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Objective: Over the past 20 years, jet ventilation techniques have been developed to enable safe and controlled microlaryngoscopy and the accurate treatment of laryngeal pathology. This study examined how advances in jet ventilation tube design have facilitated safe endolaryngeal surgery. Study design: The study documented the development and use of the Jockjet subglottic jet ventilation tube system at the Prince of Wales Hospital, Sydney. The new system consisted of two components: a Teflon tube with an outer diameter of 4 mm at the larynx, and a companion ventilator. The facility for end-tidal carbon dioxide and distal airways pressure monitoring was incorporated via dedicated channels. The Venturi jet was produced via a covered tip to prevent trauma to the tracheal mucosa. Setting: The Prince ofWales and Sydney Children's Hospitals, incorporated with The University of New South Wales. Patients: From June 2002 to March 2008 inclusive, 1000 consecutive patients underwent microlaryngeal surgery at this institution. Subglottic jet ventilation, via the Jockjet tube, was employed for 332 patients. Main outcome measures: Anaesthetic safety and intra-operative surgical access. Results: In all the 332 patients observed, surgical access was optimised and no adverse anaesthetic outcomes were encountered. Conclusion: Subglottic jet ventilation facilitates safe airway management during microlaryngeal and laser laryngeal surgery. [ABSTRACT FROM AUTHOR]

Background:Frey's syndrome and cosmesis are important considerations in parotid surgery. Placement of an interpositional barrier can prevent these complications; however, surgical technique and efficacy remain controversial.Methods:A prospective case series was collected comprising all patients undergoing primary superficial parotidectomy for benign pathology with abdominal free fat grafting between June 2007 and December 2010, performed by a single surgeon. A survey was also distributed to otorhinolaryngology consultants across Australia to assess current practice.Results:Twenty-eight patients were included. No patient had clinical symptoms of Frey's syndrome. Seventy-five per cent of patients were completely satisfied with their aesthetic outcome, 18 per cent scored 4/5 and the remaining 7 per cent (2 patients) scored 3/5. The survey revealed that 79 per cent of respondents did not use interpositional grafts.Conclusion:Abdominal free fat is ideal for grafting as it is an effective, safe, simple, accessible, fast and inexpensive method of providing an interpositional graft. [ABSTRACT FROM PUBLISHER]

Head and neck lymphedema (HNL) is an increasingly recognized complication of head and neck cancer and its treatment. However, no consensus exists on the "gold-standard" assessment tool for the purposes of diagnosis, classification, or monitoring of HNL. We conducted a systematic review of the literature regarding HNL assessment to determine the optimal method/s of assessment for patients with HNL. A review of publications between January 2000 and September 2021 was undertaken on four electronic databases. Studies were excluded if no clear assessment method of HNL was documented. Sixty-seven articles were included in the study. A wide range of assessment methods for HNL have been reported in the literature. For the purposes of diagnosis and classification of physical findings, computed tomography (CT) appears the most promising tool available for both external and internal HNL. In terms of monitoring, ultrasound appears optimal for external HNL, while a clinician-reported rating scale on laryngoscopy is the gold standard for internal HNL. Patient-reported assessment must be considered alongside objective methods to classify symptom burden and monitor improvement with treatment., (© 2022 Wiley Periodicals LLC.)

