Prevalence of Laryngeal Cancer in VideostroboscopyORIGINAL PatientsCASE REPORT ARTICLE

PrevalenceHeart Failureof Early and Laryngeal Short Stature Cancer in and a 43 Benign year-old Vocal male Cord

Katerina T. leyritana1, Ma. among Czarlota M.Patients Acelajado-Valdenor Undergoing1, Amado Videostroboscopy o. Tandoc III2 and Agnes D. Mejia1

1 in Philippine General Hospital from 2008 to 2010 Department of , College of Medicine and Philippine General Hospital, University of the Philippines Manila 2Department of Pathology, College of Medicine, University of the Philippines Manila Ryner Jose C. Carrillo, Jan Warren A. Holgado, Melfred L. Hernandez and Rene S. Tuazon

Department of , College of Medicine and Philippine General Hospital, University of the Philippines Manila

Presentation of the case require regular laxative use. There was also a report of two Videostroboscopy of the allows examination of This is a case of a 43-year-old male presenting with short more syncopal episodes. He was brought to another doctor vocal fold movement during . Mucosal waves of stature and heart failure. The patient was admitted at the in a private hospital where the assessment was still a “heart the vocal fold are demonstrated by stroboscopic lights medicine ward of the Philippine General Hospital (PGH) problem”. The patient was again prescribed unrecalled allowing illusory frame by frame movement of the vocal fold for dyspnea. This paper will investigate several issues: and again was lost to follow-up. This time, which demonstrates viscoelastic properties of the normal differentiating congenital from acquired hypothyroidism, however, symptoms were persistent. He later consulted at vocal fold epithelium and superficial lamina propria. the relationship between hypothyroidism and the another local hospital, where he was admitted and managed Decreased or absent mucosal wave changes observed may cardiomyopathies, and the therapeutic options in patients as a case of anemia and bronchial . He was discharged suggest severe dysplasia or carcinoma of the .2 with cardiomyopathy secondary to hypothyroidism. slightly improved after four days, only to have recurrent heart Laryngovideostroboscopy is the standard diagnostic test The patient had been born full term to a then 31-year- failure symptoms, prompting admission at PGH. prior to determining biopsy of the vocal cords for benign old Gravida 4 Para 3 (G4P3), the 4th of 9 siblings, with an Upon admission the patient was in mild respiratory and early malignant pathology.3 apparently unremarkable delivery at home facilitated by distress, with stable vital signs and no note of fever. Pertinent The Section of the Department of a traditional birth attendant. He was noted to be normal physical exam findings included short stature, thick lips, non- Otorhinolaryngology, Philippine General Hospital has been at birth. The patient was allegedly at par with age both pitting periorbital edema, dry skin, a displaced apical impulse, performing videostroboscopy on pay and charity patients physically and mentally until eight years old when he was crackles on both fields, and bilateral non-pitting bipedal who present with voice and swallowing symptoms since said to have stopped growing in height. He was brought to edema. There was also a 3 cm x 3 cm reducible umbilical 2000. Videostroboscopy assessments are generally based on a private doctor, whose diagnosis was undisclosed, and he hernia. However, there was no pallor, no vein distention, vocal cord image and characteristics, such as glottal closure, was given medications to increase height, which the patient no apparent congenital malformations, no cardiac murmurs phase closure, vertical level, amplitude, mucosal wave, took for only one month with no improvement. Through the and no clubbing. There was also no note of an anterior neck years, the patient was apparently well, although still