Managing Esophageal Dysphagia in the Elderly.

Managing Esophageal Dysphagia in the Elderly.

Curr Treat Options Gastroenterol. 2016 Jul 16;

Authors: Schnoll-Sussman F, Katz PO

Abstract
OPINION STATEMENT: Esophageal dysphagia in the elderly is a common clinical problem. Achalasia is a disease in which there is loss of ganglion in the myenteric plexus of the lower esophageal sphincter resulting in incomplete relaxation of that muscle causing a functional obstruction to outflow. Treatment is aimed at reducing sphincter pressure allowing for gravity and the oral portion of the swallow to propel the bolus through the esophagus. Pneumatic dilatation, Heller myotomy (laparoscopic), and the newest procedure peroral endoscopic esophageal myotomy (POEM) are all reasonable options for effective treatment even in the elderly. The choice depends on the decision of the patient, subtype of achalasia, local expertise, and fitness for surgery. Patients over 45 with type 2 achalasia respond exceptionally well to pneumatic dilation, and we recommend consideration of this technique if expertise is available. POEM has achieved excellent short-term results and if local expertise exists, it should be strongly considered especially in patients with type 3 achalasia. Type 1 achalasia may respond slightly better to myotomy, either Heller or POEM. Proton pump inhibitors remain the treatment of choice for GERD and should not be avoided in the elderly for fear of adverse reactions. While none of the FDA warnings nor concern for chronic renal failure or dementia can be dismissed, much more research is needed before we accept that PPIs are truly causal. Surgery for GERD in patients over 65 is as effective as in the young and should be considered in appropriate candidates. Eosinophilic esophagitis, while not common in the elderly, frequently results in clinically important dysphagia. PPIs, topical oral steroids, and dietary interventions are all used individually and together to improve symptoms. PPIs remain first line and are required twice daily for at least 8 weeks as an initial trial. Dilation with either balloons or polyvinyl dilators are highly effective in patients with rings and focal strictures, can be performed safely, and limit the number of medications an elderly patient needs to take.

PMID: 27423892 [PubMed - as supplied by publisher]

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Clinical features of recurrence and osteoporotic changes in benign paroxysmal positional vertigo.

Clinical features of recurrence and osteoporotic changes in benign paroxysmal positional vertigo.

Auris Nasus Larynx. 2016 Jul 13;

Authors: Kim SY, Han SH, Kim YH, Park MH

Abstract
OBJECTIVE: Several previous studies have demonstrated that comorbidities, secondary causes, physical inactivity, and osteoporosis may cause recurrence of benign paroxysmal positional vertigo (BPPV). However, there has also been some controversy over the clinical course(s) and cause(s) of recurrent BPPV (rBPPV). We identified clinical features and associated factors, including decreased bone mineral density, in the recurrence of BPPV.
METHODS: In total, 198 patients with idiopathic BPPV, diagnosed at the otolaryngology clinics of Seoul National University Boramae Medical Center, were enrolled. The medical data of these patients were reviewed retrospectively. Recurrent BPPV was defined as the recurrence of BPPV after at least 1 month of a symptom-free interval following previous successful treatment.
RESULTS: Of the BPPV patients, 67 (33.8%) were classified as rBPPV. Among them, about 16% showed changes in the involved semicircular canals and about 6% showed multiple semicircular canal involvement. rBPPV was more common in patients with comorbidities (P<0.001). Involved semicircular canals showed no statistically significant difference according to the recurrence of BPPV. The mean symptom-free interval of the rBPPV group varied from 1 to 50.2 (mean, 11.6) months; however, 90% of BPPV recurrence occurred within 24 months. Bone mineral density in dual-energy X-ray absorptiometry (DEXA) was markedly decreased in BPPV patients versus normal controls, but there were no significant differences according to BPPV recurrence.
CONCLUSION: The incidence of rBPPV in idiopathic BPPV patients was 33.8% in the present study. The mean period of recurrence after a symptom-free interval was about 11.6 months; most patients showed recurrence within 2 years after the first attack of BPPV. Furthermore, about 16% of patients suffered from rBPPV at a different kind or type of canal from the semicircular canal of the initial BPPV attack. Comorbidities, but not age, gender, or the involved semicircular canal, might be correlated with BPPV recurrence. Decreased bone mineral density did not show significant association with BPPV recurrence, but showed a significant relation with BPPV occurrence.

PMID: 27423924 [PubMed - as supplied by publisher]

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Buried free flaps in head and neck reconstruction: higher risk of free flap failure?

