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BID PPI appears to be more effective than QD PPI in achieving clinical symptom response in suspected LPR. More response was achieved at 4 months compared with 2 months. Therefore, aggressive acid suppression with BID PPI for at least 4 months is warranted for treatment of LPR.

OTAL laryngectomy and total occlusion of the larynx with tracheostomy are associated with an impaired sense of taste and smell, an increased incidence of tracheobronchial infections, stomal encrustations, loss of nasal respiration, and loss of a human-sounding voice. A fundamental consideration in treating a patient whose larynx has been irreparably damaged is whether the goals of surgery should include replacement of the larynx to improve the patient's quality of life. An early attempt to treat laryngeal cancer with a partial laryngeal transplant 1 was accompanied by rapid recurrence of the tumor, an outcome that quashed interest in the procedure for nearly two decades. Similarly, tracheal transplantation has had only limited success. 2,3 In 1987, we initiated a program to explore the potential of laryngeal transplantation. The program addressed four issues critical to successful transplantation: revascularization, reinnervation, rejection, and the ethics of transplanting an organ considered by some to be nonvital. In rats, the rate of success of laryngeal transplantation was nearly 100 percent. 4,5 In these studies in animals, we classified the histologic features of laryngeal rejection 6 ; determined the maximal tolerable period of ischemia; evaluated preservative solutions 5 ; determined doses of cyclosporine, 7 prednisone, and adjunct in vitro radiation 8 ; and studied the use of sirolimus and tacrolimus. 9 In 1998, we performed a total laryngeal transplantation in a man who had sustained a severe traumatic injury to the larynx and pharynx. 10 We describe the procedure and report the results in detail here. CASE REPORT The Patient and the DonorThe patient was a 40-year-old man who had been in a motorcycle accident 20 years earlier. His larynx and pharynx had been T crushed, leaving him aphonic. He lost his sense of smell and taste a year after the injury. He used an external device (Cooper-Rand Electrolarynx) to speak. Despite attempts at another institution to reconstruct his larynx, it was totally stenotic and shortened, with immobile arytenoid cartilages and a fragmented cricoid cartilage. A barium swallow revealed narrowing of the pharynx and upper esophagus and a pharyngolaryngeal fistula. The supraglottis was bathed in oropharyngeal secretions.Other than mild essential hypertension that was treated with valsartan and hydrochlorothiazide, the patient was healthy. Although he had mild dysphagia, his nutritional status was normal. He did not smoke. Serologic tests for cytomegalovirus and Epstein-Barr virus were negative, and his serum creatinine concentration was normal. With the exception of the tracheal stoma and the aforementioned laryngeal, tracheal, and pharyngeal abnormalities, the results of a physical examination were normal.After surgery was proposed, the patient was interviewed once by a psychiatrist and four times by members of the surgical team and a speech pathologist. All those involved agreed that the patient understood the risks and agreed that his motivation was appropriate. The procedure...

We have investigated the relationship between various voice qualities and several acoustic measures made from the vowel /i/ phonated by subjects with normal voices and patients with vocal disorders. Among the patients (pathological voices), five qualities were investigated: overall severity, hoarseness, breathiness, roughness, and vocal fry. Six acoustic measures were examined. With one exception, all measures were extracted from the residue signal obtained by inverse filtering the speech signal using the linear predictive coding (LPC) technique. A formal listening test was implemented to rate each pathological voice for each vocal quality. A formal listening test also rated overall excellence of the normal voices. A scale of 1–7 was used. Multiple linear regression analysis between the results of the listening test and the various acoustic measures was used with the prediction sums of squares (PRESS) as the selection criteria. Useful prediction equations of order two or less were obtained relating certain acoustic measures and the ratings of pathological voices for each of the five qualities. The two most useful parameters for predicting vocal quality were the Pitch Amplitude (PA) and the Harmonics-to-Noise Ratio (HNR). No acoustic measure could rank the normal voices.

Several signs of posterior laryngeal irritation (e.g., interarytenoid bar, erythema of the medial wall of the arytenoids), which are generally considered to be signs of laryngopharyngeal reflux, are present in a high percentage of nonsymptomatic individuals, raising question about their diagnostic specificity. In addition, these signs were more often detected with flexible than with rigid laryngoscopes, suggesting that flexible laryngoscopy is more sensitive but less specific in identifying laryngeal tissue irritation.

There appears to be poor correlation between signs and symptoms of LPR, particularly when monitoring therapeutic outcomes. In patients unresponsive to twice-daily proton-pump inhibitor therapy for 4 months, further aggressive therapy is unlikely to bring additional symptomatic benefit.

The rising popularity of surgery involving the laryngeal framework (surgical medialization of immobile vocal folds, vocal fold tightening, pitch variation, etc.) has resulted in increasing case experience. Little has appeared in the literature regarding complications or long-term results of this type of surgery. Several years' experience in a major referral center with various types of laryngeal framework surgery has led to a small number of complications. These have included late extrusion of the prosthesis and delayed hemorrhage. A review of these complications and recommendations for modification of technique to minimize them in the future are discussed.