of short mass.vibratory behavior, phase symmetry and periodicity. stature, with thick lips, coarse facial features and dry skin. Ventricularlaboratory folds workup and showed arytenoids cardiomegaly are also withassessed. pulmonary This He was notably slow in ambulation. He was said to have congestion,paper determines thoracic the dextroscoliosis, prevalence andof laryngeal atheromatous aorta by bronchial asthma at age 15 years, and since then he had been chestamong radiograph, PGH patients and who left ventricularunderwent hypertrophy videostroboscopy by 12-lead over a three – year period. taking salbutamol tablets occasionally for bouts of dyspnea electrocardiogram (12-l ECG) (Figures 1 and 2), normocytic occurring one to two timesIntroduction annually. normochromic anemia (Hgb 90 mg/dl), dyslipidemia, and Methods TheHoarseness patient’s is symptoms the most commonstarted inmanifestation 2001 when ofhe vocal was pre-renal azotemia (serum creatinine 123 mmol). Electrolytes Videostroboscopy recordings from Jan 2008 to Dec 2010 foldreported movement to have abnormality. sudden loss If of hoarseness consciousness. is observed During to this be on admission showed slight hyponatremia, hypokalemia, obtained using Kay Elemetrics digital strobe 9200B machine persistenttime, the patient beyond did two not weeks, have any examination symptoms ofof theheart larynx failure; is and hypochloremia (serum Na 136, K 3.35, Cl 86). Blood gases from the voice lab of the Department of warrantedno prior seizures, to rule cyanotic out vocal episodes, cord pathologies, chest pain, headache,particularly or revealed partially compensated metabolic alkalosis with mild Otorhinolaryngology, Philippine General Hospital, and earlyblurring infiltrative of vision. Heprocesses regained consciousnessof the vocal shortly fold. after While and hypoxemia. The patient was noted to be hypothyroid based corresponding assessments, were reviewed. Variables traditionalwas brought examinationto a private ,of the whoselarynx assessmentusing mirrors, was a on elevated serum thyroid-stimulating hormone (TSH) and studied include age, sex, profession, smoking history, combined“heart problem”. with symptomsHe was prescribed of hoarseness, unrecalled are medications the usual markedly decreased serum free thyroxine (FT4). The exact alcohol intake, chief complaint and diagnosis. Patients with meanstaken for of aproviding few months a diagnosis,and eventually a permanent discontinued record when of values are shown in Tables 1 and 2. presumptive diagnosis of cancer were reviewed and laryngealthe syncopal image episode and did adequate not recur. description of vocal fold Upon admission to the wards, the patient was managed definitive biopsy results were obtained. Data was encoded movementIn the isnext very four helpful years, for thethe otolaryngologist patient would in developmaking as having congestive heart failure from cardiomyopathy and analyzed using Intercooled Stata 9.2 for Windows appropriateintermittent, management progressive decisions.exertional1 dyspnea and bipedal secondary to acquired hypothyroidism. oral loop diuretics, (StataCorp LP). Mean, proportions, crude odds ratios and edema. later on this would be accompanied by generalized angiotensin-converting enzyme (ACE) inhibitors, beta- ______adjusted odds ratios were calculated. Patient records were body weakness, anorexia, and constipation, severe enough to blockers, statins, and levothyroxine were started. Electrolyte Corresponding author: Ryner Jose C. Carrillo, MD correctionanonymized; was the instituted. study was The done sections in compliance of with the Department of Otorhinolaryngology andDeclaration Cardiovascular of Helsinki Diseases and Good were Clinical co-managing Practice. the patient CorrespondingPhilippine General author: Hospital Ma. Czarlota Acelajado-Valdenor, M.D. together with the General Medicine service. DepartmentUniversity of theof MedicinePhilippines Manila Results Taft Avenue, Ermita, Manila 1000 Philippines He soon developed , upon which the Philippine General Hospital A total of 507 videostroboscopy examinations were TaftTelephone: Avenue, +632 Manila, 5264360 1000 Philippines considerations were acute pulmonary congestion, nosocomial Email: [email protected] performed from 2008 to 2010. Demographic data is Telephone: +632 554-8488 , to rule out an acute coronary event. He was later Email: [email protected]