Buried free flaps in head and neck reconstruction: higher risk of free flap failure?

Eur Arch Otorhinolaryngol. 2016 Jul 16;

Authors: Reiter M, Harréus U, Kisser U, Betz CS, Baumeister P

Abstract
Thrombosis of the pedicle is central to free flap failure, and early revision of a compromised flap is the key to successfully salvage a flap. Therefore, the majority of free flaps in reconstructive head and neck surgery are used with the ability to visually examine the flap. Sometimes, due to intra-operative circumstances, it is necessary to use a flap that cannot be monitored externally. These flaps are called buried flaps and have the reputation of being put at risk. The current literature provides only limited data to support or disprove this position. A single institution retrospective review of patient charts between 2007 and 2015 was performed. Flap monitoring was carried out with hand-held Doppler of the pedicle hourly for the first 72 h in all cases. Additional duplex ultrasound was performed in the majority of buried flaps. A total of 437 flaps were included into the study. 37 flaps (7.8 %) were identified to fulfill the criteria of a buried free flap. In total, four patients had complications, three of which required operative reexploration. All interventions were successful, resulting in no flap loss in our series. An accurate operation technique combined with meticulous monitoring protocols supported by duplex ultrasound can result in satisfactory outcome of buried flaps. No enhanced risk of flap loss of buried flaps was found in our cohort.

PMID: 27423643 [PubMed - as supplied by publisher]

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Primary unclassified sarcoma of the parotid gland: a case of diagnostic and therapeutic challenge.

Primary unclassified sarcoma of the parotid gland: a case of diagnostic and therapeutic challenge.

Eur Arch Otorhinolaryngol. 2016 Jul 16;

Authors: Saravakos P, Hartwein J, Fayyazi A

Abstract
Malignant salivary gland sarcomas represent a clinically and histologically diagnostic challenge. Primary unclassified sarcomas of the parotid gland consist a rare salivary gland tumor. We report an unusual case of such a tumor, which occurred in the right parotid gland of a 54-year-old male and presented as an asymptomatic painless mass. The pathologoanatomical examination revealed a rhabdoid large-cell unclassified sarcoma. The patient was treated with superficial parotidectomy and adjuvant radiotherapy. No recurrence was noted in a 10-year follow-up period. Due to the rare occurrence of primary unclassified sarcomas, there is no evidence-based treatment of choice. An optimal approach is best planned in a multidisciplinary setting, taking into consideration the resectability of the tumor, individual patient characteristics, presence of local or distant metastatic activity, local infiltrative behavior and tumor stage. A close follow-up of the patient is strongly recommended.

PMID: 27423642 [PubMed - as supplied by publisher]

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Classification of suprabullar pneumatization according to the skull base attachment of the second lamella.

Classification of suprabullar pneumatization according to the skull base attachment of the second lamella.

Eur Arch Otorhinolaryngol. 2016 Jul 16;

Authors: Tan KL, Lee WH, Kim JW

Abstract
The skull base attachment of the second lamella and suprabullar pneumatization are likely to be consistent landmarks if they are systematically classified. This study aimed to classify the pneumatization pattern according to the second lamella skull base attachment. A total of 202 computed tomography sides of 101 patients who underwent endoscopic sinus surgery were studied. Suprabullar pneumatization was defined as air cells present above the ethmoid bulla between the second and third lamellae. Its pattern was classified according to the air cell number and location as in the frontal cell classification. Type 0 suprabullar pneumatization was defined as no air cells between the ethmoid bulla and skull base; type 1, as a single suprabullar cell; and type 2, as multiple suprabullar cells above the ethmoid bulla. In type 3 pneumatization, the second lamella extended into the frontal sinus forming a frontal bullar cell. Type 2 was the most prevalent (40.1 %), followed by types 1, 3, and 0 (24.3, 23.3, and 12.4 %, respectively). The distance between the second lamella and anterior ethmoid artery was 8.93, 8.30, 8.50, and 11.25 mm in types 0, 1, 2, and 3 pneumatization, respectively. No patients had intraoperative injuries in the anterior ethmoid artery or lateral lamella. The second lamella skull base attachment and suprabullar pneumatization pattern could be systematically classified and be a consistent landmark to identify the frontal sinus opening.

PMID: 27423641 [PubMed - as supplied by publisher]

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Videofluoroscopic evaluation of pharyngeal swallowing dysfunction after esophagectomy with three-field lymph node dissection.

