Hepatic Kupffer cell blockade reduces mortality of acute hemorrhagic pancreatitis in mice

BACKGROUND: Recovery of upper aerodigestive tract function after reconstruction of segmental oromandiblectomy defects is frequently incomplete. The purpose of this study was to quantitate postreconstruction function and define variables that predict functional outcome in this population. METHODS: A prospective study of 21 patients who underwent microvascular free tissue transfer reconstruction of segmental oromandibular defects was performed. Measures of swallowing, speech, bite, and oral intake were performed preoperatively and at 1, 3, 6, and 12 months postoperatively or until plateau. Preoperative versus maximal postoperative measures were compared and correlated with nine potentially predictive variables. Univariate and multivariate analyses were performed to determine the most significant predictive factors. RESULTS: Baseline function in the study population was abnormal. Postoperative bite force improved, but swallowing, speech, and oral intake were worse than preoperative. Significant (univariate) predictors of outcome included diagnosis of cancer, tongue resection, pharynx resection, and flap skin paddle area. Only tongue resection remained significant in multivariate analysis. CONCLUSIONS: Increasing need for oropharyngeal lining replacement, especially after tongue resection, is the most important predictor of functional outcome in reconstruction of segmental mandible defects.     

Swallow recovery in an oral cancer patient following surgery, radiotherapy, and hyperthermia

BACKGROUND: No study has examined the nature and extent of swallowing impairment in oral cancer patients following treatment with combined hyperthermia and interstitial radiotherapy. Few studies have examined the effects of voluntary swallow maneuvers (supersupraglottic and Mendelsohn) on pharyngeal phase swallowing in the oral cancer patient treated with surgery or radiotherapy. This study examined the effects of combined radiotherapeutic salvage treatments of hyperthermia and interstitial implantation and swallow recovery using swallow maneuvers in a surgically treated and irradiated oral cancer patient. METHODS: The patient under study, a 51-year-old man, underwent radiotherapy, according to Radiation Therapy Oncology Group (RTOG) protocol #8419, consisting of a combination of interstitial irradiation and hyperthermia to the base of tongue, for a recurrent squamous cell cancer. He underwent videofluorographic (VFG) examination of his swallowing, a modified barium swallow at three time points: 2 days following radiotherapy treatment (VFG1), 4 weeks later (VFG2), and 8 months later (VFG3). Temporal and biomechanical analyses of swallows were performed at each time point. RESULTS: Swallow maneuvers and time resulted in improved laryngeal elevation and laryngeal vestibule closure during the swallows on VFG2. Maximum upper esophageal sphincter (UES) opening width and duration were more normal. Fewer swallows were required for bolus clearance through the pharynx. Base of tongue tissue necrosis occurred as a complication of radiotherapy between VFG2 and VFG3, with resultant severe reduction in posterior movement of the tongue base, incomplete tongue base contact to the posterior pharyngeal wall, reduced laryngeal elevation, and incomplete laryngeal vestibule closure during swallowing at VFG3. UES opening became less normal and a greater number of swallows were required for bolus clearance through the pharynx. CONCLUSIONS: Combined interstitial irradiation and hyperthermia can cause oropharyngeal swallowing problems. Time and swallow therapy can improve these swallow disorders. Tongue base tissue necrosis can cause further swallow impairment, emphasizing the importance of the tongue base in normal deglutition. Further studies are needed to examine the impact of combined hyperthermia and interstitial implantation for treatment of tongue base tumors on swallow functioning in a larger group of patients.     

