Alex S. Luke, Theresa M. Mairson, Inna A. Husain, Seth E. Kaplan
Publication date 02-10-2023
Objective Granular cell tumor of the larynx is an uncommon, typically benign lesion that may be confused for a malignant neoplasm based on histopathology. This review examines cases of granular cell tumor of the larynx in adults to highlight key distinctions in diagnosis/management and demonstrate how misclassification may lead to unnecessary escalations in therapy.
Data Sources and MethodsA systematic search of Pub Med, Ovid, and EBSCO Search Hosts was completed in December 2021. The search yielded 501 articles with 87 full-text articles included in the review. Primary search terms included granular cell, tumor, larynx, and adult. Primary endpoints were patient presentation, primary management, pathological features, and disease course.
ResultsA systematic review of 87 articles identified 200 patients with granular cell tumors (GCTs) of the larynx. Of the 200 patients, 50.3% were males and 49.7% were females. Of these, 54.0% were reported as white patients, and 46.0% were reported as black patients. The most common presenting symptoms were dysphonia (85.9%) and stridor/dyspnea (14.1%). On examination, the lesions were most commonly polypoid/nodular and firm. Pseudoepitheliomatous hyperplasia (PEH) was identified in 33.5% of cases, and 2% of cases were malignant. GCTs were misdiagnosed as other malignant lesions in 11% of cases. In benign cases, 13.5% of patients underwent additional surgeries beyond simple excision/laryngofissure, including laryngectomy and neck dissection. Less than 2% of lesions reoccurred.
Conclusion Granular cell tumors of the larynx are typically benign lesions that may be misdiagnosed with unnecessary escalation of treatment. However, most lesions resolve via primary surgical excision. Laryngoscope, 2023
Shaunak N. Amin, Jennifer M. Siu, Patricia L. Purcell, James P. Manning, Jason Wright, John P. Dahl, Jason S. Hauptman, Richard A. Hopper, Amy Lee, Scott C. Manning, J. Nathaniel Perkins, Srinivas M. Susarla, Randall A. Bly
Publication date 30-09-2023
Frontonasal dermoids are congenital nasal masses that have an association with intracranial extension. Imaging with CT and/or MRI is required for treatment planning. We found no difference between the two imaging modalities in the largest case series published.
Objective To review cases of congenital frontonasal dermoids to gain insight into the accuracy of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) in predicting intracranial extension.
Methods This retrospective study included all patients who underwent primary excision of frontonasal dermoids at an academic childrens hospital over a 23-year period. Preoperative presentation, imaging, and operative findings were reviewed. Receiver operating characteristic (ROC) statistics were generated to determine CT and MRI accuracy in detecting intracranial extension.
Results Search queries yielded 129 patients who underwent surgical removal of frontonasal dermoids over the study period with an average age of presentation of 12 months. Preoperative imaging was performed on 122 patients, with 19 patients receiving both CT and MRI. CT and MRI were concordant in the prediction of intracranial extension in 18 out of 19 patients. Intraoperatively, intracranial extension requiring craniotomy was seen in 11 patients (8.5%). CT was 87.5% sensitive and 97.4% specific for predicting intracranial extension with an ROC of 0.925 (95% CI 0.801, 1), whereas MRI was 60.0% sensitive and 97.8% specific with an ROC of 0.789 (95% CI 0.627, 0.950).
Conclusion This is the largest case series in the literature describing a single institutions experience with frontonasal dermoids. Intracranial extension is rare and few patients required craniotomy in our series. CT and MRI have comparable accuracy at detecting intracranial extension. Single-modality imaging is recommended preoperatively in the absence of other clinical indications.
Level of EvidenceIV Laryngoscope, 2023
Juha T. Laakso, Heidi Oehlandt, Ilkka Kivekäs, Teemu Harju, Jussi Jero, Saku T. Sinkkonen
Publication date 30-09-2023
This was a multicenter double-blinded randomized placebo-controlled trial. Here we present the trial design to evaluate the efficacy of BET, and the results of a pilot study with 3- and 12-months follow-up. The pilot study demonstrates that our protocol is feasible, and that blinded RCTs are dearly needed.
Introduction Balloon Eustachian tuboplasty (BET) is used to treat obstructive Eustachian tube dysfunction (OETD) and recurrent otitis media with effusion (OME). However, there are no indisputable evidence of its efficacy. Here, we present a multicenter, double-blinded, randomized, placebo-controlled trial (MDRCT) design to evaluate the efficacy of BET, and the results of a pilot trial with 3- and 12-months follow-up.
Material and Methods This was a prospective MDRCT. For a pilot study, OETD (n = 10) and OME (n = 5) patients were recruited and followed. Detailed inclusion and exclusion criteria were used. Participants were randomized at beginning of the operation to active or sham surgery. All procedures were performed under local anesthesia. Controls were performed in double-blinded manner (both patient and physician), at 3 and 12 months after the procedure.
Results Altogether, 20 ears were treated and followed for 12 months, including 14 active BETs and 6 sham surgeries. Both the active and sham surgery were performed under local anesthesia without problems or deviations from the protocol. There were no differences in the preoperative symptoms (ETDQ-7) or objective measures (tympanometry, Valsalva and Toynbee maneuvers, tubomanometry, Eustachian tube score) between active and sham surgery arms. During follow-up, we noticed largely similar reduction in subjective symptoms and improvement in Eustachian tube score both in active and sham surgery arms.
Conclusions The pilot study demonstrates that our MDRCT protocol is feasible, and that blinded RCTs are dearly needed to objectively measure the efficacy of BET.
Level of Evidence2 Laryngoscope, 2023
Keishi Matsuda, Hiroumi Matsuzaki, Dai Fujiwara, Kiyoshi Makiyama, Takeshi Oshima
Publication date 30-09-2023
Intraoperative narrow-band imaging has a high papilloma detection rate in patients with respiratory papillomatosis and can potentially reduce the number of surgeries required for them.
Objective Narrow-band imaging (NBI) is considered useful for detecting respiratory papillomatosis. However, the choice between preoperative and intraoperative NBI depends on the facility. We investigated the usefulness of NBI and determined whether preoperative NBI can replace intraoperative NBI with a comparable detection rate.
Methods In this retrospective cohort study conducted at single a tertiary care center, patients with respiratory papillomatosis treated between 2017 and 2022 were enrolled. We systematically compared preoperative white light imaging (WLI) with preoperative and intraoperative NBI. The primary endpoints were the papilloma detection rate and lesion site assessed by the Derkay scoring system. The secondary endpoints were the risk factors for increased Derkay scores.
Results The study included 127 patients with papilloma. Intraoperative NBI yielded significantly higher Derkay scores than preoperative WLI (p < 0.001) and preoperative NBI (p = 0.004). The papilloma detection rates of preoperative WLI and preoperative NBI were not significantly different. Intraoperative NBI detected more lesions than preoperative NBI in 37 of 127 (29%) patients; the overall number of additional lesions was 47 of 279 (17%). Compared with preoperative NBI, intraoperative NBI yielded significantly higher scores for the vocal cords (p = 0.005), false vocal cords (p = 0.010), and ventricle of the larynx (p < 0.001). Elevated Derkay scores were significantly associated with male sex (p = 0.012) and alcohol consumption (p = 0.007).
Conclusion Intraoperative NBI is more accurate in detecting papillomatous lesions, and preoperative NBI cannot replace intraoperative NBI.
Level of Evidence4 Laryngoscope, 2023
Konstantina M. Stankovic, Shelley Batts, D. Bradley Welling, Sasa Vasilijic
Publication date 30-09-2023
In patients with vestibular schwannoma (VS), different levels of immune factors were observed in schwannoma vs. Schwann cells, and in tumor-associated macrophages vs. blood-derived macrophages, some of which were correlated with worse hearing and larger tumors. Inflammation may play a key role in VS-associated hearing loss.
Objectives This study compared the immune-related secretory capacity of human vestibular schwannoma (VS) and tumor-assisted macrophages (TAMs) with their normal counterparts (Schwann cells SC and peripheral blood monocyte-derived macrophages Mo-MFs, respectively), and examined relationships with presurgical hearing and tumor size.
MethodsVS tumors (n = 16), auditory nerve (n = 1), blood (n = 9), and great auricular nerves (n = 3) were used. SCs (S100B+) and TAMs (CD68+) were isolated from VS tissue for culture. The secreted levels of 65 immune-related factors were measured and compared using unpaired t-tests with Welch correction (schwannoma vs. SCs) or Mann–Whitney tests (TAMs and Mo-MFs). Associations between factor concentration and word recognition (WR), pure-tone average (PTA), and tumor size were evaluated with Spearman correlation.
Results Secreted factors with significantly higher concentrations in schwannoma versus SC supernatants included IL-2 and BAFF, whereas MMP-1, IL-6, FGF-2, VEGF-A, MIP-3α, and GRO-α concentrations were significantly higher in TAMs versus Mo-MFs (all p < 0.05). Worse WR was significantly associated with higher secretion of fractalkine, eotaxin-3, CD30, and IL-16 by VS cells; IP-10, eotaxin-3, multiple interleukins, GM-CSF, SCF, and CD30 by TAMs; and TNF-α and MIP-1α by Mo-MFs (all p < 0.05). Worse PTA was significantly correlated with higher secretion of IL-16 by VS cells (p < 0.05). Larger tumor size was significantly correlated with higher secretion of eotaxin by VS cells, and of IL-7, IL-21, and LIF by TAMs (all p = 0.017).
Conclusions Differential secretion of immune-related factors was observed in schwannoma versus normal SCs and in TAMs versus Mo-MFs, some of which were correlated with worse hearing and larger VS tumors.
Level of EvidenceN/A Laryngoscope, 2023
Jessica Bertram, Chad Nieri, Leighton Reed, M. Boyd Gillespie
Publication date 30-09-2023
Objectives To determine the sialendoscopy findings associated with positive findings on minor salivary gland biopsy.
Study Design Single-center retrospective study.
Methods Patients ≥18 years old who underwent sialendoscopy from 2016 to 2022 and were evaluated for SS via labial minor salivary gland biopsy. Biopsy positive and negative patients were compared on the primary outcome measure of sialendoscopy findings. Data were abstracted from the sialendoscopy operative notes and included involved gland, location of ductal pathology, and the presence of scarring, stenosis, mucus plugs, webs, and dilations. Additional characteristics included demographics, presenting symptoms, caffeine or tobacco, use of drying medications, and need for additional treatments.
Results The final cohorts included 22 biopsy positive and 21 biopsy negative patients with a total of 42 glands in the biopsy positive and 37 glands in the biopsy negative groups. Biopsy positive patients were found to require dilation at the hilum and distal duct at significantly higher rates than biopsy negative patients (p < 0.0001). However, there was no statistical difference in scarring, stenosis severity, mucus, webs, or dilations between each group.
Conclusion The outcomes of this study suggest that there are no distinct sialendoscopy findings associated with biopsy positive patients. The presence of significant distal stenosis on sialendoscopy may be associated with positive minor salivary biopsy. Other endoscopic parameters are likely more consistent with non-specific chronic sialadenitis.
Level of Evidence3 Laryngoscope, 2023
Kiminobu Sato, Takashi Kurita, Fumihiko Sato, Kiminori Sato, Shun‐ichi Chitose, Takeharu Ono, Hirohito Umeno
Publication date 29-09-2023
Transcription factor HIF-1α and induced VEGF likely play roles in the pathogenesis of RE of the vocal fold in hypoxic microenvironments. Transcription factor HIF-1α and induced VEGF are potential therapeutic targets for RE.
Objectives The most frequent etiologic factor of Reinkes edema (RE) is considered to be smoking. However, the mechanism for the onset and development of the disease remains unclear. Hypoxia-inducible factor-1α (HIF-1α) is an oxygen-dependent transcriptional activator which plays crucial roles in angiogenesis in hypoxic microenvironments. HIF-1α induces the expression of vascular endothelial growth factor (VEGF) which involves angiogenesis and enhances vascular permeability. This study investigated the roles of HIF-1α in the pathogenesis of RE.
Methods Surgical specimens of RE from patients who underwent endolaryngeal microsurgery were used. Normal vocal folds were used as a control group. Expression of HIF-1α and VEGF was analyzed by immunohistochemistry. Three-dimensional fine structures of the vessels in RE were investigated using correlative light and electron microscopy (CLEM) technique.
ResultsHIF-1α and VEGF were broadly expressed in the stromal, inflammatory, and endothelial cells in the lamina propria of the vocal fold of RE. The expression of HIF-1α and VEGF of RE were significantly higher than in the lamina propria of the normal vocal fold mucosa. CLEM showed vascularization and telangiectasia and there were many dilated capillaries with thin endothelium not covered with pericytes indicating the vessels were fragile.
Conclusion Transcription factor HIF-1α and induced VEGF likely play roles in the pathogenesis of RE. And increased vascular permeability with fragile vessels in angiogenesis is likely to be an etiology of RE. Transcription factor HIF-1α and induced VEGF are potential therapeutic targets for RE.
Level of EvidenceNA Laryngoscope, 2023
Nicholas Fung, Cara M. Fleseriu, Randall J. Harley, Nayel I. Khan, Seungwon Kim
Publication date 29-09-2023
Perineural invasion is a known indicator of poor outcomes in oral cavity squamous cell carcinoma. In this study, the prognostic value of subcategorization of perineural invasion into three categories—extratumoral, peripheral, and intratumoral—was examined. Extratumoral perineural invasion (PNI) and peripheral PNI were associated with worse overall survival when compared with PNI negative disease. However, intratumoral PNI was found to be no different compared with PNI negative disease.
Objective To evaluate whether subcategorization of perineural invasion (PNI) improves the prognostic resolution of the American Joint Committee on Cancer, Eighth Edition (AJCC8) staging system in oral cavity squamous cell carcinoma (OCSCC).
MethodsOCSCC tumor specimens from patients seen at a tertiary care institution who underwent primary surgical resection between January 2019 and June 2021 were sorted into four PNI categories: negative, intratumoral, peripheral, and extratumoral. The prognostic effect of these PNI categories were assessed through Kaplan–Meier, Cox regression, and log-rank testing using recurrence-free survival (RFS) and overall survival (OS) as primary and secondary outcomes respectively.
ResultsA total of 158 patients were examined. The median follow-up time was 21 months. PNI subcategorization further stratified RFS (p = 0.007) and OS (p = 0.002). Extratumoral PNI was associated with a 4.5-fold increase in recurrence risk (adjusted hazards ratio aHR: 4.53; 95% confidence interval CI: 1.1–18.66) and worse OS when compared with PNI negative disease (aHR: 5.71; 95% CI: 1.0–32.67). Peripheral PNI was associated with worse OS (aHR: 5.7; 95% CI: 1.35–24.08) but not worse RFS (p = 0.18) when compared with PNI negative disease. Interestingly, intratumoral PNI was not associated with significant differences in RFS (p = 0.087) or OS (p = 0.22) when compared with PNI negative disease.
Conclusions Subcategorization of OCSCC tumors into extratumoral, peripheral, and intratumoral PNI stratifies RFS and OS when compared with patients with PNI negative disease in an incremental fashion. This pilot study suggests that there may be added benefit in subcategorization of PNI in the prognostic evaluation of OCSCC.
Level of EvidenceIV Laryngoscope, 2023
Sebastian M. Jara, Eric R. Thuler, Michael J. Hutz, Jason L. Yu, Crystal S. Cheong, Normand Boucher, Marianna Evans, Raj C. Dedhia
Publication date 29-09-2023
Surgically assisted rapid palatal expansion (SARPE) addresses transverse maxillary deficiency, a known contributor to nasal obstruction and sleep breathing issues. We describe the feasibility, preliminary outcomes, and safety of posterior palatal expansion via subnasal endoscopy (2PENN), a modified SARPE procedure, aimed at achieving anterior and posterior maxillary expansion. The results of this pilot study show that 2PENN is an effective and safe technique for achieving both anterior and posterior maxillary expansion in patients with transverse maxillary deficiency.
Objective Surgically assisted rapid palatal expansion (SARPE) addresses transverse maxillary deficiency, a known contributor to nasal obstruction. The purpose of this study was to assess the feasibility, preliminary outcomes, and safety of posterior palatal expansion via subnasal endoscopy (2PENN), a modified SARPE procedure, aimed at achieving anterior and posterior maxillary expansion.
