Automatic speaking valve in tracheo-esophageal speech: treatment proposal for a widespread usage

PURPOSE

Aim of this study was to calculate the percentage of the Automatic Speaking Valve (ASV) use in a large cohort of laryngectomized patients with voice prosthesis (VP) and to analyze the main reasons for non-use. Subsequently, a specific rehabilitation training was proposed.

METHODS

One hundred-ten laryngectomized patients with VP were enrolled in the first phase of the study (census). Among them, 57 patients were included in the second phase (intervention), in which a training based on moving phonatory exercises was proposed. Structured questionnaires were used before and after training in order to investigate ASV use rate (days/week and hours/day; reasons for impeding the ASV use), average adhesive life-time during ASV use; hands-free speech duration; skin irritation. Patients also expressed their degree of on a VAS scale from 0 to 100.

RESULTS

In the census phase the percentage of use of ASV (everyday, without problems) was equal to 17.27% (19/110 patients). The main causes of disuse concerned excessive fatigue and poor durability of the adhesives. The analysis of the results pre vs. post-training showed a statistically significant increase (p < 0.05) in all the investigated parameters. Patients reported a good level of treatment compliance (average frequency of performing exercises equal to 4.2 ± 2.5 days/week for 1.4 ± 1.01 h/day) and high degrees of satisfaction. After treatment, the percentage of use of AVS increased by 43% reaching a rate of 60% (66/110 patients).

CONCLUSION

A specific and targeted approach that simulate the phonatory and breathing difficulties of everyday life can increase the ASV usage rate.

Perceptual Evaluation of the Tracheoesophageal Voice: Italian Validation of the Sunderland Tracheoesophageal Perceptual Scale

OBJECTIVES

This study aimed to validate the Sunderland Tracheoesophageal Perceptual Scale (SToPS) in the Italian language by checking the inter- and intra-rater reliability.

STUDY DESIGN

Scale validation METHODS: The validation of the tool involved the following steps: (1) translation and adaptation of the SToPS into Italian language; (2) recruitment of participants (60 laryngectomized patients with a voice prosthesis and 12 health professionals-six speech and language therapists (SLTs) and six ear, nose, and throat surgeons-classified into experienced (Exp) or not at assessing voice; (3) recording of patients' speech samples; (4) perceptual evaluation of recorded speech samples (test and retest) performed by the 12 health professionals; and (5) statistical analysis (quadratic weighted Cohen kappa and weighted kappa of Light coefficients).

RESULTS

When all raters were considered as one group, an agreement ≥0.50 was reached for all parameters. The "ExpSLTs" group rated more reliably than the other groups, achieving a "good" intrarater agreement for 9/10 parameters. Despite the interrater coefficients were lower than the intrarater ones for all rater groups, "ExpSLTs" obtained the best levels of interrater agreement, achieving a level of agreement ≥0.50 for all parameters. Finally, considering intrarater+interrater agreement ("good + good" or "good + moderate"), the "ExpSLTs" group showed the greatest agreement, attaining all parameters that met the criteria for "good" or "moderate" agreement levels.

CONCLUSIONS

The Italian version of SToPS can be considered a reliable tool. As in the original version, expert SLTs are the better judges for tracheoesophageal voice assessment.

Improving Hands-Free Speech Rehabilitation in Laryngectomized Patients with a Moldable Adhesive

OBJECTIVE

This study aims to assess the product performance of a new moldable peristomal adhesive with corresponding heating pad designed to facilitate and improve automatic speaking valve (ASV) fixation for hands-free speech in laryngectomized patients.

METHODS

Twenty laryngectomized patients, all regular adhesive users with prior ASV experience, were included. Study-specific questionnaires were used for data collection at baseline and after two weeks of moldable adhesive use. The primary outcome parameters were adhesive lifetime during hands-free speech, use and duration of hands-free speech, and patient preference. Additional outcome parameters were satisfaction, comfort, fit, and usability.

RESULTS

The moldable adhesive enabled ASV fixation adequate for hands-free speech in the majority of participants. Overall, the moldable adhesive significantly increased adhesive lifetime and duration of hands-free speech compared to participants' baseline adhesives (p < 0.05), regardless of stoma depth, skin irritation, or regular use of hands-free speech at baseline. The participants who preferred the moldable adhesive (55% of participants) experienced a significant increase in the adhesive lifetime (median of 24 h, range 8-144 h) and improved comfort, fit, and ease of speech.

CONCLUSION

The moldable adhesive's lifetime and functional aspects, including the ease of use and custom fit, are encouraging outcomes and enable more laryngectomized patients to use hands-free speech more regularly.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2965-2970, 2023.

Combined treatment of muscle tension dysphonia: voice therapy with instrumental postural rehabilitation

Objectives

This investigation aimed to propose a new rehabilitation technique that combines voice exercises and instrumental postural rehabilitation for patients with muscle tension dysphonia (MTD).

Methods

We enrolled nine dysphonic patients (8 women and 1 man, aged 22-55 years). Voice assessment included strobovideolaryngoscopy, Maximum Phonation Time (MPT), perceptual evaluation by GRBAS scale and patient's self-rating by Italian version of the Voice Handicap Index (VHI). Vestibular function was evaluated by the Bed Side Examination and Video Head Impulse test (VHIT). Postural control was evaluated by Dynamic Posturography (DP) using the Sensory Organization Test (SOT) and analysing the Equilibrium Score (ES) and balance subsystems (somatosensorial, visual, vestibular).

Results

All cases underwent different types of voice exercises combined with balance training based on NeuroCom Balance Master Protocols, once a week for six 35-minutes sessions. After therapy, an improvement in MPT, VHI, GRBAS scores and endoscopic laryngeal features was obtained. DP results at baseline were normal and after therapy we showed a slight improvement of ES (somatosensorial and visual components).

Conclusions

A combined rehabilitation technique for MTD, by improving the attention to postural control, allows for significant improvement in vocal symptoms.

Rehabilitation After Total Laryngectomy: An Integrated Protocol Remotely Delivered During COVID-19

The aim of this paper was to evaluate the results of an integrated treatment delivered remotely to laryngectomized patients with voice prosthesis. Eighteen laryngectomized patients were treated remotely in groups co-led by a speech therapist and a psychologist ("Online Group"). The results were compared with those of 17 patients ("In-Person Group") previously studied. The two groups obtained comparable results on all parameters of the INFVo perceptual rating scale, in the DEP, ANX, PHO and HOS areas of the Symptom Check List-90-Revised questionnaire, and in the areas investigated by the WHOQOL-B questionnaire. The "In-Person Group" obtained statistically better results on the Italian Self-Evaluation of Communication Experiences after Laryngeal Cancer questionnaire. Although the in-person treatment favored the acceptance of the new voice and the development of conversational skills, telerehabilitation guaranteed an adequate level of assistance in terms of voice acquisition, prevention of anxiety and depression, and recovery of a good QoL.

Is There Any Reliable Predictor of Functional Recovery Following Post-thyroidectomy Vocal Fold Paralysis?

BACKGROUND

Predicting definitive outcomes of post-thyroidectomy vocal fold paralysis (VFP) is challenging. We aimed to identify reliable predictors based on intraoperative neuromonitoring (IONM) and flexible fiberoptic laryngostroboscopy (FFL) findings.