1218 ACTAACTA MEDICAMEDICA PHILIPPINAPHIlIPPINA VOL.Vol. 46 43 NO. N0. 43 20092012 Prevalence of LaryngealHeart Failure Cancer and Short in Videostroboscopy Stature in a 43 year-old Patients male

summarizedTable 1. Initial in l aboratoryTable 1. ResultsSignificantly, 45.4% of examined Because PGH-ORL is a referral center and caters to patients patients were male; 40.5% were smokers, 45% had alcohol coming from various institutions, the definitive diagnosis of CBC Blood chem. Urinalysis ABG intake, and 19% were professional voice users (e.g., teachers, all patients recommended for direct laryngoscopy with singers). (TableReference 1). The mostResult common chief complaintReference biopsyResult is not necessarilyColor complete.straw AmongpH the 31 7.408patients Value among patientsValue was hoarseness (77.6%) followed by globus diagnosed with laryngeal cancer, 10 underwent direct WBC 5-10 4.5 RBS 3.9-6.1 6.3 Transp Clear pCo2 49.1 sensationRBC (5.9%).4-6 (Table 2) The commonHGBA1C diseases observed4.27-6.07 laryngoscopy6.4 withSp Gravity biopsy under1.010 charityp oservices2 in70 PGH- wereHGB vocal cord120-150 nodules (17.4%),90 laryngopharyngealBUN reflux2.6-6.4 ORL.5.0 Nine subjectspH were confirmed8.0 to haveHCo 3Squamous31.3 Cell (16.6%),HCT vocal0.38-0.48 cord paresis 0.27(12.8%), cystCREA (10.4%), polyp53-115 Carcinoma,123 whileSugar one was diagnosedNEG witho2 satsevere dysplasia.93.6 (8.1%)MCV and presumptive80-100 Fl cancer (6.1%).A lDefiniteB laryngeal34-50 Initial32 findings Proteinshow that videostroboscopyNEG Fio2 has 21%a 90% MCH 27-31 PG TAG 0.34-1.7 0.82 RBC 0-1 Temp 36.9 cancer verified by biopsy is 1.8%. (Table 3) positive predictive value for laryngeal cancer diagnosis. MCHC 320-360 G/l HDl 0.91-1.56 0.67 WBC 0-2

RDW 11.5-15.5% lDl 1.1-3.8 4.21 Cast PBS Table 1. Demographics of patients undergoing PlT 200-400 Inc ToTAl CHol 4.2-5.2 5.25 Epith cell DiscussionRare Slight poikilocytosis, videostroboscopy (N=507) RETIC 0.005-0.015 AST 15-37 95Persistent hoarsenessBacteria for otwocc’l weeksacanthocytes, generally ovalocytes, warrants

SEG 50-70% 48 AlT 30-65 referral91 to Mucusan thotorhinolaryngologistRare slight toxicfor granulation, indirect AgelYMPH (mean) 20-44% 46.550 years old (rangeAlk po4 11 – 84 years old) 184 Crystals Rare laryngoscopy, as the pathology may possiblyslight anisocytosis be worse than GenderMoNo (male) 2-9% 45.4%2 (230/507)NA 140-148 136.9 Am urates 4 SmokerEo 0-4% 40.5%0 (189/462)K 3.6-5.2 a simple3.35 . The clinical practice guideline of 2009 by AlcoholBASo intake 0-2% 45%0 (203/447) Cl 100-108 AAOHNS86 recommends that laryngoscopy of patients Professional voice user 19.3 (74/383) BlAST 0% 0 CA++ 2.12-2.52 presentin2.37 g with hoarseness be done when symptom

P duration2.27 is of a maximum of three months or anytime if Table 2. Chief complaints of patientsMG++ undergoing0.74-1 0.83 4 videostroboscopy there are symptoms leading to suspicion of serious disease. The patients referred to PGH-ORL for videostroboscopy Hoarseness 77.6% (392/505) usually have varied durations of symptoms as well as fat pad. Cardiac enzymes were not consistent with an acute TableGlobus 2. sensation Thyroid Function Tests5.9% (30/505) associated risk factors. Dysphonia 4.8% (24/505) coronaryVideostroboscopy event (Table 3),has however, the capacity intravenous to (IV)differentiate heparin Dysphagia Reference