Comparative study between intra-anal sponge and needle electrode for electromyographic evaluation of constipated patients

PURPOSE: The aim of this study was to compare the intra-anal sponge electrode with the conventional needle electrode for electromyography of the pelvic floor in constipated patients. MATERIALS AND METHODS: Forty consecutive patients (27 females) with a mean age of 64.3 (range, 15-87) years who had chronic constipation were prospectively evaluated for electromyographic evidence of nonrelaxation or paradoxical contraction of the puborectalis and external anal sphincter during simulated defecation. The soft intra-anal sponge electrode and then the concentric needle electrode were used in each patient as an internal control. Furthermore, in all patients, cinedefecography was used as an independent standard to confirm the diagnosis. Agreement was calculated using the kappa statistic. RESULTS: Confirmation of needle electromyography was noted in 19 of 20 patients (95 percent) who had sponge electromyographic evidence of paradoxical activity. Similarly, concurrence was noted in 19 of 20 patients (95 percent) with normal relaxation of the puborectalis observed with the sponge electrode. Agreement between needle and sponge electromyography was very good (kappa = 0.9), between needle electromyography and cinedefecography was fair (kappa = 0.4), and between sponge electromyography and cinedefecography was moderate (kappa = 0.5). Furthermore, needle electromyography was more painful in all patients compared with sponge electromyography. CONCLUSION: The soft sponge surface intra-anal electrode is an excellent alternative to the needle electrode for assessment of puborectalis activity in constipated patients. Sponge electromyography has the advantage of being as accurate as, but less painful than, needle electromyography.     

Complete eradication of Aspergillus fumigatus from the lung in an immunocompromised patient by oral itraconazole

Fifty-three deaf subjects with a history of prelingual profound bilateral sensorineural hearing loss, similar language habilitation with hearing aids, and normal velopharyngeal structures underwent a study protocol including speech evaluation, behavioral pure-tone audiometry, videonasopharyngoscopy, multiview videofluoroscopy, and electromyography of the velopharyngeal muscles. Subjects were divided into two groups: the first group included 13 subjects with normal nasal resonance or mild hypernasality (four normals and nine with mild hypernasality); the second group had subjects with severe hypernasality and severe articulation deficits. Pure-tone thresholds, velopharyngeal closure patterns, and electromyographic activity of velopharyngeal muscles were similar for both groups of subjects. However, in subjects with severe hypernasality, despite normal muscle activity as observed by electromyography, velopharyngeal valving activity lacked rhythm and strength during speech. It is concluded that deaf subjects may present a functional disorder of the velopharyngeal sphincter related to absence of auditory regulation during phonation. Visual biofeedback using videonasopharyngoscopy may be useful for treating this disorder.     

Vertical infraclavicular brachial-plexus blockade. A clinical study of reliability of a new method for plexus anesthesia of the upper extremity

BACKGROUND: Historically, total laryngectomy with voice-prosthesis insertion and near-total laryngectomy were the surgical options advocated for advanced supraglottic and transglottic tumors classified as T3-T4. METHODS: The present retrospective study reviewed our experience with neo-adjuvant chemotherapy and supracricoid partial laryngectomy with cricohyoidopexy (SCPL-CHP) in a series of 60 patients with an isolated, untreated, advanced supraglottic/transglottic invasive squamous cell carcinoma classified as T3-T4. RESULTS: The Kaplan-Meier 5-year actuarial survival, local failure, nodal failure, and distant metastasis estimates were 72.7%, 8.3%, 9.2%, and 9.8%, respectively. Survival was significantly reduced in patients with nodal failure (p = .001) and distant metastasis (p = .007). Overall, a 91.7% laryngeal preservation rate and a 98.3% local control rate were achieved. CONCLUSION: Our report was a retrospective analysis and did not present a control group exclusively managed with SCPL-CHP. Therefore, we were unable to demonstrate that the use of neo-adjuvant chemotherapy prior to SCPL-CHP allowed for an increase in local control, laryngeal preservation, and survival. However, the use of neo-adjuvant chemotherapy allowed for remobilization of a fixed arytenoid cartilage in 10 patients who thus became amenable to SCPL-CHP. The key role of neo-adjuvant chemotherapy in this series was as a prognostic indicator for suitability for SCPL-CHP in the case of supraglottic-transglottic tumor with arytenoid cartilage fixation. Our data also supported the notion that SCPL-CHP is a valid alternative to total laryngectomy with voice prosthesis insertion and near-total laryngectomy in selected patients with a previously untreated supraglottic/transglottic invasive squamous cell carcinoma classified as T3-T4. Furthermore, the successful use (in terms of surgical outcome, laryngeal preservation, and survival) of SCPL-CHP after neo-adjuvant chemotherapy suggested that laryngeal organ-preservation strategies, in advanced endolaryngeal transglottic and/or supraglottic invasive squamous cell carcinoma, should not be limited to the use of laryngeal radiotherapy after neo-adjuvant chemotherapy.     