METHODS

Among 1172 thyroid operations performed from April to December 2021, all patients who exhibited vocal fold paralysis (VFP) at post-operative laryngoscopy were included. IONM data, including type of loss of signal (LOS), were collected. Patients underwent FFL, with arytenoid motility assessment, at 15, 45 and 120 days post-operatively. Patients were divided into two groups: those who recovered vocal fold motility (VFM) by the 120th post-operative day (recovery group) and those who did not (non-recovery group).

RESULTS

Fifty-nine VFP cases (5.0% of total patients) met the inclusion criteria. Eight patients were lost at follow-up and were excluded. Overall, 9 patients were included in the non-recovery group (0.8% of total patients) and 42 in the recovery group. Among various predictive factors, only arytenoid fixation (AF) at the 15th post-operative day and Type I LOS were significant predictors for no VFM recovery (p = 0.007, RR = 9.739, CI:1.3-72.3 and p = 0.001, RR = 9.25, CI:2.2-39.3 for AF and Type I injury, respectively). The combination of type of LOS and arytenoid motility at the 15th post-op day yielded satisfactory predictive values for the progression of transient VFP to permanent.

CONCLUSIONS

Arytenoid motility at the 15th post-op day and type II LOS are associated with recovery of VFM. Type of LOS and FFL could be included in the follow-up protocols of patients with VFP to reliably predict clinical outcomes.

Optimizing Pulmonary Outcomes After Total Laryngectomy: Crossover Study on New Heat and Moisture Exchangers

OBJECTIVE

To evaluate the effects of new devices-heat and moisture exchangers (HMEs) and adhesives-on pulmonary symptoms, subject adherence, quality of life, dermatologic symptoms, and patient satisfaction after laryngectomy.

STUDY DESIGN

Prospective crossover study.

SETTING

Between December 2020 and April 2021, 40 patients were enrolled who had undergone laryngectomy, routinely used HMEs and adhesive, and were followed in our Department of Otolaryngology-Head and Neck Surgery.

METHODS

Patients were allocated into group A (new products) or group B (usual care) for 6 weeks. Then the 2 groups reversed, and each patient acted as his or her own control. Patients kept a diary and cough tally sheet. At baseline and after each 6-week period, 2 questionnaires were administered: EQ-5D (European Quality of Life-5 Dimensions) and CASA-Q (Cough and Sputum Assessment Questionnaire).

RESULTS

Six weeks of using new products resulted in the following effects for both groups: (1) a significant reduction in daily forced expectoration and dry coughs, (2) a significant improvement in all domains of the CASA-Q, (3) an increase in adherence to HME use, (4) a significant reduction in shortness of breath and skin irritation, and (5) significantly better scores in the anxiety/depression domain of the EQ-5D.

CONCLUSION

Achieving this reduction in patients who were already highly adherent to HME use is clinically relevant and underscores the importance of using better-performing HMEs that can compensate for the humidification deficit. Improving pulmonary symptomatology could reduce patient restrictions in daily life and avoidance of social activity, with a consequent positive effect on quality of life.

Voice Telerehabilitation in Iatrogenic Unilateral Vocal Fold Paralysis: From Necessity to Opportunity in the COVID-19 Time

OBJECTIVE

To evaluate results of telerehabilitation (TR) during the coronavirus disease 2019 pandemic for the treatment of dysphonia caused by permanent post-thyroidectomy unilateral vocal fold paralysis (UVFP).

METHODS

Forty subjects with post-thyroidectomy UVFP (onset <1 month) underwent TR. Videostrobolaryngoscopy, acoustic and perceptual voice analysis and patient self-assessment were carried out in person before, at the end of TR and 6 months later.

RESULTS

Twenty-five subjects spontaneously recovered full vocal fold motility at some time during follow-up, whereas 15 had a permanent UVFP at the end of the follow-up period. These subjects constituted our study group. At the early posttherapy control 10/15 subjects (66.6%) showed a complete glottal closure, while in 5/15 (33.3%) a glottal gap remained (P = 0.03). These results did not change 6 months after TR. At the late posttherapy control the maximum phonation time improved significantly (P = 0.02). Both post-therapy Voice Handicap Index scores were significantly lower than the pre-therapy ones (P = 0.04). Grade, Breathiness, and Asthenia parameters of the Grade-Roughness-Breathiness-Asthenia-Strain scale improved 6 months after TR (P < 0.05). The number of voice signals suitable for acoustic analysis increased significantly after therapy. Finally, 87% of patients were satisfied with TR.

CONCLUSIONS

With careful patient selection, TR may be considered as a promising method for voice therapy in postthyroidectomy UVFP.

Speech perception in noise in children with dyslexia: Does speech sound disorder matter?

The aim of this observational cohort study with a control group is to compare consonant perception skills in quiet and in noise in children with typical language and learning development and in children with dyslexia, with and without Speech Sound Disorder (SSD). Three groups were included: A control group of twenty children with normal reading abilities and typical language development, twelve children with dyslexia and typical language development and thirteen children with dyslexia and SSD. All subjects received a consonant recognition test in three different listening conditions (quiet, + 10 and 0 Signal-to-Noise Ratio). In all test conditions, children with dyslexia and SSD had significantly lower consonant recognition scores than the control group and the children with dyslexia and typical language development (p < .0001). The poorer performances observed in children with dyslexia and SSD may be explained by impaired phonological processing underlying both conditions.

Long-term voice outcomes and quality of life after open partial horizontal laryngectomy type II vs. total laryngectomy: A cross-sectional study

OBJECTIVES

We aim to analyse long-term voice outcomes and quality of life (QoL) in patients undergoing open partial horizontal laryngectomy type II (OPHL type II) and to compare them to those obtained by patients undergoing total laryngectomy (TL) with voice prosthesis (VP).

DESIGN

Cross-sectional cohort study.

SETTING

Patients undergoing surgery for advanced laryngeal cancer, assessed during the usual follow-up consultations at the Phoniatric Unit (February 2020-December 2020).

PARTICIPANTS

Forty-five patients were enrolled and divided into two groups: OPHL group and TL group.

MAIN OUTCOMES MEASURES

Acoustic analysis, maximum phonation time, INFV₀  scale, I-SECEL, UW-QoL-V4 and MDADI questionnaires were used to assess the long-term outcomes.

RESULTS

Voices of patients undergoing OPHL Type II were worse than those of laryngectomised patients with VP. Nevertheless, scores in voice and dysphagia-related QoL were comparable and scores in the social domain of QoL were higher in OPHL group.

CONCLUSIONS

Open partial horizontal laryngectomy Type II allows an acceptable voice recovery and a satisfactory QoL.

A one-year time frame for voice prosthesis management. What should the physician expect? Is it an overrated job?

Management of late complications represents the main reason for reluctance in using voice prosthesis rehabilitation. The aim of this paper is to report our experience by describing the one-year management of a large cohort of patients in order to clarify how demanding management is in terms of burden on clinicians. Between June 2017 and June 2018, each access made at the Otolaryngology Clinic of our Institute for issues related to prosthesis by 70 laryngectomised patients rehabilitated by voice prosthesis was registered in a specific database. A review of the data provided information on the incidence, management and outcomes of adverse events encountered during the selected time frame. In addition, a T test was used to evaluate the differences between irradiated and non-irradiated patients and between primary and secondary tracheo-oesophageal-puncture. Leakage through the prosthesis was the most common cause for access (51.86%). The median number of accesses per patient per year was 3.47. The speech therapist autonomously managed 18.1% of accesses. The median number of accesses per patient per year needing a physician was 2.84. The median lifetime of the prosthesis was 4.85 months. Radiotherapy or modality (primary or secondary) of the puncture did not influence the number of accesses per year or the prosthesis lifetime. This retrospective analysis of results highlighted the most frequent issues and the most effective measures to deal with them, which allowed us to define a systematic algorithm to standardise and ease long-term outpatient management.

