Esophageal motor function in laryngopharyngeal reflux is superior to that in classic gastroesophageal reflux disease

Laryngopharyngeal reflux (LPR) in otolaryngology patients appears to be different from classic gastroesophageal reflux disease (GERD). In particular, esophagitis and its principal symptom, heartburn, considered the diagnostic sine qua non of GERD, are often absent in LPR. It has therefore been postulated that LPR patients have superior esophageal function. Esophageal acid clearance (EAC) is a measure of the ability of the esophagus to restore neutral pH after reflux events have occurred. It is considered an excellent overall measure of esophageal function. The mean EAC can be calculated from 24-hour pH monitoring data. A comparison of EAC in patients with GERD and LPR has not been previously reported. To compare the EAC of 1) patients with LPR alone, 2) patients with GERD alone, 3) patients with both LPR and GERD, and 4) patients without either LPR or GERD, we studied 200 otolaryngological patients who had undergone 24-hour double-probe (simultaneous pharyngeal and distal esophageal) pH monitoring, 50 in each group. The subgrouping of each patient was determined by previously established pH monitoring criteria. We defined GERD as abnormal esophageal reflux and LPR as abnormal pharyngeal reflux. The patients with GERD had a mean (+/-SD) EAC of 1.44 +/- 1.2 minutes, and those with LPR had a mean EAC of 1.00 +/- 1.00 minutes (p < .05). The patients with both GERD and LPR had a mean EAC of 1.53 +/- 1.01 minutes. The patients without reflux had a mean EAC of 0.53 +/- 0.38 minutes. We conclude that patients with LPR have significantly better EAC than those with GERD. These data suggest that patients with LPR have superior esophageal function. This finding may clarify our understanding of the differences in mechanisms, symptoms, and incidence of esophagitis in patients with LPR and GERD.

Effects of gum chewing on pharyngeal and esophageal pH

We investigated the effects of gum chewing on pharyngeal and esophageal pH levels in patients with laryngopharyngeal reflux (LPR) who were undergoing reflux testing. Forty consecutive, unselected, adult patients who were undergoing ambulatory double-probe (simultaneous pharyngeal and esophageal) pH monitoring for diagnosis of LPR were asked to chew 2 sticks of gum 4 times during their pH studies. Twenty subjects chewed regular sugarless gum, and 20 subjects chewed a sugarless gum containing bicarbonate. The subjects recorded the beginning and end of each gum-chewing period. The mean pH values for the gum-chewing intervals and for comparable pre-gum-chewing intervals were analyzed statistically for both the pharyngeal and esophageal probe data. The regular gum group and the bicarbonate gum group were analyzed separately. In addition, the gum-chewing pH data were compared to controls, ie, normal postcibal buffering effects. The data show that gum chewing consistently increases esophageal and pharyngeal pH, and that bicarbonate gum causes greater increases than regular gum. For patients with LPR, gum chewing appears to be a useful adjunctive antireflux therapy.

Transnasal esophagoscopy

BACKGROUND

Transnasal esophagoscopy (TNE), a new diagnostic technology, allows comprehensive, in-office examination of the esophagus without sedation.

OBJECTIVE

To report the authors' experience using TNE.

METHODOLOGY

Retrospective review of 100 consecutive patients undergoing TNE.

RESULTS

The most frequent indications for TNE were screening examination of the esophagus in reflux, globus, and/or dysphagia patients (n = 79), biopsy of a lesion in the laryngopharynx, trachea, or esophagus (n = 8), screening examination of the esophagus in head and neck cancer patients (n = 5), tracheoscopy and bronchoscopy (n = 4), and evaluation for an esophageal foreign body (n = 2). Four procedures were aborted secondary to a tight nasal vault. Significant findings were found in 44% (42/96). The most frequent findings were esophagitis (n = 19), Barrett's (n = 6), hiatal hernia (n = 4), and carcinoma (n = 5).

CONCLUSIONS

TNE is safe and well tolerated by patients with topical anesthesia alone. TNE may replace radiographic imaging of the esophagus in otolaryngology patients with reflux, globus, and dysphagia.

Cell biology of laryngeal epithelial defenses in health and disease: preliminary studies

Esophageal epithelium has intrinsic antireflux defenses, including carbonic anhydrases (CAs I to IV) that appear to be protective against gastric reflux. This study aimed to investigate the expression and distribution of CA isoenzymes in laryngeal epithelium. Laryngeal biopsy specimens collected from the vocal fold and interarytenoid regions were analyzed by Western blotting and immunofluorescence. Carbonic anhydrases I and II were expressed by the majority of samples analyzed. In contrast, CA III was differentially expressed in the interarytenoid samples and was not detected in any vocal fold samples. The expression of CA III was increased in esophagitis as compared to normal esophageal tissue. Carbonic anhydrase I and III isoenzymes were distributed cytoplasmically in the basal and lower prickle cell layers. The laryngeal epithelium expresses some CA isoenzymes and has the potential to protect itself against laryngopharyngeal reflux. Laryngeal tissue may be more sensitive to injury due to reflux damage than the esophageal mucosa because of different responses of CA isoenzymes.

Ambulatory 24-hour double-probe pH monitoring: the importance of manometry

OBJECTIVE

Historically, manometry has been used for sphincter localization before ambulatory 24-hour double-probe pH monitoring to ensure accurate placement of the probes. Recently, direct-vision placement (DVP), using transnasal fiberoptic laryngoscopy (TFL), has been offered as an alternative technique. Presumably, DVP might be used to precisely place the proximal (pharyngeal) pH probe; however, using DVP, there appears to be no way to accurately position the distal (esophageal) probe. The purpose of this study was to evaluate the accuracy of DVP for pH probe placement using manometric measurement as the gold standard.

METHODS

Thirty patients undergoing pH monitoring participated in this prospective study. Each subject underwent manometric examination of the esophagus to determine the precise location of the upper and lower esophageal sphincters (UES and LES). In addition, external anatomic landmarks were used to estimate interprobe distances. A physician blinded to the manometry results then placed a pH catheter using DVP so that the proximal probe was located just above the UES. The results were recorded and compared with those obtained by manometry.

RESULTS

Accurate DVP of the proximal pH probe was achieved in 70% (23 of 30) of the subjects. The use of external anatomic landmarks to estimate interprobe distance resulted in accurate positioning of the distal probe in only 40% (12 of 30) of the subjects. Using fixed interprobe distances of 15 cm and 20 cm, distal probe position accuracy was 3% (1 of 30) and 40% (12 of 30), respectively. Therefore, using DVP, the distal esophageal probe was in an incorrect position in 60% to 97% of subjects.

