070), and a significant congruence of SPECT and QTE findings occurred in the left anterior cortical quadrant (p = .011). These findings indicate that dysfunction of cortical perfusion and/or cortical electrophysiology is associated with spasmodic dysphonia in the majority of subjects studied.

The posterior approach to sphenoethmoidectomy represents an alternative to the better known modifications of endoscopic paranasal sinus surgery. We present our modifications and experience with this technique over the last 4 years, and explain our rationale for selection of patients to be managed by this approach. This operation has proven useful in patients with extensive sinus disease, and/or previous surgery that has resulted in loss of normal anatomic landmarks to the sinuses.

The acute surgical management of the severely injured larynx is among the more demanding problems in laryngology, with early treatment decisions determining the outcome of both the airway and voice. To assist the physician with such decision-making, we report the rationale and operative techniques used at our institution to surgically manage 62 of 120 patients with acute laryngeal injuries for more than two decades. Such experience hopefully will also serve to help resolve several of the prevailing controversies over the care of such patients.

Objectives: The objectives of this study were to: 1) implement web-based instruments for assessing and documenting the general competencies of otolaryngology resident education, as outlined by the Accreditation Council of Graduate Medical Education (ACGME); and 2) examine the benefit and validity of this online system for measuring educational outcomes and for identifying insufficiencies in the training program as they occur. Methods: We developed an online assessment system for a surgical postgraduate education program and examined its feasibility, usability, and validity. Evaluations of behaviors, skills, and attitudes of 26 residents were completed online by faculty, peers, and nonphysician professionals during a 3-year period. Analyses included calculation and evaluation of total average performance scores of each resident by different evaluators. Evaluations were also compared with American Board of Otolaryngology-administered in-service examination (ISE) scores for each resident. Convergent validity was examined statistically by comparing ratings among the different evaluator types. Results: Questionnaires and software were found to be simple to use and efficient in collecting essential information. From July 2002 to June 2005, 1,336 evaluation forms were available for analysis. The average score assigned by faculty was 4.31, significantly lower than that by nonphysician professionals (4.66) and residents evaluating peers (4.63) (P < .001), whereas scores were similar between nonphysician professionals and resident peers. Average scores between faculty and nonphysician groups showed correlation in constructs of communication and relationship with patients, but not in those of professionalism and documentation. Correlation was observed in respect for patients but not in medical knowledge between faculty and resident peer groups. Resident ISE scores improved in the third year of the study and demonstrated high correlation with faculty perceptions of medical knowledge (r = 0.65, P = .007). Conclusions: Compliance for completion of forms was 97%. The system facilitated the educational management of our training program along multiple dimensions. The small perceptual differences among a highly selected group of residents have made the unambiguous validation of the system challenging. The instruments and approach warrant further study. Improvements are likely best achieved in broad consultation among other otolaryngology programs.

Considerable epidemiological evidence exists to link thyroid disease with differing patterns of dietary consumption, in particular, cruciferous vegetables. We have been studying the anti-thyroid cancer (TCa) activity of indole-3-carbinol (I3C) found in cruciferous vegetables and its acid catalyzed dimer, 3,3'-diindolylmethane (DIM). There are no studies as yet to elucidate the effect of these compounds on the altered proliferative patterns in goiter or thyroid neoplasia. In this study, we tested the anti-proliferative effects of I3C and DIM on four different thyroid cancer cell lines representative of papillary (B-CPAP and 8505-C) and follicular carcinoma of the thyroid (CGTH-W-1 and ML-1), and primary human goiter cells. Cell survival and IC50 values for I3C and DIM were calculated by the XTT assay and cell cycle distribution analysis was done by flow cytometry. DIM was found to be a better anti-proliferative agent than I3C in both papillary and follicular TCa resulting in a greater cytotoxic effect at a concentration over three fold lower than predicted by the molar ratio of DIM and I3C. The anti-proliferative activity of DIM in follicular TCa was mediated by a G1 arrest followed by induction of apoptosis. DIM also inhibited the growth of primary goiter cells by 70% compared to untreated controls. Contrary to traditional belief that cruciferous vegetables are "goitrogenic", DIM has anti-proliferative effects in glandular thyroid proliferative disease. Our preclinical studies provide a strong rationale for the clinical exploration of DIM as an adjuvant to surgery in thyroid proliferative disease.