Methods This prospective case series included consecutive adult patients with findings of transverse maxillary deficiency that underwent the 2PENN procedure from 4/2021 to 4/2022. Patients completed pre- and post-operative clinical evaluations, Nasal Obstruction and Septoplasty Effectiveness (NOSE) questionnaires, and computed tomography (CT), with measures including expansion at the level of the posterior nasal spine (PNS), first maxillary inter-molar distance (IMD), and anterior nasal spine (ANS).
Results The cohort (N = 20) was middle-aged (39 ± 11 years), predominantly male (80%), and overweight (BMI 28 ± 4 kg/m2). The majority (85%) of patients had sleep breathing issues, of which 10 (59%) had polysomnography-confirmed obstructive sleep apnea (OSA). Full anterior–posterior separation of the mid-palatal suture line was evident on all post-operative CT scans, with mean expansion at the PNS of 3.6 ± 1.3 mm, IMD of 6.1 ± 1.6 mm and ANS of 7.0 ± 1.6 mm (p < 0.001). Following surgery, mean NOSE scores improved from 57 ± 23 to 14 ± 13 (p < 0.001). One patient required maxillary antrostomy for post-operative sinusitis.
Conclusion2PENN is an effective and safe technique for achieving both anterior and posterior maxillary expansion in patients with transverse maxillary deficiency. Further study is warranted to better understand the effect of 2PENN in patients with OSA, particularly as it relates to improving pharyngeal patency.
Level of Evidence4 Laryngoscope, 2023
Camille Clarysse, Jeroen Meulemans, Charlotte van Lierde, Annouschka Laenen, Pierre Delaere, Vincent Vander Poorten
Publication date 29-09-2023
This article comprises a critical appreciation and external validation of the Laryngoscore and the mini-Laryngoscore, two tools to predict difficult laryngeal exposure. Some suggestions to optimize these tools are given and a new tool, available on http://www.predictdle.be, is proposed.
Objective The Laryngoscore was described in 2014 as a practical preoperative assessment tool to predict difficult laryngeal exposure (DLE) during transoral approaches to the larynx. In 2019 the authors proposed a version with a reduced number of variables, called the mini-Laryngoscore. We aim to critically appraise and externally validate these two tools and if needed and possible, to optimize these tools.
Methods103 consecutive patients who underwent a microlaryngoscopy between November 2017 and June 2020 at the Leuven University Hospitals were prospectively included and subjected to a presurgical evaluation of 15 parameters and a peroperative scoring of the anterior commissure visualization. Subsequent analysis focused on the concordance of our findings with those of Piazza et al., the discriminatory ability of the test, and the validity of the included items. We then evaluated a modified prediction tool.
Results Of 103 patients, 18 (17.5%) had DLE. The Laryngoscore and mini-Laryngoscore predicted this with a “good” C-index of respectively 0.727 (95%CI: 0.608–0.846) and 0.714 (95%CI: 0.605–0.823). A newly created prediction tool including only three parameters (Interincisors gap, upper jaw dental status and previous treatments) showed a better discriminatory ability (C-index = 0.835, 95%CI: 0.726–0.944) than the original Laryngoscore, a finding that needs further external validation.
Conclusion The original Laryngoscore and the mini-Laryngoscore displayed a good discriminative ability. Some parameters can be left out of the Laryngoscore without losing discrimination. An even better prediction model seems possible, using a weighted sum of selected predictor variables and by using the parameters in their continuous form.
Level of Evidence2 Laryngoscope, 2023
Richard H. Law, Katherine A. Larrabee, Andrew J. Stefan, Daniel L. Quan, Edward L. Peterson, Michael C. Singer
Publication date 29-09-2023
Objective The primary goal of this study was to determine in patients with normohormonal primary hyperparathyroidism (NHHPT) what percent reduction in post-excision intraoperative parathyroid hormone (IOPTH) from baseline would yield a rate of cure comparable to that in patients with classical primary hyperparathyroidism (PHPT).
Methods This is a retrospective cohort study of patients who underwent parathyroidectomy between July 2013 and February 2020. Demographic data, preoperative, intraoperative, and postoperative metrics were collected. Patients with NHHPT were compared to those with classical PHPT. Subgroup analyses were performed.
Results Of the 496 patients included in the study, 66 (13.3%) were of the normohormonal variant based on preoperative intact parathyroid hormone (PTH) levels and 28 (5.6%) based on baseline IOPTH levels. The cure rates in the two normohormonal groups were not significantly different from their classical counterparts (98.4% and 100.0% vs. 97.1%, p = 1.000). The median percent decline in post-excision IOPTH from baseline that achieved cure in the normohormonal groups were 82.6% and 80.4% compared to their respective controls at 87.3%, p = 0.011 and p = 0.001. Although the rate of multiglandular disease was higher in one of the normohormonal variant groups, this difference was due to a higher rate of double adenomas, not four-gland hyperplasia.
Conclusion Patients with NHHPT undergoing parathyroidectomy can expect cure rates similar to that in patients with classical PHPT. The results of this study indicate that achieving an 80% drop or more in IOPTH levels predicts a high likelihood of cure. This is true irrespective of whether the patient is deemed normohormonal based on preoperative or intraoperative testing.
Level of Evidence Level 3 Laryngoscope, 2023
Shilpa M. Rao, P. Daniel Knott, Larissa Sweeny, Aaron Domack, Alice Tang, Rusha Patel, Amy L. Pittman, J. Reed Gardner, Mauricio A. Moreno, Jumin Sunde, Taylor B. Cave, Nicolaus D. Knight, Ben Greene, Patrik Pipkorn, Arjun S. Joshi, Punam Thakkar, Keven Ji, Sara Yang, Brent A. Chang, Mark K. Wax, Carissa M. Thomas
Publication date 29-09-2023
A multi-institutional study to determine the microvascular-free flap outcomes and ideal timing for free flap reconstruction in patients with midface defects resulting from invasive fungal sinusitis.
Objectives Microvascular free tissue transfer is routinely used for reconstructing midface defects in patients with malignancy, however, studies regarding reconstructive outcomes in invasive fungal sinusitis (IFS) are lacking. We aim to describe outcomes of free flap reconstruction for IFS defects, determine the optimal time to perform reconstruction, and if anti-fungal medications or other risk factors of an immunocompromised patient population affect reconstructive outcomes.
Methods Retrospective review of reconstruction for IFS (2010–2022). Age, BMI, hemoglobin A1c, number of surgical debridements, and interval from the last debridement to reconstruction were compared between patients with delayed wound healing versus those without. Predictor variables for delayed wound healing and the effect of time on free flap reconstruction were analyzed.
Results Twenty-seven patients underwent free flap reconstruction for IFS. Three patients were immunocompromised from leukemia and 21 had diabetes mellitus (DM). Patients underwent an average of four surgical debridements for treatment of IFS. The interval from the last IFS debridement to flap reconstruction was 5.58 months (±5.5). Seven flaps (25.9%) had delayed wound healing. A shorter interval of less than 2 months between the last debridement for IFS and reconstructive free flap procedure was associated with delayed wound healing (Fisher Exact Test p = 0.0062). Other factors including DM, BMI, HgA1c, and bone reconstruction were not associated with delayed wound healing.
Conclusion Patients with maxillectomy defects from IFS can undergo microvascular-free flap reconstruction with good outcomes while on anti-fungal medication. Early reconstruction in the first 2 months after the last IFS debridement is associated with delayed wound healing.
Level of EvidenceIV Laryngoscope, 2023
Barak Ringel, Zachary A. Kons, Eric H. Holbrook, Stacey T. Gray
Publication date 29-09-2023
In this study of 734 patients undergoing maxillary antrostomy at a single institution, odontogenic sinusitis (ODS) incidence was found to rise sharply after the onset of the pandemic. Additionally, the presentation of ODS during the COVID-19 pandemic was found to be more advanced.
Objectives The COVID-19 pandemic affected the epidemiology of several diseases. This study aims to compare the incidence of surgically treated odontogenic sinusitis (ODS) before and during the COVID-19 pandemic and identify unique features.
MethodsA retrospective chart review of patients who underwent at least maxillary antrostomy at a tertiary referral center was performed.
The patients were divided into two cohorts: “pre-COVID” (March 2018 to February 2020) and “COVID” (March 2020 to February 2022). Data on demographics, comorbidities, and treatment interventions were collected and analyzed.
Results Of the 734 patients who underwent maxillary antrostomy, 370 (50.4%) were operated on during the COVID period, with a mean age of 53.1 ± 15.7 years. ODS was found as the etiology of 22 (6%) and 45 (12.2%) of the pre-COVID and COVID cases, respectively (p = 0.006). Although no difference was found in the incidence of diabetes (p = 0.9) or obesity (p = 0.7) between groups, a trend toward higher incidence of immunosuppression was found in the pre-COVID patients (18.2% vs. 0%, p = 0.06). A higher incidence of sphenoid sinus involvement (31.8% vs. 8.9%, p < 0.05) was identified in the pre-COVID group; however, no differences in ethmoid (86.4% vs. 86.7%, p = 0.999) or frontal sinus involvement (54.5% vs. 37.8%, p = 0.3) were found between the groups.
Conclusion There was an increase in the incidence of ODS during the first 2 years of the COVID-19 pandemic compared to the 2 years prior. Similar clinical characteristics were found in both groups. Future studies focusing on specific etiologies to explain ODS preponderance may help determine optimal treatment and prevention strategies.
Level of Evidence Level III Laryngoscope, 2023
Brett A. Campbell, Victoria B. Flormann, Roger B. Davis, Pavan S. Mallur
Publication date 29-09-2023
We examine efficacy of EMG-guided Botox injection to the laryngeal adductor compartment for treatment of idiopathic chronic cough. The treatment is effective, and subjective improvement correlates with CSI scores, even in patients with pulmonary co-morbidities. There were minimal complications with rate that was comparable to historical data.
Objectives Studies examining electromyography (EMG)-guided laryngeal onobotulinumtoxinA (BTxA) injection for chronic cough reveal promising efficacy, however, are limited by small cohorts and absent quantifiable outcomes. It further remains unclear if pulmonary disease limits efficacy, or if vagal motor neuropathy prognosticates response. We hypothesize BTxA injection results in qualitative improvement in cough, decrease in Cough Severity Index (CSI), no change in Voice Handicap Index-10 (VHI-10), and complication rates comparable to historical data. We also examine the correlation of pulmonary comorbidities and vocal fold hypomobility with treatment efficacy.
Study Design Retrospective review.
Methods Charts for patients receiving percutaneous adductor compartment BTxA injection for cough were reviewed for the binary outcome of patient-reported presence or absence of improvement. Generalized estimating equations regression models were used to analyze the change in CSI (ΔCSI) and the correlation of ΔCSI with qualitative outcomes. Multivariable analyses were used to examine correlation of vocal fold hypomobility and pulmonary disease with qualitative outcomes and ΔCSI.
Results Forty-seven patients underwent 197 BTxA injections from June 2012 to June 2022. A statistical proportion of 0.698 (0.599–0.813, p < 0.0001) or 69.8% of injections resulted in subjective improvement. Mean ΔCSI was −2.12 (0.22–4.02, p < 0.05), indicating overall improvement. With and without subjective improvement, estimated ΔCSI was −4.43 and +2.68, respectively (p < 0.0001). VHI-10 did not change (0.69, p = 0.483). Neither pulmonary disease nor vocal fold hypomobility correlated with subjective improvement or ΔCSI. Dysphagia occurred following 15 (7.6%) injections with no aspiration pneumonia or hospitalization.
ConclusionsBTxA injection to the laryngeal adductors may effectively treat cough with limited risk for serious complications.
Level of Evidence4 Laryngoscope, 2023
Robert A. Morrison, David T. Fetzer, Amber Patterson‐Lachowicz, Sarah McDowell, Julianna C. Smeltzer, Ted Mau, Adrianna C. Shembel
Publication date 29-09-2023
Optical flow from ultrasound videos was used to measure paralaryngeal muscle movement velocity and variability in subjects with and without a primary muscle tension dysphonia. There were significant group differences on standard clinical voice and laryngoscopic metrics but not with optical flow measures.
Objectives The paralaryngeal muscles are thought to be hyperfunctional with phonation in patients with primary muscle tension dysphonia (pMTD). However, objective, quantitative tools to assess paralaryngeal movement patterns lack. The objectives of this study were to (1) validate the use of optical flow to characterize paralaryngeal movement patterns with phonation, (2) characterize phonatory optical flow velocities and variability of the paralaryngeal muscles before and after a vocal load challenge, and (3) compare phonatory optical flow measures to standard laryngoscopic, acoustic, and self-perceptual assessments.
Methods Phonatory movement velocities and variability of the paralaryngeal muscles at vocal onsets and offsets were quantified from ultrasound videos and optical flow methods across 42 subjects with and without a diagnosis of pMTD, before and after a vocal load challenge. Severity of laryngoscopic mediolateral supraglottic compression, acoustic perturbation, and ratings of vocal effort and discomfort were also obtained at both time points.
Results There were no significant differences in optical flow measures of the paralaryngeal muscles with phonation between patients with pMTD and controls. Patients with pMTD had significantly more supraglottic compression, higher acoustic perturbations, and higher vocal effort and vocal tract discomfort ratings. Vocal load had a significant effect on vocal effort and discomfort but not on supraglottic compression, acoustics, or optical flow measures of the paralaryngeal muscles.
Conclusion Optical flow methods can be used to study paralaryngeal muscle movement velocity and variability patterns during vocal productions, although the role of the paralaryngeal in pMTD diagnostics (e.g., vocal hyperfunction) remains suspect.
Level of Evidence2 Laryngoscope, 2023
Marn Joon Park, Ji‐Won Choi, Ji Heui Kim, Yoo‐Sam Chung, Myeong Sang Yu
Publication date 29-09-2023
Sinonasal organizing hematoma (OH) is an uncommon, nonneoplastic condition that produces epistaxis, a reddish mass, and bony skeletal structural damage, sometimes mistaken for a malignant tumor. Gd-enhanced-MR exhibited the highest sensitivity to diagnose sinonasal OH (87%) compared with contrast-enhanced-CT (53%), punch biopsy (49%), and non-enhanced-CT (16%) (all p 0.05). Fewer than 20% of sinonasal OH patients had persisting systemic comorbidities, bleeding tendencies, or surgery. Sinonasal OH incidence rose by 1.05 patients per year (p 0.05) during the last 23 years, and endoscopic-assisted surgery can remove it safely and efficiently without embolization in nearly all instances.
Introduction Sinonasal organizing hematoma (OH) is a rare, nonneoplastic lesion that often presents with epistaxis, a reddish mass, and destruction of the involved sinonasal structures. Due to its rarity, the demographics, diagnostic modalities, treatment strategies, and outcomes have not yet been studied in a large, long-term study.
Materials and Methods Retrospect cohort of 112 sinonasal OH patients treated between 1997 and 2020 in a tertiary, university hospital were evaluated. Demographics, systemic comorbidities, sinonasal surgery history, serum laboratory tests, radiological findings, and treatment results were collected. The present study aimed to assess the accuracy of preoperative computed tomography (CT), Gadolinum-enhanced magnetic resonance (MR), and punch biopsies in detecting sinonasal OH as the most likely diagnosis. In addition, incidental differences by age and year of diagnosis were calculated using the Poisson log-linear regression model.
Results The median age was 44, and 58% were male. Fewer than 20% of these cases had a chronic systemic comorbidity, bleeding tendency, or sinonasal surgery history. MR had the highest accuracy of (87%) to detect sinonasal OH as the most likely diagnosis, compared with contrast-enhanced-CT (53%), punch biopsy (49%), and non-enhanced-CT (16%) (all <0.05). Sinonasal OH incidence did not vary by age, but the yearly rate significantly increased by 1.05 times over 23 years (p < 0.05). Notably, 84% of 112 patients received surgical removal through the assistance of an endoscope, and none had substantial bleeding without preoperative embolization.
Conclusion Sinonasal OH was observed regardless of age, sex, systemic comorbidities, bleeding tendency, prior sinonasal surgery, or trauma. Preoperative MR gives the highest accuracy for detecting this disease. Sinonasal OH may be safely managed with endoscopic-assisted surgery removal without embolization.