Value4.6% (23/505) Result (overlapping with oral warfarin) was still given to cover for Throat clearing 4.4% (22/483) between voice pathologies. A rigid laryngoscope allowing Free T4 (0.8-2.0) 0.02 ng/dl the presence of a possible lV thrombus as demonstrated LaryngealTSH mass (0.4-6.0) 0.6% (3/502) 24.75 Uiu/ml larger and brighter image, combined with strobe light, Neck mass 0.6% (3/505) byprovides rheologic a more stasis detailed on cardiac examination ultrasound. of glottic Medications closure, weremucos shiftedal wave, to IVand diuretics amplitude and toinotropes; detect subtleoral digoxin vocal foldwas Table 3. Presumptive diagnosis of patients undergoing started.pathology. IV6 antibiotics It also allowswere givenevaluation for possible of effectiveness pulmonary of videostroboscopy infection.treatment Theof patientspatient later with on organic showed lesionsimprovement, of the andlarynx. was7 eventually weaned off from ventilatory support, extubated, Vocal cord 17.4% (88/507) Vocal cord nodules were generally more common (odds 16.6% (84/507) ratio of 2.8) among professional voice users, such as Vocal cord paralysis or paresis 12.9% (65/507) Tableteachers, 3. Cardiac preachers, Enzymes call center agents, as they are generally 10.4% (53/507) more subject to voice abuse (Table 4). Small vocal cord Vocal cord 8% (41/507) Reference Range (mmoL) Result Laryngeal cancer 6.1% (31/507) nodulesQualitative will generally require voice rest andPo rehabilitation.SITIVE Early glottic cancer 5.3% (27/507) LaryngopharyngealTroponin I reflux will require diet modification and Glottic cancer with fixed cord 0.8% (4/507) protonCK-MB pump inhibitors. 0-6.0While inter-observer 1.14variations do Glottic cancer by biopsy 1.8% (9/507) CK-ToTAl 21-232 543 Tuberculosis of the larynx 4.9% (25/507) occur, the most important utility of the diagnostic test is to Non specific dysphonia 4.5% (24/505) determine which patients need to undergo surgical biopsy as Sulcus vocalis 3.2% (16/507) treatment to improve voice or as diagnostic test to rule out Papilloma 3.0% (15/507) cancer.8,9 Vocal cord cysts, polyps and cancer will require Laryngitis 2.8% (14/507) Erythroplakia, Leukoplakia, Keratosis 2.8% (14/507) direct laryngoscopy with microscope and corresponding FigurePost operative 1. Electrocardiogram stroboscopy upon admission2.4% (12/507) biopsy under general anesthesia to provide definite Presbylarynx 1.2% (6/507) diagnosis and to treat underlying pathology.10 Twenty-one Supraglottic mass 1% (5/507) (21) subjects of 507 patients were given a presumptive transferredReinke’s edema to the intensive care unit (ICU)0.8% (4/507) for ventilatory Arytenoid granuloma 0.8% (4/507) diagnosis of laryngeal cancer based on vocal cord support and closer monitoring. on bedside cardiac ultrasound, Glottic web 0.6% (3/507) morphology and patient profile, and were advised to thereSupraglottic was a stenosis finding of eccentric left ventricular0.4% (2/507) hypertrophy, undergo direct laryngoscopy with biopsy to establish a more globalSubglottic hypokinesia stenosis with depressed overall0.4% (2/507)systolic function definitive diagnosis. However, data from only 10 charity withAtrophy concomitant of the vocal spontaneouscords echo contrast0.4% on(2/507) left ventricular Capillary ectasia 0.4% (2/507) patients were available for analysis. Of these, nine cases (lV) cavity suggestive of rheologic stasis, the ejection fraction Arytenoid dislocation 0.2% (1/507) were determined to be squamous cell carcinoma and one wasNormal 25%, videostroboscopy with moderate mitral regurgitation,6.7% (34/507) moderate was found to have severe dysplasia after biopsy. aortic regurgitation with aortic sclerosis, severe tricuspid The most important risk factors for cancer include age, regurgitationA presumptive with mild diagnosis pulmonary of laryngeal hypertension, cancer pulmonary was made male gender and history of smoking and alcohol. All 9 onregurgitation, 31 of 507 andpatients minimal based pericardial on vocal effusion cord ormorphology. pericardial Figure 2. Chest radiograph on admission