Object. Allergic fungal sinusitis (AFS) is a form of paranasal mycosis that often involves bone destruction and extension into the orbit and anterior skull base. Treatment consists of surgical extirpation and a course of corticosteroids. Despite frequent intracranial involvement, AFS is rarely reported in the neurosurgical literature. Methods. The records of 21 patients with the histological diagnosis of AFS were reviewed. The histological diagnosis was based on findings of branching septated fungi interspersed with eosinophilic mucin and Charcot—Leyden crystals without fungal invasion of soft tissue. The average age of the 21 patients in this study was 25 years (range 9–46) and the male/female ratio was 3.75:1. All patients were immunocompetent. All had a history of chronic sinusitis and imaging findings of expansile disease involving multiple sinuses. Fifteen patients had nasal polyposis, eight had erosion of bone, which was observed on computerized tomography (CT) scans, eight had disease extending intracranially, and six had disease that involved the lamina papyracea. All patients underwent transnasal and/or transmaxillary endoscopic approaches for debridement and irrigation, six underwent orbital decompression, and three underwent a bifrontal craniotomy for removal of intracranial extradural disease. No patient had a cerebrospinal fluid leak. Postoperatively, one patient was treated with amphotericin B and the other 20 were treated with a short course of corticosteroids. The follow-up period ranged from 2 to 19 years. Conclusions. Allergic fungal sinusitis is a unique form of fungal disease that may mimic anterior skull base and paranasal sinus tumors. A cranial base team approach of neurosurgeons and otolaryngologists is recommended. Most cases can be successfully managed with transnasal and/or transmaxillary endoscopic techniques. A craniotomy is rarely indicated unless there is the suspicion of dural invasion or extensive intracranial and/or intraorbital involvement that is inaccessible from below.

Background Localization of dural fistulas in the region of the anterior or lateral skull base may be difficult. For many years, a sodium fluorescein solution of 0.5 to 5% (2.5-50 mg) has been administered intrathecally by way of the lumbar space. However, fluorescein is not commercially available for this stated purpose in either Germany or the United States. Methods Retrospectively, 420 fluorescein applications by the authors were retrospectively analyzed. Under the Freedom of Information Act, the United States Federal Drug Administration and the manufactures of fluorescein were queried for adverse reaction reports. Results Four hundred twenty fluorescein applications in 305 patients could be evaluated. Mean age of recipients was 46.9 years, ranging from 1 to 82 years. At a concentration of 5% fluorescein, 26 patients on the day of surgery and 69, 37, 34, and 14 patients on days 2 through 4 suffered from minor side effects that may or may not have been related to this drug. Two of these patients had grand mal seizures, which were attributable to simultaneous intrathecal application of contrast medium. All other side effects were thought to be the result of a postspinal headache and related lumbar puncture. At a concentration of 0.5%, the intraoperative intrathecal administration of 0.5 to 2 mL of fluorescein followed by 4 to 5 days of lumbar drainage resulted in some degree of spinal headache without other complications. In both groups, no patient had sequelae longer than 4 weeks. An additional seven complications were reported to the Federal Drug Administration and the fluorescein manufacturers at doses of 100 to 700 mg. Conclusions Complications from intrathecal application of fluorescein appears to be dose dependent. At concentrations of 5%, or preferably lower, side effects are transient. A grand mal seizure can be minimized when following the general cautions of lumbar puncture and dose. The patient should be supervised for 24 hours. A written informed consent from patients for use of fluorescein is recommended.

Objective Traditionally, surgical approaches to the sellar region require the use of the operating microscope. Over the past decade endoscopic surgery has gained much popularity because of advances in optics and illumination. Endoscopic surgery of the sellar region has been performed successfully. The goal of the present study was to quantify the amount of exposure to the sellar and suprasellar region that the endoscope provides versus the microscope, with three different anterior approaches to the sellar region. Methods The transethmoidal, endonasal-transsphenoidal, and sublabial-transsphenoidal approaches were performed on 14 formalin-fixed cadaver heads with a 0 degrees endoscope and repeated with the operative microscope. The distances of relevant surgical landmarks and the amount of exposure superior and anterior to the dorsum sella, as well as the lateral exposure, were measured. The mean distances were then used to calculate the volume of exposure for each of the approaches. Results It was found that the endoscope provided greater view than the operating microscope in all three approaches. The difference was statistically significant using a paired Student t test and a signed-rank test (P Conclusion The authors believe that endoscopic surgery of the sellar region can be performed safely and effectively, while providing the surgeon with a view that is superior to that afforded by the operating microscope.