Neck complaints before and after uncomplicated thyroidectomy: prevalence, postoperative outcome and relationships with thyroid weight and reflux like symptoms

PURPOSE

The surgical thyroid disease includes upper aerodigestive complaints with not homogenous prevalence and specific features. The purpose was to analyze before and after total thyroidectomy (TT) the prevalence and severity of voice, swallowing, respiratory, and reflux airway symptoms in relation with thyroid weight.

METHODS

A total of 98 consenting patients undergoing TT were enrolled. Preoperatively, 1 and 3 months after TT, patients underwent videolaryngoscopy, subjective evaluation of voice (VIS), swallowing (SIS and EAT-10), respiratory (mMRC), and reflux symptoms (RSI, Gerd-Q). The scores were analyzed based on thyroid weight (<25 gr, 26-50 gr, 51-75 gr, >75 gr) and post-operative score gain was calculated from the score before TT and the follow-up examination.

RESULTS

In total, 40/98 selected cases of uncomplicated TT completed the postoperative evaluation. Endoscopic signs suggestive of reflux disease were observed in 1/40 (2.5%) and 0/19 cases before and after TT respectively. The prevalence of cases with abnormal reflux symptom index decreased significantly after surgery (8/40 vs 1/40) (p < 0.05), similarly occurred for the Gerd-Q (4/40 vs 1/40) (p < 0.05). Three months after TT the voice, swallowing and respiratory scores were significantly lower than the preoperative ones (p < 0.05). The SIS correlated positively with EAT-10 and RSI. After 3 months the postoperative score gain of voice, swallowing, respiratory, and reflux symptoms (Gerd-Q) was statistically higher (p < 0.05) in the cases with heaviest gland.

CONCLUSIONS

The surgical thyroid disease is associated to mild aerodigestive preoperative compressive symptoms, that include respiratory abnormalities and reflux like symptoms, regardless of the gland weight. In absence of endoscopic signs of airway reflux the presence of reflux symptoms suggests an overlapping with thyroid neck complaints. The patients undergoing uncomplicated TT had improvement in compressive symptoms and the greatest improvement is seen in larger goiters.

Patients With Voice Prosthesis Rehabilitation During the COVID-19 Pandemic: Analyzing the Effectiveness of Remote Triage and Management

Objective

To describe a remote approach used with patients with voice prosthesis after laryngectomy during the COVID-19 pandemic and the resulting clinical outcomes in terms of voice prosthesis complications management, oncological monitoring, and psychophysical well-being.

Study Design

Prospective cohort study.

Setting

Otolaryngology Clinic of the University Polyclinic A. Gemelli, IRCCS Foundation.

Subjects and Methods

All patients with voice prosthesis who underwent laryngectomy followed by our institute were offered enrollment. Patients who agreed to participate were interviewed to inquire about the nature of the need and to plan a video call with the appropriate clinician. Before and 1 week after the clinician’s call, patients were tested with the Hospital Anxiety and Depression Scale. Degrees of satisfaction were investigated with a visual analog scale. A comparison between those who accepted and refused telematic support was carried out to identify factors that influence patient interest in teleservice.

Results

Video call service allowed us to reach 37 (50.68%) of 73 patients. In 23 (62.16%) of 37 cases, the video call was sufficient to manage the problem. In the remaining 14 cases (37.83%), an outpatient visit was necessary. Participants who refused telematic support had a significantly shorter time interval from the last ear, nose, and throat visit than patients who accepted (57.95 vs 96.14 days, P = .03). Video-called patients showed significantly decreased levels of anxiety and depression (mean Hospital Anxiety and Depression Scale total score pre– vs post–video call: 13.97 vs. 10.23, P < .0001) and reported high levels of satisfaction about the service.

Conclusion

Remote approach may be a viable support in the management of patients with voice prosthesis rehabilitation.

Proposal for a myofunctional therapy protocol in case of altered lingual frenulum. A pilot study

In this article, the authors propose a specific Myofunctional Therapy Protocol for patients with altered lingual frenulum. In such cases tongue muscles are hypofunctioning and their range of motion is reduced. To compensate for this limitation, dysfunctional lingual motor patterns are established, such as the use of some muscles at the expense of others; this negatively affects the development and functions of the stomatognathic system. The Myofunctional Therapy Protocol presented in this pilot study was developed with the aim of making the muscles of the tongue, the floor of the mouth and the soft palate more coordinated, and increasing muscle contraction strength, in order to produce improvements on the muscle tone, on orofacial and nasal functions and a better wound healing and functional recovery in the case of surgical therapy (frenulotomy).

Integrated rehabilitation after total laryngectomy: a pilot trial study

BACKGROUND

Acquisition and acceptance of the alaryngeal voice, psychological state, and Quality of Life (QoL) of laryngectomized patients.

METHODS

Thirty-two patients who underwent total laryngectomy were included in the study; 17 of them were treated by a psychologist and a speech therapist (experimental group); 15 performed only speech therapy (control group).

RESULTS

The experimental group showed a significant improvement in all parameters of the INFVo scale, in the score of the Environment subscale and in the total score of the I-SECEL (Self-Evaluation of Communication Experiences after Laryngeal Cancer); in the Depression, Obsession-Compulsion and Paranoia areas of the SCL-90-R (Symptom Check List-90-Revised); and in the Social area (REL) of the WHOQOL-B (World Health Organization Quality of Life Scale-Brief).

CONCLUSIONS

An integrated rehabilitative approach to laryngectomized patients improves emotional state and psychosocial aspects and promotes acceptance and use of the new voice and recovery of a better quality of life.

OnabotulinumtoxinA for adductor spasmodic dysphonia (ADSD): Functional results and the role of dosage

OBJECTIVE

To report the results of functional outcome, dose trend and relationship between onabotulinumtoxinA (onabotA) dosage and the severity of disease or time between therapy sessions in patients affected by adductor spasmodic dysphonia (ADSD).

PATIENTS AND METHODS

Thirty-two patients underwent 193 EMG-guided intracordal injections of a starting dose of 2 MU of onabotA. At enrollment, each subject was administered the VHI. The response was evaluated using a subjective rating scale (0-100% of normal phonation).

RESULTS

The quality of voice improved significantly after 1 month and stabilized by 3 months. The percentage of normal voice improved 33.34 ± 11.5% (min 26 - max 68). The functional gain was significantly worse in patients presenting with ADSD associated with dystonias in other body regions (31% vs 45% - p < 0.05). The mean dose employed was 3.64 MU (min 1 - max 6) with a trend of increasing dosages up to the 5th treatment after which the doses stabilized over time. The pre-treatment VHI showed a weakly positive correlation with the cumulative dose at the 5th and 10th injections. Benefit duration and the mean between treatment interval were 103 and 136 days respectively. The correlation between dose and inter-injection time is weakly negative (r = -0.22, p < 0.05), however, this is influenced predominantly by the first-to-second injection. After this initial treatment effect, the correlation becomes weakly positive (r = 0.12).