VOL.Vol. 4643 NO.N0. 4 3 2009 2012 ACTAACTA MEDICAMEDICA PHILIPPINAPHIlIPPINA 1913 Prevalence of Laryngeal Cancer in Videostroboscopy PatientsCASE REPORT subjects with cancerHeart by biopsy Failure were andmale Shortand non Stature overseas in dataa 43 may year-old be due to male variable protocols and risk professional voice users. Multiple logistic regression analysis factors, as well as differing definitions of disease. The showedKaterina that age T. is l theeyritana most 1imp, Ma.ortant Czarlota risk factor M. Acelajado-Valdenor for cancer videostroboscopy1, Amado o setup. Tandoc in PGHIII2 and-ORL Agnes is unique D. Mejia in that1 all of the larynx. (Table 5) This study allows association of patients seen in out-patient services undergo laryngoscopy diagnosis of cancer1Department and ofsmoking. Medicine, CollegePrevious of Medicine studies and have Philippine indirectly General Hospital, using University mostly ofmirror the Philippines examination Manila with option of shown that the induction2Department time and of Pathology, dose Collegeresponse of Medicine, rigid University or f lexible of the Philippines laryngeal Manila endoscopes when the instrument relationship between smoking and cancer of the larynx is available. Patients presenting with laryngeal symptoms, establishes causality between smoking and cancer of the e.g., hoarseness and globus pharyngeus, are referred to the larynx.11 In this study, association between smoking and videostroboscopy unit for detailed and documented alcohol versus the diagnosis of cancer is observed as well. It examination of the vocal fold mucosa. The findings should be noted, however, that possible examiner bias may contribute to the otolaryngologist’s decision making on who affect videostroboscopyPresentation readings. of the For case example, if a patient requirewill undergo regular a morelaxative invasive use. There procedure was alsofor both a report benign of andtwo hasThis a history is a case that of includes a 43-year-old smoking male and presenting alcohol, withand othershort moremalignant syncopal pathologies. episodes. InHe the was patients brought with to another presumptive doctor staturerisk factors and suchheart as failure. age and The sex, patient the examiner was admitted may be atmore the indiagnosis a private of hospitalcancer, videostroboscopywhere the assessment also provideswas still detaileda “heart medicinelikely to come ward up of with the thePhilippine presumptive General diagnosis Hospital of (PGH)cancer problem”.visualization The of patientmucosal was wave again and prescribed gross vocalunrecalled fold forand dyspnea.be recommended This paper for direct will laryngoscopyinvestigate severaland biop issues:sy for medicationsmovement. It and differentiates again was between lost to glotticfollow-up. cancer This stages. time, A differentiatingconfirmation. Multivariatecongenital fromanalysis acquired showed hypothyroidism, that age is the however,prioritized symptoms elective direct were laryngoscopersistent. pyHe andlater biopsy consulted under at themost importantrelationship of thebetween risk factors. hypothyroidism and the anothermicroscopy local and hospital, formal where he was is admitted done in andpatients managed with cardiomyopathies, and the therapeutic options in patients aslaryngeal a case of cancer. anemia This and bronchialprotocol allowsasthma. early He was detection discharged and Tablewith cardiomyopathy 4. Logistic regression secondary analysis to hypothyroidism. for vocal cord nodules slightlymanagement improved of laryngealafter four days,cancer only in to situation have recurrent of limited heart andThe risk patient factors had been born full term to a then 31-year- failurehospital