For 11 years, we primarily relied on frontal sinus oblit­ eration with fat via an osteoplastic flap approach to treat the majority of patients with medically refractive, chronic frontal sinusitis. For the past 4 years, we have primarily used an endoscopic, intranasal approach for initial surgi­ cal management of patients with disease similar to those treated in the earlier ll-year period. We made this tran­ sition to endoscopic frontal sinusotomy because of the following: 1. The advent of rigid fiberoptic endoscopes provides excellent visualization of the frontal recess and medial frontal sinus. 2. Recognition of the role of the anterior ethmoids in recurrent frontal sinusitis and the ability afforded to op­ erate at this site by endoscopes. 3. Knowledge of such surgery being used in Europe. 4. Our desire to minimize the surgical technique for the initial treatment of medically refractive disease.l" Last year, we reported our initial experience with en­ doscopic frontal sinusotomy. This article updates that experience and better describes our surgical technique. 1

Objectives: To develop an anatomic and functionally based approach to endoscopic intranasal ethmoidectomy. To develop such an approach using the salient features of the anterior to posterior (AP) and posterior to anterior (PA) intranasal sinus operations. To assess the safety of this form of ethmoidectomy in a patient population. Study Design: Retrospective chart review of patients undergoing ethmoidectomy by author or by residents under his direct supervision. Setting : University teaching hospital. In the 509 patients meeting study criteria, 168 anterior ethmoidectomies, 586 total ethmoidectomies, 264 sphenoidotomies, 290 frontal sinusotomies, and 838 antrostomies were performed between April 1992 and August 1997. Results: A complication rate of 0.98% and revision rate 2.9% were observed. Conclusions: Combining an AP approach to conserve sinus anatomy with a PA approach to avoid surgery directed toward the skull base provides a functional and safe procedure as demonstrated by the reported results.

Digital recordings of thyroarytenoid (TA) myoelectric activity (via percutaneous hooked-wire electrodes) were obtained for 10 normal control subjects and 10 subjects with spasmodic dysphonia during performance of five tasks of varying complexity: quiet breathing, Valsalva maneuver, whispered / i /, voiced / i /, and “beep beep went the heap.” Time-frequency power spectral density functions, PSD ( f , t ), were determined for a selected segment of the signals, and measures of median frequency, mean frequency, bandwidth, and center frequency of PSD ( f , t ) were derived for each sample point. Statistical median, mean, standard deviation, minimum, maximum, and mode of the power spectral density measures were computed to compose feature vectors for each TA myoelectric recording. Statistical pattern recognition procedures using maximum likelihood classification tests were applied to the feature space to discriminate disordered from normal speakers for each task. Findings indicate a high level of discriminability between subject groups for phonated speaking tasks in contrast to low levels of discriminability for whispered and nonspeech tasks. Graphical presentations of three-dimensional PSD ( f , t ) plots are given that illustrate changes in spectral characteristics of TA EMG at the onset of laryngospasm.

Fine-needle aspiration has assumed a large role in the evaluation of head and neck masses. It has been found to be simple, quick, accurate, and cost-effective in the workup of patients with unknown head and neck masses. This article reviews these advantages and the role of fine-needle aspiration in the evaluation of head and neck masses.

Papillary thyroid cancer (PTC) is the most prevalent endocrine and thyroid malignancy. The ability of PTC to invade and migrate great distances contributes to distant metastases, which represent the most common cause of PTC-related death. The urokinase plasminogen activator (uPA) and the urokinase plasminogen receptor (uPAR) are key mediators of tumor invasion. Upon binding to uPAR, pro-uPA is converted to its active form, which is then capable of cleaving plasminogen to plasmin. Plasmin can then degrade components of the basement membrane and extracellular matrix, a prerequisite for tumor cell invasion and metastasis. The binding of uPA by uPAR also seems to mediate several signaling events that contribute to a migratory phenotype, as well as various growth signals. In this study, we analyzed uPA and uPAR expression in PTC and normal thyroid tissue, and examined in vitro how uPA and uPAR contribute to an invasive/metastatic phenotype, as well as the functional consequences of inhibiting this system. uPA and uPAR RNA were also significantly higher in patients with metastatic disease. Casein-plasminogen zymography and western blotting demonstrated increased active uPA secreted by BCPAP cells compared to NTHY-Ori-3-1. Fluorimetric assays revealed that BCPAP CM was able to activate plasminogen, resulting in measureable casein hydrolysis. This casein hydrolysis was prevented by the addition of several specific uPA inhibitors. The in vitro invasion phenotype of BCPAP cells was augmented by the addition of plasminogen, and this augmentation was reversed by inhibitory anti-uPA and anti-uPAR antibodies. Cells transfected with siRNA against uPAR demonstrated decreased migratory and invasive potentials as measured by Matrigel invasion assays. Finally, uPAR-knockdown cells exhibited decreased proliferation when compared to non-targeting siRNA transfectant cells. These data provide new functional evidence of the uPA/uPAR system's role in PTC invasion/metastasis and demonstrate the attractiveness of uPA and uPAR as molecular biomarkers and therapeutic targets. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 520.