Antimicrobial peptides: an emerging concept in cutaneous biology

In muscle tension dysphonia (MTD) excessive tension of both the internal and external laryngeal muscles is observed. In the present pilot study, 9 pairs of surface electrodes were used to determine the electromyographic (EMG) characteristics of different muscles in the perioral area and anterior neck before and during phonation. Eleven patients with MTD and 5 normal speakers were included within the study. The results show a 6-8-fold increase of EMG activity and/or an alternation of the EMG activity level in the perioral and supralaryngeal muscles before and during phonation in most of the patients with MTD. It is not clear whether these muscles are activated as compensation for excessive tension of internal laryngeal muscles, or whether they are responsible for some of the voice disorders.     

Multiple osteocartilaginous exostosis. A follow-up study

In order to evaluate the results of voice and speech rehabilitation after total laryngectomy some acoustic parameters (fundamental frequency, waveform perturbation) were examined in 18 total laryngectomy patients. Eight of these subjects had previously been surgically rehabilitated with a tracheal-esophageal phonatory valve while 10 had been submitted to esophageal speech rehabilitation. Analysis of results has shown that tracheal-esophageal voices are more likely to provide a stable fundamental frequency; there is also a tendency toward more clearly defined harmonics; jitter and shimmer are more similar to the values of normal subjects compared with those observed in esophageal speech. Such results seem to depend on a more regular vibration pattern in the pharyngeal-esophageal segment, due to the more efficient expiratory flow in tracheal-esophageal speech. Moreover we were able to demonstrate a correlation between the objective parameters evaluated and the subjective score on speech acceptability.     

A videofluoroscopic comparison of straw and cup drinking: the potential influence on dental erosion

Tracheostoma valves are often required in the rehabilitation process of speech after total laryngectomy. Patients are thus able to speak without using their hands to close the tracheostoma. The improved Groningen tracheostoma valve consists of a "cough" valve with an integrated ("speech") valve, which closes for phonation. The cough valve opens as the result of pressure produced by the lungs during a cough. The speech valve closes by the airflow produced by the lungs, thus directing air from the lungs into the esophagus at a deliberately chosen moment. An experimental setup with a computer-based acquisition program was developed to measure the pressure at which the cough valve opened and the flow at which the speech valve closed. In addition, the airflow resistance coefficient of the tracheostoma valve was defined and measured with an open speech valve. Both dry air from a cylinder and humid expired air were used. Results showed a pressure range of 1-7 kPa to open the cough valve and a flow range of 1.2-2.7 l/s to close the speech valve. These values were readily attained during speech, while the flow range occurred above values reached in quiet breathing. The device appeared to function well in physiological ranges and was optimally adjustable to an individual setting. No significant differences were measured between air from a cylinder and humid expired air. Findings showed that methods used to obtain results could be employed as a reference method for comparing aerodynamic characteristics of tracheostoma valves.     

