From April 1987 to April 1992, 116 phonosurgical procedures were performed to treat glottal incompetence. The initial numbers of these surgical procedures included the following: 29 primary Silastic medializations, 3 primary Silastic medializations with arytenoid adduction, 53 secondary Silastic medializations, 4 secondary Silastic medializations with arytenoid adduction, and 11 bilateral Silastic medializations. These procedures are useful in treating unilateral true vocal cord paralysis, scarring, bowing, or paresis, as well as bilateral true vocal cord bowing. Of the initial 100 patients, 16 later underwent a revision with either a larger implant's being placed or an arytenoid adduction. Primary Silastic medialization is the placement of an implant under general anesthesia in the same surgical setting in which laryngeal innervation is sacrificed. Secondary Silastic medialization is the placement of an implant under local anesthesia for a preexistent vocal cord malfunction. In either case, overall voice results for unilateral paralysis are very good. Primary Silastic medialization significantly decreases the postoperative rehabilitation period in skull base patients because of the immediate postoperative glottal competence and decreased use of perioperative tracheotomy. Bilateral implants yielded good results in 6 patients with presbylaryngis, but 6 other patients with bowing from other causes experienced only moderate improvement in speech quality. There were no implant extrusions; however, 1 implant was removed secondary to a persistent laryngocutaneous fistula in a patient who had previously undergone laryngeal irradiation. This was the only complication in this series.

Burnout is widely prevalent among U.S. otolaryngology residents and is present at greater levels than those seen in chairs or faculty of the same specialty. Work hours predict emotional exhaustion, and adherence to the ACGME 80-hour workweek may help protect against burnout and its deleterious consequences in residents of all specialties.

Efforts to ablate soft tissue with conventional lasers have been limited by collateral damage and by concern over potential photochemical effects. Motivated by the thermal-confinement model, past infrared investigations targeted the OH-stretch mode of water with fast pulses from lasers emitting near 3,000 nm (refs 1, 7-9). What does a free-electron laser offer for the investigation of tissue ablation? Operating at non-photochemical single-photon energies, these infrared sources can produce trains of picosecond pulses tunable to the vibrational modes of proteins, lipids and/or water. We report here that targeting free-electron laser radiation to the amide II band of proteins leads to tissue ablation characterized by minimal collateral damage while maintaining a substantial ablation rate. To account for these observations we propose a novel ablation mechanism based on compromising tissue through resonant denaturation of structural proteins.

A survey was conducted to identify demographics and standards of care for treatment of hypopharyngeal squamous cell carcinoma in the United States. Data were accrued from voluntary submission of cancer registry and medical chart information from 769 hospitals representing 2939 cases diagnosed from 1980 to 1985 and 1990 to 1992. Clinical findings, diagnostic procedures employed, treatment practices, and outcome are presented. Overall, 5-year disease-specific survival was 33.4%, which segregated to 63.1% (stage I), 57.5% (stage II), 41.8% (stage III), and 22% (stage IV). Survival was best for patients treated with surgery only (50.4%), similar with combined surgery and irradiation (48%), and worse with irradiation only (25.8%). This analysis provides a standard to which current treatment practice and future clinical trials may be compared.

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Burnout was prevalent among US academic otolaryngologists, although levels were lower than those of otolaryngology chairs and residents. Modification of risk factors, such as allowing sufficient faculty time for research and administrative activities, should be undertaken to curb the development of burnout and its deleterious sequelae.

The SVHI is a reliable and valid tool for assessing self-perceived handicap associated with singing problems.

The anterior cervical approach is commonly used for access to the cervical spine. Vocal fold paralysis (VFP), a complication of this approach, is underrepresented in the literature. A review of the database of the Vanderbilt Voice Center revealed 289 patients with VFP, including 16 patients who developed paralysis as a result of an anterior cervical approach. The paralysis was on the right side in all but 1 patient. Compared to patients who developed VFP after thyroidectomy and carotid endarterectomy, patients with VFP after an anterior cervical approach have a higher incidence of aspiration and dysphagia, suggesting the presence of trauma to the superior laryngeal and pharyngeal branches as well as the recurrent branch of the vagus nerve. Two patients had partial return and 1 patient had complete return of vocal fold movement within 10 months. Of the remaining 13 patients, 8 underwent vocal fold medialization with improvement of symptoms. Two patients are 6 and 7 months postinjury and await vocal fold medialization. Two patients are 27 months and 45 months postinjury and are considering vocal fold medialization. The remaining patient was lost to follow-up. An anatomic-geometric analysis of the right and left recurrent laryngeal nerves was performed by using measurements obtained from computed tomography scans of 8 patients with idiopathic unilateral VFP, as well as experience gained through surgical and cadaveric dissections. We conclude 1) the anterior cervical approach may place multiple branches of the vagus nerve at risk; 2) because of anatomic-geometric factors, the right-sided anterior cervical approach may carry a greater risk to the ipsilateral recurrent laryngeal nerve than does the left; and 3) an understanding of the anatomy and geometry presented herein allows relatively safe exposure from either side of the neck.