The acute care of 139 consecutive patients with external laryngeal trauma over a 27-year period is reported. This article represents an effort to periodically reevaluate our care of this relatively infrequent injury and to share our changes and refinements in treatment. This series provides the means to test and establish basic principles in the acute care of external laryngeal trauma because (1) the number of years encompassed by the article, (2) most patients were managed by one physician, (3) the relative consistency of management principles throughout the series, and (4) the delivery of trauma care in Dallas County, Texas, reflects a broad sampling of this injury within the geographic area.

Vocal symptoms in spasmodic dysphonia (SD) range from strain-strangle phonation and glottal-stop phonatory breaks of adductor SD to breathy phonation and aspirate phonatory breaks of abductor SD. Many SD subjects show both symptom types. Heterogeneity in vocal symptoms contributes to controversy surrounding the etiology(s) of SD. Acoustic/perceptual analyses of vocal symptoms are inconclusive in resolving this controversy. This investigation moves the search for distinguishing features of adductor and abductor SD to the level of neuromuscular control and analysis of intrinsic laryngeal muscle (adductor and abductor) activity. Subjects rated perceptually as primarily adductor or abductor SD sustained production of vegetative gestures and isolated speech sounds (/i/ and /s/). Qualitative and quantitative analyses of electromyographic signals recorded from thyroarytenoid (TA) failed to differentiate SD subjects by symptom type. Analysis of TA and posterior cricoarytenoid (PCA) activity in one abductor SD revealed high levels in both muscles during production of the voiced vowel. Data suggest that a possible explanation for symptom heterogeneity in SD is the relation between disrupted neuromotor input to laryngeal muscles and reflexive or conscious compensations constrained by laryngeal biomechanics.

This study combines measures of linguistic and vocal performance and long-latency auditory electrophysiology to investigate task-dependent variability in spasmodic dysphonia (SD). Linguistic performance was evaluated using several measures of relatively complex linguistic ability (i.e., discourse analysis). Vocal performance was evaluated by measuring acoustic laryngeal reaction time (LRT) for tasks that differ in complexity. Normal structure of the cortex and subcortex was confirmed by magnetic resonance imaging. Cortical function was measured using multichannel quantitative auditory evoked potentials (AEPs). As a group, SD subjects who demonstrated subtle linguistic deficits also demonstrated prolonged LRT for the complex task and repeated and persistent auditory electrophysiologic abnormalities over the anterior quadrant of the left hemisphere. As a group, linguistically normal SD subjects demonstrated no significant increase in LRT for the complex task and no recurrent electrophysiologic abnormalities over the left anterior cortex relative to normal controls. Results support a neurogenic origin of SD and suggest that some aspects of inter- and intrasubject variability may be related to differences in loci and magnitude of cortical abnormalities.

• Spasmodic dysphonia is a disturbance of phonation with laryngeal spasms. We report voice and neurologic examination findings in 45 subjects. Neurologic abnormalities were found in 32 subjects (71.1%). Rapid alternating movement abnormalities, weakness, and tremor were common. Incoordination and spasticity were rare. Lower extremity findings were frequent. Abnormalities were bilateral. Spasmodic dysphonia severity was related to age. Type, severity, and duration of vocal symptoms were not different for subjects with or without neurologic abnormalities. Vocal tremor was more frequent in neurologically abnormal subjects. Involvement of a pallidothalamic—supplementary motor area system could account for neurologic findings, brain imaging findings, and clinical heterogeneity. The view emerging is that spasmodic dysphonia is a manifestation of disordered motor control involving systems of neurons rather than single anatomical sites.

