DR. KOUFMAN TO BE KEYNOTE SPEAKER AT LARYNGOLOGY DISORDERS UPDATE COURSE

Dr. Jamie Koufman to be Keynote and Featured speaker at the LARYNGOLOGY DISORDERS UPDATE COURSE. Sponsored by Harvard Medical School Department of Otolaryngology, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts, (May 19-20, 2011), Course Directors: Ramon Franco, Jr., M.D. & Phillip C. Song, M.D.

Lectures of Jamie Koufman, M.D., F.A.C.S., Director, Voice Institute of New York, 200 West 57th Street, Suite 1203, New York, NY 10019, Tel: (212) 463-8014, Professor of Clinical Otolaryngology, Medical College of New York, jamie@voiceinstituteny.com; www.voiceinstituteofnewyork.com  (Note: PDFs provided for references with asterisks)

WILLIAM MONTGOMERY LECTURE: IN-OFFICE LARYNGOLOGIC SURGERY

Although the concept of office-based laryngeal surgery is old, its emergence as an essential component of contemporary laryngology has been recent. Indeed, within the last decade, the synergistic confluence of three technologies — (1) high-resolution distal-chip endoscopes with operating side-channels, (2) fiber-delivered angiolytic lasers, and (3) safe, efficient, and effective topical anesthesia — have made unsedated endoscopy the state of the art for the diagnosis and treatment of many laryngeal and aerodigestive tract conditions.

Unsedated, office-based laryngeal [laser] surgery (UOLS) is the preferred method for managing papillomas, hemorrhagic polyps, Reinke’s edema, most vascular lesions, leukoplakia, dysplasia, and epithelial malignancy. The morbidity, cost, and complication rates of UOLS are less, and the results are often superior to traditional surgical methods.

From a practical perspective, transnasal esophagoscopy (TNE), while not strictly a laryngeal procedure, also falls under the UOLS umbrella because of all the new office-based endoscopic procedures, TNE is the most often performed. TNE is indicated for patients with globus, dysphagia, laryngopharyngeal reflux, and GERD. The TNE scope is the endoscope most often used to perform other (laryngeal) office-based procedures in our specialty of otolaryngology.

This talk will also highlight some key elements in the evolution of aerodigestive tract endoscopy and surgery, the advantages and disadvantages of different wavelength lasers in laryngology, vocal fold injection augmentation, tracheobronchial procedures, the limitations of current technology, and some of the potential future applications of future technologies.

References

Koufman JA, Rees CJ, Frazier WD, Kilpatrick LA, Wright SC, Halum SL, Postma GN. Unsedated office-based laryngeal laser surgery: Review of 443 cases using three wavelengths. Otolaryngol Head Neck Surg 137:146-51, 2007.

Koufman JA. Introduction to office-based surgery in laryngology. Curr Opin Otolaryngol Head Neck Surg. 15:383-6, 2007.

Franco RA. In-office laryngeal surgery with the 585-nm pulsed dye laser. Curr Opin Otolaryngol Head Neck Surg 15:387-93, 2007.

Rees CJ, Halum SL, Wijewickrama RC, Koufman JA, Postma GN. Patient tolerance of in-office pulsed dye laser treatments to the upper aerodigestive tract. Otolaryngol Head Neck Surg. 134:1023-7, 2006.

Rees CJ, Postma GN, Koufman JA. Cost savings of unsedated office-based laser surgery for laryngeal papillomas. Ann Otol Rhinol Laryngol 116:45-48, 2007.

Amin MR, Postma GN, Setzen M, Koufman JA. Transnasal esophagoscopy: A position statement from the American Bronchoesophagological Association (ABEA). Otolaryngol Head Neck Surg 138:411-13, 2008.

Jobe BA, Hunter JG, Chang EY, et al. Office-based unsedated small-caliber endoscopy is equivalent to conventional sedated endoscopy in screening and surveillance for Barrett’s esophagus: a randomized and blinded comparison. Am J Gastroenterol 101:2693-703, 2006.

LARYNGOPHARYNGEAL REFLUX (LPR): WHAT YOU DON’T YET KNOW

The symptoms of gastroesophageal reflux disease (GERD) are heartburn and indigestion, but most people with laryngopharyngeal reflux LPR) have hoarseness, sore throat, globus, dysphagia, chronic cough, and post-nasal drip, but no heartburn. Because people with LPR often don’t have typical digestive GI symptoms, LPR is sometimes referred to as “silent reflux.”

Reflux (LPR/GERD) is epidemic! Since the 1970s reflux has increased an average of 4% per year. Today, 40% Americans (125 million people) have it, 22% with GERD and another 18% with LPR. Reflux also is affecting younger and younger patients. In a recent study, we reported that 37% of the 20-30-year-old age group had reflux.

Also since the 1970s, the prevalence of reflux-related esophageal adenocarcinoma has skyrocketed an alarming 850%. And during this same time period despite greater emphasis on esophageal surveillance by endoscopy, the mortality of esophageal cancer has increased seven-fold. Similarly, esophageal precancer (Barrett’s esophagus) rates now approach 10% of patients who undergo screening esophageal examination for LPR as well as for GERD.