Level of Evidence4 Laryngoscope, 2023
Elton M. Lambert, Uma Ramaswamy, Sharada H. Gowda, David R. Spielberg, Joseph L. Hagan, Emily Xiao, Sean Liu, Natalie Villafranco, Tiffany Raynor, Rahul G. Baijal
Publication date 28-09-2023
The purpose of this study was to identify risk factors for perioperative complications and long-term morbidity in infants from the neonatal intensive care unit (NICU) presenting for a tracheostomy. This single-center retrospective cohort study found an incidence of severe perioperative complications of 4.4%, including perioperative cardiac arrest and death, with the number of pulmonary hypertension medication classes preoperatively as a significant risk factor. Furthermore, approximately 81% of patients had a gastrostomy tube placement at the time of the tracheostomy and 62% of patients were ventilator dependent 2 years following the tracheostomy. Our study provides critical perioperative and long-term data to neonatologists, pediatricians, surgeons, anesthesiologists, and families about the expected course of infants from the NICU presenting for a tracheostomy.
Objective The purpose of this study was to identify risk factors for perioperative complications and long-term morbidity in infants from the neonatal intensive care unit (NICU) presenting for a tracheostomy.
Methods This single-center retrospective cohort study included infants in the NICU presenting for a tracheostomy from August 2011 to December 2019. Primary outcomes were categorized as either a perioperative complication or long-term morbidity. A severe perioperative complication was defined as having either (1) an intraoperative cardiopulmonary arrest, (2) an intraoperative death, (3) a postoperative cardiopulmonary arrest within 30 days of the procedure, or (4) a postoperative death within 30 days of the procedure. Long-term morbidities included (1) the need for gastrostomy tube placement within the tracheostomy hospitalization and (2) the need for diuretic therapy, pulmonary hypertensive therapy, oxygen, or mechanical ventilation at 12 and 24 months following the tracheostomy.
Results One-hundred eighty-three children underwent a tracheostomy. The mean age at tracheostomy was 16.9 weeks while the mean post-conceptual age at tracheostomy was 49.7 weeks. The incidence of severe perioperative complications was 4.4% (n = 8) with the number of pulmonary hypertension medication classes preoperatively (OR: 3.64, 95% CI: (1.44–8.94), p = 0.005) as a significant risk factor. Approximately 81% of children additionally had a gastrostomy tube placed at the time of the tracheostomy, and 62% were ventilator-dependent 2 years following their tracheostomy.
Conclusion Our study provides critical perioperative complications and long-term morbidity data to neonatologists, pediatricians, surgeons, anesthesiologists, and families in the expected course of infants from the NICU presenting for a tracheostomy.
Level of Evidence Level 3 Laryngoscope, 2023
Vidit Talati, Katie Holland, Shehbaz M. Ansari, Peter Filip, Sarah Khalife, Miral D. Jhaveri, Bobby A. Tajudeen, Peter Papagiannopoulos, Pete S. Batra
Publication date 28-09-2023
Objective To analyze clinical and radiographic features that may impact the rate of focal hyperostosis (FH) on computed tomography (CT) for primary and recurrent sinonasal inverted papillomas (IPs) as well as highlight factors that may affect concordance between FH and IP true attachment point (TAP).
Methods All IPs resected between 2006 and 2022 were retrospectively reviewed. CTs were read by a neuroradiologist blinded to operative details. IP with malignancy was excluded. Operative reports and long-term follow-up data were evaluated.
Results Of 92 IPs, 60.1% had FH, 25% had no CT bony changes, and 20.7% were revision cases. The recurrence rate for rhinologists was 10.5% overall and 7.3% for primary IPs. Primary and revision IPs had a similar rate of FH (63% vs. 52.6%; p = 0.646) and FH–TAP agreement (71.7% vs. 90%; p = 0.664). Nasal cavity IPs, especially with septal attachment, were more likely to lack bony changes on CT (57.1%) compared to other subsites (p = 0.018). Recurrent tumors were 16 mm larger on average (55 mm vs. 39 mm; p = 0.008). FH (75.0% vs. 60.9%; p = 0.295), FH–TAP concordance (91.7% vs. 74.4%; p = 0.094), and secondary IP (18.8% vs. 20.3%; p = 0.889) rates were similar between recurrent and nonrecurrent tumors.
Conclusion Primary and revision IPs have a similar rate of FH and FH–TAP agreement. Nasal cavity IPs are less likely to exhibit bony CT changes. Lower recurrence was associated with smaller size and fellowship training but not multiple TAPs, revision, FH absence, or FH–TAP discordance.
Level of Evidence3 Laryngoscope, 2023
Alessandro Vinciguerra, Sarah Atallah, Francesco Boaria, Joffrey Molher, Benjamin Verillaud, Florian Chatelet, Philippe Herman
Publication date 28-09-2023
Medial petrous apex cholesterol granuloma is a benign lesion which treatment is generally based on a trans-nasal marsupialization. When the artificial ostium is created, it is usually kept open with local flaps, like the septal nasopharyngeal “kite flap”, a reliable local vascularized flap. Laryngoscope, 2023
Pubmed PDF WebDesi P. Schoo, Bryan K. Ward, Margaret R. Chow, Andrianna I. Ayiotis, Celia Fernández Brillet, Peter J. Boutros, Kelly E. Lane, Claudia N. Lee, Brian J. Morris, John P. Carey, Charles C. Della Santina
Publication date 28-09-2023
Karolina A. Plonowska‐Hirschfeld, Arushi Gulati, Erika M. Stephens, Edgar Ochoa, Mary Jue Xu, Patrick K. Ha, Chase M. Heaton, Sue S. Yom, Jason W. Chan, Alain Algazi, Hyunseok Kang, William R. Ryan
Publication date 28-09-2023
Objective To prospectively compare the impact of treatment modality on patient-reported quality of life (QOL) in human papillomavirus-associated oropharynx squamous cell carcinoma (HPV + OPSCC).
Study Design Prospective cohort study.
Setting Academic medical center.
Methods One hundred one patients with American Joint Committee on Cancer (AJCC) 8th edition T1-3 N0-2 HPV + OPSCC completed the European Organization for Research and Treatment of Cancer Quality of Life Core questionnaire and Head and Neck Module pretreatment and 3-month and 1-year posttreatment. Mean score changes were compared to published minimal clinically important differences.
Results Patients underwent surgery alone (SA: N = 42, 42%), surgery with adjuvant radiation (S-RT: N = 10, 10%), surgery with adjuvant chemoradiation (S-CRT: N = 8, 8%), definitive radiation (RT: N = 11, 11%), or definitive chemoradiation (CRT: N = 30, 30%). SA, S-CRT, and CRT patients all reported clinically significant difficulty with sense of taste/smell persisting at 1 year. S-CRT and CRT patients reported statistically and clinically significant worse salivary dysfunction and problems with social eating at 1 year than SA. S-CRT patients reported statistically and clinically significant worse fatigue and head and neck pain compared to CRT and SA patients at 3 months, but normalized at 1 year. S-CRT compared to S-RT had statistically and clinically worse physical and role functioning and swallowing difficulties at 3 months but this difference was resolved by 1-year posttreatment.
ConclusionHPV + OPSCC patients after SA report the lowest posttreatment QOL impact, whereas after S-CRT report the highest symptom burden. Careful selection for definitive surgery is important given the possibility of adjuvant CRT. Patients can experience persistent sense taste and smell difficulties at 1 year with all treatment modalities.
Level of Evidence3 Laryngoscope, 2023
Nicholas J. Thompson, Margaret T. Dillon, Evan P. Nix, Andrea B. Overton, A. Morgan Selleck, Matthew M. Dedmon, Kevin D. Brown
Publication date 28-09-2023
This study looked at cochlear implant recipients who had normal to moderately-severe low-frequency hearing at their preoperative appointment but lost this hearing after surgery. Results show that they still had significantly improved performance with the cochlear implant compared to before surgery.
Objective Determine variables that influence post-activation performance for cochlear implant (CI) recipients who lost low-frequency acoustic hearing.
MethodsA retrospective review evaluated CNC word recognition for adults with normal to moderately severe low-frequency hearing (preoperative unaided thresholds of ≤70 dB HL at 250 Hz) who were implanted between 2012 and 2021 at a tertiary academic center, lost functional acoustic hearing, and were fit with a CI-alone device. Performance scores were queried from the 1, 3, 6, 12, and 24-month post-activation visits. A linear mixed model evaluated the effects of age at implantation, array length (long vs. mid/short), and preoperative low-frequency hearing (normal to mild, moderate, and moderately severe) on speech recognition with a CI alone.
Results113 patients met the inclusion criteria. There was a significant main effect of interval (p < 0.001), indicating improved word recognition post-activation despite loss of residual hearing. There were significant main effects of age (p = 0.029) and array length (p = 0.038), with no effect of preoperative low-frequency hearing (p = 0.171). There was a significant 2-way interaction between age and array length (p = 0.018), indicating that older adults with mid/short arrays performed more poorly than younger adults with long lateral wall arrays when functional acoustic hearing was lost.
ConclusionCI recipients with preoperative functional low-frequency hearing experience a significant improvement in speech recognition with a CI alone as compared to preoperative performance—despite the loss of low-frequency hearing. Age and electrode array length may play a role in post-activation performance. These data have implications for the preoperative counseling and device selection for hearing preservation candidates.
Level of Evidence Level IV Laryngoscope, 2023
Michael S. Benninger, Brooke A. Quinton, William S. Tierney, Victoria L. Gau, Rebecca C. Nelson, Candace M. Hrelec, Paul C. Bryson
Publication date 26-09-2023
This is the first study to report on the outcomes of 46 patients who underwent unilateral or bilateral SLN block for non-cough laryngeal hypersensitivity complaints to study its efficacy and perceived patient benefit in various disorders involving the “irritable larynx.”Objective(s)To investigate the effect of superior laryngeal nerve (SLN) block in patients with non-cough complaints relating to laryngeal who have failed conventional medical therapy.
Methods Retrospective chart review of 46 patients who underwent SLN block for non-cough indications between July 2019 and March 2022 was performed. Demographics, comorbidities, and patient-reported outcomes were collected.
The primary diagnoses for this group included: odynophagia, throat pain, cervicalgia, muscle tension dysphonia, globus sensation, hyoid bone syndrome, and Eagle syndrome.
Results The cohort underwent an average of 1.24 bilateral injections (range 0–7) and 0.87 unilateral injections (range 0–4). About 35 of 46 patients reported an average of 51.0% improvement in their symptoms, with the treatment effect lasting 7.60 weeks on average. On subgroup analysis, the patients with spasmodic dysphonia, odynophagia, and hyoid bone syndrome had the best percent improvement on average (75%–77.5%). Patients with globus sensation had the lowest percent improvement on average in response to this therapy, reporting only about 25%. Five patients experienced a mild adverse reaction immediately following injection which resolved spontaneously.
Conclusion The use of in-office SLN block for non-cough disorders involving the larynx requires further study with larger sample sizes to better delineate the efficacy of these applications.
Level of Evidence4 Laryngoscope, 2023
Kirsten Meenan, Pranati Pillutla, Dinesh K. Chhetri
Publication date 26-09-2023
Brooke A. Quinton, William S. Tierney, Michael S. Benninger, Rebecca C. Nelson, Victoria L. Gau, Candace M. Hrelec, Paul C. Bryson
Publication date 26-09-2023
We describe the outcomes of a cohort of 163 patients who received a series of bilateral superior laryngeal nerve blocks as an in-office treatment for refractory chronic cough. This study is the first to attempt to quantify efficacy and duration of benefit, compare injection contents, and describe adverse effects when utilizing this therapy in a moderate sample of patients.
Objective(s)The aim was to investigate the utilization and efficacy of bilateral superior laryngeal nerve block in patients with refractory chronic cough.
MethodsA retrospective chart review of 164 patients with refractory chronic cough who underwent bilateral SLN block at a single institution between November 2018 and September 2022 was performed. Demographics, comorbidities, and patient-reported outcomes including pre- and postinjection Leicester Cough Questionnaire (LCQ) scores were collected and analyzed.
Results The cohort underwent an average of 2.97 bilateral injections (range 1–22), containing either corticosteroid and local anesthetic or corticosteroid alone. Notably, 116 of 164 of patients reported an average of 67.3% reduction in their symptoms, with the treatment effect lasting 7.60 weeks on average. The average pre- and postinjection LCQ scores were 9.70 and 13.82, respectively. A lower LCQ score represents a greater impairment of health status due to cough, and the minimum important change is 1.3 points between questionnaires. The average improvement on LCQ following bilateral SLN block was 4.11 points for this cohort.
Conclusion The use of in-office bilateral SLN block is an effective treatment that can be used alone or in conjunction with oral medications for the treatment of refractory chronic cough.
Level of Evidence4 Laryngoscope, 2023
Do Hyun Kim, Sung Won Kim, Mohammed Abdullah Basurrah, Se Hwan Hwang
Publication date 26-09-2023
Objectives To conduct a systematic review and meta-analysis of published articles to assess the impact of inferior turbinate/meatus augmentation in patients diagnosed with empty nose syndrome (ENS).
Data Sources Pub Med, Cochrane database, Embase, Web of Science, SCOPUS, and Google Scholar.
Review Methods Six databases were searched to December 2022. We retrieved studies evaluating improvements in refractory ENS-related symptoms based on various patient-reported outcome measures after inferior turbinate/meatus augmentation.
Results As a result of meta-analysis, Sinonasal Outcome Test, Empty Nose Syndrome 6-Item Questionnaire (ENS6Q), and depression scores were measured at 1 week; 1, 3, and 6 months; and later than 12 months after intervention for patients with ENS. All scores revealed significant symptom improvement. By reference to the minimal clinically important difference of the ENS6Q (6.25), inferior turbinate/meatus augmentation relieved the nasal symptoms of ENS in the long term. Although the improvements in anxiety scores at 1 week (0.4133 −0.3366; 1.1633, 0.00, I2 = NA) and 1 month (0.4525 −0.0529; 0.9579, I2 = 0.0%) were not statistically significant, the scores differed significantly at 3 months (0.7351 0.4143; 1.0559, I2 = 28.4%), 6 months (0.8297 0.6256; 1.0337, I2 = 37.2%), and longer than 12 months (0.7969 0.4768; 1.1170, I2 = 0.0%).
Conclusion These data and analysis suggest that performing inferior turbinate/meatus augmentation on ENS patients may improve not only nasal symptom scores but also accompanying psychological problems such as anxiety and depression. Laryngoscope, 2023
Necati Enver, Lucas G. Axiotakis Jr., Lucian Sulica, Michael J. Pitman
Publication date 25-09-2023
Objectives The primary objective was to assess the perspectives of recent laryngology fellowship graduates on office-based procedure training, with a secondary objective to compare this with previous research on perspectives of fellowship directors.
Methods Recent laryngology fellowship graduates were surveyed via an online survey platform regarding post-fellowship practice and various aspects of office-based procedure training, including perceived competence, mentorship, and barriers.
Results There were 51 respondents. Seventy-six percent of respondents felt they “definitely” received adequate office procedure training. Number of procedures as primary surgeon was significantly associated with perception of adequate training (OR 1.54, 95% CI: 1.08–2.19, p = 0.018) and high post-fellowship office procedure volume (OR 1.56, 95% CI: 1.02–2.39, p = 0.040). Fellows reported a lower percentage of procedures as primary surgeons compared with program directors (46.8% vs. 61.9%, p = 0.028). Fellows and directors agreed that informal debriefs were more commonly employed than more structured training elements such as checklists and simulators. Of nine office procedures, laryngeal electromyography, KTP laser, and transnasal esophagoscopy had the greatest decreases in practice after training.
Conclusion Although most recent laryngology fellowship graduates endorse adequate office-based procedure training, a range of individual experiences exists, and office procedure volume, both overall and across individual procedures, may decrease after fellowship. Fellows performing office procedures as primary surgeons may be linked to perceived quality of training and post-fellowship volume.
Level of EvidenceN/A Laryngoscope, 2023
Michael A. Edwards, Emily Brennan, Amy L. Rutt, Divya Muraleedharan, John D. Casler, Aaron Spaulding, Dorin Colibaseanu
Publication date 23-09-2023
This study aimed to determine the utilization of Caprini guideline indicated VTE prophylaxis and impact on VTE and bleeding outcomes in patients after ORL surgeries.