Videofluoroscopic evaluation of pharyngeal swallowing dysfunction after esophagectomy with three-field lymph node dissection.

Eur Arch Otorhinolaryngol. 2016 Jul 16;

Authors: Kumai Y, Samejima Y, Watanabe M, Yumoto E

Abstract
To determine the factors inducing aspiration following esophagectomy with three-field lymph node dissection (3FL) and the effect of the chin-down maneuver combined with supraglottic swallow (CDSS). Retrospective analysis of a consecutive case series. Videofluoroscopic (VF) evaluations of 25 patients who consulted with our out-patient clinic from 2006 to 2012 for swallowing dysfunction following esophagectomy with 3FL without tracheostomy were reviewed. The penetration aspiration scale (PAS) was used for evaluation. The assessment parameters of VF examination were set as follows: laryngeal elevation, peristaltic wave of the pharynx, upper esophageal sphincter opening, and bolus residue in the pyriform sinus and vallecula after swallowing. Associations of the degree of aspiration with these parameters and the effect of CDSS maneuver on PAS were statistically examined. Fourteen patients had swallowing dysfunction with PAS score (1-3). Disturbance of laryngeal elevation was significantly correlated with the degree of aspiration (p = 0.021). Multivariate logistic regression analysis demonstrated that reduced laryngeal elevation significantly enhanced aspiration (p = 0.0026). Sixteen patients had already acquired compensated chin-down swallowing at the time of VF (Group I). Among the remaining nine patients (Group II), the PAS score was significantly (p < 0.05) improved after training in chin-down swallowing. The mean PAS score of the Group I patients was not significantly different from that of the Group II patients after the training in CDSS. Laryngeal aspiration following esophagectomy with 3FL is significantly correlated with reduced laryngeal elevation and can be ameliorated after training in CDSS.
LEVEL OF EVIDENCE IV:

PMID: 27423640 [PubMed - as supplied by publisher]

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Classification of suprabullar pneumatization according to the skull base attachment of the second lamella.

Classification of suprabullar pneumatization according to the skull base attachment of the second lamella.

Eur Arch Otorhinolaryngol. 2016 Jul 16;

Authors: Tan KL, Lee WH, Kim JW

Abstract
The skull base attachment of the second lamella and suprabullar pneumatization are likely to be consistent landmarks if they are systematically classified. This study aimed to classify the pneumatization pattern according to the second lamella skull base attachment. A total of 202 computed tomography sides of 101 patients who underwent endoscopic sinus surgery were studied. Suprabullar pneumatization was defined as air cells present above the ethmoid bulla between the second and third lamellae. Its pattern was classified according to the air cell number and location as in the frontal cell classification. Type 0 suprabullar pneumatization was defined as no air cells between the ethmoid bulla and skull base; type 1, as a single suprabullar cell; and type 2, as multiple suprabullar cells above the ethmoid bulla. In type 3 pneumatization, the second lamella extended into the frontal sinus forming a frontal bullar cell. Type 2 was the most prevalent (40.1 %), followed by types 1, 3, and 0 (24.3, 23.3, and 12.4 %, respectively). The distance between the second lamella and anterior ethmoid artery was 8.93, 8.30, 8.50, and 11.25 mm in types 0, 1, 2, and 3 pneumatization, respectively. No patients had intraoperative injuries in the anterior ethmoid artery or lateral lamella. The second lamella skull base attachment and suprabullar pneumatization pattern could be systematically classified and be a consistent landmark to identify the frontal sinus opening.

PMID: 27423641 [PubMed - as supplied by publisher]

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Review of hematological indices of cancer patients receiving combined chemotherapy & radiotherapy or receiving radiotherapy alone.

Review of hematological indices of cancer patients receiving combined chemotherapy & radiotherapy or receiving radiotherapy alone.

Crit Rev Oncol Hematol. 2016 Jun 29;

Authors: Shahid S

Abstract
We observed the outcomes of chemotherapy with radiotherapy (CR) or radiotherapy (RT) alone for cancer patients of larynx, breast, blood and brain origins through complete blood count (CBC). Following were more depressed in CR patients: mean corpuscular hemoglobin-MCH & lymphocytes-LYM, hematocrit, mean corpuscular hemoglobin concentration-MCHC, hemoglobin-HB and red blood cells-RBC. In RT patients, following were more depressed: LYM, MCH and MCHC. Overall, in all cancer patients, the lymphocytes were depressed 52%. There existed a significant difference between white blood cells and RBC in both CR and RT patients. A significant moderate negative correlation is found in HB with the dose range 30-78 (Gray) given to the CR cancer patients. More number of CBC parameters affected in patients treated with CR and RT; but in less percentage as compared to patients who treated with RT alone. The cancer patients suffered from anemia along with immune modulations from the treatments.