Idiotype vaccination strategies against a murine B-cell lymphoma: dendritic cells loaded with idiotype and bispecific idiotype x anti-class II antibodies can protect against tumor growth

BACKGROUND: Following extensive resections of head and neck tumors, re-establishing speech and masticatory function are of crucial importance for the patient. METHODS: In 23 patients with vascularised jejunal grafts for reconstruction of the intraoral mucosa, tongue and floor of mouth, a speech intelligibility test was performed, tongue and floor of mouth mobility was investigated using a 3.5 MHz ultrasound scanner. In another 18 patients with vascularised bone grafts for reconstruction of the mandible, masticatory function was analysed using a T-scan system and a miniature pressure transducer. RESULTS: Speech results with jejunal grafts in the lateral floor of mouth/tongue region may attain 91.4%, in anterior floor of mouth reconstructions 63.4%. Patients with implant-bone dentures and vascularised bone grafts prefer the non-reconstructed side for chewing. Masticatory force is significantly diminished compared to a control group. DISCUSSION: Lack of neurosensitive feedback mechanisms may be responsible for diminished chewing pressure and also for inferior speech results despite good floor-of-mouth/tongue mobility. CONCLUSIONS: Despite complex microvascular tissue reconstructions, severe functional impairments remain and necessitate further investigations on improvement of postoperative speech, swallowing and chewing function.     

Persistent dysphagia after laser uvulopalatoplasty: a videoradiographic study of pharyngeal function

In a follow-up study of 79 patients two years after laser uvulopalatoplasty 21 (27%) reported persistent postoperative dysphagia, with aspiration symptoms in 22%. None of the patients had suffered from recurrent pneumonia. A total of 4% of the patients regretted the treatment because of their dysphagia problems. The objective of this study was to examine oral and pharyngeal function videoradiographically during swallowing in the patients with persistent dysphagia, to determine whether the subjective symptoms of dysphagia correlated with objective signs of pharyngeal dysfunction. Pharyngeal function during swallowing was deviant in 76% of the dysphagic patients. In 52% of the dysphagic patients premature leakage of bolus down to different levels of the pharynx, from the tongue base to sinus piriformis, was observed before the swallowing reflex was elicited. In the dysphagic patients substantial bolus retention was observed on the epiglottis or in the valleculae alter the propagation wave had passed (43%) as well as epiglottal dysmotility (24%). Of the dysphagic patients, 10% could not avoid aspiration during the examination. These findings could explain the symptoms reported by the patients.     

Ultrasound assessment of swallowing in malnourished disabled children

Oral motor dysfunction is common in children with neurological impairment. Nutritional advice depends upon an accurate assessment of feeding potential in these cases. Videofluoroscopic assessment of oral motor function has been the accepted "gold standard" investigation for several years but has significant drawbacks, including the time constraints set by the use of ionizing radiation and the problems posed by the cumbersome equipment needed in mimicking the child's normal feeding situation. Ultrasonography (US) has been suggested as an alternative or additional investigation of oral motor function in children with neurological impairment. We prospectively evaluated a scoring system derived from US assessment of oral motor function in 32 malnourished disabled children with feeding problems by comparing them with a group of matched control children without neurological impairment. US imaging provided useful information with regard to the oral cavity and the soft tissue structures, capturing the salient features of tongue/hyoid/palate activity and bolus transport across the tongue and through the hypopharyngeal area. The mean percentage score obtained by US assessment of oral motor function in children with neurological impairment was 54.3 +/- 23.2 and from children without neurological impairment 91.9 +/- 12.7 (p < 0.0001). Scores for the oral and pharyngeal phases of swallowing were also very significantly lower than that in the control group, both phases being equally impaired in the disabled children. This study has demonstrated that a scoring system based on US assessment of different components of oral motor activity detects statistically significant differences in the feeding capabilities of children with neurological impairment.     

Evaluation and treatment of speech and swallowing disorders associated with myopathies

Dysphagia, or disordered swallowing, can be demonstrated at any time over the course of many myopathies. Ability to swallow may be impaired because of weakness, inflammation, or dysfunction of the oropharyngeal, laryngeal, and esophageal musculature. Dysphagia may occur during the progression of disease regardless of whether the patient is properly treated. The presentation of signs of dysphagia can vary among patients because of differing patterns of weakness or incoordination of the facial muscles, lips, tongue, palate, pharyngeal constrictors, or smooth and striated muscles of the esophagus. Although the literature has focused on problems in the esophagus, scant attention has been paid to the oropharynx, which is often equally affected. Studies suggest that surgical myotomy and botulinum toxin injection may provide benefits for some patients with esophageal dysfunction. Although the condition is pervasive, there is little information on the incidence of dysphagia in muscular disorders. Because a major complication of dysphagia is aspiration, any sign of swallowing impairment demands medical attention and treatment.     