CONCLUSIONS

Our data confirm the efficacy of onabotA to improve the quality of voice in cases of ADSD. The trial period for optimal dosage lasted up to a mean of five injections. The dosage of onabotA impacted the length of response and was influenced by the severity of ADSD. Finally the efficacy of onabotA did not change significantly after repeated administrations.

A specific protocol of myo-functional therapy in children with Down syndrome. A pilot study

In this article the authors propose a specific myofunctional therapy protocol for children with Down syndrome. For these patients, who usually present with atypical swallowing problems, mouth breathing and lip incompetence, the use of a myofunctional therapy protocol with specific exercises has been shown to improve orofacial and nasal functions. In addition to the functional results, such as the correction of the atypical swallowing, restoration of lip competence, breathing improvement and reduction of nasal rhinorrhea, there were also aesthetic results. This protocol can be useful to improve the quality of life of these patients.

Evaluation of pharyngeal muscle activity through nasopharyngeal surface electromyography in a cohort of dysphagic patients with acute ischaemic stroke

Oro-pharyngeal dysphagia is frequently present during the acute phase of stroke. The aim of the present study was to evaluate whether the recording of surface EMG using a nasopharyngeal (NP) electrode could be applied to evaluation of pharyngeal muscle activity in acute stroke patients and if this neurophysiological measure is related with clinical assessment of swallowing. Patients were examined and clinical severity was assessed with the National Institute of Health Stroke Scale (NIHSS) score; dysphagia was evaluated through bedside screening test using the Gugging Swallowing Scale (GUSS). Extension of the ischaemic lesion was measured by quantitative score, based on CT scan [Alberta Stroke Programme Early CT Score (ASPECTS)]. We analysed 70 patients; 50 were classified as dysphagic (Dys+), and 20 as non-dysphagic (Dys–). Each participant underwent a surface NP EMG recording performed with a NP electrode, made of a Teflon isolated steel catheter, with a length of 16 cm and a tip diameter of 1.5 mm. The electrode was inserted through the nasal cavity, rotated and positioned approximately 3 mm anteroinferior to the salpingo-palatine fold. At least four consecutive swallowing-induced EMG bursts were recorded and analysed for each participant. Swallowing always induced a repetitive, polyphasic burst of activation of the EMG, lasting around 0.25 to 1 sec, with an amplitude of around 100-600mV. Two parameters of the EMG potentials recorded with the NP electrode were analyzed: duration and amplitude. The duration of the EMG burst was increased in Dys+ patients with a statistically significant difference compared to Dys- patients (p < 0.001). The amplitude was slightly reduced in the Dys+ group, but statistically significant differences were not observed (p = 0,775). Nevertheless, the burst amplitude showed a significant inverse correlation with NIHSS [r(48) = –0.31; p < 0.05] and ASPECTS scores [r(48) = –0.27; p < 0.05], meaning that the burst amplitude progressively reduced with an increase of clinical severity (NIHSS) and topographic extension of brain lesions in CT (ASPECTS). These results suggest that NP recordings can give a semi-quantitative measure of swallowing difficulties originating from pharyngeal dysfunction, in fact, electromyographic findings suggest reduced pharyngeal motility.

Music identification skills of children with specific language impairment

BACKGROUND

To date very few studies have investigated the musical skills of children with specific language impairment (SLI). There is growing evidence that SLI affects areas other than language, and it is therefore reasonable to hypothesize that children with this disorder may have difficulties in perceiving musical stimuli appropriately.

AIMS

To compare melody and song identification skills in a group of children with SLI and in a control group of children with typical language development (TD); and to study possible correlations between music identification skills and language abilities in the SLI group.

METHODS & PROCEDURES

This is a prospective case control study. Two groups of children were enrolled: one meeting DSM-IV-TR(®) diagnostic criteria for SLI and the other comprising an age-matched group of children with TD. All children received a melody and a song identification test, together with a test battery assessing receptive and productive language abilities.

OUTCOMES & RESULTS

30 children with SLI (mean age = 56 ± 9 months) and 23 with TD (mean age = 60 ± 10 months) were included. Melody and song identification scores among SLI children were significantly lower than those of TD children, and in both groups song identification scores were significantly higher than melody identification scores. Song identification skills bore a significant correlation to chronological age in both groups (TD: r = 0.529, p = 0.009; SLI: r = 0.506, p = 0.004). Whereas no other variables were found explaining the variability of melody or song identification scores in either group, the correlation between language comprehension and song identification in the SLI group approached significance (r = 0.166, p = 0.076).

CONCLUSIONS & IMPLICATIONS

The poorer music perception skills of SLI children as compared with TD ones suggests that SLI may also affect music perception. Therefore, training programmes that simultaneously stimulate via language and music may prove useful in the rehabilitation of children affected by SLI.

Patients' experiences with HMEs and attachments after total laryngectomy

OBJECTIVES

The short-term and long-term beneficial effects of HME use by laryngectomees are well described in literature. In this study, we document how laryngectomised patients, who previously did not use an HME, get accustomed to the use of HME and attachments.

PARTICIPANTS

Thirty patients, who were at least 3 months post-laryngectomy and previously did not use an HME, were followed for 12 weeks and were asked to complete questionnaires about their experiences with the HME and attachments.

RESULTS

Results show that when patients start using an HME, they report some difficulties with breathing resistance during the first 2 weeks of use. However, after 6 weeks, they have become accustomed to the breathing resistance and after 12 weeks over 96% reports that breathing was equal or less strenuous compared with breathing though an open stoma. Only a small proportion of patients experienced problems with increased coughing when starting HME use.

CONCLUSIONS

This study provides insight in the way laryngectomised patients are experiencing the use of HMEs in the first weeks. These outcomes can contribute to a better knowledge of HME use by healthcare providers and help them to manage patient expectations and improving support to patients in achieving compliant HME use.

Pulmonary Rehabilitation After Total Laryngectomy: A Multicenter Time-Series Clinical Trial Evaluating the Provox XtraHME in HME-Naïve Patients

BACKGROUND

Both the immediate beneficial physiological changes in a laboratory setting and the long-term clinical outcomes of heat and moisture exchanger (HME) use are well described. So far, there has not been any research published that provides detailed insight in the pattern of changes in both respiratory function and patients' experiences with HMEs in the first weeks of use.

METHODS

A multicenter time-series study design with a 2-week double baseline period. All patients used the XtraHME for 12 weeks afterward. Data were collected 2 weeks, 6 weeks, and 12 weeks after the start of HME use.

RESULTS

Data of 30 patients were analyzed. Pulmonary symptoms decreased significantly during the 12 weeks of HME use. After 2 weeks, a significant decrease in daily coughs and daily forced expectorations was seen. The general quality of life showed a significant increase throughout the study. More general physical complaints also significantly decreased with HME use. Patient satisfaction with the HME was high.

CONCLUSIONS

This study shows that there is a significant influence of the XtraHME on pulmonary status that can already be observed after 2 weeks of using the XtraHME and continues to improve further after 6 weeks of XtraHME use.

Vocal fold nodules in school age children: attention deficit hyperactivity disorder as a potential risk factor

OBJECTIVE

To evaluate the presence of symptoms of inattention and hyperactivity/impulsivity in a population of school age children affected by vocal fold nodules.