Why such high rates of reflux disease, Barrett’s, and esophageal cancer? Amazing as it may seem, the answer is the high acidity of the contemporary American diet. Indeed, since mandated by the FDA in 1973, ascorbic, acetic, and citric acids have been used as the primary additives (“preservatives”) in all bottled and canned foods and beverages to discourage bacterial growth and prolong shelf life. By law, the pH of canned and bottled foods and beverages must be pH <4.

Topics also included in this presentation are the cell biology of LPR, including the stability and activity of human pepsin and its role is the pathogenesis of disease (including laryngeal cancer); analysis of the systemic failure of medical specialists (otolaryngology, gastroenterology, and pulmonology) to accurately diagnose and effectively treat LPR; and finally, advances in the diagnosis and treatment of LPR.

References

Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): A clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an   experimental investigation of the role of acid and pepsin in the development of laryngeal injury.Laryngoscope 101 (Suppl. 53):1-78, 1991

Koufman JA. Low-Acid Diet for Recalcitrant Laryngopharyngeal Reflux: Therapeutic Benefits and Their Implications. Ann Otol Rhinol Laryngol 120:281-287, 2011.

Koufman JA, Belafsky PC, Daniel E, Bach KK, Postma GN. Prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux. Laryngoscope 112:1606-1609, 2002.

Johnston N, Dettmar PW, Bishwokarma B, Lively MO, Koufman JA. Activity/stability of human pepsin: Implications for reflux attributed laryngeal disease. Laryngoscope. 117:1036-9, 2007.

Reavis KM, Morris CD, Gopal DV, et al. Laryngopharyngeal reflux symptoms better predict the presence of esophageal adenocarcinoma than typical gastroesophageal reflux symptoms. Ann Surg 239:849-56, 004.

Koufman JA, Block C. Differential diagnosis of paradoxical vocal fold movement. American Journal of Speech and Hearing. 17:327-34, 2008.

Johnston N, Bulmer D, Gill GA, Panetti M, Ross PE, Pearson JP, Pignatelli M, Axford A, Dettmar PW, Koufman JA. Cell biology of laryngeal epithelial defenses in health and disease: Further studies.Ann Otol Rhinol Laryngol 112:481-491, 2003.

Johnston N, Knight J, Dettmar PW, Lively MO, Koufman JA. Pepsin and carbonic anhydrase isoenzyme III as diagnostic markers for laryngopharyngeal reflux disease. Laryngoscope 114:2129-34, 2004.

Johnston N, Dettmar PW, Lively MO, Koufman JA. Effect of pepsin on laryngeal stress protein (Sep70, Sep53, and Hsp70) response: Role in laryngopharyngeal reflux disease. Ann Otol Rhinol Laryngol 115:47-58, 2006.

Knight J, Lively MO, Johnston N, Dettmar PW, Koufman JA. Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope 115:1473-8, 2005.

Halum SL, Postma GN, Johnston C, Belafsky PC, Koufman JA. Patients with isolated laryngopharyngeal reflux are not obese. Laryngoscope 115:1042-5, 2005.

Belafsky PC, Postma GN, Koufman JA. The validity and reliability of the reflux finding score (RFS). Laryngoscope 111:1313-1317, 2001.

Smoak BR, Koufman JA. Effects of gum chewing on pharyngeal and esophageal pH. Ann Otol Rhinol Laryngol 110:1117-1119, 2001.

Westcott CJ, Hopkins MB, Bach KK, et al. Fundoplication for laryngopharyngeal reflux. J American College of Surgeons 199:23-30, 2004.

DIAGNOSIS AND MANAGEMENT OF VOCAL FOLD BOWING

For 25 years, the author has used transnasal flexible laryngosocpy (TFL) as the first and primary laryngeal examination method for patients with laryngeal and voice disorders. With TFL, laryngeal biomechanics can be routinely assessed. Under normal physiological circumstances, the vocal folds close along their lengths, like two hands clapping on a hinge.

Glottal closure problems are ubiquitous and yet they continue to be under-diagnosed and under-treated. Hyperkinetic biomechanics, muscle tension patterns, are seen in the majority of patients, particularly those with striking-zone pathology.

The focus of this presentation is the diagnosis and treatment of vocal fold weakness, bowing, paresis, atrophy, and presbylaryngis. For enhancing glottal closure, injection augmentation and medialization laryngoplasty are the author’s preferred methods. Patient and procedure selection criteria and timing of surgery are discussed as well as specific technical aspects.

References

Koufman JA. Laryngoplasty for vocal cord medialization: An alternative to Teflon. Laryngoscope 96:726-731, 1986.

Koufman JA. Surgical correction of dysphonia due to bowing of the vocal cords. Annals of Otol Rhinol Laryngol 98:41-45, 1989.

Koufman, JA, Postma, GN. Bilateral medialization laryngoplasty. Operative Techniques in Otolaryngology 10:321-324, 1999.