Background: Ansa cervicalis-to-recurrent laryngeal nerve anastomosis (ARA) is an established technique for the treatment of recurrent laryngeal nerve (RLN) injury after head and neck surgery. However, the optimal timing of ARA remains unclear, and the evidence bases for ARA performed at each timepoint after RLN injury have not previously been clearly distinguished. We conducted a systematic review of the literature to evaluate the efficacy of ARA performed at different timepoints on postoperative voice outcomes., Methods: A review of English-language journal articles published in the last 20 years was undertaken on three electronic databases: Ovid MEDLINE, PubMed and Embase. Studies with a focus on paediatric RLN injury, bilateral RLN injury, ansa cervicalis anatomy and non-ARA techniques alone were excluded., Results: Twenty eight articles were included in the review. ARA was performed as a delayed surgery in 16/28 studies (57%), while immediate ARA was utilized in 14/28 studies (50%). On qualitative synthesis, delayed ARA was shown to be effective in improving patient-reported, subjective observer-reported and objective observer-reported voice outcomes. Likewise, a substantial body of evidence was identified demonstrating postoperative voice improvement with immediate ARA. On direct comparison of timepoints, some benefit was shown for early delayed ARA relative to late delayed operations, while no comparative data for immediate versus delayed repair were available in the literature., Conclusions: ARA at both delayed and immediate timepoints is effective in the treatment of patients with RLN injury after head and neck surgery. The timing of ARA may have some influence on its efficacy, with early delayed repair potentially associated with superior outcomes to late delayed operations, and immediate ARA offering several practical advantages relative to delayed repair. Further comparative studies are required to better characterize the optimal timing of ARA after RLN injury., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Epiglottitis is typically considered a pediatric disease; however, there is growing evidence that the incidence of adult epiglottitis has changed since the introduction of the Haemophilus influenzae vaccine. The literature is composed of multiple small series with differing findings. To date, there has been no attempt to collaborate evidence on predictors of airway intervention in this disease., Methods: The population of interest was adults with a diagnosis of epiglottitis. The primary outcome in this review was incidence of airway intervention. A comprehensive literature search was conducted of the MEDLINE and Embase databases, and a separate random-effects model meta-analysis was undertaken for all outcome data. Moderator tests for comparison between prevaccine and postvaccine estimates were made, and absolute risk difference (RD) and relative risk (RR) calculations were made for all predictors of airway intervention., Results: Thirty studies and a total of 10,148 patients were finally included for meta-analysis. A significant decrease in airway intervention was seen post vaccine introduction introduction from 18.8% to 10.9% (P = 0.01). The presence of an abscess (RD 0.27, P = 0.04; RR 2.45, P < 0.001), stridor (RD 0.64, P < 0.001; RR 7.15, P < 0.001), or a history of diabetes mellitus (RD 0.11, P = 0.02; RR 2.15, P = 0.01) were associated with need for airway intervention., Conclusion: In the postvaccine era, clinicians should expect to have to secure airways in 10.9% of cases. The presence of an epiglottic abscess, stridor, or a history of diabetes mellitus are the most reliable clinical features associated with need for airway intervention., Level of Evidence: NA Laryngoscope, 130:465-473, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Advanced-stage olfactory neuroblastoma requires multimodal therapy for optimal outcomes. Debate exists over endoscopic endonasal surgery in this situation. Stage-matched open and endoscopic surgical therapy were compared., Methods: Patients from 6 cancer institutions were assessed. Stratification included dural involvement, Kadish stage, nodal disease, Hyams' grade, approach, and margin status. At follow-up, local control, nodal status, and evidence of distant metastases were recorded with any subsequent therapy. Statistical analyses to identify risk factors for developing recurrence and survival differences were performed., Results: One hundred nine patients were assessed (age 49.2 ± 13.0 years; 46% women) representing Kadish A stage (10%), Kadish B stage (25%), and Kadish C stage (65%). The majority of the patients (61.5%) underwent endoscopic resection, 53.5% within Kadish C stage. Within-stage survival analysis favored endoscopic subgroup for Kadish C stage (log-rank P = .017) nonsignificant for Kadish B stage (log-rank P = .39)., Conclusion: Stage-matched survival was better for the endoscopically treated group compared to the open surgery group, with high negative margin resections obtained., (© 2017 Wiley Periodicals, Inc.)

Objectives: To assess the indications for lingual tonsillectomy; to report our experience with lingual tonsillectomy, and to present the evolution of our surgical technique., Methods: A review of 5-years experience from a prospectively maintained database of 28 patients was performed together with a focused review of the international literature. Therapeutic procedures included lingual tonsillectomy with access via the Boyle-Davis gag or suspended video laryngoscope and with the resection via diathermy, CO(2) laser, or microdebrider., Results: The indication for lingual tonsillectomy was upper airways obstruction in 22 patients and recurrent infection in six. The operative time for lingual tonsillectomy ranged from 35 to 80 minutes (mean time, 43 minutes). The perioperative in-hospital stay ranged from one to three days for 27 patients. All did very well postoperatively., Conclusion: Lingual tonsillar pathology may cause significant morbidity and is frequently the cause of persisting peripheral obstructive sleep apnea syndrome after adenotonsillectomy. Lingual tonsillectomy performed with video laryngoscopy and microdebrider resection is feasible and safe and provides good results.