Assessment of Swallowing Ability Scale for oral and oropharyngeal cancer patients

The Swallowing Ability Scale (SAS) has been recently reported by us. This scale is a new method to assess dysphagia after therapy for oral and oropharyngeal cancer. The preliminary results on 23 patients showed that the scale was reliable and sensitive to functional differences across a broad spectrum of oropharyngeal dysphagia after therapy. This paper confirmed the above facts in 73 oral and oropharyngeal cancer patients who were treated in two hospitals between 1995 and 1996. As stated in the previous paper, SAS consists of a 2-step questionnaire: the MTF score and the Dysphagia score. The MTF score is a simple and practical assessment tool consisting of three subscales: 1) Method of intake, 2) Time of intake, and 3) Food. The Dysphagia score is a relevant assessment tool for defining patients' anatomic or physiologic swallowing disorders. In 40 patients with wide resection of the tongue, the Dysphagia score (p < 0.05) and the MTF score (p < 0.01) were significantly decreased. And we found a correlation between the MTF score and the Dysphagia score (r = 0.78, p < 0.001) in 73 patients. The usefulness of the SAS will be further studied for the assessment of rehabilitation to improve postoperative dysphagia.     

Staurosporine stimulates phospholipase D activation in human polymorphonuclear leukocytes

Oropharyngeal pressure during swallowing was studied in a total of 40 healthy adult males and females in two age groups (21-27 yr and 62-75 yr). Effects of bolus volume, bolus viscosity, age, and gender were analyzed, and dry and bolus swallows were compared. The duration of the intrabolus pressure, reflecting the pressure exerted by the tongue on the bolus and preceding the generation of the pharyngeal pressure, was significantly affected by bolus volume. The duration of oropharyngeal pressure was affected by age, gender, and bolus type (bolus vs. dry swallow). Peak oropharyngeal pressure was not affected by any of the test factors, although there was a tendency for older subjects to have higher pressures than young subjects.     

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.     

Pharyngoplasty in patients with cleft lip and palate after maxillary advancement

The development of velopharyngeal incompetence and increased hypernasality after maxillary advancement has been described previously by several authors. If speech and velopharyngeal function deteriorate after maxillary advancement, pharyngoplasty is frequently the treatment procedure of choice because of the natural cause of the deficit. Of 91 cleft lip and palate patients who have undergone maxillary advancement at the Australian Cranio-Facial Unit, 23 patients received a pharyngoplasty after surgery. Thirteen of these patients who had pre- and postoperative speech evaluations were included in this study. Of the 13 patients, six patients received a superiorly based pharyngeal flap, two patients underwent an orticocheal pharyngoplasty, and five patients received either a revision or augmentation of the previous flap based on results of preoperative examinations. Serial nasendoscopic evaluations were available for 11 of these 13 patients, and they demonstrated that velopharyngeal function improved after pharyngoplasty in six patients and was unchanged in five patients. Of the 13 patients, 10 improved and three patients were unchanged on an intelligibility rating. Nine of the 13 patients demonstrated decreased hypernasality and four patients were unchanged. Hyponasality decreased in two patients increased in one patient, and was unchanged in one patient. Because the results obtained are considered acceptable, the authors conclude that pharyngoplasty can be used effectively to treat velopharyngeal dysfunction subsequent to Le Fort I maxillary advancement.     