CONCLUSION

For double-probe pH monitoring, the proximal probe can be accurately positioned by DVP; however, there is no precise way to determine the interprobe distance required to correctly position the distal pH probe. Failure to accurately position the distal probe results in grossly inaccurate esophageal acid-exposure times. Thus, manometry is needed to ensure valid double-probe pH monitoring data.

Proton pump inhibitor resistance in the treatment of laryngopharyngeal reflux

OBJECTIVE

To describe the occurrence of relative proton pump inhibitor (PPI) drug resistance in the treatment of laryngopharyngeal reflux (LPR).

STUDY DESIGN AND SETTING

A retrospective review was performed for 1053 consecutive adults undergoing double-probe (simultaneous esophageal and pharyngeal) pH testing in our laboratory. Two hundred five patients who had pH studies performed while taking at least a daily dose of PPI therapy were identified; 167 qualified for further analysis. The pH data was reviewed for the presence of abnormalities in either esophageal or pharyngeal acid exposure to evaluate drug efficacy.

RESULTS

Forty-four percent (74/167) of the study patients demonstrated abnormal levels of acid exposure. Results were further analyzed to compare failure rates based on different dosage regimens. Patients on once daily doses of PPI failed at a rate of 56%, with lower failure rates for higher-dose regimens.

CONCLUSIONS

A significant number of LPR patients on PPI therapy demonstrate relative drug resistance.

The validity and reliability of the reflux finding score (RFS)

BACKGROUND

The evaluation of medical and surgical outcomes relies on methods of accurately quantifying treatment results. Currently, there is no validated instrument whose purpose is to document the physical findings and severity of laryngopharyngeal reflux (LPR).

OBJECTIVE

To evaluate the validity and reliability of the reflux finding score (RFS).

METHODS

Forty patients with LPR confirmed by double-probe pH monitoring were evaluated pretreatment and 2, 4, and 6 months after treatment. The RFS was documented for each patient at each visit. For test-retest intraobserver reliability assessment, a blinded laryngologist determined the RFS on two separate occasions. To evaluate interobserver reliability, the RFS was determined by two different blinded laryngologists.

RESULTS

The mean age of the cohort was 50 years (+/- 12 standard deviation [SD]). Seventy-three percent were women. The RFS at entry was 11.5 (+/- 5.2 SD). This score improved to 9.3 (+/- 4.7 SD) at 2 months, 7.3 (+/- 5.5 SD) at 4 months, and 6.1 (+/- 5.2 SD) at 6 months of treatment (P <.001 with trend). The mean RFS for laryngologist no. 1 was 10.8 (+/- 4.1 SD) at the initial screening and 10.8 (+/- 4.0 SD) at the repeat evaluation (r = 0.95, P <.001). The mean RFS for laryngologist no. 2 was 11.1 (+/- 3.8 SD) at the initial screening and 10.9 (+/- 3.7 SD) at the repeat evaluation (r = 0.95, P <.001). The correlation coefficient for interobserver variability was 0.90 (P <.001).

CONCLUSIONS

The RFS accurately documents treatment efficacy in patients with LPR. It demonstrates excellent inter- and intraobserver reproducibility.

Laryngospasm and diaphragmatic arrest in immature dogs after laryngeal acid exposure: a possible model for sudden infant death syndrome

Laryngopharyngeal reflux has been proposed as a possible cause of sudden infant death syndrome (SIDS). We investigated the efferent laryngeal and diaphragmatic responses to acid exposure on the laryngeal mucosa using a neonatal canine model. Electromyographic (EMG) recordings from the thyroarytenoid muscle and the diaphragm were measured with hooked-wire electrodes. Reproducible laryngospasm responses occurred in all animals after laryngeal exposure to hydrochloric acid at pH 2.0 or less. Laryngospasm occurred in combination with tachypnea and increased diaphragmatic activity in most of the animals. Laryngospasm was associated with prolonged apnea and total cessation of diaphragmatic EMG activity in 1 animal, and in another, initial tachypnea was followed by erratic diaphragmatic activity and brief apnea. Laryngeal acid exposure (below pH 2.0) causes laryngospasm and may result in paradoxical apneic events in neonatal dogs. Acid-induced, laryngospasm-associated apnea may represent a potential cause of SIDS, and the immature dog appears to be an excellent model for further investigations.

Vagal neuropathy after upper respiratory infection: a viral etiology?

PURPOSE

To describe a condition that occurs following an upper respiratory illness, which represents injury to various branches of the vagus nerve. Patients with this condition may present with breathy dysphonia, vocal fatigue, effortful phonation, odynophonia, cough, globus, and/or dysphagia, lasting long after resolution of the acute viral illness. The patterns of symptoms and findings in this condition are consistent with the hypothesis that viral infection causes or triggers vagal dysfunction. This so-called postviral vagal neuropathy (PVVN) appears to have similarities with other postviral neuropathic disorders, such as glossopharyngeal neuralgia and Bell's palsy.

MATERIALS AND METHODS

Five patients were identified with PVVN. Each patient's chart was reviewed, and elements of the history were recorded.

RESULTS

Each of the 5 patients showed different features of PVVN.

CONCLUSIONS

Respiratory infection can trigger or cause vocal fold paresis, laryngopharyngeal reflux, and neuropathic pain.

Hemicricoidectomy for voice rehabilitation following hemilaryngectomy with ipsilateral arytenoid removal

The purpose of this article is to describe an approach to reconstruction of the larynx after vertical partial laryngectomy with removal of the ipsilateral arytenoid cartilage. This method addresses the problem of postoperative posterior glottal incompetence (aphonia with or without aspiration). The technique involves resection of the ipsilateral half of the cricoid cartilage, use of an inferiorly based strap muscle flap for vocal fold reconstruction, and placement of a customized stent. This technique may be used at the time of the primary cancer extirpation or as a secondary rehabilitative procedure. Generally, patients who have undergone this procedure have had minimal postoperative breathiness with good phonatory and airway function. We recommend this reconstructive technique for patients with large posterior defects following hemilaryngectomy.

Diagnostic laryngeal electromyography: The Wake Forest experience 1995-1999

BACKGROUND

Laryngeal electromyography (LEMG) is a valuable diagnostic/prognostic test for patients with suspected laryngeal neuromuscular disorders.