Objective The aim was to determine the utilization of Caprini guideline-indicated venous thromboembolism (VTE) prophylaxis and impact on VTE and bleeding outcomes in otolaryngology (ORL) surgery patients.
Methods Elective ORL surgeries performed between 2016 and 2021 were retrospectively identified. Logistic regression models were used to examine the association between patient characteristics and receiving appropriate prophylaxis, inpatient, 30- and 90-day VTE and bleeding events.
ResultsA total of 4955 elective ORL surgeries were analyzed. Thirty percent of the inpatient cohort and 2% of the discharged cohort received appropriate risk-stratified VTE prophylaxis. In those who did not receive appropriate prophylaxis, overall inpatient VTE was 3.5-fold higher (0.73% vs. 0.20%, p = 0.015), and all PE occurred in this cohort (0.47% vs. 0.00%, p = 0.005). All 30- and 90-day discharged VTE events occurred in those not receiving appropriate prophylaxis. Inpatient, 30- and 90-day discharged bleeding rates were 2.10%, 0.13%, and 0.33%, respectively. Although inpatient bleeding was significantly higher in those receiving appropriate prophylaxis, all 30- and 90-day post-discharge bleeding events occurred in patients not receiving appropriate prophylaxis. On regression analysis, Caprini score was significantly positively associated with likelihood of receiving appropriate inpatient prophylaxis (odds ratio OR 1.05, confidence interval CI 1.03–1.07) but was negatively associated in the discharge cohort (OR 0.43, CI 0.36–0.51). Receipt of appropriate prophylaxis was associated with reduced odds of inpatient VTE (OR 0.24, CI 0.06–0.69), but not with risk of bleeding.
Conclusion Although Caprini VTE risk-stratified prophylaxis has a positive impact in reducing inpatient and post-discharge VTE, it must be balanced against the risk of inpatient postoperative bleeding.
Level of Evidence3 Laryngoscope, 2023
Cara Damico Smith, Nainika Nanda, Kemberlee Bonnet, David Schlundt, Catherine Anderson, Sara Fernandes‐Taylor, Alexander Gelbard, David O. Francis
Publication date 23-09-2023
Diagnostic odyssey refers to the patient experience from symptom onset to diagnosis of a rare disease. We investigated the drivers of odyssey length through semi-structured interviews, in an effort to improve health care for iSGS patients.
Objective Idiopathic subglottic stenosis is a rare disease, and time to diagnosis is often prolonged. In the United States, some estimate it takes an average of 9 years for patients with similar rare disease to be diagnosed. Patient experience during this period is termed the diagnostic odyssey. The aim of this study is to use qualitative methods grounded in behavioral-ecological conceptual frameworks to identify drivers of diagnostic odyssey length that can help inform efforts to improve health care for iSGS patients.
Methods Qualitative study using semi-structured interviews. Setting consisted of participants who were recruited from those enrolled in a large, prospective multicenter trial. We use directed content analysis to analyze qualitative semi-structured interviews with iSGS patients focusing on their pathways to diagnosis.
Results Overall, 30 patients with iSGS underwent semi-structured interviews. The patient-reported median time to diagnosis was 21 months. On average, the participants visited four different health care providers. Specialists were most likely to make an appropriate referral to otolaryngology that ended in diagnosis. However, when primary care providers referred to otolaryngology, patients experienced a shorter diagnostic odyssey. The most important behavioral-ecological factors in accelerating diagnosis were strong social support for the patient and providers willingness to refer.
Conclusion Several factors affected time to diagnosis for iSGS patients. Patient social capital was a catalyst in decreasing time to diagnosis. Patient-reported medical paternalism and gatekeeping limited specialty care referrals extended diagnostic odysseys. Additional research is needed to understand the effect of patient–provider and provider–provider relationships on time to diagnosis for patients with iSGS.
Level of Evidence4 Laryngoscope, 2023
Yupeng Liu, Dante J. Nicotera, Aseeyah A. Islam, Kate Dunsky, Judith E. C. Lieu
Publication date 23-09-2023
Objective Effective management of retropharyngeal abscess (RPA) may predicate upon identification of key patient characteristics. We analyzed characteristics and outcomes of pediatric patients with RPA to identify prognostic factors associated with successful surgical intervention.
MethodsA financial database was searched for pediatric otolaryngology patients with RPA from 2010 to 2021. Medical charts were reviewed for demographics, presenting history, physical examination, laboratory testing, imaging, surgical findings, and hospital course. Bivariate analyses were performed to identify potentially significant predictors of positive drainage. These variables were included in multivariate analysis of surgical outcomes.
Results Of 245 total patients, 159 patients (65%) received surgery and 86 patients (35%) received antibiotics only. Patients with restricted cervical motion, neck swelling, and computed tomography (CT) cross-sectional area (CSA) >2 cm2 were more likely to receive surgery. Rim enhancement on CT imaging was associated with positive surgical drainage (odds ratio OR 2.58, 95% confidence interval CI 1.16–5.74). However, no variables from clinical symptoms or physical exam were associated with positive drainage. Variables that approached significance were included in multivariate analysis, which revealed only rim enhancement predicted positive drainage (OR 2.57, 95% CI 1.13–5.83). The mean length of stay (LOS) was 2.6 versus 3.5 days (p < 0.001) for medical vs surgical treatment groups, respectively.
Conclusion Our study revealed a high success rate of medical management. Although patient characteristics and clinical features were not significant predictors of surgical outcomes, CT findings such as rim enhancement were strongly associated with positive surgical drainage.
Level of Evidence2 Laryngoscope, 2023
Nicole Maronian, Claudia Cabrera, John Dewey, Tanya Meyer
Publication date 22-09-2023
The aim of this study was to identify the incidence of head and neck cancer (HNC) in patients diagnosed with globus pharyngeus. Overall, 4/377 patients ultimately developed HN cancer, for an overall incidence of 1% for the 4-year period of 2015–2019. Given the long term follow-up of this population, the overall incidence of developing a head and neck cancer with a presenting symptom of globus is low. This is the largest study to date to report the percentage of patients endorsing globus pharyngeus to then subsequently develop HNC. This helps otolaryngologists to reassure patients who have a normal comprehensive exam, flexible endoscopy, and targeted studies.
Objectives Globus pharyngeus (GP) is a perplexing problem that accounts for 4% of referrals to otolaryngologists. Workup can be extensive and may not be definitive in terms of etiology. The concern that lingers is that of a subtle cancer, which can prolong anxiety and increase testing cost. The aim of this study was to identify the incidence of head and neck cancer (HNC) in patients diagnosed with GP.
Methods Longitudinal data were captured from two academic institutions, identifying patients with a new diagnosis of globus pharyngeus in 2015. The patient cohort was tracked for at least 4 years to assure follow-up and ability to determine if a HNC developed. Additional demographic data was also collected to determine most common consults, treatments, and testing employed.
Results Excluding patients with previous diagnosis of HNC, 377 patients were identified who presented with GP in 2015 that had at least 4 years of follow-up. Demographics were predominantly women (64.65%), with a mean age of 56.48 years at diagnosis, and the most common provider specialty on the first visit was otolaryngology (39.52%). Four patients ultimately developed HN cancer, for an overall incidence of 1% for the 4-year period of 2015–2019.
Conclusions Given the long-term follow-up of this population, the overall incidence of developing a head and neck cancer, with a presenting symptom of globus, is low. This is the largest study to date to report the percentage of patients endorsing GP to then subsequently develop HNC. This helps otolaryngologists to reassure patients who have a normal comprehensive exam, flexible endoscopy, and targeted studies.
Level of EvidenceIV Laryngoscope, 2023
Hye Yeon Ko, Hae Jeong Nam, Min Hee Kim
Publication date 22-09-2023
We found that 6.7% (17,270/257,123) of the patients had at least one recurrence of SSNHL. The recurrence rate appeared to decrease with age and increase with an increase in the number of recurrences and over time. We found an increase in the incidence of ankylosing spondylitis and a decrease in the incidence of type 2 diabetes mellitus, myocardial infarction, and hemorrhagic stroke in patients with recurrence.
Objectives The aims of this study were to investigate the cumulative recurrence rate of SSNHL and to determine association between comorbidities and recurrence of SSNHL by comparing patients with and without recurrence.
Methods Using the National Health Insurance Claims Database (NHICD) from 2009 to 2020, we conducted a population-based study. We only enrolled patients whose records showed a prescription for steroid and audiometry findings as well as an appropriate diagnostic code. Recurrence of SSNHL was defined as an episode of SSNHL greater than or equal to 3 months after the first episode of SSNHL. We compared the recurrence rate of SSNHL according to age and number of SSNHL recurrences. We also explored comorbidities including autoimmune, metabolic, chronic renal diseases, cancer, and migraine associated with recurrent SSNHL.
ResultsA total of 257,123 patients were identified. We found that 6.7% (17,270/257,123) of the patients had at least one recurrence of SSNHL. The recurrence rate increases with the number of recurrences and over time. The incidence per 100,000 people tended to increase with age, and the recurrence rate appeared to decrease with age. We found an increase in the incidence of ankylosing spondylitis (AS) and a decrease in the incidence of type 2 diabetes mellitus (T2DM), myocardial infarction (MI), and hemorrhagic stroke in patients with recurrence.
Conclusion For patients with recurrence or AS, considerable efforts should be made to prevent recurrence. As SSNHL is an emergent otologic condition, when symptoms occur, they should receive immediate treatment. Additional well-designed population-based studies are required to generalize our results.
Level of Evidence3 Laryngoscope, 2023
"Lauren F. Tracy, D. ONeil Danis III, Timothy Rodriggs, Rohith Kariveda, Gregory A. Grillone"
Publication date 21-09-2023
A cohort of 71 patients with laryngotracheal amyloidosis compared outcomes by treatment with surgery (n = 40), radiation (n = 11), and observation (n = 20). There was no difference in demographics, presenting symptoms or systemic workup between treatment groups. Patients with subglottic and tracheal amyloid were more likely to have radiation for symptom treatment.
Objectives Localized laryngotracheal amyloidosis (LA) is a rare disease that can impact phonation and respiration. Treatment options include observation, surgery, and radiation therapy (RT). Given the rare incidence of LA, evidence regarding optimal management and long-term outcomes is limited.
Study design Retrospective cross-sectional analysis.
Methods All patients with LA presenting to an international amyloid center from 1999 to 2022 were analyzed.
Patients were categorized by treatment modality: surgery, RT, or observation. Patient and disease factors including demographics, clinical presentation, and progression with need for additional treatment were evaluated.
Results Seventy-one patients (27M:44F) with LA were treated with surgery (n = 40), RT (n = 11), and observation (n = 20). Gender distribution, age at diagnosis, and systemic workup did not differ significantly between treatment cohorts. A correlation was identified between LA location and treatment modality, with higher rate of subglottic/tracheal amyloid in RT patients vs. surgery and observation patients (90% and 52% respectively), p < 0.005. Surgery patients had a median of two surgeries for disease management (range: 1–32) and RT patients had median five surgeries prior to RT (range: 0–17).
Six patients required tracheotomy: 3/40 surgery, 3/11 RT and 0/20 in observation cohort. Surgery and RT patients had a longer duration of follow-up (mean 6.7 and 11.7 years) compared with the observation cohort (5.7 years).
Conclusion Laryngotracheal amyloidosis is a rare disease with variable presentation. Selective surgery of involved subsites is the primary treatment, though multiple surgeries may be needed to optimize function. Observation is appropriate for those with minimal symptoms. For recalcitrant disease, and particularly subglottic/tracheal amyloid, radiotherapy can be beneficial.
Level of Evidence4 Laryngoscope, 2023
Albina S. Islam, Graham Pingree, Andrew Chafin, Thomas H. Fitzpatrick IV, Ryan S. Nord
Publication date 21-09-2023
This study investigates the incidence of sensing lead malfunction with the Inspire device for obstructive sleep apnea, utilizing a retrospective review of 190 patients from a single institution as well as reviews adverse events associated with the sensing lead component via an analysis of the FDA Manufacturer and User Facility Device Experience (MAUDE) database. Results indicate a 2.1% rate of sensing lead malfunction, with cases demonstrating internal component issues and sensing lead tip separation. Such malfunctions put patients at risk for migration of the isolated tip, emphasizing the importance of understanding failure scenarios for optimal patient management.
Objectives Upper airway stimulation (UAS) is an effective treatment for patients with obstructive sleep apnea. The device consists of a stimulating electrode, an internal pulse generator, and a respiratory sensing lead. The purpose of this study is to characterize the incidence of sensing lead malfunction necessitating revision surgery in a high-volume center in conjunction with a review of the FDA Manufacturer and User Facility Device Experience (MAUDE) database reports on adverse events associated with the sensing lead component.
Methods Patients age ≥18 implanted with the device were reviewed between July 2017 and June 2022. Those determined to have sensing lead malfunction were analyzed. The FDA MAUDE database was reviewed for reports associated with “Inspire Model 4323 Respiratory” and “Inspire Model 4340 Respiratory” between January 2014 and September 2022.
Results One hundred ninety patients underwent UAS at our institution during the study period and four (2.1%) patients were found to have sensing lead malfunction. Analysis of the MAUDE database revealed 122 reports of adverse events associated with the sensing lead component, with 72% (88/122) of these requiring revision surgery. The most frequently reported adverse event was sensing lead tip separation from lead body, noted in 46% of these reports (56/122).
Conclusion The functionality of the sensing lead component is vital to the integrity of the UAS device and is measurable through waveform analysis. To provide optimal care after device implantation, it is essential to have a comprehensive understanding of the scenarios in which this component fails, the incidence of such events, and appropriate management.
Level of Evidence4 Laryngoscope, 2023
Elisabeth C. Lohrer, Thomas Hummel, Valentin A. Schriever, Janine Gellrich
Publication date 19-09-2023
Sarah E. Grond, Matthew J. Urban, Michael J. Hutz, Phillip LoSavio
Publication date 19-09-2023
Infection and extrusion of hardware are known complications of hypoglossal nerve stimulation surgery. We present a unique case of an extruded hardware lead successfully managed with reimplantation without need for explantation and new device placement. The topic will be discussed in context of the body of literature related to extruded medical device management. Laryngoscope, 133:2821–2822, 2023
Pubmed PDF WebDayton Rand, Brian J. Dlouhy, Sohit Paul Kanotra
Publication date 19-09-2023
We present an extended external rhinoplasty approach with bilateral marginal and alar base incisions for removal of a nasal dermoid cyst with intracranial extension in a 3-year-old patient. This approach provides adequate exposure, enables nasal bone osteotomies, and allows access to the skull base while achieving a cosmetically acceptable scar. Laryngoscope, 133:2798–2802, 2023
Pubmed PDF WebKachorn Seresirikachorn, Andrea Sit, Lu Hui Png, Larry Kalish, Raewyn G. Campbell, Raquel Alvarado, Richard J. Harvey
Publication date 19-09-2023
Carolyns window approach aims to remove the limitation created by the anterior-posterior depth to make a Draft 2a frontal sinusotomy easier for the surgeon. The approach is a 0° endoscope technique and provides an excellent view of the frontal sinus and recess.
Objectives Due to the complexity and variety of the frontal recess and sinus anatomy, traditional Draf 2a frontal sinus surgery is challenging. The thickness of the nasofrontal beak and anterior–posterior dimensions of the frontal recess contribute to this complexity. Carolyns window technique eliminates the limitation of anterior–posterior depth to facilitate a Draf 2a frontal sinusotomy. The approach is a 0° endoscope technique and provides an excellent view of the frontal sinus and recess. We describe Carolyns window approach to frontal sinus surgery and the perioperative outcomes.
Methods Consecutive adult patients in whom Carolyns window technique was applied for frontal sinus dissection as part of the endoscopic management of both inflammatory and neoplastic disease were assessed. The primary outcome was frontal sinus patency. Secondary outcomes were surgical morbidity, defined as early (<90 days) or late (>90 days).
Results Forty-five patients (49.1 ± 17.9 years, 48.9% Female) were assessed. All patients had successful frontal sinus patency (100% 95CI: 92.1%–100%). Morbidities were adhesion (4.8%), crusting (2.4%), pain (1.2%), and bleeding (1.2%) in the early postoperative period. There were no other morbidities in the early and late postoperative periods.