Cricohyoidopexy in selected infrahyoid epiglottic carcinomas presenting with pathological preepiglottic space invasion

Nineteen patients who presented with infrahyoid epiglottic squamous cell carcinoma with gross pathological preepiglottic space invasion, not amenable to a partial horizontal supraglottic laryngectomy, were offered a supracricoid partial laryngectomy with a cricohyoidopexy technique; this was an attempt to preserve physiological phonation, respiration, and deglutition while achieving the same local control rate as with a total laryngectomy. Preoperative chemotherapy and bilateral jugulocarotid lymph node dissection were performed in all cases. Patients were monitored for at least 5 years or until death. No patients were unavailable for follow-up. The 5-year actuarial survival (Kaplan-Meier method) was 84.2%. Local recurrence, nodal recurrence, and distant metastasis occurred once in our series, while six patients presented with a second primary tumor. We present, analyze, and compare functional results with those of the previously reported series. Our experience with the supracricoid partial laryngectomy with a cricohyoidopexy, in the face of selected infrahyoid epiglottic squamous cell carcinoma invading the preepiglottic space, not amenable to a partial horizontal supraglottic laryngectomy, suggested that a total laryngectomy might be avoided without decreasing the cure rate.     

Macrolides in the management of streptococcal pharyngitis/tonsillitis

OBJECTIVE: This study aimed to compare the hearing changes in the long term after vestibular neurectomy, endolymphatic mastoid shunt, and medical treatment in classic Meniere's disease. STUDY DESIGN: A retrospective case review was conducted based on audiologic follow-up between 5 and 21 years. SETTING: The study was performed at two centers in Bari University Hospital, one performing vestibular neurectomy as the first surgical procedure for Meinere's disease and the other, endolymphatic mastoid shunt. PATIENTS AND INTERVENTIONS: Of 68 patients with intractable idiopathic Meniere's disease, 29 underwent middle fossa vestibular neurectomy, and 17 had endolymphatic mastoid shunt; 22 were offered surgery but declined. MAIN OUTCOME MEASURES: Outcome measures were puretone average (PTA), speech reception threshold, and speech discrimination score before and after treatment. RESULTS: PTA declined by an average of 9.3 dB in neurectomy patients, 13.3 dB in patients undergoing endolymphatic mastoid shunt, and 18.1 dB in patients who were offered surgery but declined. Patients were subdivided into two cohorts based on their preoperative or initial PTA. In the patients who had PTA scores worse than 50 dB initially, the PTA declined an average of 4.3 dB in the vestibular neurectomy group, 11.5 dB in the endolymphatic sac group, and 4 dB in the nonsurgical group. In the patients with PTA > or = 50 dB initially, the PTA declined an average of of 25.3 dB in the vestibular neurectomy group, 16.1 in the endolymphatic sac group, and 26.2 dB in the nonsurgical group. Although shunt patients with good hearing initially deteriorated less than neurectomy patients and less than patients who declined surgery, the difference was not significant. CONCLUSIONS: These results indicate that patients with poor hearing stabilized, while patients with good hearing continued to deteriorate. The same conditions were observed in the patients who had surgery and those who were offered surgery but declined.     

Vaccinal strain of Brucella abortus 19-BA in ticks (Argasidae) infected by feeding

Bladder and urethral function was studied in 21 patients with lesions of the cauda equina or conus medullaris using gas cystometry, integrated sphincter electromyography, uroflowmetry and computer assisted measurement of detrusor and urethral innervation. An areflexic cystometrogram, impaired electromyographic sphincter activity and delayed reflex-evoked potentials from stimulation of the detrusor muscle and urethra were the most consistent indicators of lesions of the conus medullaris and/oather than the ice water test is suggested.     

Tongue reconstruction: outcomes with the rectus abdominis flap

Advanced carcinoma of the oral cavity is a devastating disease, with the potential for severe speech and swallowing dysfunction. This is a retrospective review documenting the outcome of 14 patients who underwent resection of at least 75 percent of their tongue with preservation of the larynx and an intact mandible. Reconstruction was accomplished with rectus abdominis free tissue transfer. There were seven male and seven female patients between the ages of 25 and 77 years (mean, 55 years) who underwent total (eight patients) or subtotal (six patients) glossectomy and reconstruction. Decannulation of the tracheostomy tube was performed in 12 patients (86 percent) at an average of 3.5 months postoperatively. One patient required interval laryngectomy for intractable aspiration 1 month postoperatively. Independent evaluation of speech, articulation, and deglutition was performed. Fifty percent of patients achieved oral intake of pureed foods or better. Sixty-four percent had acceptable speech. Reconstruction with rectus abdominis free tissue transfer is a viable method for rehabilitation, improving quality of life after total or subtotal glossectomy with laryngeal preservation.     