OBJECTIVE

To report our experience with diagnostic LEMG at the Center for Voice Disorders of Wake Forest University and to evaluate the impact of LEMG on clinical management.

METHODS

Retrospective chart review of 415 patients who underwent diagnostic LEMG over a 5-year period (1995-1999).

RESULTS

Of 415 studies, 83% (346 of 415) were abnormal, indicating a neuropathic process. LEMG results altered the diagnostic evaluation (eg, the type of radiographic imaging) in 11% (46 of 415) of the patients. Unexpected LEMG findings (eg, contralateral neuropathy) were found in 26% (107 of 415) of the patients, and LEMG results differentiated vocal fold paralysis from fixation in 12% (49 of 415). Finally, LEMG results altered the clinical management (eg, changed the timing and/or type of surgical procedure) in 40% (166 of 415) of the patients.

CONCLUSIONS

LEMG is a valuable diagnostic test that aids the clinician in the diagnosis and management of laryngeal neuromuscular disorders.

Laryngopharyngeal reflux symptoms improve before changes in physical findings

BACKGROUND

Patients with laryngopharyngeal reflux (LPR) undergoing treatment appear to have improvement in symptoms before the complete resolution of the laryngeal findings.

OBJECTIVE

To determine whether patients with LPR experience an improvement in symptoms before the complete resolution of the laryngeal findings.

METHODOLOGY

Forty consecutive patients with LPR documented by double-probe pH monitoring were evaluated prospectively. Symptom response to therapy with proton pump inhibitors was assessed at 2, 4, and 6 months of treatment with a self-administered reflux symptom index (RSI). In addition, transnasal fiberoptic laryngoscopy (TFL) was performed and a reflux finding score (RFS) was determined for each patient at each visit.

RESULTS

The mean RSI at entry was 19.3 (+/- 8.9 standard deviation) and it improved to 13.9 (+/- 8.8) at 2 months of treatment (P <.05). No further significant improvement was noted at 4 months (13.1 +/- 9.8) or 6 months (12.2 +/- 8.1) of treatment. The RFS at entry was 11.5 (+/- 5.2), and it improved to 9.4 (+/- 4.7) at 2 months, 7.3 (+/- 5.5) at 4 months, and 6.1 (+/- 5.2) after 6 months of treatment (P <.05 with trend).

CONCLUSIONS

Symptoms of LPR improve over 2 months of therapy. No significant improvement in symptoms occurs after 2 months. This preliminary report demonstrates that the physical findings of LPR resolve more slowly than the symptoms and this continues throughout at least 6 months of treatment. These data imply that the physical findings of LPR are not always associated with patient symptoms, and that treatment should continue for a minimum of 6 months or until complete resolution of the physical findings.

Fascia Augmentation of the Vocal Fold: Graft Yield in the Canine and Preliminary Clinical Experience

INTRODUCTION

Glottal insufficiency resulting from vocal fold bowing, hypomobility, or scar is frequently treated by injection augmentation. Injection augmentation with fat, collagen, gel foam, polytef, and recently, fascia lata has been previously reported. Variable graft yield and poor host-tissue tolerance have motivated the continued search for an ideal graft substance.

STUDY DESIGN

A prospective trial of autologous fascia augmentation of the vocal cord in the human and in an animal model.

METHODS

Autologous fascia injection augmentation (AFIA) was evaluated in 8 canines and 40 patients at our institution between 1998 and 2000. The animal study compared graft yield from AFIA with autologous fat yield. The outcome measure was graft yield calculated from histological examination of larynges 12 weeks after injection augmentation. Clinical trial outcome measures included symptom surveys, acoustical voice analyses, and subjective voice assessments. Mean follow-up was 9 months.

RESULTS

In the canine larynx, the mean graft yield for AFIA was 33% (range, 5%-84%) compared with autologous lipoinjection (47%; range, 7%-96%; P =.57). Subjective improvement in vocal quality was reported by 95% of patients (38 of 40) after AFIA. Preoperative and postoperative voice analysis data were obtained from 26 patients. Subjective voice rating demonstrated a significant improvement after AFIA (P <.0001). Acoustical parameters of jitter, shimmer, noise-to-harmonic ratio, phonatory range, and degree unvoiced improved significantly (P <.05) in all patients after fascia augmentation.

CONCLUSIONS

Based on the animal study, we concluded that graft yields are excellent but variable for AFIA. The result is similar in variability and overall yield to autologous lipoinjection. Subjective and objective analyses of voice outcomes after AFIA are universally improved. Fascia appears to be an excellent alternative to lipoinjection in properly selected cases of glottic insufficiency.

Unilateral or Localized Reinke???s Edema (Pseudocyst) as a Manifestation of Vocal Fold Paresis: The Paresis Podule

BACKGROUND

The nosology of free-edge vocal fold lesions remains imprecise. In particular, the lesion termed pseudocyst remains enigmatic, because its histology is poorly defined and because its etiology is unknown. We define pseudocyst as a discrete, unilateral, localized area of Reinke's edema (without a capsule), usually occurring at the midportion of the free-edge striking zone.

OBJECTIVE

To report the demographic and clinical findings, as well as discuss our diagnostic and therapeutic strategies, in patients with unilateral Reinke's edema or pseudocyst.

METHODOLOGY

All patients diagnosed with unilateral Reinke's edema or pseudocyst over a 2-year period (1998-1999) were identified from the clinical database of the Center for Voice Disorders of Wake Forest University, Winston-Salem, North Carolina. The record of each patient was retrospectively reviewed.

RESULTS

Thirteen patients were identified, 12 of whom were female. The mean age was 36 years. Sixty-nine percent (9 of 13) had unilateral pseudocyst and 31% (4 of 13) had unilateral Reinke's edema. All patients had documented vocal fold paresis on laryngeal electromyography. The 9 patients with pseudocyst underwent excision of their lesions; 7 had bilateral medialization laryngoplasties, 1 had lipoinjection, and 3 did not have surgical intervention. Significant improvement was noted postoperatively on a self-administered glottal insufficiency (symptom) index (P <.001).

CONCLUSION

Unilateral Reinke's edema and localized Reinke's edema (pseudocyst) are distinct clinical entities, occurring most frequently in women in their fourth decade. The finding of unilateral Reinke's edema or pseudocyst should alert the clinician to the likelihood of vocal cord paresis. Surgical intervention with medialization laryngoplasty appears to be beneficial.