Conclusion Carolyns window approach to frontal sinusotomy is a technique that evolves from previously described approaches. Successful frontal sinus patency with very low morbidities is achieved while still working with a 0° endoscope. The “axillectomy” performed simplifies frontal recess surgery by removing the anteroposterior diameter limitation and the dexterity required in angled endoscopy and instrumentation. The inferior-based lateral wall mucosal flap and free mucosal grafting expedite the mucosal healing process. Laryngoscope, 133:2496–2501, 2023
Seyed Mohammadmehdi Samimi Ardestani, Farrokh Heidari, Mehraveh Sadeghi Ivraghi, Niloufar Saeedi, Ali Bagheri‐Hagh, Saeed Sohrabpour, Seyed Hadi Samimi Ardestani, Nasrin Yazdani, Ebrahim Karimi
Publication date 19-09-2023
Intracapsular dissection approaches in surgical resection of carotid body tumors. Laryngoscope, 133:2627–2630, 2023
Pubmed PDF WebIan Sunyecz, Norman Orabi, Steven Coutras
Publication date 19-09-2023
Emphysematous epiglottitis is a rare manifestation of epiglottitis wherein free air accumulates within the epiglottis, potentially leading to rapid upper airway obstruction. Physicians should be familiar with the diagnosis and treatment of this life-threatening condition.
Epiglottitis is a bacterial infection of the upper respiratory tract that can be rapidly progressive and life-threatening. Though predominantly seen in unvaccinated children, there seems to be a shift with the incidence of adult cases rising following the Haemophilus Influenza B (HiB) vaccine. There are several reports of epiglottitis manifesting as an abscess, but few cases report on the formation of an emphysematous abscess. Additionally, little is known on the bacterial etiology of such infections. Here, we present a case of a patient found to have acute emphysematous epiglottis managed with fiberoptic intubation, drainage, and culture of the abscess. Laryngoscope, 133:2747–2750, 2023
Samuel H. Selesnick
Publication date 19-09-2023
Fred F. Telischi, Donald T. Weed
Publication date 19-09-2023
Publication date 19-09-2023
Publication date 19-09-2023
Ryan J. Huang, Amanda Del Risco, Kristal M. Riska, Matthew W. Cooper, Nicholas W. Clark, Samantha J. Kaplan, David Kaylie, Howard W. Francis
Publication date 19-09-2023
Despite its relatively high prevalence, our understanding of the natural clinical course of acute low-tone hearing loss without vertigo remains incomplete. This scoping review found that the majority of patients presenting with acute low-tone hearing loss without vertigo experience hearing improvement. Recurrence and/or fluctuation are common and progression to Menieres disease occurs in a small proportion of patients.
Objective Despite its relatively high prevalence, our understanding of the natural clinical course of acute low-tone hearing loss (ALHL) without vertigo remains incomplete. The purpose of this study is to summarize the findings of studies that evaluated recovery from hearing loss (HL), recurrence and/or fluctuation of HL, and progression to Menieres Disease (MD) of patients presenting with ALHL without vertigo.
MethodsA scoping review of the English literature was performed. On May 14, 2020 and July 6, 2022, MEDLINE, Embase, and Scopus were searched to identify articles related to the prognosis of ALHL. To be included, articles had to present outcomes that were clearly distinguishable for patients with ALHL without vertigo. Two reviewers evaluated articles for inclusion and extracted data. Disagreements were adjudicated by a third reviewer.
Results Forty-one studies were included. There was extensive heterogeneity between studies in regard to defining ALHL, treatment methods, and time of follow-up. Most of the cohorts (39 out of 40) reported partial or complete recovery of hearing in the majority (>50%) of patients, although reports of recurrence were relatively common. Progression to MD was infrequently reported. Shorter time from onset of symptoms to treatment predicted better hearing outcomes in 6 of 8 studies.
Conclusion The literature suggests that although the majority of patients with ALHL experience hearing improvement, recurrence and/or fluctuation are common, and progression to MD occurs in a minority of patients. Additional trials utilizing standardized inclusion and outcome criteria are needed to determine the ideal treatment for ALHL.
Level of EvidenceNA Laryngoscope, 133:2457–2469, 2023
Do Hyun Kim, Sung Won Kim, Geun‐Jeon Kim, Mohammed A. Basurrah, Se Hwan Hwang
Publication date 19-09-2023
The minimally invasive thyroidectomy approaches were not inferior to conventional thyroidectomy in terms of operative outcomes or perioperative complications, and provided high cosmetic satisfaction.
Objectives Minimally invasive and remote surgical approaches for thyroid tumors have been developed primarily for cosmetic benefit. However, conventional meta-analysis could not provide comparative data between new techniques. This network meta-analysis would be able to provide data for clinicians and patients to compare cosmetic satisfaction and morbidity by comparing surgical methods.
Data Sources The Pub Med, EMBASE, MEDLINE, SCOPUS, Web of Science, Cochrane Trials, and Google Scholar.
Review methods The nine interventions included minimally invasive video-assisted thyroidectomy (MIVA), endoscopic and robotic bilateral axillo-breast-approach thyroidectomy (EBAB and RBAB, respectively), endoscopic and robotic retro-auricular thyroidectomy (EPA and RPA, respectively), endoscopic or robotic transaxillary thyroidectomy (EAx and RAx, respectively), endoscopic and robotic transoral approaches (EO and RO, respectively), and a conventional thyroidectomy. We recorded the operative outcomes and perioperative complications; pairwise and network meta-analyses were performed.
ResultsEO, RBAB, and RO were associated with good patient cosmetic satisfaction. EAx, EBAB, EO, RAx, and RBAB were associated with significantly more postoperative drainage than the other methods. Postoperatively, more flap problems and wound infections were found in the RO than control group, and more transient vocal cord palsy was found in the EAx and EBAB groups. MIVA ranked first in terms of operative time, postoperative drainage amount, postoperative pain, and hospitalization, but cosmetic satisfaction was low. EAx, RAx, and MIVA ranked higher than the other approaches in terms of operative bleeding.
Conclusion It was confirmed that minimally invasive thyroidectomy achieves high cosmetic satisfaction and is not inferior to conventional thyroidectomy in terms of surgical results or perioperative complications. Laryngoscope, 133:2470–2479, 2023
Alice E. Huang, Erik P. Chan, Christopher M. Stave, Zara M. Patel, Peter H. Hwang, Michael T. Chang
Publication date 19-09-2023
This scoping review aims to analyze the growing body of literature on the utilization of social media in otolaryngology. Myriad studies demonstrate the application of social media to patient education, professional networking, study recruitment, and obtaining cross-sectional data. However, there remains a paucity of well-controlled studies delineating the benefits and limitations of social media for these various indications.
Objective Social media (SM) is an increasingly popular medium for the medical community to engage with patients, trainees, and colleagues. This review aimed to identify reported uses of SM in otolaryngology-head and neck surgery (OHNS), assess the quality of evidence supporting these uses, and identify gaps in the literature. With the relative lack of regulatory guidelines for the development of SM content, we hypothesized that the quality of content available on SM would be highly variable.
Data Sources and MethodsA scoping review was performed of English-language peer-reviewed studies published to date discussing SM use in any form within OHNS. Three reviewers independently screened all abstracts. Two reviewers independently extracted data of interest from the full text of articles identified from the preliminary abstract screen.
Results171 studies were included, with 94 (54.9%) studies published between 2020 and 2022. 104 (60.8%) studies were conducted in the US. 135 (78.9%) used cross-sectional or survey-based methodology; only 7 (4.1%) were controlled studies. SM was most commonly employed for professional networking (n = 37 21%), and within subspecialties of otology (n = 38 22%) and rhinology/allergy (n = 25 15%). Facebook was most frequently used for study recruitment (n = 23 13.5%), You Tube for patient education (n = 15 14.6%), and Twitter for professional networking (n = 16 9.4%).
ConclusionSM use within OHNS is increasing rapidly, with applications including patient education, professional networking, and study recruitment. Despite myriad articles, there remains a paucity of well-controlled studies. As SM becomes integrated into healthcare, particularly for applications directly impacting patient care, higher levels of evidence are needed to understand its true impact. Laryngoscope, 133:2447–2456, 2023
Alice E. Huang, Michael T. Chang
Publication date 19-09-2023
Thomas Muecke, Joshua Kovoor, Giri Krishnan, Stephen Bacchi, Weng Onn Chan
Publication date 19-09-2023
Adil Aldhahrani, Jeffrey Pearson, Chris Ward
Publication date 19-09-2023
Luke Stanisce, Nadir Ahmad, Donald H. Solomon, Nadeem Kolia, Lucia D. Garcia, Thomas C. Spalla, John P. Gaughan, Yekaterina Koshkareva
Publication date 19-09-2023
Over 50% of new patients seen via in-hospital consultation without prior outpatient evaluation were lost to follow-up. ENT-related illnesses necessitating hospitalization and those of Oncology and Pediatric subspecialties were independent predictors for establishing outpatient care. Pre-assigning appointments prior to discharge were associated with increased outpatient adherence, as supported by randomized prospective evidence.
Objective(s)This investigation aimed to define the rate of outpatient follow-up after in-hospital consultation, identify factors associated with establishing care, and evaluate an alternative scheduling process to improve outpatient adherence.
Methods Two-phase, prospective study at an academic, tertiary-care institution from March 2020 to August 2022. First, all patients not previously known to our practice encountered via inpatient consult who warranted outpatient follow-up were prospectively captured. Logistic regression analysis was used to identify demographic, disease, and practice factors predictive of follow-up. Second, a randomized control trial was performed to validate the effects of pre-assigning appointments prior to discharge.
Results Six hundred subjects were included in the final study cohort; 500 in phase-one, and 100 randomized during phase-two. In the phase-one cohort, 54% (n = 272) were lost to follow-up. Multivariate analysis showed increased odds of outpatient follow-up when appointments were pre-assigned before discharge (odds ratio OR: 3.69 95% confidence interval CI: 2.29–5.96, p < 0.001), the primary reason for hospitalization was ENT and consult-related (OR: 3.29 1.92–5.64, p < 0.001), and the diagnosis was one of Oncology (OR: 1.93 1.02–3.69, p = 0.045) or Pediatrics (OR: 3.36 1.41–7.98, p = 0.006) subspecialties. During phase-two, subjects randomized for pre-assigned appointments had higher outpatient follow-up (82%) compared to the control group (20%) (p < 0.001).
Conclusion Hospital-based consultations represent an important referral pathway for new patients. Disease characteristics may identify patients less likely to follow-up upon discharge. Appointment scheduling protocols, including pre-assigning appointments, are modifiable targets for improving adherence to care. Laryngoscope, 133:2540–2545, 2023
Victoria Idowu, Julie Christensen, Andrea M. Gross, Eva Dombi, Jennifer R Miles, Kelly King, Jennifer Chisholm, Christopher Zalewski, Andrea Baldwin, Patricia Whitcomb, Crystal Burgess, Brigitte C Widemann, Carmen C Brewer, Hung Jeffrey Kim
Publication date 19-09-2023
Objectives To characterize otologic and audiologic manifestations in our NF1 cohort and explore the relationship between otologic and audiologic findings in a subset of patients with ear-related plexiform neurofibromas (PNs).
Methods Audiologic and otologic clinical evaluations were conducted on 102 patients with NF1 in a natural history study (5–45 years; M = 14.4 years; Mdn = 14). Testing included pure tone and speech audiometry, middle ear function, neurodiagnostic auditory brainstem response (ABR), auditory processing, and MRIs of the head and neck region. Patients referred to this study had an overall higher incidence and burden of PNs than the overall NF1 population.
Results The majority of subjects in this cohort had normal hearing sensitivity (81%) and normal middle ear function (78%). Nineteen participants had hearing loss that ranged in degree from mild to profound, with the majority in the mild range. Hearing loss was twice as likely to be conductive than sensorineural. In patients with ear-related PNs (n = 12), hearing loss was predominantly conductive (60%). Seventy-five percent of ears with PNs had atypical tympanometric tracings that could not be characterized by the classic categories. In all 20 patients with a PN in the temporal bone, the ear canal was affected, and the PNs often extended to the surrounding soft tissue regions.
Conclusions People with NF1-related PNs in the temporal bone and adjacent skull base should have audiometric and otologic monitoring. Addressing hearing concerns should be part of routine clinical evaluations in patients with NF1. Magnetic resonance imaging (MRI) should be performed in patients with NF1 who have hearing loss.
Level of Evidence3 Laryngoscope, 133:2770–2778, 2023
Anaïs Rameau, Katerina Andreadis, Vinayak Ganesan, Mark S Lachs, Tony Rosen, Fei Wang, Alexandra Maddox, Holger Klinck, Sid M. Khosla, Charles Farbos de Luzan, Shyam Madhusudhana
Publication date 19-09-2023
In canine laryngeal model, we found that several acoustic parameters could predict presence of material on the vocal folds, and identified a possible acoustic biomarker of swallowing dysfunction.
Background Current protocols for bedside swallow evaluation have high rates of false negative results. Though experts are not consistently able to screen for aspiration risk by assessing vocal quality, there is emerging evidence that vocal acoustic parameters are significantly different in patients at risk of aspiration. Herein, we aimed to determine whether the presence of material on the vocal folds in an excised canine laryngeal model may have an impact on acoustic and aerodynamic measures.
Methods Two ex vivo canine larynges were tested. Three liquids of different viscosities (1:100 diluted glycerin, pure glycerin, and honey-thick Varibar) were placed on the vocal folds at a constant volume. Acoustic and aerodynamic measures were obtained in both adducted and abducted vocal fold configurations. Intraglottal high-speed imaging was used to approximate the maximum divergence angle of the larynges in the studied conditions and examine its relationship to vocal efficiency (VE) and acoustic measures.
Results In glottic insufficiency conditions only, we found that several acoustic parameters could predict the presence of material on the vocal folds. Based on the combination of the aerodynamic and acoustic data, we found that decreased spectral energy in the higher harmonics was associated with decreased VE in the presence of material on the vocal folds and/or glottic insufficiency.
Conclusion Decreased spectral energy in the higher harmonics of the voice was found to be a potential biomarker of swallowing dysfunction, as it correlates with decreased vocal efficiency due to material on the vocal folds and/or glottic insufficiency, both of which are known risk factors for aspiration.
Level of EvidenceNA Laryngoscope, 133:2517–2524, 2023
Karl R. Khandalavala, Kieran Boochoon, Makayla Schissel, W Wesley Heckman, Katie Geelan‐Hansen
Publication date 19-09-2023
Objective To evaluate the impact of age and the American Society of Anesthesiologists (ASA) classification on post operative outcomes as well as the changes in the National Surgical Quality Improvement Program (NSQIP) database reporting of comorbidity index variables in patients with facial fractures.
Methods The NSQIP database was queried for facial fracture repair CPT codes between 2012 and 2019 and for modified Frailty Index (mFI) and modified Charlson Comorbidity Index (mCCI) variables between years 2006 and 2018.
The predominant question analyzed two preoperative risk factors: patient and ASA classification. Chi-square analysis, Kruskal-Wallis, Mann–Whitney, Spearman correlation, and multivariable logistic regression were used to evaluate age and ASA classification with wound dehiscence, superficial surgical site infection (SSSI), deep wound infection (DWI), readmission status, and return to the OR. The reporting of indices variables was evaluated with descriptive statistics.
Conclusion In this large database with univariate analysis, patients with a higher ASA classification and older patients experience significantly increased risks of readmission, return to the OR, and longer hospital stays. On multivariate analyses, ASA classes II, III, and IV are independently associated with increased risk of readmission and return to the OR, while controlling for patient age. The reporting of all mFI and mCCI variables were consistent from 2006 to 2010, but after 2011, there has been inconsistent or absent reporting of variables, therefore, conclusions on the impact of comorbidities on facial fracture repair are unreliable.
Level of Evidence4 Laryngoscope, 133:2572–2577, 2023
Mark M. Mims, William W. Shockley, Joseph Madison Clark
Publication date 19-09-2023
The butterfly graft is used to repair the internal nasal valve, but concerns remain regarding the postoperative appearance of the supra tip. This study finds casual observers do not view the supra tip region of a postoperative butterfly graft patient negatively.