Objective: The role of proton pump inhibitors (PPIs) in suspected GERD-related chronic laryngitis (CL) is controversial. Hence, we performed a meta-analysis of the existing randomized controlled trials (RCTs) to evaluate the efficacy of PPIs in this disorder., Methods: Data extracted from MEDLINE (1966 to August 2005), Cochrane Controlled Trials Register (1997 to August 2005), EMBASE (1980 to August 2005), ClinicalTrials.gov website, and meetings presentations (1999-2005). Published and unpublished randomized placebo-controlled trials of PPIs in suspected GERD-related CL were selected by consensus. Random effects model was utilized with standard approaches to quality assessment, sensitivity analysis, and an exploration of heterogeneity and publication bias. The primary outcome measure was defined as the proportion of patients with >or=50% reduction in self-reported laryngeal symptoms., Results: Pooled data from 8 studies (N = 344, PPI 195, placebo 149; mean age 51 yr; males 55%; study duration 8-16 wk) were analyzed. No significant quantitative heterogeneity was found among the studies (chi2= 11.22, P= 0.13). Overall, PPI therapy resulted in a nonsignificant symptom reduction compared to placebo (relative risk 1.28, 95% confidence interval 0.94-1.74). No clinical predictors of PPI response were identified on meta-regression analysis done at study level., Conclusions: PPI therapy may offer a modest, but nonsignificant, clinical benefit over placebo in suspected GERD-related CL. Validated diagnostic guidelines may facilitate the recognition of those patients most likely to respond favorably to PPI treatment.

Objectives: To quantify the incidence of intranasal extension of adenoid tissue and residual adenoidal obstruction of the posterior choanae following traditional curette adenoidectomy to determine the efficiency of adenoid curettage and the usefulness of intraoperative endoscopic examination and powered-shaver adenoidectomy in achieving better postnasal patency., Design: Prospective intraoperative endoscopic evaluation of the posterior choanae and nasopharynx of a case series of 130 patients before and after curette and powered-shaver adenoidectomy., Setting: Tertiary referral center., Patients: One hundred thirty consecutive pediatric patients with obstructive adenoidal hypertrophy undergoing adenoidectomy., Main Outcome Measures: The degree of residual postnasal obstruction due to adenoid tissue was assessed endoscopically (grades 0-3) after curette and adjuvant powered-shaver adenoidectomy. The presence of intranasal adenoid tissue was also recorded., Results: Following traditional curette adenoidectomy, 51 (39%) of 130 patients had residual obstructive adenoid with 42 patients (32%) having occlusive intranasal adenoid tissue. Having determined the presence of remaining obstructive tissue with intraoperative nasal endoscopy in these 51 patients, complete airway patency was achieved with powered-shaver adenoidectomy., Conclusion: The presence of intranasal extension of adenoids obstructing the posterior choanae is common in children with adenoid hypertrophy. Traditional adenoidectomy is ineffective in removing this tissue and may also leave obstructive tissue high in the nasopharynx. Intraoperative nasal endoscopy allows assessment of the completeness of surgery. Powered-shaver adenoidectomy enables complete removal of obstructive adenoid tissue thereby ensuring postnasal patency.

The aim of endonasal sinus surgery is to ameliorate sinonasal symptoms and to achieve a functional nose. Although the importance of opening the ostiomeatal complex is accepted, the role of middle turbinate surgery remains controversial. Although some surgeons emphasize the importance of maintaining the middle turbinate as a physiological humidifier and anatomic landmark, others resect it without adverse sequelae. To date, there have only been limited reviews published to support either approach. This paper examines 1,106 matched patients who underwent similar functional endonasal sinus surgery with (509 patients) or without (597 patients) middle turbinate surgery. We demonstrate a paucity of complications and the potential outcome benefits of judicious partial middle turbinate resection in some patients with more severe rhinosinusitis.