METHODS

Parents and teachers of 18 children with vocal fold nodules (10 males, eight females; aged between 6 and 12 years) and 20 matched controls without dysphonia and/or vocal fold diseases (11 males, nine females; aged between 6 and 12 years) completed Attention-Deficit/Hyperactivity Disorder (ADHD) rating scale for parents (SDAG [Scala per i Disturbi di Attenzione/Iperattività per Genitori]) and teachers (SDAI [Scala per i Disturbi di Attenzione/Iperattività per Insegnanti) rating scales containing in two subscales items that specifically evaluate the symptoms of ADHD according to the DSM-IV. All children were subjected to videolaryngoscopy.

RESULTS

The group with vocal fold nodules scored significantly higher than the controls; the difference between the two groups was statistically significant for both the subscales of both questionnaires (SDAG and SDAI) (P < 0.05). Four children in the group with vocal fold nodules who scored higher than 14 in at least one subscale were referred for psychiatric evaluation. For two of the children, both male, a diagnosis of combined ADHD was formulated.

CONCLUSIONS

ADHD is a possible risk factor for the development of vocal fold nodules in childhood. SDAG and SDAI rating scales may supplement the diagnostic assessment of children with vocal fold nodules.

Case report of patients treated with an orthodontic and myofunctional protocol

BACKGROUND

Occlusion alterations can be associated to bad habits (such as thumb sucking, oral breathing, atypical swallowing and labial interposition) which can lead to functional anomalies.

CASE REPORT

Three cases are reported with the good results of myofunctional and orthodontic therapy.

CONCLUSION

When there are bad habits, orthodontics should be combined with a myofunctional therapy.

Causal relationship between malocclusion and oral muscles dysfunction: a model of approach

AIM

Bad habits result in altered functions which with time can cause anomalies of the orofacial morphology. To solve these problems, orthodontic treatment can be supported by myofunctional therapy in order to recover the normal functionality of the oral muscles. The aim of this study is to assess the need to treat patients with neuromuscular disorders, from both the occlusion and the muscles condition approach in order to obtain the balance needed for the stability of treatment.

MATERIALS AND METHODS

A sample of 23 patients with atypical swallowing was included in this study, some of them presented thumb sucking and oral breathing. After case history collection, in order to make a correct orthodontic and functional diagnosis, correction of anomalies was carried out since they could compromise the success of the therapy (maxillary contraction, oral breathing, and short lingual fraenum). Then a different therapeutic approach was applied on the basis of the specific dental features.

RESULTS

Both from the diagnostic and therapeutic point of view, important results were achieved especially through muscle analysis with dynamometer and surface electromyography.

CONCLUSION

Orthodontic therapy, in the presence of bad habits, is not enough to solve orthodontic issues, it must be combined with a myofunctional treatment. The success of the therapy is granted only when patients and their family comply with the treatment and all factors which can prevent success of the therapy are removed.

Investigation on the music perception skills of Italian children with cochlear implants

OBJECTIVE

To compare the music perception skills of a group of Italian-speaking children with cochlear implants to those of a group of normal hearing children; to analyze possible correlations between implanted children's musical skills and their demographics, clinical characteristics, phonological perception, and speech recognition and production abilities.

METHODS

18 implanted children aged 5-12 years and a reference group of 23 normal-hearing subjects with typical language development were enrolled. Both groups received a melody identification test and a song (i.e. original version) identification test. The implanted children also received a test battery aimed at assessing speech recognition, speech production and phoneme discrimination.

RESULTS

The implanted children scored significantly worse than the normal hearing subjects in both musical tests. In the cochlear implant group, phoneme discrimination abilities were significantly correlated with both melody and song identification skills, and length of device use was significantly correlated with song identification skills.

CONCLUSIONS

Experience with device use and phonological perception had a moderate-to-strong correlation to implanted children's music perception abilities. In the light of these findings, it is reasonable to assume that a rehabilitation program specifically aimed at improving phonological perception could help pediatric cochlear implant recipients better understand the basic elements of music; moreover, a training aimed at improving the comprehension of the spectral elements of music could enhance implanted children's phonological skills.

Patients treated with orthodontic-myofunctional therapeutic protocol

The aim of this study is to report three cases that needed myofunctional and orthodontic treatment and the good results achieved after the therapy. Orthodontic treatment alone, in presence of bad habits, is not enough to solve the orthodontic issues, so it needs to be combined with myofunctional treatment.

ENT function in a 14-days guinness scuba dive

Scuba diving is known to affect the rhino-pharyngo-tubaric district (RPT unit). The aim of the study was to document function modifications of the RPT unit in 6 Italian divers (3 men and 3 women) who lived for 14 days consecutively at a depth of 8-10 m, breathing air (21% oxygen) at a pressure ranging between 1.8 and 2 ATA. RPT and inner ear assessment were carried out before the dive (TIME 0) and 24 h (TIME 1) after resurfacing, in order to investigate diving-related RPT and inner ear alterations. Physical examination after resurfacing revealed: fungal external otitis, otoscopic findings consistent with middle ear barotraumas and rhinosinusitis. Rhino-manometry showed a remarkable increase in inspiratory nasal flow and a substantial decrease in nasal resistance. No epithelial cell disruption was retrieved comparing pre and post resurfacing samples. Post-diving tubaric dysfunction was found. Pure tone audiometry revealed a bilateral 40 dB HL hearing loss at 4 kHz in 1 diver. Relevant PTA functions did not seem to be affected by the experiment, no remarkable changes were found at the Sensory Organisation Test and at the Motor Control Test. The 14-day underwater period had a positive effect on nasal flows and resistances.

Multidisciplinary approach in the treatment of T1 glottic cancer. The role of patient preference in a homogenous patient population

BACKGROUND AND PURPOSE

To compare oncological outcome and voice quality among a uniform and well-defined subset of patients with T1 glottic carcinoma.

PATIENTS AND METHODS

Patients, affected by laryngeal glottic carcinoma, treated by laser CO2 surgery or radiotherapy, have been analyzed. Overall survival and disease-free survival were calculated. In order to verify differences in functional outcomes and voice quality, all patients were interviewed during their last follow-up visit during 2009 using the VHI (Voice Handicap Index) questionnaire. The data were analyzed using the MedCalc software.

RESULTS

A total of 143 patients were analyzed: 73 underwent surgery and 70 underwent radiotherapy. No statistically significant differences were found between the two groups in terms of overall survival and disease-free survival; dividing patients into stages T1a and T1b also made no difference. In order to evaluate the differences in outcomes for surgery and radiotherapy, patients were interviewed using the VHI questionnaire. Better scores for each category in the VHI were found for patients receiving radiotherapy compared to surgery (physical: p = 0.0023; functional: p < 0.0001; environmental: p < 0.001). The median VHI score for radiotherapy patients was 4, while for surgical patients it was 18 (p < 0.0001).

CONCLUSION

This study confirms the well-known knowledge that results from radiotherapy and surgery in early glottic cancer treatment are equivalent. Furthermore, the role of patient preference in the treatment modality choice and the value of a multidisciplinary approach for a detailed and multi-oriented discussion with the patient are outlined.