Objective The butterfly graft is an effective technique for improving the internal nasal valve, however, there is hesitancy among surgeons due to possible aesthetic changes. This study aims to determine if average observers rated the post-operative appearance of the butterfly graft negatively.
Methods An online survey was distributed by social media to non-medical observers in which they rated either the pre-operative or post-operative appearance of 22 patients noses (11 butterfly graft, 11 spreader graft). A heat map was used to determine if the supratip region was rated as the least aesthetically appealing. Post-operative ratings and heat maps of the butterfly graft patients were compared to pre-operative ratings as well as ratings of the spreader graft group.
Results226 observers responded. There was no difference in the pre-operative and post-operative rating of the butterfly graft group (58.27 vs. 58.00, p = 0.88) or the number of supratip regions selected as least attractive (165 vs. 169, p = 0.60). Similarly, there was no difference in post-operative ratings between the butterfly graft group and spreader graft group (58.00 vs. 58.21, p = 0.63) or in selection of the supratip as the least attractive region (169 vs. 172, p = 0.74).
Conclusion The butterfly graft did not negatively affect observers opinion of patients noses.
Level of Evidence3 Laryngoscope, 133:2578–2583, 2023
Neal R. Godse, Carl H. Snyderman
Publication date 19-09-2023
The study is a retrospective review of readmissions in a high-volume, quaternary care center. Post-operative neck infection and bleeding were the most common reasons for unplanned readmission and are high-value targets in ongoing efforts to mitigate hospital readmission.
Objectives To identify common reasons for readmission following otolaryngologic surgery at a high-volume center and identify possible risk factors for readmission.
Methods Retrospective chart review of readmissions identified by hospital-based electronic medical record reporting mechanism.
Results From January 2019 to September 2020, there were 87 readmissions following 808 index surgeries. The most common reason for readmission was for planned surgery (23%), followed by post-operative neck infection, bleeding, or pneumonia. Patients with unplanned readmissions had significantly longer index admission duration than patients who were not readmitted (median 7 days vs. median 5 days, resp.; p = 0.0056). Analysis of cases of unplanned readmission for neck infection and bleeding identified the oral cavity/pharynx as the most common site of initial surgery and that a majority of patients had a history of radiation therapy.
Conclusion Neck infection, bleeding, and pneumonia were the most common reasons for unplanned readmission following otolaryngologic surgery, and a large portion of patients required additional procedures during readmission. Unplanned readmissions for bleeding were significantly more costly than readmissions for neck infections. Long-index hospitalizations, index surgery involving the oral cavity and pharynx, and a history of radiation therapy may be useful clinical features that could stratify the risk of readmission.
Level of Evidence4, retrospective chart review Laryngoscope, 133:2546–2552, 2023
James W. Schroeder Jr.
Publication date 19-09-2023
Objective To demonstrate the importance of utilizing fiberoptic endoscopic evaluation of swallowing (FEES) when evaluating breastfeeding infants with suspected dysphagia. Failure to recognize and account for the fundamentally different physiology of the primarily breastfed infant can lead to false assumptions about the safety of breastfeeding in this understudied patient population.
Methods Case-series. The medical records of patients referred to an urban, university-based, pediatric hospital for FEES from February 2017 to October 2020 were reviewed. Their presenting symptoms, dysphagia severity, comorbidity, dysphagia workup, and management were analyzed. The standardized Dysphagia Outcome and Severity Scale was used to appraise dysphagia severity.
Results204 FEES exams were reviewed. 35 were conducted on breastfed infants. 34 of the 35 infants calmed for the FEES exam while breastfeeding. Cohorts were defined by a particular presenting sign (cough, laryngeal congestion, choking, and respiratory illness) and anatomical characteristic (laryngomalacia, vocal cord paralysis, aspiration, penetration, etc.) and then compared to all other exams. The average dysphagia score for all the exams was 2.37. Patients presenting with laryngeal congestion had an average dysphagia score of 2.81. There was no difference in dysphagia score based on comorbidities or anatomy.
ConclusionsFEES is the instrumental exam of choice when evaluating a primarily breastfed infant who has suspected dysphagia. The exam is well tolerated and provides accurate, objective information while accounting for this populations unique swallowing physiology. Primarily breastfed infants presenting with laryngeal congestion are more likely to have clinically worse dysphagia than those presenting with other clinical symptoms.
Level of Evidence4 Laryngoscope, 133:2803–2807, 2023
Aarti Agarwal, Ramez Philips, Kathryn Landers, Samantha Savitch, Eric Barbarite, Howard Krein, Ryan Heffelfinger
Publication date 19-09-2023
Orbital defects have a profound impact on orbital function and symmetry of the face and are difficult to reconstruct given the complexity of this area. The paramedian forehead flap is feasible for medial periorbital reconstruction with acceptable functional and symmetrical outcomes and low morbidity.
Background Orbital defects have a profound impact on orbital function and symmetry of the face and are difficult to reconstruct given the complexity of this area. The paramedian forehead flap (PMFF) has not been well studied in reconstruction of orbital defects.
Methods Retrospective review of patients who underwent reconstruction of periorbital defects with PMFF between 2016 and 2021. Variables were ocular adnexal asymmetry, functional outcomes, and orbital complications.
Results Eighteen patients met inclusion criteria. Mean defect size was 11.1 ± 7.5 cm. The most common subsite involved was medial canthus in 88.9% of patients. There was no statistically significant difference between mean medial canthus to midline ratio and mean medial brow to midline ratio when compared to the assumed normal of 1. The medial canthus to pupil ratio and medial canthus to lateral canthus ratio had a statistically significant mean difference from 1.0 (p = 0.003 for both). In 22.2% of patients, the orbit was functional with impairment; the remaining had no impairment. Surgical sequelae occurred in 12/18 (66.7%) of patients, most commonly epiphora in 9/18 (50%) of patients, and ectropion in 5/18 (27.7%).
Conclusion The PMFF is feasible for medial periorbital reconstruction with acceptable functional and symmetrical outcomes and low morbidity.
Level of Evidence4 Laryngoscope, 133:2584–2589, 2023
Sudeepti Vedula, Lena Kheir, Patrick Hu, Aman M. Patel, Dylan F. Roden, Richard C. Park
Publication date 19-09-2023
Sinonasal adenocarcinoma is a rare primary malignancy treated with surgical resection with or without adjuvant radiotherapy. In this study, we saw that radiation therapy may not have an attributable survival benefit.
Objectives This study aims to investigate the utility of adjuvant radiation in patients who undergo surgical resection for the management of node-negative sinonasal adenocarcinoma (SNAC).
Study Design Retrospective database review.
Methods The 2004–2016 National Cancer Data Base (NCDB) was used to extract patients with surgically resected node-negative SNAC. Kaplan–Meier survival analysis and Cox-Proportional Hazards Modelling were used to analyze the impact of adjuvant radiation on overall survival (OS) following surgery.
Results349 patients with SNAC underwent surgical resection. Of these patients, 154 (44.1%) received adjuvant radiotherapy (RT). Although there was no significant difference in race, age, or sex of those receiving RT, those receiving RT have more advanced diseases and are more likely to have positive margins. Kaplan Meier analysis showed no significant difference in 5-year OS in patient who received adjuvant RT in comparison to those who underwent surgical resection alone (65.7% vs. 72.6%, respectively; p = 0.378). In addition, when looking at only patients with positive margins, 5-year OS still did not have a significant difference (73.8% vs. 61.6%, respectively; p = 0.101). Only patients with clinical AJCC T4 showed a statistically significant survival benefit with adjuvant RT (56.9% vs. 29.9%, respectively; p = 0.009).
Conclusions Adjuvant RT does not appear to provide a significant survival benefit in patients with resected SNAC, with the exception of those with clinically AJCC T4 disease.
Level of Evidence4 Laryngoscope, 133:2603–2612, 2023
Nicholas Talbot, Margaret Heller, Sarah Nyirjesy, Brandon Kim, Brad DeSilva, Laura Matrka
Publication date 19-09-2023
Superior laryngeal nerve block with steroid and local anesthetic is an emerging therapy for neurogenic cough secondary to hypersensitivity of the superior laryngeal nerve. Over 70% of patients endorsed subjective improvement after injection and 40% of patients endorsed benefit after initial nonresponse. No localizing symptoms, specific cough features, or aspects of the medical history helped predict response, suggesting that a broader range of patients may be offered the intervention.
Objective Neurogenic cough related to hypersensitivity of the internal branch of the superior laryngeal nerve (SLN) is often treated with neuromodulating medications, which can cause considerable side effects. An alternative therapy is steroid and local anesthetic injection of the SLN (“SLN block”), initially proposed to benefit those with lateralizing symptoms (tenderness over the thyrohyoid membrane or unilateral cough source). Our objectives are to determine if SLN block produces subjective symptomatic improvements and if repeat injections further improve symptoms, and evaluate clinical factors potentially predictive of response.
Methods Retrospective chart review of 54 patients receiving SLN blocks at a tertiary medical academic center from January 2010 to June 2020. Medical history and anticipated predictors of positive response, including stigmata of laryngeal hypersensitivity, were recorded. Outcomes included symptomatic response, number of injections required, and side effects. Response was defined subjectively by asking patients whether the injection was beneficial and objectively by using CSI scores.
Results Fifty-four patients met the inclusion criteria. Thirty-eight patients (70.4%) endorsed improvement. No variables were identified as positive predictors of response. Thirty-two of the 38 (84.2%) endorsed improvement after one injection. Six of 15 (40%) patients who failed the first injection had positive response to the second. No significant side effects were reported.
Conclusion No localizing symptoms, specific cough features, or aspects of the medical history helped predict response, suggesting that a broader range of patients may be offered the intervention. The majority of patients reported symptomatic improvement and repeat injections may benefit patients with initial nonresponse.
Level of Evidence4 Laryngoscope, 133:2647–2653, 2023
Jackie Yang, Tyler Crosby, Sophia Chen, Uche C. Ezeh, Sachi Patil, Paul E. Kwak, Wanda A. Chin, Milan R. Amin
Publication date 19-09-2023
We conducted a prospective, single-blinded randomized controlled trial at an ambulatory surgery center comparing two standard-of-care anesthesia regimens for laryngeal surgeries using a direct laryngoscopy approach: anesthesia with paralysis using rocuronium and anesthesia without paralysis using a continuous remifentanil/propofol infusion. Intraoperative impressions, anesthesia data, and post-operative patient surveys were collected. Anesthesia with paralysis during direct laryngoscopy was associated with more favorable surgical conditions and post-op pain compared to anesthesia with propofol and remifentanil.
Objective To compare outcomes between two standard-of-care anesthesia regimens for operative laryngoscopy: general anesthesia with a neuromuscular blocking agent (NMBA) versus remifentanil and propofol (non-NMBA).
Methods This was a prospective, single-blinded, randomized controlled trial at a tertiary care center. Patients were randomized to either anesthesia using rocuronium (NMBA) or with remifentanil/propofol infusion alone (non-NMBA). Intraoperative impressions, anesthesia data, and post-operative patient surveys were collected.
Results Sixty-one patients who underwent suspension laryngoscopy from 2020 to 2022 were included (25 female, 36 male, ranging 20–81 years). Thirty patients were enrolled in the NMBA arm and 31 patients in the non-NMBA arm. Heart rate and mean arterial pressure were higher in the NMBA (p < 0.01). Patients in the non-NMBA group were more likely to require vasopressors (p = 0.04, RR = 3.08 0.86–11.05). Surgeons were more frequently satisfied with conditions in the NMBA group (86.7%) compared to the non-NMBA group (58.1%, p < 0.01). Procedures were more likely to be paused due to movement in the non-NMBA group (45.1%) compared to the NMBA group (16.6%, p < 0.03, RR = 2.26 1.02–4.99). Patients in the non-NMBA group were more likely to endorse myalgia the week after surgery (44%) compared to the NMBA group (8.3%, p < 0.01) and reported higher average pain levels on a 0–10 pain scale (3.7) compared to the paralysis group (2.0).
Conclusions Anesthesia with rocuronium was associated with better intraoperative conditions and postoperative pain compared to anesthesia with remifentanil/propofol. Remifentanil/propofol were associated with lower blood pressure and suppression of laryngoscopy-associated tachycardia.
Level of Evidence2 Laryngoscope, 133:2654–2664, 2023
Blair M. Barton, Mohammed Mamdani, Catherine Lumley, Jeffrey Blumberg, Benjamin Y. Huang, Samip N. Patel
Publication date 19-09-2023
Few studies have shown significant bone resorption over time in scapula free flaps for mandibulectomy defects. Our series show high rates of osseous union and limited bone resorption that is equivalent to other vascularized osseous flaps.
Objectives Bone resorption of more conventional vascularized bone grafts have been well described showing minimal resorption over time. Few studies have evaluated osseous union and bone resorption in scapula tip free flaps (STFF) in the reconstruction of mandibulectomy defects. We aimed to describe our series on STFF with respect to osseous union and bone resorption over time.
Methods Retrospective chart review of patients receiving STFF from January 2014–January 2017 (n = 25). A neuroradiologist analyzed follow-up CT scans to assess (1) STFF complete, partial, or no osseous union with native mandible and (2) STFF volume change over time in a subset with multiple follow-up scans (n = 18).
Results Twenty-three of 25 patients (92%) showed complete or partial STFF osseous union with native mandible either distally or proximally. STFF volume change ranged from +4.8 to −54% (median −0.5%) over median follow-up interval of 23 months. History of chemoradiation therapy, bisphophonate use, sex, age, or smoking history did not correlate with bone resorption.
ConclusionsSTFFs shows high rates of osseous union and limited bone resorption that is equivalent to, or less than, vascularized fibular and iliac crest flaps. Clinically, this translates into both optimal healing and functional and cosmetic outcomes, especially in the setting of prior therapies.
Level of Evidence4 Laryngoscope, 133:2597–2602, 2023
Marta Filauro, Alessandro Ioppi, Alberto Vallin, Claudio Sampieri, Marta De Vecchi, Giulia Gabella, Pietro Benzi, Francesco Mora, Giorgio Peretti
Publication date 19-09-2023
Benign laryngeal lesions have traditionally been treated surgically through suspension laryngoscopy. In the present study, we report comparable vocal results with an office-based transnasal endoscopic approach with a fiber laser capable of providing favorable morbidity and reduced operation times.
Objective Benign laryngeal lesions have traditionally been treated through suspension laryngoscopy under general anesthesia (GA). Recently, the development of operative videoendoscopes coupled with photoangiolytic lasers has allowed clinicians to treat these conditions in the outpatient clinic. We report our experience in the office-based (OB) setting for the treatment of patients affected by vocal fold polyps (VFPs) and Reinkes edema (RE), comparing it to patients treated under GA.
MethodsA retrospective analysis was conducted on patients affected by VFP or RE. A 445 nm diode blue laser was used through the operative channel of a flexible video-endoscope for OB procedures, while GA surgeries were carried out with cold steel instrumentation. The Voice Handicap Index-10 (VHI-10) represented the primary outcome. Endoscopic outcomes, duration, and morbidity of the procedures were investigated as secondary outcomes.
ResultsA total of 153 patients were retrospectively enrolled. 52 were treated in an OB setting, while 91 underwent GA. Regarding patients with RE, both the OB and GA cohorts showed a significant improvement in VHI-10 (from 12.7 to 2.6 and 19.5 to 5.1, respectively; p < 0.001), as did those with VFPs (from 11.8 to 2.3 and 15.9 to 2.9 respectively; p < 0.001). No differences were found when comparing VHI-10 in the OB and GA cohorts. The mean procedural time of OB treatment (4.9 min) was significantly shorter than GA (37.1 min). No adverse events were reported.
Conclusion Our data demonstrate the efficacy and safety of the OB setting. For selected patients, OB treatments offer comparable vocal outcomes, favorable morbidity, and reduced operation times, making them an appealing alternative to the traditional approach.
Level of Evidence3 Laryngoscope, 133:2665–2672, 2023
Evan Jon Propst, Nikolaus Ernst Wolter
Publication date 19-09-2023
The Myer-Cotton grade of subglottic stenosis depends on the style of endotracheal tube used. Using updated values from currently available endotracheal tubes aims to keep this grading system valid with respect to surgical approach and outcomes following surgery.