Background: This study presents the current aetiology of and management options for vocal fold paralysis., Methods: One hundred and eight patients with unilateral vocal fold paralysis, managed by The Sydney Voice Clinic from 1989 to 1996, are reviewed. Aetiology of the palsy was classified as iatrogenic (45 of 108), idiopathic (36 of 108) and other defined causes (27 of 108). Nineteen patients were observed with the rest being managed with speech therapy alone (38 of 108), surgery (24 of 108) or surgery with adjuvant speech therapy (27 of 108). Surgical techniques included vocal fold augmentation (n = 43), thyroplasty (n = 20) and laryngeal re-innervation (n = 12)., Results: Overall 78 of 108 patients had restoration of near normal to normal voice with an additional 14 attaining a very good voice or better (voice outcome <2)., Conclusions: Early intervention for symptomatic patients was found to be rewarding and safe. Vocal fold augmentation with autologous fat was particularly successful in achieving sustained improvement of voice.

Objectives/hypothesis: Review the roles of aggressive gastroesophageal reflux management and speech therapy in the treatment of patients with vocal process granulomas. Describe and assess our investigation and management protocol., Study Design: Retrospective review of 55 patients with 61 vocal granulomas treated according to a standard protocol at the Sydney Voice Clinic. Comparison with previous published series and review of the relevant literature pertaining to granulomas and to reflux. Description of laryngopharyngeal reflux grading, investigative modalities, and treatment regimen., Methods: Case notes were reviewed and tabulated for age, sex, diagnosis, predisposing factors for granuloma formation, grade of laryngopharyngeal reflux, investigations, treatment, resolution, and recurrence. All patients were followed up for at least 12 months after resolution., Results: Fourteen of the 61 granulomas occurred after intubation. Ten patients were professional voice users. Our assessment of the 55 granuloma patients revealed an incidence of 76% of gastroesophageal reflux disease in patients with and without known vocal fold trauma. There was a 50% recurrence rate following surgical excision. However, aggressive antireflux therapy, lifestyle modifications, and adjuvant speech therapy were successful in achieving resolution of most of the granulomas and preventing recurrence. In four patients, antireflux surgery was required and total resolution of the granulomas followed., Conclusions: Vocal process granulomas have perplexed laryngologists with their indeterminate pathogenesis and tendency to recur. Multiple surgical excisions and a variety of combined medical regimens have been used to treat granulomas with variable success. Recurrence after excision commonly occurs as the underlying causative factors have not been appropriately managed and may re-establish the chronic inflammatory process. We found acid reflux to be a common factor in the majority of our patients with granulomas. Therefore treatment should focus on managing both reflux and any functional voice disease or disorder. The only indications for laryngeal surgery are to resolve diagnostic doubt or to treat acute airway compromise. Based on results, we suggest an algorithm for the investigation and management of vocal process granulomas founded on appropriate antireflux and speech therapy.

The purpose of this study was to investigate the structure and function of larynges of 35 subjects with normal voices. Volunteers aged between 20 and 50 years with no history of voice disorders or laryngeal surgery, no current allergies, no formal voice training, and no hyperactive gag reflex were required to perform various vocal manoeuvres that were carried out under continuous and stroboscopic light. An assessment form was devised to record the condition and function of the larynx. The videotapes of the procedure were rated by experienced judges. The Australian Fiberscopic Profile was devised to record the relevant parameters under continuous light. Videostroboscopic ratings were carried out using the Bless protocol rating. High interjudge agreement was found across the two rating profiles.

The Australian Fiberscopic Profile (AFP) was developed for use in a previous study of normal voices to provide standard documentation for examining the larynx under continuous light. The AFP is being used currently in five specialized voice clinics in Australia to collect data on dysphonic voices. After use with 40 clients it became obvious that a revision with clearer definitions of the parameters was needed to make it a more useful clinical tool.