Occult laryngeal pathology in a community-based cohort

BACKGROUND

Little information is available regarding the prevalence of laryngeal pathology in adults.

PURPOSE

To estimate the prevalence of occult laryngeal pathology in a community-based cohort of adults over 40 years of age.

METHODS

One hundred consecutive volunteers over age 40 with no history of voice disorders were enrolled. All completed a self-administered laryngeal symptom questionnaire and underwent a comprehensive head and neck examination including transnasal fiberoptic laryngoscopy.

RESULTS

The mean age of the cohort was 61 years. Vocal fold bowing (presbylaryngis) was present in 72% of the patients, and findings of laryngopharyngeal reflux were present in 64% of the cohort. In addition, other laryngeal pathology were identified in 21%. Only 12% had a completely normal laryngeal examination.

CONCLUSIONS

Occult laryngeal pathology is very common in persons over 40. Findings suggestive of laryngopharyngeal reflux are present in 64%, and vocal fold bowing is present in 72% of persons over 40.

Endoscopic arytenoid repositioning for unilateral arytenoid fixation

OBJECTIVES

To describe a new endoscopic technique for medialization of the laterally fixed arytenoid. The surgical technique, endoscopic arytenoid repositioning, is described, and the results of a series of cases are discussed.

STUDY DESIGN

Retrospective chart review.

METHODS

Eight patients underwent the procedure. Six patients were available for long-term follow-up. Preoperative and postoperative voice ratings were compared to evaluate the success of the procedure. Follow-up ranged from 3 to 64 months (mean follow-up, 31.5 mo).

RESULTS

Long-term follow-up in six cases revealed that 67% (4 of 6) patients had normal or near-normal postoperative voices and one patient experienced moderate improvement. The mean preoperative voice score was 4.24, and the mean postoperative voice score was 1.83 (range, 1-5). The difference was statistically significant (P < 0.001).

CONCLUSIONS

Endoscopic arytenoid repositioning is a newly described procedure with a very specific indication: a unilateral, laterally fixed arytenoid complex resulting in a severely dysphonic voice. Though technically demanding, this procedure provides a promising option for medialization of the posterior glottis in a scarred larynx.

Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders

OBJECTIVES

The goal was to estimate the prevalence of laryngopharyngeal reflux (LPR) in patients with laryngeal and voice disorders.

STUDY DESIGN AND SETTING

This was a prospective study of 113 unselected, new patients with laryngeal and voice disorders. Patients completed an extensive medical history form including a reflux symptom profile. A comprehensive otolaryngologic examination was performed with photographic transnasal fiberoptic laryngoscopy. Patients with both symptoms and findings of LPR (78/133, 69%) underwent ambulatory 24-hour double-probe pH monitoring.

RESULTS

Seventy-three percent (57/78) of patients undergoing pH testing had abnormal studies. Thus 50% (57/113) of the entire the study population had pH-documented reflux. Of the diagnostic sub-groups studied, the highest incidence of reflux was found in patients with vocal cord neoplastic lesions (88%) and patients with muscle tension dysphonias (70%). LPR was infrequently found in patients with neuromuscular disorders.

CONCLUSION

LPR occurs in at least 50% of all patients at our center with laryngeal and voice disorders at presentation.

Vocal fold paresis

Vocal fold paresis (VFP) is a relatively common and often overlooked condition that can be difficult to diagnose based on the laryngeal examination alone. A retrospective review of the records of 50 consecutive adult patients with VFP was performed. In each case, the diagnosis of VFP was confirmed by laryngeal electromyography. The presenting symptoms were dysphonia (100%), vocal fatigue (76%), diplophonia (40%), and odynophonia (12%), and the findings were unilateral vocal fold hypomobility (50%), unilateral bowing (36%), and bilateral bowing (22%). Laryngoplasty and/or lipoinjection was performed in 54% of the subjects, and significant vocal improvement was achieved in 85%. VFP appears to be underdiagnosed because many VFP patients have compensatory hyperkinetic disorders at presentation. Although the diagnosis of VFP may be suspected based on the patient's symptoms and findings, the diagnostic sine qua non is laryngeal electromyography. In addition, surgical treatment for VFP appears to be safe and effective.

Reflux in infants with laryngomalacia: results of 24-hour double-probe pH monitoring

Laryngomalacia is the most common cause of stridor in children. Previous studies using barium esophagrams or single-probe esophageal pH testing have indicated that 68% to 80% of infants with laryngomalacia have reflux. A recent study in a large series of pediatric patients has shown that these 2 testing modalities are relatively insensitive in detecting reflux when compared with 24-hour double-probe pH testing. This study was undertaken to determine the incidence and frequency of reflux in children with laryngomalacia by use of 24-hour double-probe pH monitoring. Twenty-four children with endoscopically diagnosed laryngomalacia underwent 24-hour double-probe pH testing. The distal probe was placed in the lower esophagus, and the proximal probe was placed just above the cricopharyngeus immediately posterior to the larynx. All 24 (100%) children had pharyngeal acid exposure as judged by the proximal pH probe. These children had a mean of 15.21 episodes of reflux to the level of the pharynx during the 24-hour study period. In contrast, only 16 (66%) children had abnormal acid exposure as measured by the distal esophageal probe. These results indicate that essentially all children with laryngomalacia have reflux of gastric acid to the pharyngeal level. Multiple authors have documented the detrimental effects of acid and the accompanying pepsin in the larynx and tracheobronchial tree. Persistent laryngeal edema is an almost universal finding in patients with reflux to the pharyngeal level and is a common finding in children with laryngomalacia. In some patients with laryngomalacia, reflux may be the primary cause of their airway compromise, whereas in others it may be a significant cofactor exacerbating a preexisting neurologic or anatomic abnormality.