symptoms, ward capacity. prompting Early admissionlaryngeal cancerat PGH. may undergo old Gravida 4 Para 3 (G4P3), the 4th of 9 siblings, with an radiotUponherapy admission or conservation the patient laryngectomy was in mild to attainrespiratory cure Risk factor Odds Ratio, crude Odds Ratio, adjusted apparently unremarkable(95% CI)delivery at home(95% facilitated CI) by distress,with voice with preservation. stable vital signsCancer and of no the note larynx of fever. with Pertinent airway a Agetraditional birth0.98 attendant. (0.96-0.99) He was0.98 noted (0.96-1.00) to be normal physicalcompromise exam usuallyfindings warrantsincluded shortadmission stature, forthick emergent lips, non- atMale birth. gender The patient0.3 (0.15 was-0.47) allegedly 0.45at (0.20par- 1.00)with age both pittingbiopsy periorbitaland securing edema, of dryairway skin, aand displaced generally apical does impulse, not Smoking history 0.4 (0.24-0.72) 0.98 (0.43-2.24) physically and mentally until eight years old when he was cracklesundergo onvideostroboscopy. both lung fields, Theand idealbilateral situati non-pittingon and bipedalfuture Alcohol intake 0.4 (0.24-0.70) 0.59 (0.27-1.29) saidOccupation to have stopped3.3 (1.8 growing-5.9)* in height.2.8 (1.5 He-5.4)* was brought to edema.direction There of the was department also a 3 is cm to havex 3 cm a database reducible and umbilical unified *a Positiveprivate association doctor, between whose vocal diagnosis cord nodules andwas professional undisclosed, voice use and he hernia.system However,wherein all there patient was filesno pallor, are integrated no neck vein with distention, recorded was given medications to increase height, which the patient noendoscopy apparent findings congenital on firstmalformations, consult. This no will cardiac allow murmurs a more Tabletook for 5. only Logistic one monthregression with noanalysis improvement. for laryngeal Through cancer the anddirect no assessment clubbing. Thereof protocol was also effectiveness no note of and an efficiency.anterior neck verifiedyears, the by patient biopsy was (9 apparently Squamous well, cell althoughcarcinoma) still and of short risk mass. factors ______stature, with thick lips, coarse facial features and dry skin. laboratory workup showed cardiomegaly with pulmonary He was notably slow in ambulation. He was said to have congestion,References thoracic dextroscoliosis, and atheromatous aorta by Risk factor Odds Ratio, crude (95% CI) Odds Ratio, bronchial asthma at age 15 years, and since then he had been chest1. Bless radiograph, DM, Swift E.and Stroboscopy, left ventricular New diagnostic hypertrophy techniques by and 12-lead applied adjusted (95% CI) physiology. In: Fried MP, ed. The larynx, a multidisciplinary approach, 2nd ed. takingAge salbutamol1.04 tablets (0.99-1.09)* occasionally for bouts1.02 (0.96 of- 1.08)*dyspnea electrocardiogramMissouri: Mosby-Yearbook, (12-l ECG)Inc.; 1996. (Figures pp. 81-100. 1 and 2), normocytic occurringMale gender one to twoAll cancer times patients annually. are male* NA** normochromic2. Gamboa J, Echeverri anemiaa L, (Hgb Molina 90 B, mg/dCobeta lI. ),Stroboscopic dyslipidemia, assessment and of SmokingThe patient’s history 14.8symptoms (2.5-87.3)* started in 2001NA** when he was pre-renalchronic azotemia laryngitis. Acta (serum Otorrinolaringol creatinine Esp. 123 2006; mmo 57(6):266l).-9. Electrolytes Alcohol intake 13.7 (2.19-85.4)* NA** 3. Bigenzahn W, Steiner E, Denk DM, Turetschek K, Frühwald F. Stroboscopy reportedOccupation to have Allsudden cancer patientsloss of are consciousness. non- NA** During this on admissionand imaging showedin interdisciplinary slight diagnosishyponatremia, of early stageshypokalemia, of laryngeal time, the patient didprofessional not have voice any users* symptoms of heart failure; and hypochloremiacarcinoma. Radiologe. (serum 1998; 38(2) Na:101 136,-5. K 3.35, Cl 86). Blood gases *Clinically and statistically important risk factors 4. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guidelines: no prior seizures, cyanotic episodes, chest pain, headache, or revealedhoarseness partially (dysphonia). compensated Otolaryngol metabolicHead Neck Surg. alkalosis 2009; 141(3 with Suppl mild 2): **In the study group, sex, smoking, alcohol intake and occupation were dropped in blurring of vision. He regained consciousness shortly after and hypoxemia.S1-S31. The patient was noted to be hypothyroid based the multiple logistic regression analysis was brought to a private physician, whose assessment was a on5. elevatedVan Houtte serum E, Van Lierdethyroid-stimulating K, D'Haeseleer E, Claeyshormone S. The (TSH) prevalence and of laryngeal pathology in a treatment-seeking population with dysphonia. “heartIt isproblem”. interesting He to was note prescribed that among unrecalled treatment medications – seeking markedlyLaryngoscope. decreased 2010; 120(2):306 serum-12. free thyroxine (FT4). The exact taken for a few months and eventually discontinued when values6. Casiano are shownRR, Zaveri in TablesV, Lundy 1 andDS. Efficacy2. of videostroboscopy in the patients in other countries, the prevalence of laryngeal the syncopal episode did not recur. Upondiagnosis admission of voice disorders. to the Otolaryngol wards, the Head patient Neck Surg. was 1992; managed 107(1):95- pathology diagnosed using videostroboscopy is higher in 100. In the next four years, the patient would develop as having congestive heart failure from cardiomyopathy females than males. The most common pathology is usually 7. Kluch W, Olszewski J. The use of laryngostroboscopy in diagnostics and intermittent, progressive exertional dyspnea and bipedal secondaryresults of to evaluation acquired of treatmhypothyroidism.ent of patients with oral organic loop lesions diuretics, in the functional dysphonia, followed by vocal fold nodules larynx. Otalaryngol Pol. 2009; 63(7):11-5. edema. later on this would be accompanied by generalized angiotensin-converting enzyme (ACE) inhibitors, beta- (prevalence rates of 41% and 15% of the examined patients, 8. Rosen CA. Stroboscopy as a research instrument: development of a perceptual body weakness, anorexia, and constipation, severe enough to blockers,evaluation statins, tool. Laryngoscope. and levothyroxine 2005; 115(3):423 were-8. started. Electrolyte respectively.5 In contrast, the most common pathology correction9. Cutler JL, was Cleveland instituted. T. The clin icalThe usefulness sections of laryngeal of Endocrinology videostroboscopy diagnosed in the PGH ORL videostroboscopy unit is vocal and the role of high speed cinematography in laryngeal evaluation. Curr and Cardiovascular Diseases were co-managing the patient cordCorresponding nodule (found author: inMa. 17.4% Czarlota of Acelajado-Valdenor,examined patients). M.D. Only 1 Opin Otolaryngol Head Neck Surg. 2002. 10(6); 462-6. rd Department of Medicine together10. Colton with RH, Caspar the General FK. Understanding Medicine Voice service. Problems, 3 ed. Philadelphia: out of 5 patients seen were voice professionals in the local Lippincott Williams and Wilkins; 2006. pp. 12-63, 100-115. Philippine General Hospital He soon developed respiratory failure, upon which the setting, compared to 41% of the voice treatment seeking 11. Terrell JE, Fisher SG, Wolf GT for Veterans Affair Laryngeal Cancer Study Taft Avenue, Manila, 1000 Philippines considerations were acute pulmonary congestion, nosocomial population abroad.5 The discrepancies between local and Group. Long-term quality of life after treatment of laryngeal cancer. Arch Telephone: +632 554-8488 pneumonia,Otolaryngol to Head rule Neck out Surg. an acute1998; 124(9):96 coronary4-71. event. He was later Email: [email protected]

1220 ACTAACTA MEDICAMEDICA PHILIPPINAPHIlIPPINA VOL.Vol. 46 43 NO. N0. 43 20092012