Objectives Determine percentage of subglottic stenosis using current endotracheal tube (ETT) cross-sectional areas as actual, compared with previously published ETT cross-sectional areas as expected, and determine if style of ETT could result in a change in percentage of stenosis or Myer-Cotton grade.
Study Type Cross-sectional study.
Design Prospective analysis.
Methods Eight styles of uncuffed pediatric ETT from four manufacturers ranging from 2.0 to 6.0 inner diameter (ID) were evaluated. ID and outer diameter (OD) measurements were obtained from each companys specification sheets. Cross-sectional area was calculated for each ETT using the formula (Area = πr 2). The cross-sectional areas of each current ETT (actual) were compared with those of previously published ETTs (expected) based on age, and the degree of stenosis was calculated using the formula 1- (Area actual/Area expected) × 100%. Ranges of percentage for each style of ETT were calculated.
Results There was an increase in range of OD and area with increasing size of ETT ID, with the largest range in OD being 0.8 mm, and the largest range in area being 10.55 mm2. The median interquartile range (IQR), range of percentage stenoses was 11 (5%), ranging from 0% to 21%. Seven of 28 (25%) ranges were found to span two Myer-Cotton grades.
Conclusions The Myer-Cotton grade of subglottic stenosis depends on the style of ETT used. Using updated values from currently available ETTs aims to keep this grading system valid with respect to surgical approach and outcomes following surgery.
Level of EvidenceNA Laryngoscope, 133:2808–2812, 2023
"Karla ODell, Valerie Huang, Joseph Acevedo, Lindsay Reder, Michael Johns, Li Ding"
Publication date 19-09-2023
Serial in office steroid injection help avoid operative intervention regardless of stenosis etiology. Follow up of at least 2 years suggest that serial in office steroid injection can avoid operative intervention long term. There is potential cost savings associated with serial steroid injection over traditional endoscopic dilation.
Objectives To evaluate the long-term benefit of serial in-office steroid injections (SISI) in the treatment of subglottic and proximal tracheal stenosis (SG/PTS). Evaluate cost of SISI compared to endoscopic dilation (ED).
Study Design Retrospective study and cost analysis.
Methods All patients with SGS/PTS with at least two consecutive in-office steroid injections between 2013 and 2021 were evaluated. Patients with less than 2 years of follow-up data after the initial SISI series were excluded. Demographics, etiology of stenosis, total injections performed, time between steroid series, surgery-free interval (SFI) and adverse events were collected. For patients with known surgical history before SISI, pre-SISI SFI was compared. Institutional billing records and the national CMS average reimbursement were evaluated. Total charges for three treatment strategies (ED alone, ED with post-operative SISI and primary intervention with SISI) were also compared.
Results Forty-nine patients were included; 29 (59%) idiopathic, 11 (22%) traumatic and 9 (18%) rheumatologic. Mean (SD) follow-up time after the first SISI was 3.41 years (1.5), range (2.08–7.25 years). 79% (39/49) did not require additional surgery during the entire follow-up period. The SFI improved from a mean 13.5 months (SD 12.6; range 2–42 months) pre-SISI to a mean (SD) of 42 months (SD 20.2; range 10–87 months) (p < 0.0001) after SISI. Annual average charges for ED alone in our cohort was $15,383.28, compared to $7,070.04 for SISI.
ConclusionsSISI are an effective treatment for patients with SG/PTS. In-office steroid injections could offer cost savings for the patient.
Level of Evidence4 Laryngoscope, 133:2673–2679, 2023
Prasanth Pattisapu, Sara Kinter, Randall A. Bly, John P. Dahl, Jonathan A. Perkins, Xing Wang, Kathleen C. Y. Sie
Publication date 19-09-2023
Objective Patients with 22q11.2 deletion syndrome (22q11DelS) often present with velopharyngeal dysfunction (VPD). VPD in patients with 22q11DelS is multifactorial beyond velopharyngeal insufficiency (VPI) alone, and differences in surgical outcomes are poorly understood. Our objective was to determine whether patients with 22q11DelS have an increased risk for persistent VPI after sphincter pharyngoplasty compared to patients without 22q11DelS.
Methods We completed a retrospective cohort study of patients with 22q11DelS undergoing sphincter pharyngoplasty between 1995 and 2019 using a VPD clinic database. Patients with 22q11DelS were compared to a cohort of 2:1 frequency-matched (age, degree of velopharyngeal closure) patients without 22q11DelS. Variables included patient characteristics, surgical history, perceptual speech evaluation, and degree of closure on nasopharyngoscopic evaluations. Primary outcomes included postoperative VPI severity and hypernasality. Speech and nasopharyngoscopic characteristics were compared using Fishers exact test. Postoperative VPI severity and hypernasality were compared between groups via relative risks (RR) from mixed effects Poisson regression models, with random effects of age and velopharyngeal closure.
Results134 patients (51 22q11DelS, 83 matched) were included, with mean age of 7.3 years (standard deviation 3.0) and 50% male. Cohorts had similar preoperative speech characteristics and nasopharyngoscopic findings. Patients with 22q11DelS had similar postoperative VP function as patients without 22q11DelS (RR 0.85, CI 0.46–1.57 for VPI severity, RR 0.83, CI 0.45–1.53 for hypernasality). Even after adjusting by preoperative variables, no differences were seen between both groups.
Conclusion Matched for age and pre-operative velopharyngeal closure, patients with and without 22q11DelS and VPI had similar benefits after sphincter pharyngoplasty.
Level of Evidence Non-randomized controlled cohort study, 3 Laryngoscope, 133:2813–2820, 2023
Matthew L. Rohlfing, Alexander T. Hillel, Elizabeth Wohler, Nara Sobreira, Elizabeth J Phillips, Simon A. Mallal, Alexander Gelbard
Publication date 19-09-2023
Idiopathic subglottic stenosis is a rare disease with incompletely understood pathophysiology. This study investigated for association with human leukocyte antigen allele variations, which have important contributions to other airway disease including granulomatosis with polyangiitis. There was no specific HLA association identified for idiopathic subglottic stenosis.
Objective Despite recent scientific inquiry, idiopathic subglottic stenosis (iSGS) remains an enigmatic disease. The consistent demographics of the affected population suggest genetic factors may contribute to disease susceptibility. Given the inflammation observed in the affected proximal airway mucosa, we interrogated disease association with human leukocyte antigen (HLA) polymorphisms. Polymorphisms in the HLA locus have previously been shown to influence individuals susceptibility to distinct inflammatory diseases.
Methods High-resolution HLA typing of 37 iSGS patients was compared with 1,242,890 healthy Caucasian controls of European ancestry from the USA National Marrow Donor Program and 281 patients with granulomatosis with polyangiitis (GPA).
Results Complete HLA genotyping of an iSGS population showed no significant associations when compared to a North American Caucasian control population. Unlike GPA patients, iSGS was not associated with allele DPB1*04:01 nor did allele homozygosity correlate with disease severity.
Conclusions There was not a detectable HLA association observed in iSGS. These results support the concept that iSGS possesses a distinct genetic architecture from GPA. If genetic susceptibility exists in iSGS, it likely lies outside the HLA locus.
Level of EvidenceNA, basic science Laryngoscope, 133:2533–2539, 2023
Kosuke Tochigi, Keisuke Miyashita, Satoshi Aoki, Hikaru Sakamoto, Kazuhiro Omura, Yasuhiro Tanaka
Publication date 19-09-2023
This study aimed to clarify the equipment for the safe removal of nasal foreign bodies. Suction, paper clips, and cotton swabs were considered beneficial equipment for the safe removal of nasal foreign bodies because of minimizing complications and their high versatility.
Objective The treatment of nasal foreign bodies involves safe and reliable removal. Few reports have investigated the relationship between equipment and the incidence of complications.
Methods This retrospective study included 300 patients with nasal foreign bodies (average: 3.28 years, interquartile range: 2–4 years). Patients background, characteristics of nasal foreign body, equipment to remove the nasal foreign body, and complications were obtained from medical records. Statistical analysis was performed using Pearsons chi-square test for associated factors and the incidence of epistaxis among the complications.
Results Nasal foreign bodies were found and removed in 256 patients. Forceps, hooks, suction, modified paper clips, and cotton swabs were mainly used to remove the nasal foreign bodies. Epistaxis due to the removal procedure was observed in 26 patients. The occurrence of epistaxis differed depending on the equipment (p = 0.077) and was less frequent in suction and paper clips than in forceps (p < 0.05 and p = 0.077). Epistaxis was not observed when a cotton swab was used. Aspiration and septal perforation were not observed. A statistical relationship was not detected between the hardness of foreign bodies and the occurrence of epistaxis (p = 0.251). The incidence of epistaxis was higher in cases nasal foreign bodies remained for 1 day and over than in cases foreign bodies were removed within 1 day (p < 0.05).
Conclusions This study revealed that suction, modified paper clips, and cotton swabs could be beneficial options for minimizing complications in the removal of nasal foreign bodies.
Level of Evidence4 Laryngoscope, 133:2553–2557, 2023
Kristine Tanner, Heidi J. Robison, Maya Elena Stevens, Ray M. Merrill, Christopher Dromey, Julie Barkmeier‐Kraemer, M. Ben Christensen
Publication date 19-09-2023
This study examined the effects of a combination corticosteroid plus long-acting beta2-adrenergic agonist inhaler (IC) on rabbit phonation. Rabbits received twice-daily doses of either Advair HFA or aerosolized saline for 8 weeks; larynges were then excised and mounted on a benchtop phonatory apparatus. Results showed significantly greater onset pressure and flow for LABA IC versus control rabbits.
Objectives This study examined the effects of a combination corticosteroid plus long-acting beta2-adrenergic agonist inhaler (IC) on rabbit phonation.
Methods White New Zealand male rabbits were assigned randomly to experimental and control groups (n = 11 per group). The experimental group received twice-daily doses of Advair HFA™ (fluticasone propionate 45 mcg and salmeterol 21 mcg) via a veterinary facemask with 1-way valve and spacer; the control group received aerosolized saline. After 8 weeks, animals were euthanized, larynges excised, frozen, and subsequently thawed and mounted on a standard bench apparatus. Phonation was elicited during 15 successive trials, and phonation threshold pressure (PTP; cmH2O) and flow (PTF; L/min) were quantified.
Results Repeated measures analysis of variance indicated significant differences between the experimental and control groups (p < 0.05). Mean PTP and PTF values were higher (worse) for rabbits that received Advair HFA™.
Conclusion Following 8-week exposure to ICs, rabbit larynges required greater air pressure and flow to initiate phonation. Because even modest phonation onset differences can have a meaningful clinical impact on voice function, these findings suggest that LABA ICs may put patients at risk for voice disorders. Furthermore, these voice disorders may occur within a relatively short timeframe. The results from this study have important clinical implications for voice care in those who use ICs.
Level of EvidenceNA Laryngoscope, 133:2680–2686, 2023
K. Miyamura, E. Mori, D. Nakashima, M. Miura, S. Chiba, N. Otori
Publication date 19-09-2023
The relationship between steroid use and endoscopic lesion location in the postoperative course of ECRS patients was examined, and sphenoethmoidal recess lesions were a risk factor for the need for postoperative steroids. These findings call for more appropriate use of steroids in the postoperative management of ECRS.
Objectives Eosinophilic chronic rhinosinusitis (ECRS) is known to recur after surgery. The treatment choice for recurrent ECRS, such as oral steroids or biological agents, must be chosen carefully, and identifying the lesion location may be useful. This study aimed to evaluate the postoperative course of ECRS patients and assess the relationship between endoscopic lesion location and postoperative oral steroid use.
Methods Patients with chronic rhinosinusitis who underwent bilateral endoscopic sinus surgery from April 2018 to March 2020 were divided into two groups based on the presence or absence of oral steroid use after surgery.
The primary endpoint was the lesion location on endoscopic findings during surgery: middle turbinate, middle meatus, superior turbinate, superior meatus, nasal septum, and sphenoethmoidal recess. Subjective symptoms, blood tests, and computerized tomography (CT) findings (Lund-Mackay score) were evaluated as secondary endpoints.
Results Among 264 patients, 88 were diagnosed histologically with ECRS (mean 48.98 ± 1.40 years, 67 males/21 females). Twenty-three patients were steroid-using, 65 were steroid-free, and six stopped attending their appointments. Patients with sphenoethmoidal recess lesions were significantly more likely to require steroids (p = 0.019). There was a significant association between steroid use and younger age (p = 0.041), olfactory dysfunction (p = 0.021), and all sinuses (Frontal sinus: p < 0.001, Anterior ethmoid sinus: p = 0.002, Posterior ethmoid sinus: p = 0.011, Maxillary sinus: p = 0.018, Sphenoid sinus: p = 0.034, Total score: p < 0.001).
ConclusionA sphenoethmoidal recess lesion was a risk factor for requiring postoperative steroids. Young age, olfactory dysfunction, and preoperative severe CT findings were also significant risk factors.
Level of Evidence3 Laryngoscope, 133:2511–2516, 2023
Katherine L. Marks, Manuel E. Díaz Cádiz, Laura E. Toles, Daniel P. Buckley, Lauren F. Tracy, J. Pieter Noordzji, Gregory A. Grillone, Cara E. Stepp
Publication date 19-09-2023
Objective The purpose of this study was to determine whether automated estimates of vocal creak would differentiate speakers with adductor laryngeal dystonia (AdLD) from speakers with muscle tension dysphonia (MTD) and speakers without voice disorders.
Methods Sixteen speakers with AdLD, sixteen speakers with MTD, and sixteen speakers without voice disorders were recorded in a quiet environment reading aloud a standard paragraph. An open-source creak detector was used to calculate the percentage of creak (% creak) in each of the speakers six recorded sentences.
ResultsA Kruskal-Wallis one-way analysis of variance revealed a statistically significant effect of group on the % creak with a large effect size. Pairwise Wilcoxon tests revealed a statistically significant difference in % creak between speakers with AdLD and controls as well as between speakers with AdLD and MTD. Receiver operating characteristic curve analyses indicated that % creak differentiated AdLD from both controls and speakers with MTD with high sensitivity and specificity (area under the curve statistics of 0.94 and 0.86, respectively).
Conclusion Percentage of creak as calculated by an automated creak detector may be useful as a quantitative indicator of AdLD, demonstrating the potential for use as a screening tool or to aid in a differential diagnosis.
Level of Evidence3 Laryngoscope, 133:2687–2694, 2023
Gladys Ornelas, Hassler Bueno Garcia, David J. Bracken, Kristen Linnemeyer‐Risser, Todd P. Coleman, Philip A. Weissbrod
Publication date 19-09-2023
This pilot study evaluated high-density surface electromyography (HDsEMG) during pharyngeal swallows of five different bolus textures from eight healthy human subjects. Results indicate HDsEMG can differentiate swallows of varying consistencies through analysis of EMG signal features such as power and peak counts while maintaining a spatial orientation. This may prove useful in both future diagnostic and behavioral swallow applications.
Objective Swallowing is a complex neuromuscular task. There is limited spatiotemporal data on normative surface electromyographic signal during swallow, particularly across standard textures. We hypothesize the pattern of electromyographic signal of the anterior neck varies cranio-caudally, that laterality can be evaluated, and categorization of bolus texture can be differentiated by high-density surface electromyography (HDsEMG) through signal analysis.
Methods An HDsEMG grid of 20 electrodes captured electromyographic activity in eight healthy adult subjects across 240 total swallows.
Participants swallowed five standard textures: saliva, thin liquid, puree, mixed consistency, and dry solid. Data were bandpass filtered, underwent functional alignment of signal, and then placed into binary classifier receiver operating characteristic (ROC) curves. Muscular activity was visualized by creating two-dimensional EMG heat maps.
Results Signal analysis results demonstrated a positive correlation between signal amplitude and bolus texture. Greater differences of amplitude in the cranial most region of the array when compared to the caudal most region were noted in all subjects. Lateral comparison of the array revealed symmetric power levels across all subjects and textures. ROC curves demonstrated the ability to correctly classify textures within subjects in 6 of 10 texture comparisons.
Conclusion This pilot study suggests that utilizing HDsEMG during deglutition can noninvasively differentiate swallows of varying texture noninvasively. This may prove useful in future diagnostic and behavioral swallow applications.