• Guidelines are presented for the management of acute external laryngeal trauma based on personal experience and basic principles evolved over the past two decades. Accurate assessment of the extent of injury has permitted stratification of treatment ranging from observation to open reduction and internal fixation of the laryngeal skeleton. Results are often predictable and frequently lead to restoration of the voice and airway. ( Arch Otolaryngol Head Neck Surg . 1991;117:35-39)

This paper describes a systems architecture useful for scientific investigations that require the acquisition and analysis of multiple, time-synchronous signals in large volume. The architecture has recently been developed by this group to enhance our capability to research and quantify central nervous system function in the production of normal and pathologic speech. The architecture utilizes modern advances in desktop microcomputers and has been designed so that vocal motor control laboratories (or similar settings) with modest funding can more fully participate in comprehensive investigations of speech production. Research experiments organized with this architecture may involve many more subjects and measures than previously possible without significant increases in time and personnel resources. This paper will demonstrate the technique and practicality of this architecture as it is being used to successfully guide research to map hierarchic central nervous system regions of involvement in two speech disorders: Spasmodic dysphonia and stuttering. The architecture has broad usefulness to many areas of otolaryngology and health science.

On November10, 1993, the annual meeting of the Society of University Otolaryngologists (SUO) was held in Washington, DC. The purpose of that meeting was to discuss issues relevant to academic otolaryngology, health care reform, and the training of otolaryngology subspecialists. The proposals by Congress (S.1315,H.R.2804 by Rockefeller, Durenberger, Waxman, and Cardin, and S.1215 by Kasselbaum and Simpson) and the Clinton Administration to alter the health care delivery system in the United States are likely to profoundly alter American medicine. These proposals include specific mandates for postgraduate medical education (GME) that should be of concern to both academic and private practice otolaryngologists. Although the proposals change nearly daily, they share a common theme. The most important of the various GME proposals is the Administration mandate that, by 2002, at least 55% of all residents should be enrolled in generalist training programs. Generalists are defined as practitioners of family medicine

Perceptual ratings of vocal abnormality in spasmodic dysphonia (SD) are confounded by high variability in the severity, quality (strain‐strangle versus aspirate), and task sensitivity of symptoms. Perceptual ratings are also relatively distant from the physiologic source of vocal disruption. Investigations at the neuromuscular level are closer to the source of disruption and may be informative. Thyroarytenoid myoelectric activity was recorded while SD and normal control subjects produced multiple tokens of sustained vowel, word repetition, and sentence tasks. Quantitative amplitude measures were submitted to several principal components analyses to develop models of neuromotor abnormality in SD. Analyses yielded quantitative indices of the magnitude and task‐sensitivity of thyroarytenoid activity. A between‐group model that included one measure across the three tasks achieved 100% discrimination of normal control and SD subjects on one component. The within‐group model failed to separate perceptually diff...

The authors have previously described an extradural transmaxillary approach to the anterior compartment of the cavernous sinus. In an effort to expand the surgical access to that area without necessitating a craniotomy or wide transfacial dissection, they present a modification of the transmaxillary approach to the sellar region and cavernous sinus. Methods: The approach was developed on 12 fresh and 12 embalmed cadaveric specimen, and 2 dry skulls. The initial sublabial incision is followed by a maxillotomy to expose the course of the infraorbital nerve (terminal branch of maxillary branch of the trigeminal nerve) on the roof of the maxillary sinus. The route of the infraorbital nerve is traced to the pterygopalatine fossa as a guide to the foramen rotundum. Superomedial drilling of the foramen rotundum is then performed to reveal the contents of the superior orbital fissure. After the nerves are safely identified in the superior orbital fissure, medial enlargement of the window into the cavernous sinus is made possible by drilling the lateral and posterior wall and septum of the sphenoid sinus. Results: The combined transmaxillary transsphenoidal approach offers an excellent exposure of the sellar and infrasellar region. The approach offers clear visualization of the ipsilateral loop of the carotid artery, the pituitary fossa, and the cranial nerves of the ipsilateral cavernous sinus. Mean operative reach is 38 mm from the posterior wall of the maxillary sinus to the ipsilateral carotid loop and 56 mm to the contralateral loop. The width of the operative window is 26 mm at the base within the cavernous sinus. Conclusion: The model offers a minimally invasive approach that avoids the need for craniotomy or violating the nasal cavity. It may be safely employed to access vascular as well as invasive lesions of the sellar and infrasellar region. The approach offers excellent visualization of the ipsilateral intracavernous carotid artery with both proximal and distal control, as well as cranial nerves III, IV, VI, V2, the hypophyseal region, and the medial aspect of the contralateral cavernous sinus.