Correlation of laryngeal and pharyngeal carcinomas and 24-hour pH monitoring of the esophagus and pharynx

The cause of laryngeal and pharyngeal carcinomas is likely multifactorial. Smoking is an important factor, but mucosal damage from gastroesophageal reflux may also contribute. The purpose of this study was to determine whether gastroesophageal reflux is more common in patients with laryngeal or pharyngeal carcinomas than in those without these malignancies. Over an 8-year period, we correlated the results of clinical and radiographic examinations of the pharynx and esophagus to pH monitoring results in 798 patients with a variety of upper aerodigestive tract symptoms and who underwent both pH monitoring and barium esophagography. In this group, 63 patients (52 men, 11 women) had laryngeal or pharyngeal carcinomas, and 735 patients (319 men, 416 women) had neither malignancy. Abnormal pH findings were defined as a total percentage of esophageal acid exposure time of 6% or more as determined with the esophageal probe, or any reflux event detected with the pharyngeal probe. Thirty-four of 63 patients with carcinomas (54%) had abnormal pH-monitoring results: Esophageal acid exposure was abnormal in 10 patients, pharyngeal acid exposure was abnormal in 7 patients, and acid exposure was abnormal in both areas in 17 patients. Of the 735 patients without malignancies, 365 (50%) had abnormal pH-monitoring results (p > 0.05). In this population of patients, abnormal results of pH monitoring were common, occurring in 399 (50%) of 798 patients, but no significant difference was found between results in those with and without laryngeal or pharyngeal carcinomas. Therefore, our study found that gastroesophageal reflux as shown by pH monitoring was not more common in patients with these malignancies.

Bilateral medialization laryngoplasty

OBJECTIVES

To present indications, techniques, and results of bilateral medialization laryngoplasty (BML).

STUDY DESIGN

Retrospective review of 39 consecutive patients who had BML for correction of glottal insufficiency attributable to presbylaryngis (n = 16), bilateral vocal fold paresis (n = 13), unilateral paralysis with contralateral bowing (n = 4), and other miscellaneous neurologic diseases (n = 6).

METHODS

Complete preoperative and postoperative clinical and acoustical data were analyzed for 74% (29/39) of the subjects. All 39 subjects completed a patient survey to assess their long-term outcomes.

RESULTS

Overall, 90% (35/39) of the patients who had BML experienced significant improvement in voice and swallowing function. Subsequently, 36% (14/39) of the patients underwent adjunctive lipoinjection for closure of small residual glottal gaps (vocal "fine-tuning"). Of the BML patients (with or without lipoinjection) who had complete preoperative and postoperative voice data, 83% (24/29) had complete glottal closure after surgery, resulting in normal or near-normal voices. Eighty-five percent (33/39) of the patients responded that they "would have surgery again." Of the six patients who said that they would not have surgery again, three had good results and one had progressive neurologic disease. The mean duration of follow-up was 17 months.

CONCLUSIONS

BML is an effective rehabilitative surgical treatment for symptomatic vocal fold bowing. In addition, lipoinjection is useful as an adjunct to BML to enhance the voice outcome in selected cases.

Extraesophageal pediatric reflux: 24-hour double-probe pH monitoring of 222 children

Although extraesophageal gastric reflux has been implicated as a cause of many pediatric airway and respiratory diseases, its prevalence in these conditions remains unknown due to the relative lack of sensitivity and/or specificity of traditional reflux testing methods. A prospective study of 222 children (ages 1 day to 16 years) was performed with 24-hour double-probe (simultaneous esophageal and pharyngeal) pH monitoring. Seventy-six percent (168/222) of the study population had abnormal findings in either one or both of the pH probes. Of those, 46% (78/168) had pharyngeal reflux (extraesophageal gastric acid documented by the pharyngeal probe), despite having normal esophageal acid exposure times according to the esophageal probe. Thus, had the pharyngeal probe not been used, 46% of the children with documented extraesophageal (pharyngeal) reflux would have been falsely presumed to have normal reflux parameters. Patients with laryngeal abnormalities, pulmonary abnormalities, and emesis had significantly more pharyngeal acid reflux (p < .001) than patients with nonrespiratory symptoms. These data suggest that extraesophageal reflux may be underestimated by single-probe intraesophageal monitoring alone, and that laryngopharyngeal reflux may play a role in the pathogenesis of the conditions studied.

Sensitive assay for measurement of antibodies to Clostridium botulinum neurotoxins A, B, and E: use of hapten-labeled-antibody elution to isolate specific complexes

The measurement of chicken and human antibodies to Clostridium botulinum neurotoxins A, B, and E was accomplished by affinity isolation of complexes containing these antibodies. By this approach, a mixture of toxin with the test antibody, fluoresceinated antibody, and enzyme (Russell's viper venom factor X activator)-labeled antibody is allowed to form a complex in solution phase. This complex is then bound to a matrix containing antifluorescein antibody. All components not bound to the matrix are washed off, and the complex is isolated intact by elution with fluorescein, which competes with the complex for binding to the antifluorescein matrix. The eluted complex is then bound to a matrix which specifically binds the test antibody (anti-chicken immunoglobulin Y [IgY] or anti-human IgG), and the bound complex is measured by using the enzyme label. Using this approach, we were able to measure as little as 1 ng of specific antibody per ml from affinity-isolated, monospecific chicken antibody preparations and to measure antibody specifically from IgY fractions of monospecific chicken antibody preparations. Human antibodies from subjects immunized with pentavalent toxoid preparations were detectable at dilutions as great as 24,300-fold, and undiluted serum from most control subjects showed no measurable antibody. Antibody was also measured in 65 subjects who were receiving preparations of neurotoxin A (BOTOX) for the treatment of spastic disorders. Eighteen of them had toxin-specific antibody reactive with toxin B, and two of them had toxin-specific antibody reactive with toxin A. The two patients having antibody to toxin A were refractory to treatment with this toxin. This approach of isolation of hapten-labeled immune complexes under nondenaturing conditions with hapten is broadly applicable to the specific measurement of antibodies present at very low concentrations in serum.

The etiology and pathogenesis of laryngeal carcinoma

Epidemiologic data suggest that the etiology and pathogenesis of laryngeal carcinoma are influenced by environmental and lifestyle-related factors, such as tobacco use, ethanol consumption, and exposure to toxic substances. In addition, dietary factors, irradiation, papilloma virus infection, and laryngopharyngeal reflux seem to be significant carcinogenic cofactors. This article presents a multi-factorial model of laryngeal mucosal carcinogenesis.