The techniques of nonmuscular closure of hypopharyngeal defect following total laryngectomy: the assessment of complication and pharyngoesophageal segment

The usual method of reconstructing a hypopharyngeal defect during total laryngectomy includes pharyngeal muscle layer closure, which may result in high pharyngoesophageal pressure. We hypothesize that nonclosure of the pharyngeal muscle can reduce the pressure of the pharyngoesophageal segment which can reduce the chances of the formation of pharyngocutaneous fistulae. A technique of nonmuscular closure of a hypopharyngeal defect is presented. The differences in the rate of fistula formation and swallowing function between patients with usual and nonmuscular closure were also studied. Sixty consecutive laryngectomees were enrolled in this study. Thirty patients received usual closure after total laryngectomy, whereas the other 30 patients underwent non closure of their pharyngeal muscles. One patient (3.3 per cent) in the nonmuscular closure group and three patients (10 per cent) in the usual closure group developed a pharyngocutaneous fistula. The pharyngoesophageal pressures of the nonmuscular closure group were significantly lower than those of the usual closure group. We conclude that the technique of nonclosure of the pharyngeal constrictor muscle after total laryngectomy is relatively more simple and is not associated with a higher rate of fistula formation. Furthermore, nonclosure of the pharyngeal constrictor muscle is preferable to muscular closure because it reduces the spasm of the pharyngoesophageal segment which limits voice rehabilitation.     

Metabolism of enkephalins in head membranes of the leech Theromyzon tessulatum by peptidases: isolation of an enkephalin-degrading aminopeptidase

This study quantified the effects of the supraglottic maneuver (SGM) and super supraglottic maneuver (SSGM) on laryngeal and pharyngeal movements before and during swallow. Simultaneous videofluoroscopic and videoendoscopic examinations of oropharyngeal swallowing were performed in eight healthy volunteers with and without maneuvers. Data analysis compared 1) temporal relationships of oropharyngeal events, 2) airway conditions at the time of selected oropharyngeal events, and 3) biomechanical computer analysis of swallowing events. Using these maneuvers, normal subjects produced earlier cricopharyngeal opening, prolonged pharyngeal swallow, some degree of laryngeal valving before swallow, and change in extent of vertical laryngeal position before swallow. These changes are more successful and maintained longer with the SSGM than the SGM. We concluded that breath-holding maneuvers alter not only airway conditions before swallow but also both the temporal relationships and biomechanical events during oropharyngeal swallow.     

Amelanotic lentigo maligna melanoma of the face: a case report and review of the literature

Neuroleptic medications may result in extrapyramidal symptoms that can affect swallowing. Both oral and pharyngeal phases of swallowing may be affected. Unlike the more common causes of dysphagia, especially in the elderly, drug-induced dysphagia may be reversible. This report describes a case of neuroleptic-induced dysphagia in an elderly male with Alzheimer's disease. When the loxapine was discontinued, the dysphagia improved significantly.     

Caroli''s disease]

Radiotherapy given during treatment of oral and pharyngeal malignancy is frequently associated with colonization of the oral mucosa by Candida species. Treatment of these infections has included topical and systemic agents. In the present study 73 patients with oropharyngeal candidosis were treated with either amphotericin B (10 mg lozenges, four times daily for 14 days, 36 patients) or fluconazole (50 mg daily for 7 days, 37 patients). The yeasts most frequently isolated were C albicans and C glabrata. Clinical signs and symptoms showed improvement at end of treatment in 72% of patients who received amphotericin B compared with 92% of patients who received fluconazole. Mycological cure at end of treatment was achieved in 31% of the amphotericin B group and 46% of patients who received fluconazole. For both treatments the cure rate was less in denture wearers than in non denture wearers.     

Primary closure of pharyngeal remnant after total laryngectomy and partial pharyngectomy: how much residual mucosa is sufficient?