Time‐synchronous digital recordings of thyroarytenoid (TA) myoelectric activity (via percutaneous hooked‐wire electrodes) were obtained for 10 normal control and 11 spasmodic dysphonia subjects during performance of five vocal tract tasks of increasing motoric complexity: (1) quiet breathing, (2) Valsalva maneuver, (3) whispered ‖i‖, (4) voiced ‖i‖, and (5) Beep beep went the heap. Three‐dimensional power spectral density functions, PSD(f,t), were determined for a selected segment of the signals, and measures of median frequency, mean frequency, bandwidth, and center frequency of PSD(f,t) were derived for each sample point. Statistical median, mean, standard deviation, maximum, minimum, and mode of the PSD measures were computed to compose feature vectors for each signal. Discriminate analysis and maximum likelihood classification tests were applied to obtain global discrimination measures for the two subject populations as a function of task performance. Results of the analysis are reported that reveal a...

No consensus exists regarding the best method of tonsillectomy. This report concerns two popular methods: 1. electrocautery excision and 2. dissection/snare followed by point coagulation of bleeding sites. To compare these methods, a prospective, randomized, single-blinded study was conducted in which 28 patients had one tonsil removed by dissection/snare and selective cautery of bleeders and the other removed by the electrocautery. Operative time and blood loss were compared. Patients rated the severity of their pain and blood loss postoperatively. Intraoperative bleeding was significantly less on the side of cautery excision, although the operative time was longer. At follow-up, pain was rated worse on the side of cautery excision.

In Reply .—Singh's communication is both interesting and timely. We are aware of several incidents in the past 5 years of transient changes in either ocular mobility or dilatation of the pupil following injection of the lateral nasal wall or middle turbinate with lidocaine (Xylocaine). We have also learned of one episode of transient blindness following injection of the middle turbinate with lidocaine. Our own experience has been limited to transient mydriasis in a patient with widely dehiscent optic nerves within the sphenoid sinus who was undergoing extensive endoscopic surgery. In all these cases, the patient made a spontaneous, complete recovery within hours of the physician noting the ophthalmologic alterations. Given the above reports, and undoubtedly many more such similar incidents, Singh's mechanisms of dilatation of the pupil without other ophthalmologic problems, are reasonable. In recent years, the mechanism of visual changes following injection of the lateral nasal wall has

Depending on the pathologic process, the treatment of frontal sinus disease has consisted of obliteration or ablation of the sinus, or restoration of drainage into the nose. Intranasal endoscopic enlargement of the frontal recess and ostium, and removal of disease from the medial aspect of the frontal sinus offers a minimally invasive alternative to previous operations in selected patients. To better understand the indications, limitations, and potential problems with this operation, our experience with endoscopic frontal sinusotomy in 36 patients over a 30-month period is reported. During the follow-up period, 21 patients had complete resolution of all symptoms, 11 patients were improved but had at least one episode of sinusitis or headache post-operatively, and 3 patients were worse, 2 of whom required frontal sinus obliteration for control of disease. Although endoscopic frontal sinusotomy appears to be a useful alternative to traditional frontal sinus procedures in selected patients, the reader is cautioned that such surgery is technically difficult and has not yet stood the test of time required of any frontal sinus operation.

• Dysphagia secondary to partial pharyngeal stenosis after total laryngectomy is most likely attributable to the size of the reconstructed lumen. To reduce the incidence of this postoperative complication, we have utilized a modification of total laryngectomy that conserves the hypopharyngeal mucous membrane. The results of this surgical procedure are now reported in the context of two similar, contemporaneous groups of patients who underwent either standard wide-field laryngectomy or hypopharyngeal mucosa conservation laryngectomy. Statistical analysis showed no difference between groups in cancer control ( P =.80) or survival ( P =.65); whereas the group treated with hypopharyngeal conservation laryngectomy had significantly less pharyngeal stenosis as measured by dysphagia and need for dilatation ( P =.011). ( Arch Otolaryngol Head Neck Surg 1987;113:491-495)