Acid-induced laryngospasm in a canine model

A canine model was used to investigate the efferent laryngeal responses to stimulation by topically applied acid and pepsin. Five adult mongrel dogs were studied. Electromyographic recordings from the thyroarytenoid muscle were measured with hooked-wire electrodes as an acid solution (normal saline/hydrochloric acid at pH 6.0, 5.0, 4.0, 3.0, 2.5, 2.0, 1.5, and 1.0) was sequentially instilled into the larynx. Laryngospasm (tonic, sustained contraction of the thyroarytenoid muscle) occurred in all animals at pH 2.5 to 2.0 or less. Control substances such as neutral pH isotonic saline, hypotonic saline, hypertonic saline, water, and pepsin alone failed to produce laryngospasm. Next, solutions containing both acid (in the same pH range) and pepsin were tested. The laryngeal responses were similar to those of acid alone. The superior laryngeal nerves were sectioned bilaterally and the above experiments repeated. None of the test solutions produced laryngospasm; however, when capsaicin (1%) was instilled into the subglottis, laryngospasm occurred. Thus, chemoreceptors in the subglottis (supplied by the recurrent laryngeal nerves) appear to be responsive to capsaicin stimulation but not to acid stimulation. The data suggest that pH-sensitive chemoreceptors in the canine larynx cause laryngospasm (when the pH of the test solution is 2.5 or less) and that these acid receptors are supplied by the superior laryngeal nerves.

Laryngeal biomechanics of the singing voice

By transnasal fiberoptic laryngoscopy, patients with functional voice often demonstrate abnormal laryngeal biomechanics, commonly supraglottic contraction. Appropriately, such conditions are sometimes termed muscle tension dysphonias. Singers working at the limits of their voice may also transiently demonstrate comparable tension patterns. However, the biomechanics of normal singing, particularly for different singing styles, have not been previously well characterized. We used transnasal fiberoptic laryngoscopy to study 100 healthy singers to assess patterns of laryngeal tension during normal singing and to determine whether factors such as sex, occupation, and style of singing influence laryngeal muscle tension. Thirty-nine male and 61 female singers were studied; 48 were professional singers, and 52 were amateurs. Examinations of study subjects performing standardized and nonstandardized singing tasks were recorded on a laser disk and subsequently analyzed in a frame-by-frame fashion by a blinded otolaryngologist. Each vocal task was graded for muscle tension by previously established criteria, and objective muscle tension scores were computed. The muscle tension score was expressed as a percentage of frames for each task with one of the laryngeal muscle tension patterns shown. The lowest muscle tension scores were seen in female professional singers, and the highest muscle tension scores were seen in amateur female singers. Male singers (professional and amateur) had intermediate muscle tension scores. Classical singers had lower muscle tension scores than nonclassical singers, with the lowest muscle tension scores being seen in those singing choral music (41%), art song (47%), and opera (57%), and the highest being seen in those singing jazz/pop (65%), musical theater (74%), bluegrass/country and western (86%), and rock/gospel (94%). Analyzed also were the influences of vocal nodules, prior vocal training, number of performance and practice hours per week, warm-up before singing, race, smoking, and alcohol consumption.

Laryngeal Biomechanics of the Singing Voice

By transnasal fiberoptic laryngoscopy, patients with functional voice disorders often demonstrate abnormal laryngeal biomechanics, commonly supraglottic contraction. Appropriately, such conditions are sometimes termed muscle tension dysphonias. Singers working at the limits of their voice may also transiently demonstrate comparable tension patterns. However, the biomechanics of normal singing, particularly for different singing styles, have not been previously well characterized. We used transnasal fiberoptic laryngoscopy to study 100 healthy singers to assess patterns of laryngeal tension during normal singing and to determine whether factors such as sex, occupation, and style of singing influence laryngeal muscle tension. Thirty-nine male and 61 female singers were studied; 48 were professional singers, and 52 were amateurs. Examinations of study subjects performing standardized and nonstandardized singing tasks were recorded on a laser disk and subsequently analyzed in a frame-by-frame fashion by a blinded otolaryngologist. Each vocal task was graded for muscle tension by previously established criteria, and objective muscle tension scores were computed. The muscle tension score was expressed as a percentage of frames for each task with one of the laryngeal muscle tension patterns shown. The lowest muscle tension scores were seen in female professional singers, and the highest muscle tension scores were seen in amateur female singers. Male singers (professional and amateur) had intermediate muscle tension scores. Classical singers had lower muscle tension scores than nonclassical singers, with the lowest muscle tension scores being seen in those singing choral music (41%), art song (47%), and opera (57%), and the highest being seen in those singing jazz/pop (65%), musical theater (74%), bluegrass/country and western (86%), and rock/gospel (94%). Analyzed also were the influences of vocal nodules, prior vocal training, number of performance and practice hours per week, warm-up before singing, race, smoking, and alcohol consumption.

Paroxysmal laryngospasm secondary to gastroesophageal reflux

Over a 2-year period (1992 to 1994), 12 consecutive adult patients with paroxysmal laryngospasm were prospectively studied. All had had other symptoms of gastroesophageal reflux (GER); however, only 4 (33%) experienced symptoms of heartburn. Each patient underwent fiberoptic laryngeal examination, barium swallow/esophagography, and ambulatory, 24-hour, double-probe pH monitoring (pH-metry). Eleven (92%) of the 12 patients had evidence of GER on examination, and 10 (83%) had abnormal pH-metry, including 3 who demonstrated pharyngeal reflux while having normal total acid exposure times in the esophageal probe. All the patients responded to antireflux treatment, using dietary and lifestyle modifications and omeprazole, with complete cessation of the laryngospastic episodes. This study documents the role of GER in the etiology of paroxysmal laryngospasm, it highlights the advantages of double-probe pH-metry in diagnosing this extraesophageal manifestation of GER, and it demonstrates that antireflux therapy with omeprazole is effective in controlling GER-induced laryngospasm.

Correlation of lower esophageal mucosal ring and 24-h pH monitoring of the esophagus

OBJECTIVE

To study the relationship of LEMR and gastroesophageal reflux. The pathogenesis of the lower esophageal mucosal ring (LEMR) is not known. The most likely theory is that the ring results from reflux esophagitis as part of the morphological spectrum of peptic stricture.

METHODS

We correlated barium esophagrams and 24-h pH monitoring (pHM) in 343 patients (173 women, 170 men; mean age 52 yr). Patients were categorized into three groups by radiographic findings: 1) normal esophagus (n = 121), 2) hiatal hernia (HH) only (n = 174), and 3) LEMR (n =48). Abnormal pHM was defined as a total percentage of the esophageal acid exposure time of 6% or more; abnormal pHM was also analyzed relative to patient position (supine vs. upright).

RESULTS

Findings showed that 21 (17%) of 121 normal patients had abnormal pHM compared with 58 (33%) of 174 patients with HH and 15 (31%) of 48 patients with LEMR. Normal patients had a significantly lower frequency of abnormal pHM (p < 0.01) vs. the other two groups; however, no significant difference in results of pHM was found in the groups with HH and LEMR. No significant relationships of abnormal supine versus upright pHM was observed comparing the three groups.