Videostroboscopy of the pharyngoesophageal segment in total laryngectomees

OBJECTIVES: The reconstructed pharyngoesophageal segment (PES) serves as the neoglottis following total laryngectomy, as it provides the source of vibration for production of tracheoesophageal puncture (TEP) voice. To date, little information exists regarding the vibratory characteristics of the PES. The purpose of this investigation was to study the anatomy and physiology of the PES using videostroboscopy. STUDY DESIGN: Prospective study investigating the anatomy and physiology of the PES in 34 laryngectomees who used TEP speech as their primary form of communication. MATERIALS AND METHODS: Videostroboscopy and voice recordings were graded by three trained, blinded judges using a seven-point scale. RESULTS: The patients demonstrated differences that allowed for separation of patients into two main groups: "poor" and "effective" TEP speakers. The voice quality differences were explained by anatomic and physiologic characteristics of the PES. Redundant, thick, and dyssynchronous PES features were observed in patients with poor TEP speech skills; the effective speakers exhibited less redundant, thinner mucosa and more synchronous vibratory patterns. Moreover, the latter subgroup consistently demonstrated a greater degree of volitional PES control and less spasmodic activity than their poorly speaking counterparts. Length of the PES opening (measured in the horizontal plane) as well as amount and consistency of secretions did not appear to influence TEP speech or voice proficiency. CONCLUSION: Videostroboscopy in laryngectomees is a noninvasive, inexpensive, easily performed procedure that may contribute valuable information regarding the anatomy and physiology of the PES, especially in patients who experience difficulties achieving satisfactory TEP voice and speech production.     

The electrodiagnostic examination with myopathies

The values and limitations of the electrodiagnostic examination in assessing patients with possible myopathies are discussed. Limitations include: (1) no findings are specific for muscle disease; (2) the particular changes may be quite diverse; (3) myopathies of different etiologies may have the same presentation, whereas the same myopathy may have different presentations at different times; (4) a specific myopathy cannot be diagnosed; and (5) the ability to diagnose myopathy may be seriously compromised by the presence of certain disorders. Benefits include: (1) widespread muscle sampling; (2) help in determining most appropriate muscle for biopsy; (3) ascertaining, to some extent, the type of myopathy present, depending on the particular findings; (4) distinguishing entities often confused clinically with myopathies; (5) recognizing abnormalities (e.g., myotonic discharges) otherwise undetectable. Both the clinical and electrodiagnostic presentations of myopathies are discussed. Regarding the latter, the potential or actual changes seen with each component of the electrodiagnostic assessment (nerve conduction studies, late responses, repetitive stimulation studies, needle electrode examination, quantitative electromyographic studies) is reviewed.     

The timing of congenital brachial plexus injury: a study of electromyography findings in the newborn piglet

OBJECTIVE: Permanent congenital brachial plexus palsy is a recognized serious complication associated with shoulder dystocia. The timing and etiology of this injury remains controversial. Previous authorities have used adult-derived, non-brachial plexus data to extrapolate the anticipated timing for electromyographic denervation changes to date such injuries in the newborn. With use of a domestic swine model, this investigation tests the hypothesis that electromyographic evidence of brachial plexus denervation in the newborn is temporally different than that in the adult. STUDY DESIGN: Five healthy 2-day-old and two adult pigs underwent unilateral sharp transection of the brachial plexus. Daily electromyographic studies were performed in brachial plexus innervated muscle groups on the involved and contralateral (control) front limbs. Postmortem measurements of the transected nerve segments were obtained in one piglet and one adult animal. Representative hard copy recordings of individual electromyographic studies were collected. RESULTS: Immediately after surgical transection of the brachial plexus, no electromyographic evidence of denervation was observed. Uniformly in the newborn piglets, at 24 hours after transection, denervation in the form of fibrillation potentials, positive sharp waves, and complex repetitive discharges was seen. Serial testing demonstrated proximal to distal gradients of denervation over the next 24 to 48 hours. A delay in electromyographic evidence of denervation was observed in the two adult pigs until days 5 and 8, respectively. Control limb studies remained normal throughout the study period. Nerve length measurements for individual muscle groups were as follows for the adult and newborn pigs, respectively: deltoid 11.4 cm, 2.5 cm; cleidobrachialis 16.0 cm, 4.0 cm; triceps 15.5 cm, 4.5 cm; forelimb flexors 26.0 cm, 6.5 cm; and extensor carpi radialis 31.0 cm, 9.0 cm. CONCLUSION: Electromyographic evidence of brachial plexus denervation after surgical transection differs between the newborn and the adult pig. Consistent with wallerian degeneration, a correlation exists between length of the distal nerve segment and timing for electromyographic signs of denervation. These findings suggest it would be inappropriate to extrapolate the anticipated timing for electromyographic changes in the newborn on the basis of previously established adult non-brachial plexus data.     