Effects of bilateral subthalamic nucleus stimulation and medication on parkinsonian speech impairment

This study aimed to assess quantitatively the effect of bilateral subthalamic nucleus (STN) stimulation and medication on hypokinetic parkinsonian dysarthria. Twelve Italian patients (11 males and 1 female) with idiopathic Parkinson's disease (mean age 60.29+/-7.50 years) and bilateral STN implantation were studied. Neurological assessments and acoustic recordings were performed in four clinical conditions combining stimulation and medication to assess the degree of motor disabilities and speech impairment. Acoustic analysis was performed by means of the Multidimensional Voice Program and the Advanced Motor Speech Profile (Kay Elemetrics, Lincoln Park, NJ). None of the evaluated parameters deteriorated after STN deep brain stimulation. STN stimulation significantly improved motor performances and vocal tremor and provided a major stability to glottal vibration. Effect of stimulation on these parameters was superior to that of levodopa. No significant variations were observed in perceptual evaluation and in acoustic parameters related to prosody, articulation, and intensity after either stimulation or medication. The improvement of acoustic parameters related to glottal vibration and voice tremor was not accompanied by a substantial effect on speech intelligibility. STN stimulation was more effective on global motor limb dysfunctions than on dysarthria, but we did not report negative consequences on speech.

Voice and swallowing changes after thyroidectomy in patients without inferior laryngeal nerve injuries

BACKGROUND

We performed a prospective analysis on voice and swallowing alterations following total thyroidectomy (TT), in the absence of recurrent nerve injury.

METHODS

Patients aged 21 to 65 years undergoing TT, in the absence of laryngeal/pulmonary disease, previous neck surgery, or malignant diseases, were subjected to videostrobolaryngoscopy (VSL), acoustic voice analysis (AVA), and maximum phonation time (MPT) tests preoperatively and 3 months postoperatively. Voice impairment scores (VIS) and swallowing impairment scores (SIS) were obtained preoperatively, and at 1 week, 1 month, and 3 months postoperatively.

RESULTS

Among the 127 selected patients, 39 completed the postoperative evaluation. No recurrent nerve injury was observed during the postoperative VSL in any of the patients. Preoperative and postoperative AVA and MPT scores did not differ significantly. The mean postoperative VIS was significantly higher than the preoperative VIS at 1 week and 1 month after TT (13.7 and 9.6 vs 4.4, respectively; P < .05) but not 3 months after TT (6.7). The mean SIS was higher than the preoperative SIS at 1 week, 1 month, and 3 months after TT (10.3, 6.0, and 2.8 vs 0.5, respectively; P < .05).

CONCLUSIONS

Physicians should inform patients that transient voice and swallowing symptoms may occur following total thyroidectomy, and our data suggest mild symptoms may occur in the majority of operated patients.

Revisited anatomy of the recurrent laryngeal nerves

BACKGROUND

The most frequent postthyroidectomy complication is recurrent laryngeal nerve (RLN) damage with subsequent vocal cord palsy.

METHODS

We have undertaken an intraoperative study aimed to determine the course, distribution, and RLN's anatomical relationships with adjacent structures. Only its identification and its careful exposure allow prevention of iatrogenic injuries.

RESULTS

The RLN was always routinely exposed and identified in 1,543 thyroidectomies. All patients underwent laryngoscopic evaluation before surgery and at the time of discharge. A total of 2,626 RLN were observed. The number of nerves exposed to risk was 673 (25.6%). In the whole series, of 2626 nerves controlled, there were 11 (0.4%) permanent palsies.

CONCLUSIONS

Our study confirms that damage to the RLN or to one of its branches may be avoided only by identification and careful exposure of the nerve itself. An experienced surgeon with good knowledge of the anatomy of the RLN and its anatomical variations is required for uncomplicated treatment of thyroid disease.

Postoperative dysphagia versus neurogenic dysphagia: scintigraphic assessment

In order to differentiate the features of dysphagia that occur after supraglottic horizontal laryngectomy from those that occur during neurologic diseases, we divided 38 subjects into 3 groups and submitted them to oropharyngoesophageal scintigraphy. Group 1 (control group) included 15 healthy volunteeers; group 2 comprised 8 patients who had residual dysphagia at least 1 year after supraglottic laryngectomy; and group 3 included 15 patients with various neurologic and neuromuscular disorders. In group 1, the mean values (+/- 2 SD) of selected semiquantitative parameters were consistent with those reported in the literature for normal subjects. In group 2, oral, pharyngeal, and esophageal transit times were not significantly altered, and moderate tracheobronchial post-deglutitive aspiration was present (maximum value, 6.7%; mean value, 2.04%). The pharyngeal retention index was significantly increased (p = .0003) as compared to normal subjects in all cases (maximum value, 40%; mean value, 23%) and was associated in all cases with slight but consistent post-deglutitive aspiration. In group 3, the oral and esophageal phases were significantly prolonged and the retention indices were significantly increased. Statistical analysis documented a significant increase in oral transit time (p = .003), esophageal transit time (p = .01), oral retention index (p = .006), pharyngeal retention index (p = .0007), and esophageal retention index (p = .009) as compared to normal subjects. The swallowing pattern was also altered by 1) an early loss of the bolus from the oral cavity; 2) bolus fragmentation due to double or triple deglutition, reduced lingual propulsion, or the return of a small part of the bolus into the oral cavity during deglutition; and/or 3) double pharyngeal peaks in the activity-time curves. Tracheobronchial aspiration (maximum value, 90%; mean value, 9.70%) was present in some cases, mainly in patients affected by post-stroke dysphagia. On the basis of the obtained results and considering the low doses of radiation delivered to the patient (0.043 Gy), the limited invasiveness, and the excellent patient tolerance, scintigraphy appears to be clinically valid in the functional study of swallowing and in identifying different deglutition disorders.

[Validity of schintigraphy in the study of neurogenic dysphagia]

The purpose of the present study was to verify the validity and potential application of oropharyngealesophageal scintigraphy in the analysis of neurogenic dysphagia. Scintigraphy was used on 36 patients divided into 2 groups: Group 1 (control) comprised 17 healthy volunteers; Group 2 included 19 patients suffering from various neurological and neuromuscular pathologies (myasthenia gravis, Parkinson's disease, polymyositis, stroke, paralysis of the last cranial nerves). In group 1 scintigraphy provided normal results both for mode of swallowing and transit, and for the values of the various parameters studied. On the other hand, scintigraphy showed that in group 2 all oral, pharyngeal and esophageal phases of swallowing were altered vs the controls with a statistically significant increase in the average values for the oral transit time (OTT) (1.45 sec., p = 0.0005), pharyngeal transit time (OTT) (3.23 sec., p = 0.044), esophageal transit time (ETT) e19.87 sec., p = 0.005) as well as in the corresponding bolus retention indexes ORU (12.95%, p = 0.0003), FIR (15.05%, p = 0.0003) and ERI (28.63%, p = 0.002). Moreover, the quality and means of swallowing also proved altered while tracheobronchial aspiration was only seen in 6 of the 19 patients (maximum value: 90%, average value; 7.66%) with a marked prevalence in the stroke subgroup (4/8). In light of these results and considering the low dose of radiation (0.00043 Gy), the lack of invasiveness and excellent tolerability, scintigraphy has confirmed its clinical validity in the functional, objective and quali-quantitative study of deglutition, even in patients suffering from neurogenic dysphagia.

Scintigraphic assessment of swallowing after horizontal supraglottic laryngectomy

OBJECTIVE

Oral-pharyngo-esophageal scintigraphy (OPES) proved to be able to demonstrate the pharyngeal residue of the radioactive bolus after deglutition and the presence and amount of tracheobronchial aspiration, and to calculate exactly the transit time of the various swallowing phases. The aim of this study was to evaluate the real objective effectiveness of OPES in order to assess the degree of swallowing recovery after horizontal supraglottic laryngectomy (HSL).