After total laryngectomy with or without partial pharyngectomy, the remaining pharyngeal defect can be repaired either by primary closure or with additional tissue, depending on the amount of pharyngeal tissue remnant available. The aim of this study was to determine the minimum width of the pharyngeal remnant that could be safely closed primarily without causing difficulty in swallowing. A total of 52 consecutive patients who underwent total laryngectomy were entered into the study. The relaxed and stretched widths of the pharyngeal remnant were measured after removal of the specimen. The widths of the pharyngeal mucosa ranged from 1.5 to 5.0 cm relaxed (mean, 3.24 cm) and from 2.5 to 8.0 cm stretched (mean, 4.83 cm). All neopharynx was reconstructed by closing the pharynx primarily. Seven of the 52 patients developed recurrent tumor with concomitant dysphagia. Two of the 45 patients without recurrence presented with acute dysphagia from food bolus obstruction, and 1 patient developed benign inflammatory stricture following an episode of fish-bone impaction. The narrowest widths of the pharyngeal remnant in this group of 45 were 1.5 cm relaxed and 2.5 cm stretched. As these patients do not have swallowing difficulty, we conclude that in the absence of tumor recurrence, this amount of residual pharyngeal tissue is sufficient both for primary closure of the pharynx and in restoring swallowing function.     

Pharyngeal reconstruction after laryngectomy

A method of pharyngeal reconstruction following laryngectomy is described. In 44 successive laryngectomies using this technique, no postoperative pharyngocutaneous fistulas occurred. Ten of the patients had received full courses of radiation therapy prior to the surgical procedure and had recurrent carcinomas. Other reports have noted that laryngectomy following full courses of "unplanned preoperative" radiation therapy is usually associated with a high incidence of postoperative pharyngeal fistula. The pharyngeal fistula problem, and the pharyngeal repair that was used in our series, are discussed. The pharynx was closed carefully in three layers with fine, absorbable sutures, and a submucosal inverting technique was used for the important mucous membrane closure. Tube feedings were used for two weeks after surgery. A high incidence of pharyngocutaneous fistula after laryngectomy in the irradiated patient can be prevented.     

Intraoral defect coverage with muscle flaps

PURPOSE: This study investigated whether wound healing after the use of purely muscular flaps for intraoral defect coverage is negatively influenced by insipient muscular atrophy and the absence of a covering layer. MATERIALS AND METHODS: In an experimental study, microsurgical transplantation of muscle flaps from the anterior abdominal wall was carried out in 18 Lewis rats. A nerve anastomosis for motor reinnervation was not performed. Atrophy of the muscle flaps was determined by measuring the reduction of their size and weight after 3, 8, and 20 weeks. In the clinical part of the study, free muscle transplants from different donor regions (vastus lateralis, pectoralis major, internal oblique, and temporalis muscles) were used for defect coverage in various areas of the oral cavity. To study epithelization, punch biopsy specimens from the muscle surface were taken at periods of 2 to 4 weeks up to 6 months for histologic evaluation. Final evaluation of reconstruction results with special regard to speech, tongue mobility, mouth opening, chewing, and swallowing took place after 6 months. RESULTS: In the experimental study, average weight loss of the muscle flaps was 67% after 20 weeks, and the remaining surface area was 71%. The number of myocytes was only about 30% compared with control muscles, and parts of the flap appeared as a thin fibrous membrane. Clinically, this atrophy led to restricted mobility in such areas as the floor of the mouth, the buccal plane, and the tongue. Muscle flaps covering solid structures such as bones or reconstruction plates adapted well to the transplant bed, and the atrophy of the muscle led to no constriction of the surrounding tissue. Atrophy also did not have a negative effect when muscle flaps were placed in the region of the pharyngeal wall. Epithelization started from the edges after 2 weeks and was concluded after 8 weeks in all transplants if no additional radiation was performed. The muscle tissue was sufficiently resistant so that infection, fistulization, and necrosis did not occur. CONCLUSIONS: Muscle flaps undergo considerable atrophy with a cicatricial transformation and reduction of flexibility. Despite these disadvantages they can be used in the hard palate, the alveolar crest, and in the pharyngeal wall without causing functional restriction. Because of constriction of the surrounding tissues, mobile areas such as the buccal plane, the floor of the mouth, and the tongue are not suitable as sites for muscle transplants.     