CT-angiography as a non-invasive method for the evaluation of the patency of TIPSS (transjugular intrahepatic portasystemic shunt)

PURPOSE: To evaluate the feasibility of determining patency of the transjugular intrahepatic portosystemic shunt (TIPSS) by non-invasive CT angiography (CTA). MATERIALS AND METHODS: (1) Non-enhanced scanning of the shunt. (2) Bolus tracking by injecting 20 ml of non-ionic contrast material through a cubital vein access to determine the time to maximal shunt enhancement. (3) Contrast-enhanced spiral CT study applying a delay according to the time to peak of the shunt, 3 mm collimation, 5 mm table feed and 3 mm reconstruction interval. (4) 3D and multiplanar reconstructions. (5) Evaluation of the questions: intrahepatic shunt patent or not; evidence of intimal hyperplasia; evidence of stenosis and potential location. (6) Transjugular portography via the stent. (7) Comparison of angiographic findings and CT morphology. RESULTS: Eight patients had inconspicuous CTA. Four of them had a normal shunt at angiography, four had slight intimal hyperplasia. No intervention was necessary in these patients. CTA of three patients showed intimal hyperplasia (lumen reduction between 10% and 50%). The diagnosis was angiographically confirmed in all cases. Due to a high portosystemic gradient intervention was required in all. In five patients CTA and angiography showed a stenosis (reduction of shunt lumen > 50%). All required a revision including stent placement or PTA of the shunt tract. Four shunts were occluded; all occlusions were shown both in CTA and angiography. CONCLUSIONS: None of the shunts with normal findings at CTA required revision. All shunts conspicuous on CTA resulted in revision. In this study, CTA turned out to be an accurate, non-invasive method to evaluate the patency of TIPSS.     

Inhibitory effects of inhaled flunisolide on inflammatory functions of alveolar macrophages

Reconstruction after total laryngectomy ideally includes restoration of voice with protected swallowing. Local flaps and tracheo-esophageal puncture with a prosthesis are widely used to accomplish this. Persistent problems, perhaps inherent to this solution, have led to the recent use of a tubed, folded radial forearm free flap for postlaryngectomy reconstruction. This flap has produced a good voice with low phonation pressures and minimal aspiration in 7 patients. A new configuration for this flap is described and 3 patients reported. Our flap's advantages include a simplified pedicle path, ease of construction, remote microanastomosis, and safer revision. Both patients with surviving flaps rapidly developed a good voice after reconstruction. Mild aspiration in 1 delayed oral intake and forced a successful revision. Our reconfigured flap may have some technical advantages, survives to length, and restores a good voice without significant aspiration. This and its simple care make it popular with patients. Development of this flap holds promise of more complete reconstruction after total laryngectomy.     