Koufman, JA, Postma, GN, Cummins, MM, Blalock, PD. Vocal fold paresis. Otolaryngol Head Neck Surg 122:537-541, 2000.

Amin MR, Koufman JA. Vagal neuropathy after upper respiratory infection: A viral etiology? Am J Otolaryngol 22:251-256, 2001.

Mikus JL, Koufman JA, Kilpatrick SE. Fate of liposuctioned and purified autologous fat injections in the canine vocal fold. Laryngoscope 105:17-22, 1995.

Duke SG, Salmon J, Blalock PD, Postma GN, et al. Fascia augmentation of the vocal fold: Graft yield in the canine & preliminary clinical experience. Laryngoscope 111:759-764, 2001.

Koufman JA, Belafsky PC. Unilateral or localized Reinke’s edema (pseudocyst) as a manifestation of vocal fold paresis: The paresis podule. Laryngoscope 111:576-580, 2001.

Koufman JA, Postma GN, Whang C, Rees C, Amin M, Belafsky P, Johnson P, Connolly K, Walker F. Diagnostic laryngeal electromyography: The Wake Forest experience 1955-1999. Otolaryngol Head Neck Surg 124:603-606, 2001.

Koufman JA, Little FB, Weeks DB. Proximal large-bore jet ventilation for laryngeal laser surgery. Arch Otolaryngol 113:314-320, 1987.

ENDOSCOPIC LARYNGEAL CANCER SURGERY

For flat and exophytic leukoplakia, erythroplakia, and even obviously cancerous lesions, neither the laryngeal examination that is performed in the office nor any radiographic assessment can accurately predict the extent, location, and histopathology of laryngeal neoplastic disease. Even high-definition videostroboscopy in the hands of an experienced examiner cannot distinguish in situ from microinvasive from deeply invasive carcinoma. This is because of complex laryngeal anatomy and because there is almost always a significant component of inflammation in association with vocal fold neoplasia. Whether or not the patient has a smoking history, severe coexistent inflammation is often the result of laryngopharyngeal reflux (LPR). The diagnosis and treatment of laryngeal cancer may be further confounded when tangential or partial thickness biopsies fail to provide a definitive diagnosis.

Within this perplexing context, the goals of treatment remain simultaneous cancer cure with voice preservation. Towards those ends, the laryngologist must have many resources at her/his disposal as well as a willingness to individualize every case. This discussion will focus on the management of in situ, T1, and T2 disease. The author’s management algorithm includes a broad array of diagnostic and therapeutic tools.

More than half of the cases are managed in the office with the pulsed-dye laser and almost all of the others with endoscopic resection in the operating room using the CO2 laser with frozen section control of margins. Almost none of the author’s cases are subjected to radiation.

References

DeSanto LW. Selection of treatment for in situ and early invasive carcinoma of the glottis. Can J Otolaryngol 3:552-6, 1974.

Koufman JA. The endoscopic management of early squamous carcinoma of the vocal cord with the carbon dioxide surgical laser: Clinical experience and a proposed subclassification. Otolaryngol Head Neck Surg 95:531-537, 1986.

McGuirt WF, Blalock PD, Koufman JA. Comparative voice results after laser resection or irradiation on T1 vocal cord carcinoma. Arch Otolaryngol 120:951-955, 1994.

THE ART OF SURGICAL VOICE REHABILITATION AFTER CANCER TREATENT

After laryngeal cancer treatment, the combination of soft-tissue deficiency and striking-zone scarring can be vocally crippling. Conversely, some patients with unilateral partial vocal fold resections can have normal voices. Thus, the spectrum of voice outcomes after laryngeal cancer treatment extends from aphonia to normal voice depending on the degree of glottal insufficiency and the condition of the striking zone(s).

Surgical voice rehabilitation requires more innovation and creativity than almost any other area of operative laryngology. The author uses an array of surgical techniques including injection augmentation (alloplastc materials and lipoinjection), grafting (adipose tissue and fascia), laryngeal framework surgery, and even hemicricoidectomy. The latter procedure is for one of the most debilitating and difficult situations to repair, after hemilaryngectomy with sacrifice of the ipsilateral arytenoid.

For this lecture topic, the art of laryngeal reconstruction and rehabilitation after cancer treatment, case examples will be used to illustrate key points.

References

Amin MR, Koufman JA. Hemicricoidectomy for voice rehabilitation following hemilaryngectomy. Ann Otol Rhinol Laryngol 110:514-518, 2001.

Mikus JL, Koufman JA, Kilpatrick SE. Fate of liposuctioned and purified autologous fat injections in the canine vocal fold. Laryngoscope 105:17-22, 1995.

Duke SG, Salmon J, Blalock PD, Postma GN, Koufman JA. Fascia augmentation of the vocal fold: Graft yield in the canine and preliminary clinical experience. Laryngoscope 111:759-764, 2001.

Amin MR, Koufman JA. Endoscopic arytenoid repositioning for unilateral arytenoid fixation.

Laryngoscope 111: 44-47, 2001.

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