PMID: 27423975 [PubMed - as supplied by publisher]

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Clinical features of recurrence and osteoporotic changes in benign paroxysmal positional vertigo.

Clinical features of recurrence and osteoporotic changes in benign paroxysmal positional vertigo.

Auris Nasus Larynx. 2016 Jul 13;

Authors: Kim SY, Han SH, Kim YH, Park MH

Abstract
OBJECTIVE: Several previous studies have demonstrated that comorbidities, secondary causes, physical inactivity, and osteoporosis may cause recurrence of benign paroxysmal positional vertigo (BPPV). However, there has also been some controversy over the clinical course(s) and cause(s) of recurrent BPPV (rBPPV). We identified clinical features and associated factors, including decreased bone mineral density, in the recurrence of BPPV.
METHODS: In total, 198 patients with idiopathic BPPV, diagnosed at the otolaryngology clinics of Seoul National University Boramae Medical Center, were enrolled. The medical data of these patients were reviewed retrospectively. Recurrent BPPV was defined as the recurrence of BPPV after at least 1 month of a symptom-free interval following previous successful treatment.
RESULTS: Of the BPPV patients, 67 (33.8%) were classified as rBPPV. Among them, about 16% showed changes in the involved semicircular canals and about 6% showed multiple semicircular canal involvement. rBPPV was more common in patients with comorbidities (P<0.001). Involved semicircular canals showed no statistically significant difference according to the recurrence of BPPV. The mean symptom-free interval of the rBPPV group varied from 1 to 50.2 (mean, 11.6) months; however, 90% of BPPV recurrence occurred within 24 months. Bone mineral density in dual-energy X-ray absorptiometry (DEXA) was markedly decreased in BPPV patients versus normal controls, but there were no significant differences according to BPPV recurrence.
CONCLUSION: The incidence of rBPPV in idiopathic BPPV patients was 33.8% in the present study. The mean period of recurrence after a symptom-free interval was about 11.6 months; most patients showed recurrence within 2 years after the first attack of BPPV. Furthermore, about 16% of patients suffered from rBPPV at a different kind or type of canal from the semicircular canal of the initial BPPV attack. Comorbidities, but not age, gender, or the involved semicircular canal, might be correlated with BPPV recurrence. Decreased bone mineral density did not show significant association with BPPV recurrence, but showed a significant relation with BPPV occurrence.

PMID: 27423924 [PubMed - as supplied by publisher]

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Acoustic Analysis Before and After Voice Therapy for Laryngeal Pathology.

Acoustic Analysis Before and After Voice Therapy for Laryngeal Pathology.

Kathmandu Univ Med J (KUMJ). 2015 Oct-Dec;13(52):323-327

Authors: Chhetri SS, Gautam R

Abstract
Background Voice problems caused by pathologies in vocal folds are well known. Some types of laryngeal pathologies have certain acoustic characteristics. Objective evaluation helps characterize the voice and voice problems providing supporting evidences, severity of disorders. It helps assess the response to the treatment and measures the outcomes. Objective The objective of the study is to determine the effectiveness of the voice therapy and quantify the results objectively by voice parameters. Method Study includes 61 patients who presented with different types of laryngeal pathologies. Acoustic analyses and voice assessment was done with Dr. Speech ver 4 (Tiger DRS Inc.). Acoustic parameters including fundamental frequency, jitters, shimmers, Harmonic to noise ratio (HNR), Normalized noise energy (NNE) were analyzed before and after voice therapy. Result Bilateral vocal nodules were the most common pathologies comprising 44.26%. All acoustic parameters showed a significant difference after the therapy (p<0.05) except for NNE. Dysphonia due to vocal fold polyp showed no improvement even after voice therapy (p>0.05). Conclusion Acoustic analysis provides an objective, recordable data regarding the voice parameters and its pathologies. Though, few pathology require alternative therapy rather than voice therapy, overall it has a good effect on glottic closure. As the voice therapy can improve the different indices of voice, it can be viewed as imperative part of treatment and to monitor progression.

PMID: 27423282 [PubMed - as supplied by publisher]

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