Advances in Oto-Rhino-Laryngology最新文献

Pre-treatment clinical and radiological evaluations represent a key step in the proper management of hypopharyngeal carcinoma. First, office-based endoscopy allows the assessment of superficial tumor extension, signs of laryngeal infiltration, and the overall residual function of the laryngo-hypopharyngeal complex. Different tools, maneuvers, and techniques can improve this essential diagnostic step and should be considered a prerequisite to direct subsequent investigations and give an initial indication for the most appropriate treatment. Furthermore, radiologic investigations help in determining tumor deep infiltration, lymph nodes involvement, and the presence of distant metastases. These should complement clinical evaluation by giving a more precise view of the disease characteristics, its overall behavior, and pattern of spreading. The aim of the current review is to summarize the key points that should be considered when approaching hypopharyngeal tumors from a diagnostic perspective, by presenting the main advantages and drawbacks of each technique.

Subjective complaints of dizziness after mild-to-moderate traumatic brain injury are common. Alterations in the mode of injury have changed the presentation symptoms. Evolutions in neuroimaging challenge conventional concepts regarding lack of evidence of injury following mild head trauma and provide hope for elucidating the site of lesion in patients with post-traumatic balance symptoms. Yet the vestibular clinician must maintain a healthy level of suspicion regarding potential exaggeration of symptoms and disability in patients with a financial incentive. Unique conditions warrant particular attention by the vestibular clinician, including chronic traumatic encephalopathy, catastrophization, and persistent postural and perceptual dizziness. The clinical significance of abnormalities, particularly on vestibular-evoked myogenic potential testing, needs to be better defined prior to their widespread application in the medical legal arena. The role of the medical expert is to provide opinion on matters requiring special knowledge to assist the court in reaching its findings. As such, this chapter provides an update on recent advances to consider in patients with dizziness after trauma.

This chapter is a brief overview of migraine associated vertigo (MAV), focusing on the points most relevant to the practicing clinician. We review the definition of MAV, theories regarding its underlying pathophysiology, clinical presentation, epidemiology, findings on physical examination and oto vestibular testing, differential diagnosis, management and prognosis.

Two technically simple tests, vestibular evoked myogenic potential (VEMP) and subjective visual vertical/horizontal (SVV/H) test, have the potential to transform otolith function testing from the research laboratory to the outpatient clinic. Cervical- and ocular-VEMPs are short latency surface potentials produced through the activation of saccular and utricular afferents by sound and vibration. They are tests of dynamic otolith function. The SVV/H test in peripheral lesions probes static asymmetries in utricular function and represents a perceptual error in perceived gravitational vertical/horizontal. VEMPs and SVV/H enable the characterization of patterns and severity of otolith dysfunction in common vestibular disorders. Combined with tests of semicircular canal function, they provide a useful tool for eliciting diagnostic profiles in vestibular neuritis and Ménière's disease. VEMPs are valuable in the pre-surgical confirmation of superior semicircular canal dehiscence and in some cases, may alert the clinician to the presence of a vestibular schwannoma in patients with symmetrical hearing.

Hypopharyngeal cancer is uncommon in the developed world; it is mostly diagnosed in men who smoke tobacco and consume excessive alcohol and uncommon in women. However, recent trends in the developed world show that there has been an annual increase in the percentage of women with hypopharyngeal cancer. In France, there has been a significant annual percentage change in the incidence of this form of cancer - a decrease in men and a greater increase in women since the 1980s. In the developing world, India, Taiwan and other countries, the incidence of hypopharyngeal cancer has increased in both men and women. These populations indulge widely in the social habit of tobacco usage at an earlier age, both smoking and chewing, excessive alcohol drinking, along with the chewing of the areca nut. Recent research has proven that areca nut alone is carcinogenic. The combination of tobacco and alcohol has a greater multiplicative impact on increasing the risk of cancer, while the involvement of areca nut remains to be proven. The World Health Organisation has commenced a Global Mission on the cessation of smoking and reduction of alcohol intake. The effect of this work has been credited with a reduction of hypopharyngeal and other head and neck cancers. While the younger aged should be the targeted population to avoid tobacco usage, the middle and older age of the population must be targeted for quitting smoking tobacco.