METHODS

Nineteen patients entered the study, and 17 healthy subjects were included as control group (group 1). Nineteen patients in whom HSL had been performed at least 1 year before underwent OPES. They were divided into two groups: 13 patients (group 2) in whom the tracheal cannula had been removed and swallowing, phonatory, and respiratory functions were satisfactory and 6 patients (group 3) in whom the tracheostomy tube was still in situ for aspiration of liquids and scarring of the laryngeal vestibule.

RESULTS

Our results showed that in the patients who underwent HSL, all scintigraphic semiquantitative parameters and particularly aspiration percentage values and Pharyngeal Ritention Index (PRI) at 10 and 60 seconds were able to pinpoint some residual "subclinical" alteration and/or minimal surgical sequelae frequently observed after this kind of functional surgery, even though a substantially satisfactory recovery was achieved clinically (group 2 versus group 1). In addition, aspiration amounts in group 3 were markedly higher than those in group 2 (p < .0002), and mean PRI values at 10 and 60 seconds were significantly different (p < .0001) from normal mean control values (group 1).

CONCLUSION

Oral-pharyngo-esophageal scintigraphy may be regarded as a noninvasive, well-tolerated technique, with a radiation body burden within satisfactory limits of radioprotection. It appeared to be also sensitive in assessing the swallowing recovery after HSL.

Purification and characterization of two recombinant human granulocyte colony-stimulating factor glycoforms. Pharmacokinetic and activity studies of single-dose administration in mice

Two recombinant human granulocyte colony-stimulating factor (rhG-CSF) isoforms were isolated from the medium conditioned by an engineered Chinese hamster ovary (CHO) cell line. The two rhG-CSFs were characterized and were found to differ in the carbohydrate structure attached to Thr-133. The glycoform, referred to as Peak 1, contains the O-linked glycan Neu5Ac(alpha 2-3)Gal(beta 1-3)GalNAc; the Peak 2 glycoform contains the O-linked glycan Neu5Ac(alpha 2-3)Gal(beta 1-3)[Neu5Ac(alpha 2-6)]GalNAc. The two glycoforms displayed a similar biological activity in cultures of a mouse 32D C13 cell line and human bone-marrow myelo-monocytic progenitor cells (CFU-GM). In the latter test both glycoforms displayed a higher activity than nonglycosylated rMet-hG-CSF from Escherichia coli. The pharmacokinetic profile and activity of the two rhG-CSF glycoforms and of a mixture of them (Pool) were investigated in mice treated with a single injection of rhG-CSF at the doses of 125 micrograms and 250 micrograms/kg, given via the intravenous (i.v.) and the subcutaneous (s.c.) route, respectively. The plasma concentration profiles obtained were similar for all three substances and did not show any relevant differences in absorption or elimination. The pharmacokinetic parameters indicate that the three substances have similar area under the curve (AUCs), volumes of distribution, and terminal half-life. Furthermore, our data indicate a high bioavailability of the two different glycoforms of rhG-CSF when given to mice via the s.c. route either singularly or as a mixture. Detectable levels of rhG-CSF persisted for more than 8 h in the i.v. and more than 24 h in the s.c. route of administration. All three substances induced early neutrophilia in mice. All rhG-CSF-treated mice developed a two-four-fold rise in neutrophil counts as early as 4 h after the intravenous and 2 h after the subcutaneous injection. Relatively high levels of neutrophils were maintained for at least 8 and 24 h after i.v. and s.c. administration, respectively.

Production and characterisation of a recombinant single-chain anti ErbB2-clavin immunotoxin

We generated a recombinant immunotoxin, named scFv(MGR6)-Cla, composed of the Fv region of an anti ErbB2 monoclonal antibody (MGR6) fused to clavin, a type 1 ribosome-inactivating protein (RIP) from Aspergillus clavatus. ErbB2 is a tyrosine kinase receptor which is overexpressed in most adenocarcinomas; clavin is a 17 kDa ribonuclease which inhibits protein synthesis by inactivating ribosomes. A recombinant DNA construct containing the cDNA of the single chain Fv fragment (scFv) of the MGR6 antibody fused to the clavin cDNA, was expressed at high levels in Escherichia coli as an insoluble fusion protein containing an N-terminal affinity tag of six consecutive histidine residues. Inclusion bodies were denatured and the recombinant fusion protein was purified under denaturing conditions by single-step purification using immobilised metal ion affinity chromatography (IMAC). The purified immunotoxin was renatured at high yield and histidine tag removed by digestion with enterokinase. The purity of the immunotoxin obtained after refolding was confirmed by SDS-PAGE, RP-HPLC, GPC-HPLC and N-terminal sequence analysis. Cell-free protein synthesis inhibition and binding assays showed that both clavin and scFv(MGR6) maintained their properties after refolding.

Overproduction of soluble, extracellular cytotoxin alpha-sarcin in Escherichia coli

The goal of the present study was to establish the condition to obtain preparative amounts of the recombinant cytotoxin alpha-sarcin to be used for immunoconjugate production. alpha-Sarcin cDNA was isolated from Aspergillus giganteus strain MDH 18,894 and its expression in Escherichia coli was attempted by the use of both two-cistron and fusion protein-expression systems. Whereas the former resulted in low intracellular expression level of recombinant alpha-sarcin (r-Sar), the latter allowed high-level expression of the fusion protein in the culture supernatant. A variant form of alpha-sarcin with an additional threonine residue in position 1 (Thr-Sar) was obtained by proteolytic processing of the fusion protein with a final yield after purification of 40 mg/L of culture. Both recombinant proteins r-Sar and Thr-Sar were identical to native a-sarcin with respect to the biochemical properties and to the in vitro biological activity.

[Functional results after cordectomy in laryngeal fissure and in microlaryngoscopy with CO2 laser]

Videolaryngostroboscopy, psychoacoustic and spectrographic analyses were performed to evaluate vocal function in two groups of male patients who had undergone CO2Laser (n = 23) and laryngofissure cordectomy (n = 21) for the treatment of T1a glottic carcinoma. None of the patients used their voices professionally. This study revealed a good correlation between the anatomical features and voice quality. Psychoacoustic and spectrographic analysis showed that the functional results were significantly worse in the patients treated by laryngofissure (p < 0.003). In this group videolaryngostroboscopy showed a higher rate of compensation in both ventricular folds than shown in the laser-treated group (p < 0.02). The authors conclude that the functional results obtained after cordectomy depend on the various combinations of scarring patterns and compensatory hyperkinesia of the ventricular or vocal folds. The better anatomical and functional results achieved following laser cordectomy may be explained by the fact that such procedures result in better, more rapid healing processes.