A case of a multicentric chemodectoma, with the unusual combination of glomus vagale and glomus tympanicum, is presented. The patient, though asymptomatic, showed elevated levels of urinary catecholamines, suggesting some biochemical activity of the tumour. Multicentricity was unsuspected prior to selective carotid arteriography. Intra-operative haemostasis was assisted by the utilization of pre-operative selective embolization of the tumour mass. Subsequently, the injected Ivalon was confirmed histologically in the specimen. The asymptomatic small glomus tympanicum tumour was treated using embolization alone but only time will determine the effectiveness of this method of management. The vagus nerve was anatomically spared, but complete function had not returned after 2 years of follow-up.

Two hundred neck dissections performed at Toronto General Hospital over a 3 year period are reviewed. There were six intra-operative lymph leaks and five postoperative chylous fistulae. The postoperative chylous fistulae are analysed in detail and the approach to conservative management of lymph leaks is discussed. Two cases required re-exploration of the neck; difficulty in identifying the site of leakage and of sealing lymph channels is discussed. Also reported is the successful use of topical tetracycline powder in two cases and a review of the various treatment modalities advocated in the literature.

Epiglottitis (supraglottitis) in the adult, once thought a rare entity, has been reported in the literature with increasing frequency since the late 1960s. Five cases occurring in our hospital over a 12-week period prompted this report. Historical and literature reviews followed by five case reports and discussion, illustrate the important diagnostic and therapeutic features of this disease.

The combination of a myocutaneous flap with a three dimensional, bendable reconstruction plate has provided very satisfactory results in restoration of mandibular defects following surgical resections in irradiated patients. Twenty-four cases have been treated and evaluated prospectively using this technique. Patients requiring postoperative irradiation were excluded from this study. Two groups were identified. Group A (n = 20) required a myocutaneous flap to resurface the soft tissue defect and Group B (n = 4) were treated by primary closure. No failures were encountered in the group handled primarily with a myocutaneous flap combined with an AO plate. One failure occurred in the group closed primarily. Nine (38%) of the patients have maintained their plate for over 1 year. Twelve (55%) have functioned for more than 9 months. Of the remaining three (7%), one failed and the other two have been in place for more than 5 months. The results of this study demonstrate that a well-vascularized soft tissue bed in combination with stainless steel plate provides a very satisfactory, functional, esthetic and reliable method in rehabilitation of mandibular defects primarily in irradiated patients.

Six patients with cancers arising in the parotid region were treated with surgery and postoperative irradiation. All cases had extensive resections with sacrifice of the seventh nerve and primary autogenous cable graft repair. Four of the six patients had good to excellent dynamic function at 18 months; the fifth case had fair mimetic function with ability to close the eye and protect the cornea, and the final case failed to demonstrate any function at one year, but was found to have recurrent tumor at the skull base.

Laryngotracheal stenosis is a difficult problem to manage. Functional assessment is measured primarily on the ability to successfully decannulate the patient. In an effort to identify reliable, objective parameters for postoperative functional assessment, we present a retrospective study of 10 postlaryngotracheoplasty patients. All subjects underwent analysis with computerized tomography, translaryngeal manometry, acoustic reflection, flow volume loops (FVL), and voice analysis. Our results led us to conclude that accurate functional assessment is best provided by use of a combination of CT and spectral voice analysis.

The cycle of alternating distribution of nasal airflow was investigated in 15 adults. Information about cyclic activity was obtained from the areas of condensation formed by nasal expiration on the surface of a Gertner-Podoshin plate. Consecutive measurements of these areas were made at 15 minute intervals during a 6-8 h period. Five control subjects demonstrated a nasal cyclic activity which was absent in 5 patients 1-3 years post laryngectomy. Two patients with preoperative cycles showed none 3 weeks after laryngectomy. Three patients with temporary surgical diversion of supraglottic airflow showed cessation of the cycle, which resumed after restoration of the natural airway; one of these patients had undergone hemilaryngectomy with section of both superior laryngeal nerves. These results demonstrate cessation of the cycle following chronic absence of supraglottic airflow, temporary cessation during acute absence, and independence of the cycle from superior laryngeal innervation.