CONCLUSIONS

1) Most patients in this study had normal pHM, regardless of the anatomic status of the esophagogastric region; 2) patients with HH and LEMR had a higher frequency of abnormal pHM, although the two groups were not significantly different; and 3) an etiological relationship of LEMR and gastroesophageal reflux was not supported, other than its association with HH.

Association of hiatal hernia and gastroesophageal reflux: correlation between presence and size of hiatal hernia and 24-hour pH monitoring of the esophagus

OBJECTIVE

The relationship of hiatal hernia to gastroesophageal reflux disease remains controversial. Previous endoscopic and radiologic studies of hiatal hernia and reflux esophagitis have shown that hiatal hernia is a poor predictor of the presence of endoscopic esophagitis, especially for smaller hernias. Similar correlations with 24-hr pH monitoring have not been done. The purpose of this study was to determine if there is a correlation between the presence and size of hiatal hernias and gastroesophageal reflux using 24-hr pH monitoring as a measure of the degree of reflux.

MATERIALS AND METHODS

We reviewed the barium esophagograms and the results of pH monitoring of the esophagus in 319 patients (161 women and 158 men; mean age, 51 years). The presence and size of hiatal hernia were determined from the radiographic examination; size was categorized as "minimal" or "larger" (> or = 2 cm axial length). An abnormal result of pH monitoring was defined as a pH less than 4 for 6% or more of the 24-hr observation time.

RESULTS

Abnormal results of pH monitoring were found in 61 (31%) of 199 patients with hiatal hernia compared with 21 (18%) of 120 patients without hiatal hernia (p < .05). Abnormal findings of pH monitoring were present in 33 (35%) of 95 patients with a larger hiatal hernia versus 28 (27%) of 104 patients with a minimal hiatal hernia (p > .05); a significant difference (p < .05) was observed when patients without hiatal hernia were compared with those with a larger hiatal hernia.

CONCLUSION

Most patients in this study had normal results of pH monitoring of the esophagus regardless of the presence or absence of hiatal hernia. However, patients with larger hiatal hernias were more likely to have abnormal findings on pH monitoring; hiatal hernias of minimal size were a poorer predictor of the presence of abnormal gastroesophageal reflux.

Association of hiatal hernia and gastroesophageal reflux: correlation between presence and size of hiatal hernia and 24-hour pH monitoring of the esophagus

OBJECTIVE

The relationship of hiatal hernia to gastroesophageal reflux disease remains controversial. Previous endoscopic and radiologic studies of hiatal hernia and reflux esophagitis have shown that hiatal hernia is a poor predictor of the presence of endoscopic esophagitis, especially for smaller hernias. Similar correlations with 24-hr pH monitoring have not been done. The purpose of this study was to determine if there is a correlation between the presence and size of hiatal hernias and gastroesophageal reflux using 24-hr pH monitoring as a measure of the degree of reflux.

MATERIALS AND METHODS

We reviewed the barium esophagograms and the results of pH monitoring of the esophagus in 319 patients (161 women and 158 men; mean age, 51 years). The presence and size of hiatal hernia were determined from the radiographic examination; size was categorized as "minimal" or "larger" (> or = 2 cm axial length). An abnormal result of pH monitoring was defined as a pH less than 4 for 6% or more of the 24-hr observation time.

RESULTS

Abnormal results of pH monitoring were found in 61 (31%) of 199 patients with hiatal hernia compared with 21 (18%) of 120 patients without hiatal hernia (p < .05). Abnormal findings of pH monitoring were present in 33 (35%) of 95 patients with a larger hiatal hernia versus 28 (27%) of 104 patients with a minimal hiatal hernia (p > .05); a significant difference (p < .05) was observed when patients without hiatal hernia were compared with those with a larger hiatal hernia.

CONCLUSION

Most patients in this study had normal results of pH monitoring of the esophagus regardless of the presence or absence of hiatal hernia. However, patients with larger hiatal hernias were more likely to have abnormal findings on pH monitoring; hiatal hernias of minimal size were a poorer predictor of the presence of abnormal gastroesophageal reflux.

The cricothyroid muscle does not influence vocal fold position in laryngeal paralysis

The status of the cricothyroid muscle, which is innervated by the superior laryngeal nerve, is believed to influence the vocal fold position in laryngeal paralysis. It is believed that isolated lesions of the recurrent laryngeal nerve generally result in the paralyzed vocal fold assuming a paramedian position but that with lesions of both the superior and recurrent laryngeal nerves, a more lateral (intermediate or cadaveric) vocal fold position can be expected. Twenty-six consecutive patients with unilateral vocal fold paralysis underwent transnasal fiberoptic laryngoscopy (TFL) and laryngeal electromyography (LEMG). By TFL, the vocal fold positions were paramedian in 8 patients, intermediate in 7, and lateral in 11. By LEMG, 13 patients had isolated recurrent laryngeal nerve lesions and 13 patients had combined (superior and recurrent laryngeal nerve) lesions. There was no correlation between the vocal fold position and the status of the cricothyroid muscle, i.e., the status of the cricothyroid muscle by LEMG did not predict the vocal fold position nor did the vocal fold position by TFL predict the site of lesion. In addition, we investigated the possibility that the degree of thyroarytenoid muscle recruitment (tone) might correlate with vocal fold position, but no relation was found. We conclude that 1. the cricothyroid muscle does not predictably influence the position of the vocal fold in unilateral paralysis; 2. thyroarytenoid muscle recruitment (tone) does not appear to influence vocal fold position; and 3. still unidentified and unknown factors may be responsible for determining vocal fold position in laryngeal paralysis.

Fate of liposuctioned and purified autologous fat injections in the canine vocal fold

Injection of autologous fat obtained by liposuction has been reported as an augmentation technique for vocal fold paralysis. Unfortunately, it is not known whether this technique is associated with long-term graft survival. The purpose of this study, using a canine model, was to determine the volume of viable injected fat grafts when the tissue was harvested and processed by two different methods: 1. by liposuction alone, and 2. by "purification," i.e., excision of adipose tissue, followed by tissue homogenization and centrifugation in a buffering solution. The results of this study confirm that injected fat grafts survive long-term; however, the average volumetric "take" was only about 20%. Surprisingly, significantly more liposuctioned fat survived than grafts prepared by the purification method (P < .05). At 12 weeks, there was relatively little inflammation present in the tissues surrounding the injected fat, suggesting a stable fat graft volume.