Effect of muscle relaxation splint therapy on the electromyographic activities of masseter and anterior temporalis muscles

The purpose of this study was to compare the effectiveness of splint therapy on the electromyographic activity of masticatory muscles (anterior temporalis and masseter) before and after the application of a muscle relaxation splint. Electromyography recordings from the masseter and anterior temporalis muscles were analyzed quantitatively during maximal biting in the intercuspal position both before and after treatment without a splint. Fourteen patients whose chief complaint was masticatory muscle pain were selected for the study. After the initial evaluations muscle relaxation splints were applied, and the patients were instructed to use the splints for 6 weeks. Surface electromyographic recordings were taken from each patient before the beginning of clinical therapy and after 6 weeks of wearing the splints. The data obtained were analyzed through paired sample t tests and Wilcoxon's signed rank tests. The results of the study were as follows: (1) the electromyographic activity of the two muscles during maximal biting was not markedly changed after the muscle relaxation splint was used; and (2) the changes observed in electromyographic activity of the involved and noninvolved sides were insignificant as well.     

Comparison of total intravenous, balanced inhalational and combined intravenous-inhalational anaesthesia for tympanoplasty, septorhinoplasty and adenotonsillectomy

The induction of complex bilateral leg muscle activation combined with coordinated stepping movements is demonstrated in patients with complete paraplegia. This was achieved by partially unloading patients who were on a moving treadmill. In comparison to healthy subjects, the paraplegic patients displayed a less dynamic mode of muscle activation. In all other respects leg muscle electromyographic activity was modulated in a similar manner to that in healthy subjects. However, the level of electromyographic activity in the gastrocnemius (the main antigravity muscle during gait) was considerably lower in the patients. During the course of a daily locomotor training program, the amplitude of gastrocnemius electromyographic activity increased significantly during the stance phase, while inappropriate tibialis anterior activation decreased. Incompletely paraplegic patients benefited from the training with respect to performance of unsupported stepping movements on solid ground. In about half of completely paraplegic patients with low muscle tone, no beneficial effect of the training was seen. This may be due to an inhibitory effect on spinal neuronal activity by drugs patients were taking (e.g., prazosin, clonidine, cannabinoids). In this study intrathecal application of clonidine drastically reduced, while epinephrine enhanced locomotor muscle electromyographic activity. The results of this study promise to be significant in the treatment of paraplegic patients.     

Stuttering: discoordination of phonation with articulation and respiration

Complexity of phonatory and respiratory adjustments was systematically simplified in 30 adult stutterers under three speaking conditions: voiced, whispered, and articulated without phonation. Stuttering was reduced considerably when whispering and was practically eliminated when articulating silently. The possibility that stuttering consistently results from complexity of phonatory coordinations with articulation and respiration was strongly supported. Increased speaking rates under conditions that decreased stuttering seemed to be evidence that efficient rhythmical flow of speech is facilitated by simplification of phonatory and respiratory adjustments.     

Age-related changes in innervation in hypertrophic pyloric stenosis

BACKGROUND/PURPOSE: Recent reports have identified abnormal innervation of the circular muscle layer involving the fine intramuscular nerve fibers in hypertrophic pyloric stenous (HPS). HPS presenting after 3 months of age is rare. The aim of this study was to determine the distribution pattern of nerve fibers in the smooth muscle layers in HPS and correlate this with age at presentation. METHODS: Full-thickness pyloric muscle biopsy specimens were obtained from eight patients with HPS (five age 3 to 5 weeks, two age 3 months, and one age 7 months) and five controls with normal pylorus (age 5 days to 3 years). All specimens were stained with monoclonal antibody to the neural cell adhesion molecule (NCAM) using immunohistochemistry. RESULTS: There were many NCAM-positive nerve fibers in the circular and longitudinal muscle layers in the controls. No NCAM positive nerve fibers were seen in the circular or longitudinal muscle layers in the five cases of HPS in which the patients were less than 5 weeks old. In the two cases in which the patients were 3 months old, occasional NCAM-positive nerve fibers were seen in the circular layer, and moderate numbers of NCAM positive fibers were seen in the longitudinal muscle layers. Moderate numbers of NCAM-positive nerve fibers in the circular muscle layer and many NCAM positive nerve fibers in the longitudinal muscle layers were identified in the 7-month-old HPS patient. CONCLUSIONS: The data suggest that the pyloric muscle lacks innervation in the young HPS infant. Whereas, at 3 months of age the hypertrophied pyloric muscle is partially innervated, and at 7 months of age the pyloric muscle has practically normal innervation.