Computer assisted active posterior rhinomanometric determinations of resistance were made with four adult subjects. A face mask and pneumotach were used to measure respiratory airflow. The magnitude and variation of six different instantaneous and time averaged methods of calculation of resistance resulting from simultaneous measurements were compared. Over a resistance range of 1-6 cm H2O/l/sec (0.1-0.6 Pa/cm3/sec) time averaged results approximated those computed at 75 Pa and were 20-25% less than those at 150 Pa. Over the same range of nasal patencies, the coefficients of variation averaged 6-8% in 144 series of 10 measurements which were obtained from six modes of resistance computation in four subjects (total 1440). Time averaged results showed the least variation. A frequency range of 10-26 breaths/min increased the coefficient of variation only to 9% and a ventilation range of 7-24 l/min increased it to 11%, quantitative relationships between resistances and pattern of breathing were not evident. Mask positioning was critical, small maladjustments resulted in large resistive changes.

A prospective analysis of 666 patients was performed to examine the prevalence of radiologic abnormalities of the paranasal sinuses in asymptomatic adults. The initial sample group included 1000 patients who were referred for cranial computed tomographic scans for conditions such as head injuries and seizures. Patients in whom there was clinical suspicion of sinus disease were excluded from the study. A questionnaire was completed by each patient and cranial computed tomography, including magnetic resonance imaging of the paranasal sinuses, was performed. Abnormality of one or more of the paranasal sinuses was reported in 42.5% of scans. Mucosal thickening in the ethmoid sinus was the abnormality most often identified. The high frequency of reported radiologic abnormalities in asymptomatic patients highlights the importance of correlation with the clinical presentation when interpreting computed tomographic scans of the paranasal sinuses.

A clinical trial was undertaken to assess the effects of oral H1 (diphenhydramine hydrochloride) and H2 (cimetidine) histamine blockade on nasal resistance induced by topical histamine. Ten adult volunteers were tested on two separate occasions. Their noses were pretreated by oral administration of either combined H1 and H2 histamine antagonists or H1 antagonist and placebo. The nasal airflow resistive response to topical histamine was then determined. Combined histamine antagonism was significantly more effective in reducing the nasal resistive response to topical histamine than H1 antagonist alone (p less than 0.0001). Furthermore, ingestion of the oral H1 histamine antagonist, diphenhydramine hydrochloride, alone led to an increase in resistance of the unprovoked nose, whereas combined H1 and H2 antagonism did not lead to a significant change.

Several changes in nasal physiology have been reported following laryngectomy. This paper reviews these changes and investigates the cycle of alternating distribution of nasal airflow in 20 adults. Information about the cyclic activity was obtained from the areas of condensation formed by nasal expiration on the surface of a Gertner-Podoshin plate. Consecutive measurements of these areas were made at 15-minute intervals during a 6-8 hour period. Five control subjects demonstrated a nasal cyclic activity which was absent in five patients 1-3 years post-laryngectomy. Two patients with preoperative cycles showed none three weeks after laryngectomy. Three patients with a temporary surgical diversion of supraglottic airflow showed cessation of the cycle, which resumed after restoration of the natural airway; one of these patients had undergone hemilaryngectomy with section of both superior laryngeal nerves. Five patients showed no alteration after operation involving no diversion of supraglottic airflow (tonsillectomy). These results demonstrate cessation of the cycle following chronic absence of supraglottic airflow, temporary, cessation during acute absence, and independence of the cycle from superior laryngeal innervation.

Total pharyngeal reconstruction following ablative surgery has made significant advances over the past 10 years with the development of new techniques and the refinement of older methods. The reconstructive methods utilized by the authors in 26 cases over the past three years are presented. The methods employed were classified into three groups. Group A (N = 3) were reconstructed using myocutaneous flaps, Group B (N = 17) were repaired by primary gastric transposition, and Group C (N = 6) were handled using a free vascularized jejunal graft. Twenty-two of the patients received preoperative irradiation. The selection of appropriate procedure and technique, and the complications and limitations of each method are discussed.

The management of chylous fistulae remains controversial. A detailed conservative protocol and guidelines regarding surgical intervention are lacking in the literature. This paper presents our experience in the management of two cases of persistent chylous fistulae by successfully employing topical tetracycline. Our regimen of management is discussed and illustrated with the above two cases. An updated review of the pertinent anatomy, physiology, and literature is presented.