Research over the last 4 decades has revealed a great deal of information about psychiatric and functional causes, consequences, and comorbidity of vestibular syndromes. Primary care clinicians, neurologists, and otologists who are willing to set aside the 20th century notion of "psychogenic dizziness" and incorporate 21st century concepts about 5 behavioral entities into their practices will be rewarded for their efforts with a marked improvement in diagnostic acumen and therapeutic effectiveness. Panic attacks may cause or contribute to acute or episodic vestibular symptoms. Generalized anxiety and depression do the same for chronic vestibular symptoms. Fear of falling causes considerable functional impairment, particularly in the elderly. Persistent postural-perceptual dizziness, a newly defined functional vestibular disorder that was 145 years in the making, is the most common cause of chronic dizziness in neurotologic practice. These 5 disorders are the primary diagnoses in 8-10% of patients who consult neurologists or otologists for vestibular symptoms and may be present in up to 50% of patients with structural vestibular disorders. They affect the clinical course of other illnesses and outcomes of medical and surgical interventions. Fortunately, when recognized properly, they are among the most treatment responsive of all conditions that cause vestibular symptoms.

Many pharmaceuticals have ototoxicity (both cochlear and/or vestibular) as part of their adverse medication profile. The aminoglycoside class of antimicrobials has been especially well studied in this regard. Many questions remain unanswered as to how to best monitor and prevent this complication. A bilateral vestibular loss profoundly affects an individual's quality of life, physical activities, and overall independence. Paradoxically, the effects of gentamicin ototoxicity have provided further insight into the workings of the vestibular system, especially the vestibulo-ocular reflex. The microbiological activity, therapeutic use, toxicities, and genetics predisposing a person to aminoglycoside ototoxicity are presented. The clinical importance of recognizing ataxia, disequilibrium, and oscillopsia as presenting symptoms for vestibulotoxicity rather than hearing loss or vertigo is stressed. Documented risk factors and new observations regarding the spectrum of vestibular dysfunction and differences in vestibulotoxicity from multiple daily dosing vs. single daily dosing schedules are presented for the first time. While most vestibulotoxicity arises from systemic aminoglycoside administration, intratympanic application has been used therapeutically for intractable Ménière's disease. Commercially available ototopical aminoglycoside preparations for the treatment of external/middle ear disease in the presence of a tympanic membrane defect have also been documented to cause unintentional ototoxicity.

It is not uncommon for patients with hypopharyngeal cancer to present at an advanced stage of disease. Surgical treatment provides a cure for the tumour with immediate relief from obstruction to the airway and the swallowing passage. Careful planning of surgery is important to ensure good outcome of treatment and prevent complications, some of which may be fatal. The shape of the hypopharynx resembles that of a funnel, with a wide circumference above in continuity with the oropharynx, and a small circumference below where it joins with the cervical oesophagus. As a result, while small tumours require the partial removal of the hypopharynx, large tumours, especially those involving the post-cricoid region, warrant a complete, circumferential pharyngectomy. For tumours that invade the cervical esophagus, transcervical approach is still feasible, and this is facilitated by the removal of the manubrium, allowing access to the tumour and resection with clear margins. In the presence of synchronous tumours lower down in the esophagus, pharyngo-laryngo-esophagectomy is indicated. Successful reconstruction of defects after tumour extirpation allows proper wound healing and early delivery of adjuvant radiotherapy. It is also important to ensure quick recovery of the long-term swallowing function. It ranges from the use of the soft tissue flap with skin island that is sutured as a patch to the remnants of the pharyngeal mucosa, to the use of a visceral flap, such as the free jejunal flap, to repair the circumferential pharyngectomy defects. The treatment protocol is personalized according to the extent of the tumour and the characteristics of the patients.

Hypopharyngeal cancer patients have a very poor prognosis and limited therapeutic options. Seventy to eighty per cent of all hypopharyngeal cancer patients will require palliative and/or end-of-life care for incurable end-stage disease during the course of their illness. The overall proportion of hypopharyngeal cancer patients not qualifying for initial curative treatment, or requiring palliation and supportive care over time is higher than for any other subsite of the head and neck. Surgery and radiotherapy usually have a very limited role in this setting, while systemic therapy will usually compete with supportive care as the best approach. Advances in medicine and oncological treatments for the management of patients with recurrent head and neck cancer have given physicians the opportunity to prolong life where possible. However, this increase in survival might not be clinically meaningful if patients do not simultaneously experience palliative benefits, such as a reduction in symptoms and an improvement in their overall quality of life (QoL). The optimal outcome of palliative treatment is the control of symptoms with minimal treatment toxicities while improving QoL. It remains unclear if current palliative treatment options are better at improving QoL than the best supportive care. An intervention that results in insufficient or unacceptable functional status to the extent that the patient cannot achieve treatment goals - even in the course of prolonging life - is questionable. When used for palliative care purposes, surgery, chemotherapy and radiotherapy commonly have limited effectiveness in improving QoL. Moreover, if these treatments are not congruent with a patient's end-of-life goals, they could constitute low-value care.