Comparative voice results after laser resection or irradiation of T1 vocal cord carcinoma

OBJECTIVE

To compare voice results following laser resection or radiation therapy for T1a glottic carcinomas.

DESIGN

Objective recordings of acoustical data that were analyzed and calculated by an acoustic analyzer and subjective scores by patients, speech therapists, surgeons, and radiation therapists are compared.

SETTING

Academic medical center speech laboratory at an institution where patients had been treated. Archival files were searched and patients were solicited by letter to participate in this analysis.

PATIENTS

Men treated at least 6 months previously and who were without active laryngeal disease. Criteria were unilateral vocal cord carcinomatous involvement with no subglottic, anterior commissure, or arytenoid extension and tumor invasion clinically judged to be less than half of the cordal depth.

INTERVENTIONS

Thirteen patients had received approximately 63 Gy in 28 fractions, five fractions a week, with laterally opposed fields using a linear accelerator. Eleven patients had had resection of less than half of the cordal depth by using a carbon dioxide laser with a 300-microns spot size working at a 400-mm distance; 13- to 15-W power intensity with a one tenth of a second burn in a noncontinuous mode.

RESULTS

No statistically significant differences between the two study groups were found. Patients and physicians subjectively rated (1 indicates normal; 5, aphonic) the quality of voices of patients in the irradiation group (1.5 and 2.0) as slightly better than the quality of voices of patients in the laser group (2.0 and 2.4). Speech pathologists rated the voices of patients in the laser and irradiation group as indistinguishable and mildly abnormal (2.75 and 2.73).

CONCLUSION

Voice quality in highly selected patients with vocal cord carcinoma treated by laser resection can be as good as that in patients whose cancer was similarly staged after radiation therapy.

Globus pharyngeus: radiographic evaluation and 24-hour pH monitoring of the pharynx and esophagus in 22 patients

PURPOSE

The authors correlated the radiographic evaluation and 24-hour pH monitoring of the pharynx and the esophagus in patients with globus pharyngeus.

MATERIALS AND METHODS

Radiographic examination of the pharynx of 22 patients (13 women and nine men, aged 23-73 years [mean, 47 years]) included videofluoroscopy and static radiography. Twenty-four-hour double-probe pH monitoring of the pharynx (abnormal, pH < 4) and esophagus (abnormal, 6% or more total acid exposure) was performed in all patients.

RESULTS

Radiographic results were normal in 17 patients; results were abnormal in five, with four having pharyngeal dysfunction and one showing a persistent cricopharyngeal impression. Zenker diverticulum was not seen. Results at pH monitoring of the pharynx and esophagus were normal in 20 and 18 of the 22 patients, respectively. In four of five patients with abnormal radiographic studies of the pharynx, results of pharyngeal pH monitoring were normal.

CONCLUSION

Most patients with globus pharyngeus had normal results at pH monitoring and radiographic examination of the pharynx.

Endoscopic treatment of supraglottic and hypopharynx cancer

Transoral excision of supraglottic and hypopharynx cancer as a single modality is effective when lesions are selected for small size and endoscopic accessibility. Excisional biopsy with clear margins of larger supraglottic tumors in combination with postoperative radiotherapy provides an excellent treatment alternative for selected lesions in patients who are not candidates for open surgery. In this preliminary report, 45 cases using this minimally invasive approach are reviewed outlining oncologic rationale and functional advantages. A large bore tubed laryngoscope or the adjustable bivalve supraglottiscope was used along with a carbon dioxide laser in all cases. In 22 of the 45 patients (mostly T1), local en bloc excision of the primary cancer was performed as sole treatment on selected lesions of the supraglottis and hypopharynx. There were no local recurrences, however, 1 patient developed a neck recurrence and was salvaged by neck dissection. Twenty-three of the 45 patients had more extensive primaries (mostly T2, T3) and N0 necks. Transoral excisional biopsy was followed by full-course radiation therapy to the primary site and both necks. All 23 were followed a minimum of 2 years, and the median follow-up period was 58 months. Clear margins were obtained in 16 of 23, and there were no recurrences in the larynx. Two of 16 did fail in the neck and died despite neck dissection. Seven of 23 patients had positive margins and, despite full-course radiotherapy to the primary site and both necks, 5 of 7 failed locally or regionally. Two of the 7 died of their disease despite open salvage surgery. Therefore, 4 of 23 patients who underwent transoral excision of larger lesions followed by full-course radiotherapy died of recurrent cancer.

The perils of esophageal prosthesis placement in malignant tracheoesophageal fistula

Endoesophageal prostheses are sometimes used in palliative therapy of esophageal carcinoma. Placement or subsequent manipulation of these devices may require general anesthesia, and these anesthetics are fraught with potential complications, both from the patient's illness and from the prosthesis itself. The two patients in our report presented anesthetic challenges, including acute upper airway obstruction occurring outside the operating theater and management of malignant tracheoesophageal fistula.

Voice analysis of patients with endoscopically treated early laryngeal carcinoma

Endoscopic laser resection of early (T1) laryngeal carcinoma has been advocated as an alternative to radiotherapy. Heretofore, the voice characteristics following this procedure have been addressed in only one review, which included patients treated by irradiation and laser resection. We present the first review of voice findings in 22 patients treated only by endoscopic laser resection of their vocal cord carcinomas. Laser resection of selected vocal cord carcinomas produced voice function results acceptable to the patients and was rated by them to be normal to almost normal. Speech pathologists rated the voices to be near-normal to mildly abnormal. Voices after laser resection of vocal carcinoma exhibited a slightly higher fundamental frequency, a decrease in intensity and phonatory duration, and markedly higher laryngeal airway resistance. The percentage of voicing showed little deviation from normal, as did mean percentage of perturbations.

Unusual auricular complications in cutaneous oncology

The anatomic complexity of the pinna predisposes that structure to a variety of unique, site specific postoperative complications following management of skin cancer. We describe four unusual auricular complications: 1) radiochondronecrosis; 2) autonecrosis of skin during second intention healing; 3) hearing loss secondary to tragal retraction over the external auditory canal; and 4) extension of tumor through fenestrated cartilage. Well-known postoperative auricular complications are reviewed and anticipation and recognition of these unusual complications are emphasized.