[Medical-legal evaluation of laryngeal dysfunction to determine disability]

The "New Table indicating the percentage of disability resulting from injury and disabling diseases" approved by the Italian Ministerial Decree dated February 5, 1992 gives a superficial, highly disorganized handling of laryngeal pathologies. This Table only considers phonatory function disorders which are included in a special section; it totally neglects dyspnea and dysphagia of laryngeal origin. This omission cannot even be overcome on the basis of similarities since there are no analogous items listed for reference. In fact, the parameters applied to evaluate dyspnea (CV, VEMS, O2 consumption) apply to ventilation disorders of a pulmonary nature and cannot, therefore, be used in cases of laryngeal dyspnea. Moreover, the Table does not deal with dysphagia at all. In addition, the basis for the Table--the concept of permanent functional damage--is not always adhered to in giving indications for evaluation of phonatory tract damage. The purpose of the present work is not, however, to propose a different way to determine the percentages for the individual items in the tables; rather, the aim is to suggest a different, highly standardized procedure for evaluating laryngeal dysfunctions which is easy to apply.

Immunoconjugates made of an anti-EGF receptor monoclonal antibody and type 1 ribosome-inactivating proteins from Saponaria ocymoides or Vaccaria pyramidata

The present paper describes two immunoconjugates consisting of an anti-epidermal growth factor receptor (EGFR) monoclonal antibody (MAb), named Mint5, covalently linked to the type 1 ribosome-inactivating proteins (RIPs) ocymoidine (Ocy) and pyramidatine (Pyra) from Saponaria ocymoides and Vaccaria pyramidata respectively. Both antibody and toxins are shown to retain their respective biological properties upon chemical conjugation. The immunoconjugates exert specific inhibition of EGFR expressing target cell proliferation and protein synthesis in in vitro assays and also inhibit the growth of grafted human tumour cells in nude mice.

[An oropharyngeal-esophageal scintigraphic study of deglutition]

The aim of the present work was to evaluate whether oro-pharyngeal-esophageal scintigraphy could be used in the dynamic study of the various phases of deglutition and to determine whether it could be applied in otorhinolaryngological practice along with videofluoroscopy and videoendoscopy. The patients were divided into four different groups according to clinical features and the scintigraphic data were analyzed on this basis. Emphasis is placed on the ease of this technique, its tolerability and the low level of radiation. It is pointed out that scintigraphy is quite useful in determinating the exact percentage of the bolus inhaled into the trachealbronchial branch and in measuring the transit time of the various phases of deglutition in detail. In patients affected by upper airway-digestive tract neoplasms it is, therefore, possible to make a semiquantitative evaluation of the results of surgery. Moreover, with this method the results of any rehabilitation can be measured as well as the onset of compensation mechanisms.

Ultrastructural analysis of the chorda tympani nerve in facial paralysis from different etiologies

Twelve chorda tympani segments, removed from as many patients (7 females, 5 males) affected by otosclerosis (3, as controls) and from either idiopathic (4), or traumatic (3) or herpetic (2) facial paralysis, were examined by a transmission electron microscope, in order to verify chordal ultrastructural changes, the gravity of neural damage in the various types of facial paralysis and the role played by chorda tympani on the etiopathogenesis of the idiopathic form. The segments were obtained, while performing a stapedectomy in otosclerotic patients and, in facial palsy, while performing chordal neurotomy or direct decompression of the II and III portio of the VII nerve. The obtained data showed no noteworthy alterations concerning myelinated and unmyelinated nerve fibers and chordae stroma in otosclerotic patients, confirming their reliability as controls. In facial paralysis, both normal ultrastructures and alterations were noticed, even though polymorphic: unravelling and dissociation of the lamellae sheaths up to a point of degeneration with a more or less complete resorption of myelin, accumulation of dense bodies and electron-dense formation, particularly in unmyelinated fibers, vacuoles in myelinated fibers, intracytoplasmic vacuoles in Schwann cells and, in herpetic forms, an occasional presence of inflammatory cells. Such results demonstrate that, in any type of facial paralysis, the ultrastructure of the chorda tympani is constantly involved, probably due to main trunk involvement. In the idiopathic forms the alterations of the chorda look like to degenerative alterations caused by traumato-ischemic events, rather than to cytopathic lesions induced by herpetic virus.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationships between middle latency auditory responses (MLR) and speech discrimination tests in the elderly

74 subjects aged between 60 and 80 years underwent tonal audiometry, speech discrimination tests (phonetically balanced words, normal sentences and compressed sentences) and middle latency responses (MLRs) in order to evaluate possible correlations between behavioural and electrophysiological tests. The results showed that in elderly patients normal sentences are better understood than phonetically balanced words, that performances decrease dramatically when listening conditions became difficult, that auditory threshold seems to influence speech discrimination scores more than does age per se. MLRs seem to be unaffected both by age and by auditory threshold and Pa occurrence is a more reliable parameter than its latency. No correlation between speech discrimination tests and MLRs could be observed; on the contrary in the presence of abnormal speech discrimination tests the MLRs were almost normal and vice versa.

The external ear and the tympanic membrane. A three-dimensional study

The study of the anatomical variations of the external ear is important for the ear surgeon who assesses the middle ear in this way. Furthermore, the design of insert earmoulds for use with either hearing aids or portable radios requires a better knowledge of the shape of the external ear. We studied the external ear structures and the drumhead in 140 cadavers with no previous history of ear pathology. A silicone resin was used, employing a dental impression technique. These permanent impressions were analysed by means of an operating microscope. Different parameters were studied, to determine the average dimensions of the structures. The clinical significance of these results is discussed.

Auditory brainstem responses in the aged

The auditory brainstem responses (ABR) in a group of 74 aged subjects (60-80 years), affected by presbycusis were evaluated for presence of a retrocochlear involvement. The comparison of results from subjects with presbycusis with those from normally-hearing elderly subjects, and young subjects, affected by a cochlear sloping hearing loss, revealed that the latency increase of ABR observed in presbycusis is mainly correlated to the audiometric shape of the hearing loss and not to age per se.

Marijuana smoking as a possible cause of tongue carcinoma in young patients

A case of T1N0M0 carcinoma of the tongue in a male 23-year-old 'regular' marijuana smoker is described. Hemiglossectomy and complete bilateral neck dissection were carried out. No post-operative radiotherapy was given as the resection margins were histologically negative. The tumour recurred one year later in the left cervical region involving the mandible and surgery was again performed, but after three months, neck disease was still evident. The case described case implies the introduction of marijuana as a possible new risk factor in the development of oral cavity tumours. Resection of the primary lesion has to be as wide as possible even in T1 cases, due to the aggressive biological behaviour of such tumours in young subjects.

[Our experience with mandibular fractures]

The authors relate on their own experience concerning etiology, diagnosis and treatment of mandibular fractures. 320 patients (252 males and 68 females) aged between 6 and 82 years with posttraumatic fractures of the mandible, 188 with a single and 132 with multiple fractures, underwent surgical and/or orthopedic treatment. Interosseous wiring and seldom application of metallic plates were the preferred techniques when surgery was performed. Intermaxillary fixation was carried out when the orthopedic treatment was needed. Often both methods were associated. In 10% of the condylar fractures the condyle has been removed. Functional results were excellent and no serious complications could be observed. In 11% of the cases with condylar fractures some limitation of the mandibular movements could be observed, while when condyles were not involved malocclusion could be observed in 3% of the cases. The authors discuss upon etiology, by comparing their own with other experiences, upon diagnosis, which does not seem difficult if adequate radiological investigations are carried out; finally they relate briefly on the advantages and disadvantages of the different surgical and non surgical techniques. Based on their experience they conclude that interosseous wiring and, in selected cases, the application of metallic plates, using an external approach, mostly associated with intermaxillary fixation, represent a safe and adequate treatment for almost every fracture of the mandible.