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.

Immune sensorineural hearing loss is manifested in several systemic immune diseases.1,2 Although hearing loss has been previously documented in patients with Sjögren's syndrome (SS),3 the effect of SS on hearing is unclear. This prospective study was designed to assess the presence of hearing loss in 14 patients with SS and, if sensorineural hearing loss was present, to determine if the hearing loss was immune-mediated. Patients were evaluated with basic audiologic tests as well as for cellular immune inner ear reactivity as measured by the lymphocyte transformation test (LTT).4 Three patients had evidence of sensorineural hearing loss. Two patients had a positive LTT without evidence of sensorineural hearing loss. This preliminary study suggests that SS may not directly cause sensorineural hearing loss, immune-mediated or otherwise.

Aspiration can result from muscular weakness or paralysis of laryngopharyngeal muscles after lower motor neuron disorders (e.g., stroke) or unchecked gastroesophageal reflux. We submit that rehabilitation of the finely tuned swallowing mechanism should provide at least restoration of the normal dynamic relationships between glottic closure and cricopharyngeal relaxation. In three dogs under general endotracheal anesthesia, the recurrent laryngeal nerves and the pharyngeal musculature were exposed through a midline cervical incision. A tracheotomy was performed to allow unhindered laryngoscopic exposure of the vocal cords. A no. 9 endotracheal tube passed through the upper esophageal sphincter was used as a pressure transducer by saline inflation of its cuff and linked to an oscilloscope. The cricopharyngeus was placed under baseline tension with pulse trains administered by an intramuscular needle with a circuit previously used for agonist/antagonist coupling of reinnervated facial musculature. A second output channel was linked to the contralateral recurrent laryngeal nerve by a bipolar electrode. As the pulse width of the current to the recurrent laryngeal nerve increased, that to the cricopharyngeus was reciprocally decreased, producing snug glottic closure and synchronous cricopharyngeal relaxation. Results were documented on videotape. These findings were highly reproducible. We believe that the novel approach proposed in the current model offers an attractive solution to long-term aspiration problems resulting from an imbalance between vocal cord and cricopharyngeal activities.

Leiomyomas are common bengin myogenic tumors that are characteristically found in the uterus or gastrointestinal tract. Although they may occur at any site where smooth muscle is present, origin outside of the abdomen is extremely uncommon. There have been 17 reported cases of leiomyomas in the sinonasal region since 1966. 1 . 16 Two cases were reported to have originated in the paranasal sinuses.':" Two additional patients with nasal leiomyomas who have been treated at the Cleveland Clinic Foundation since 1989 are presented with a discussion of the clinical manifestations, histopathologic features, differential diagnosis, and treatment of this unusual neoplasm. CASE REPORTSCase 1. A 43-year-old woman came to the outpatient office with a 2-year history of chronic bilateral nasal obstruction, clear postnasal discharge, and intermittent right-sided epistaxis. Examination with a O-degree rigid nasal endoscope after topical vasoconstriction revealed bilateral inferior turbinate hypertrophy with a normal septum. No evidence was found of mucosal edema, polypoid masses, or purulent nasal secretions. A small "granulation-appearing" mass arose just superior to the anterior attachment of the right inferior turhinate. The mass was removed completely in the office with the patient under local anesthesia. The tumor measured 0.5 x 0.5 x 0.3 em. Hematoxylin and eosin staining revealed multiple thin-walled vascular structures in a hackground of spindle cells. Immunohistochemistry for muscle-specific actin was positive. Pathology was reported as a vascular leiomyoma. From the Departments of Otolaryngology and Communicative Disorders (Drs. Trott, Lavcrtu, and Wood) and Anatomic Pathology (Drs. Gewirtz and Sebek.) the Cleveland Clinic Foundation.

Aspiration can result from muscular weakness or paralysis of laryngopharyngeal muscles after lower motor neuron disorders (e.g., stroke) or unchecked gastroesophageal reflux. We submit that rehabilitation of the finely tuned swallowing mechanism should provide at least restoration of the normal dynamic relationships between glottic closure and cricopharyngeal relaxation. In three dogs under general endotracheal anesthesia, the recurrent laryngeal nerves and the pharyngeal musculature were exposed through a midline cervical incision. A tracheotomy was performed to allow unhindered laryngoscopic exposure of the vocal cords. A no. 9 endotracheal tube passed through the upper esophageal sphincter was used as a pressure transducer by saline inflation of its cuff and linked to an oscilloscope. The cricopharyngeus was placed under baseline tension with pulse trains administered by an intramuscular needle electrode with a circuit previously used for agonist/antagonist coupling of reinnervated facial musculature. A second output channel was linked to the contralateral recurrent laryngeal nerve by a bipolar electrode. As the pulse width of the current to the recurrent laryngeal nerve increased, that to the cricopharyngeus was reciprocally decreased, producing snug glottic closure and synchronous cricopharyngeal relaxation. Results were documented on videotape. These findings were highly reproducible. We believe that the novel approach proposed in the current model offers an attractive solution to long-term aspiration problems resulting from an imbalance between vocal cord and cricopharyngeal activities.

A 45-year-old woman manifested the primary complaint of painful oral lesions that had been present for several weeks. On examination, a tender erosion with an easily removed grayish membrane was noted in the mucobuccal sulcus (Fig. 1). A full-thickness biopsy from the ulcer edge was performed. The specimen was bisected and sent for routine histopathology and special direct immunofluorescent (IF) stains. Treatment with moderate doses of prednisone was instituted, resulting in complete remission.Pemphigus vulgaris is a chronic mucocutaneous bullous disease, affecting both children and adults, which From the Cleveland Clinic Foundation. This section is made possible through an educational grant from Xomed-Treace, your partners in surgical progress.