Result of treatment of squamous cell carcinoma of the tongue and floor of the mouth

A statistical analysis was performed on 40 patients with squamous cell carcinoma of the tongue and mouth floor, which could be followed for 6 months or more after initial treatment in the Department of Otorhinolaryngology, School of Medicine, Keio University during the 14 years from 1983 to 1996. The 5-year survival rate determined by the Kaplan-Meier method for each stage was 100% for Stage I, 77.8% for Stage II, 60.0% for Stage III and 44.4% for Stage IV. Thirteen suffered a relapse after initial treatment and patients with relapses among them have all survived after the subsequent salvage surgery. In contrast, in nine patients with cervical relapse, however, the 5-year survival rate was 11.1% with an unfavorable prognosis. This confirmed that suppressing cervical relapses is important for treating tongue and floor mouth cancers. The treatment strategy in our department is characteristic of positive enforcement of prophylactic neck dissection in the surgery and introduction of neoadjuvant chemotherapy (NAC) in the chemotherapy. Prophylactic neck dissection was performed in the 17 patients and no relapse was observed on the side of prophylactic neck dissection. NAC was performed on 26 patients in consideration of suppressed minute metastases and preserved function and 24 determinable cases were statistically analyzed. Among patients who had received NAC, the oral function was successfully preserved without surgical intervention in six patients both patients who showed complete response (CR) and four out of 14 patients who had a partial response (PR) following NAC. This may indicate that the oral function could be preserved in those patients who exhibited CR following NAC, but that preservation could be difficult in patients who exhibited PR. In addition, concerning the accumulated 5-year survival rate in relation to the effect of NAC, responders (CR + PR) accounted for 90.9% and non-responders (no change + progressive disease following NAC) for 15.0% with a very good outcome noted in the responder group. These figures suggest that responders may have a significantly good prognosis in the multivariant analysis including additional background factors before treatment as well. Accordingly, the present therapeutic measures for non-responders must be reexamined and performed more carefully and accurately as compared with those for responders.     

Effects of postural change on aspiration in head and neck surgical patients

This study was designed to define the effects of postural change on liquid aspiration during videofluorographic examination of oropharyngeal swallow in head and neck surgical patients. Thirty-two patients were given two swallows of five different amounts of liquid barium as tolerated. When aspiration occurred, the patient's head and/or body position was changed, new posture being determined by the swallowing disorder identified as the cause of the aspiration. Postural techniques were successful in eliminating aspiration on at least one volume of liquid in 81% of these patients. Patients in all surgical groups were able to use postures with equal success. A variety of positions were used in each type of surgical patient, indicating that these patients exhibited a variety of swallowing problems. Results emphasize the importance of introducing postural techniques during the radiographic study of oropharyngeal swallow to facilitate safe oral intake of liquids.     

Arthroscopic removal of an osteoid osteoma at the talar neck

PURPOSE: This study used simultaneous videomanometry to measure pressure characteristics in a group of patients with evidence of laryngeal and/or tracheal barium penetration, and to compare the results to those of one group of healthy volunteers and one group of patients with dysphagia but a normal barium swallow. MATERIAL AND METHODS: Videomanometry during barium swallowing was performed in 25 patients who showed penetration of barium into the laryngeal vestibule. Manometric abnormalities were determined by comparing these mean values with those of 25 healthy volunteers, and the frequency of manometric abnormalities was compared to that of 19 patients presenting with oropharyngeal dysphagia with a normal barium swallow. RESULTS: The frequency of abnormalities for four parameters (pharyngo-esophageal segment (PES) resting pressure, PES relaxation duration, pharyngeal peak pressure, pharyngeal contraction duration) differed significantly between the patients with penetration and those with normal barium studies. There was, however, no association between manometric abnormalities and the degree of barium penetration. CONCLUSION: The differences in manometric abnormalities between patients with laryngeal penetration and patients with normal barium swallows may be useful in identifying the mechanisms of laryngeal penetration.