Level of Evidence4 Laryngoscope, 133:2695–2703, 2023
Neeraja Konuthula, Sherise Epstein, Xing Wang, Mark E. Whipple, Randall A. Bly, Sarah N. Bowe
Publication date 19-09-2023
The objective of this study was to analyze racial/ethnic and gender disparities in the Otolaryngology match. White men were accepted at a higher rate than White women and most other racial/ethnic and gender groups who applied and matched to Otolaryngology.
Objectives Racial, ethnic, and gender disparities in the otolaryngology-head and neck surgery (OHNS) match have been described individually, but not intersectionally. Intersectionality recognizes how multiple forms of discrimination (e.g., sexism, racism) can have a combined effect. The objective of this study was to analyze racial, ethnic, and gender disparities in the OHNS match using an intersectional approach.
Methods Cross-sectional evaluation of data from otolaryngology applicants from the Electronic Residency Application Service (ERAS) and of corresponding otolaryngology residents from the Accreditation Council for Graduate Medical Education (ACGME) from 2013 to 2019. Data were stratified by race, ethnicity, and gender. The Cochran-Armitage tests assessed trends over time in the proportions of applicants and corresponding residents. Chi-square tests with Yates continuity correction were performed to evaluate differences between the aggregate proportions of applicants and corresponding residents.
Results The proportion of White men in the resident pool was increased compared to the applicant pool (ACGME 0.417, ERAS 0.375; Δ + 0.042; 95% CI 0.012 to 0.071; p = 0.03). This was also the case for White women (ACGME 0.206, ERAS 0.175; Δ + 0.031; 95% CI 0.007 to 0.055; p = 0.05). In contrast, there was a smaller proportion of residents compared to applicants among Multiracial men (ACGME 0.014, ERAS 0.047; Δ − 0.033; 95% CI −0.043 to −0.023; p < 0.001) and Multiracial women (ACGME 0.010, ERAS 0.026; Δ − 0.016; 95% CI −0.024 to −0.008; p < 0.001).
Conclusion The findings of this study imply that White men have a persistent advantage, while several racial, ethnic, and gender minorities are disadvantaged in the OHNS match. Further research is necessary to examine why these differences exist in residency selection, including evaluation during the screening, reviewing, interviewing, and ranking stages. Laryngoscope, 133:2558–2563, 2023
Abdul‐Latif Hamdan, Jad Hosri, Patrick Abou Raji Feghali, Christophe Abi Zeid Daou, Anthony Ghanem
Publication date 19-09-2023
Objective To investigate the effect of office-based blue laser therapy of vocal fold polyps on voice.
Methods The medical records and video recordings of patients who underwent office-based laser therapy in a tertiary referral center between February 2020 and May 2020, and May 2021 and October 2022 was conducted. Only patients with vocal fold polyps who had undergone office-based blue laser therapy were included. The voice was evaluated before and after surgery using the Voice Handicap Index-10 (VHI-10), GRB perceptual evaluation, acoustic analysis, and maximum phonation time.
ResultsA total of 18 patients were included. The mean age of the study group was 52.5 ± 11.94 years. The male-to-female ratio was 2:1. Ten patients of the total group (53.6%) had hemorrhagic polyps and the most common site was the mid-third of the vocal fold. All patients who presented for follow-up (n = 15) had partial or complete regression of the lesion (4 and 11, respectively). There was a significant decrease in the mean score of VHI-10 (17.6 ± 9.97 vs. 4.27 ± 5.76, p < 0.001) and in the means of grade of dysphonia (2.0 ± 0.73 to 0.5 ± 0.63, p < 0.001), roughness (1.88 ± 0.81 to 0.44 ± 0.51, p < 0.001) and breathiness (0.81 ± 0.75 to 0.13 ± 0.34 p < 0.001). There was also a marked decrease in the perturbation parameters (jitter and shimmer) and a significant increase in the MPT from 10.66 ± 4.22 s to 14.26 ± 6.26 s (p = 0.028).
Conclusion Office-based blue laser therapy is an effective treatment modality in patients with vocal fold polyps.
Level of Evidence4 Laryngoscope, 133:2712–2718, 2023
Nicholas J. Thompson, Erin M. Lopez, Margaret T. Dillon, Meredith A. Rooth, Margaret E. Richter, Harold C. Pillsbury, Kevin D. Brown
Publication date 19-09-2023
The present study assessed the long-term patterns of perceived tinnitus severity and subjective benefit for adult cochlear implant users with asymmetric and unilateral hearing loss. Results showed an early increase in subjective benefit and decrease in tinnitus severity that was sustained over the 5 year study period.
Objectives Assess the long-term patterns of perceived tinnitus severity and subjective benefit for adult cochlear implant (CI) users with asymmetric or unilateral hearing loss (AHL or UHL).
Methods Forty adults underwent cochlear implantation as part of a prospective clinical trial assessing the outcomes of CI use in cases of AHL (n = 20) and UHL (n = 20). Subjective measures included the Tinnitus Handicap Inventory (THI), the Speech, Spatial, & Qualities of Hearing Scale (SSQ), and the Abbreviated Profile of Hearing Aid Benefit (APHAB). Responses were obtained preoperatively and at routine intervals out to 5 years post-activation.
Results For subjective benefit, participants with AHL and UHL reported a significant improvement as compared to preoperative abilities, which was maintained with long-term CI use. For perceived tinnitus severity, participants with AHL and UHL reported a significant reduction with CI use as compared to preoperative perceptions. The perceived tinnitus severity significantly differed for the AHL and UHL cohorts over time. This pattern of results is likely influenced by the worse perceived severity levels for the UHL cohort preoperatively and the fluctuating perceived severity levels for some participants in the AHL cohort post-activation.
Conclusion Adults with AHL and UHL report an early, significant reduction in perceived tinnitus severity and improvement in quality of life with CI use that is generally maintained with long-term device use. Questionnaires such as the THI, SSQ, and APHAB may contribute to a more holistic assessment of the benefits of cochlear implantation in this population.
Level of Evidence2 Laryngoscope, 133:2792–2797, 2023
Thomas J. Hudson, Rayane Ait Oubahou, Luc Mongeau, Karen Kost
Publication date 19-09-2023
This study aimed to assess a computational fluid dynamic model in its ability to predict clinical respiratory distress based on a case–control study design. It demonstrated that the computed resistances were significantly related to patients who required urgent airway management. This type of model could be used to develop risk assessment models for future clinical use.
Background Obstructive upper airway pathologies are a great clinical challenge for the airway surgeon. Protection against acute obstruction is critical, but avoidance of unnecessary tracheostomy must also be considered. Decision-making regarding airway, although supported by some objective findings, is largely guided by subjective experience and training. This investigation aims to study the relationship between clinical respiratory distress and objective measures of airway resistance in laryngeal cancer as determined by computational fluid dynamic (CFD) and morphometric analysis.
Methods Retrospective CT and clinical data were obtained for series of 20 cases, defined as newly diagnosed laryngeal cancer patients who required admission or urgent airway surgery, and 20 controls. Cases and controls were matched based on T-staging. Image segmentation and morphometric analysis were first performed. Computational models based on the lattice Boltzmann method were then created and used to quantify the continuous mass flow, rigid wall, and constant static pressure inlet boundary conditions.
Results The analysis demonstrated a significant relationship between airway resistance and acute obstruction (OR 1.018, 95% CI 1.001–1.045). Morphometric analysis similarly demonstrated a significant relationship when relating measurements based on the minimum cross-section, but not on length of stenosis. Morphometric measurements also showed significance in predicting CFD results, and their relationship demonstrated that airway pressures increase exponentially below 2.5 mm. Tumor subsite did not show a significant difference, although the glottic subgroup tended to have higher resistances.
Conclusion Airway resistance analysis from CFD computation correlated with presence of acute distress requiring emergent management. Morphometric analysis showed a similar correlation, demonstrating a radiologic airway assessment technique on which future risk estimation could be performed.
Level of Evidence4 (case–control study) Laryngoscope, 133:2734–2741, 2023
Derrek A. Heuveling, Hans F. Mahieu
Publication date 19-09-2023
Endoscopic CO2-laser resection of 22 combined laryngoceles using the inversion technique. The results of this study show excellent control of combined laryngoceles using the CO2 laser inversion technique, with a reduced hospital stay and a low rate of complications and recurrence.
Objective To demonstrate the feasibility of transoral resection of, even large, combined laryngoceles by endoscopic CO2 laser resection using the inversion technique.
MethodsA retrospective study over a 25-year period of 20 patients with 22 combined laryngoceles. All patients were operated on using the CO2 laser inversion technique. Pre- and postoperative computed tomography (CT)-scans or magnetic resonance (MR) imaging were available in all patients.
Results There were no surgical problems during all procedures. One patient required a tracheotomy pre-operatively due to a compromised airway. All procedures were without intraoperative complications. Postoperatively, there were two complications: one hemorrhage, and one patient developed a granuloma with airway compromise. In two patients, residual disease was detected on postoperative imaging. One of them was re-operated several years later due to the progression of this residual external component of the laryngocele. One patient had a non-significant small internal laryngocele recurrence. The recurrence rate in this series was 2/22 (9.1%). The majority of patients (15/20) could be discharged from the hospital the day after surgery.
Conclusion The results of this study show excellent control of combined laryngoceles using the CO2 laser inversion technique, with a short hospital stay and a low rate of complications and recurrence. Even in large combined laryngoceles, CO2 laser excision using the inversion technique should be considered.
Level of Evidence4 Laryngoscope, 133:2742–2746, 2023
Fahad Rind, Songzhu Zhao, Catherine Haring, Stephen Y Kang, Amit Agrawal, Enver Ozer, Matthew O Old, Ricardo L. Carrau, Nolan B Seim
Publication date 19-09-2023
Objectives The increase in incidence of thyroid cancer correlates with strict increases in body mass index (BMI) and obesity in the United States. Thyroid hormone dysregulation has been shown to precipitate circulatory volume, peripheral resistance, cardiac rhythm, and even cardiac muscle health. Theoretically, thyroid surgery could precipitate injury to the cardiopulmonary system.
Methods The American College of Surgery National Quality Improvement Program database was queried for thyroidectomy cases in the 2007–2020 Participant User files. Continuous and categorical associations between BMI and cardiopulmonary complications were investigated as reported in the database.
Results The query resulted 186,095 cases of thyroidectomy procedures in which the mean age was 51.3 years and sample was 79.3% female. No correlation was evident in univariate and multivariate analyses between BMI and the incidence of postoperative stroke or myocardial infarction. The incidence of complications was extremely low. However, risk of deep venous thrombosis correlated with BMI in the categorical, univariate, and multivariate (OR 1.036, CI 1.014–1.057, p < 0.01) regression analysis. Additionally, increased BMI was associated with increased risk of pulmonary embolism (PE) (OR 1.050 (1.030, 1.069), p < 0.01), re-intubation (OR 1.012 (1.002, 1.023), p = 0.02), and prolonged intubation (OR 1.031 (1.017, 1.045), p < 0.01).
Conclusion Despite the rarity of cardiopulmonary complications during thyroid surgery, patients with very high BMI carry a significant risk of deep venous thrombosis, PE, and prolonged intubation.
Level of Evidence3 Laryngoscope, 133:2823–2830, 2023
Xiao Wu, Lai Sheng Pan, Bo Wen Wu, Jie Wu, Yu Xin Chen, Shen Hao Xie, Xi Chen Wan, Han Din, Jie Zhan, Li Min Xiao, Bin Tang, Tao Hong
Publication date 19-09-2023
According to the specific endoscopic endonasal subapproaches corresponding to the different trigeminal schwannomas locations, satisfactory results can be obtained for most types of tumors. It represents an effective alternative to the open transcranial approach and can also be properly used in most types of trigeminal schwannomas with experienced hands.
Objectives To describe four endoscopic endonasal subapproaches, namely, the trans-lamina papyracea, trans-prelacrimal recess, trans-Meckels cave, and transclival approaches for trigeminal schwannomas (TSs).
Methods This retrospective study reviewed the medical records and intraoperative videos of 38 patients with TSs who underwent endoscopic endonasal approach (EEA) between Jan 2013 and Dec 2021.
Results According to Jeongs classification, for TS equally in middle and posterior fossae (MP), a purely trans-Meckels cave approach was carried out in 2 cases, and a combined transclival approach was carried out in 4 cases. The four tumors that involved infratemporal fossa (two E3, one mE3, and one Mpe3) were performed via a trans-prelacrimal recess approach, and type Mpe3 was also assisted by the trans-Meckels cave approach. One patient with type E1 was treated with a trans-lamina papyracea approach. The other 27 cases, including type M, Mp, ME2, and MpE2, were all removed by a purely trans-Meckels cave approach. Thirty-six patients (97.4%) received total resection under a purely EEA. The functional abilities and preoperative symptoms of 31 patients (88.6%) improved. Eight (21.1%) patients experienced permanent neurological function deficits. Postoperative cerebrospinal fluid and intraoperative internal carotid artery injury occurred in 1 (2.6%) patient.
Conclusion According to the specific endoscopic endonasal subapproaches corresponding to the different TS locations, satisfactory results can be obtained for most types of tumors. It represents an effective alternative to the open transcranial approach and can also be properly used in most types of TS with experienced hands.
Level of Evidence4 Laryngoscope, 133:2564–2571, 2023
Qin Wang, Junjiao Hu, Wei Li, Li Huang, Xueying Pan, Zhou Zhou, Tao Yang, Rong Tao, Chao Huang, Anquan Peng, Zhiwen Zhang
Publication date 19-09-2023
Explore response to duct blockage of distinct extraosseous endolymphatic sac (eES) in Menieres. Assess symptom, inner ear function and endolymph hydrops (EH) pre-op & 40 months post-op. Better vertigo control, inner ear function and reduced EH in patients with normoplastic eES than those with atrophic eES.
Objectives To explore the possible difference in response to endolymphatic duct blockage (EDB) treatment in patients with Menieres disease (MD) with distinct pathoanatomic characteristics of the sac.
Methods In a total of 24 patients with MD receiving EDB treatment, the dynamics of the vertigo attack, hearing, vestibular function, and endolymph hydrops (EH) before surgery and 40 months following surgery in patients with normoplastic extraosseous portion of endolymphatic sac (eES) were compared with that in patients with atrophic eES.
ResultsA higher prevalence of complete vertigo control, better cochlear and vestibular function, and lower endolymph to vestibule-volume ratio were found in patients with normoplastic eES than in those with atrophic eES. Moreover, the reversal of EH was found in a total of six patients in normoplastic eES group, but no reversal of EH was detected in the atrophic eES group after surgery.
ConclusionsA difference in response to EDB treatment was shown in the MD patients with normoplastic eES and those with atrophic eES; the reversal of EH was found in the normoplastic eES group, but not in the atrophic eES group after surgery, suggesting two distinct pathologies in the eESs may underlie the pathogenesis of EH in two subgroups of MD patients.
Level of Evidence4 Laryngoscope, 133:2761–2769, 2023
Qin Lin, Chen Li, Xiaoxia Lin, Shuchun Lin, Wei Chen, Xiaoqiang Chen, Xiaoting Huang, Desheng Wang
Publication date 19-09-2023
The CONUT score is a prognostic marker for patients with resectable advanced hypopharyngeal cancer Objective The purpose of this study was to investigate the prognostic significance of the preoperative controlling nutritional status (CONUT) score in patients with resectable advanced hypopharyngeal cancer.
Methods This retrospective study included 113 advanced hypopharyngeal cancer patients who underwent curative resection in our hospital from 2013 to 2017. The association between the CONUT score and clinicopathological variables was evaluated. The association between CONUT score and survival was analyzed using Kaplan–Meier survival curves and Cox regression. The efficacy of the CONUT score and other immune-nutritional markers to predict prognosis was compared using a time-dependent receiver operating characteristic (ROC).
Results Patients were divided into the high-CONUT score group (≥3) and the low-CONUT score group (≤2) according to ROC analysis. The CONUT score was associated with body mass index (p = 0.047), monocyte (p = 0.021), pharyngocutaneous fistula (p = 0.045), flap repairment (p = 0.034), tumor (T) classification (p = 0.034), node (N) classification (p = 0.036), subsite of tumor (p = 0.035), and negative pathologic factors (p < 0.001). Tumor, node, metastasis (TNM) stage, negative pathologic factors, adjuvant radiotherapy, postoperative chemoradiotherapy, and CONUT score were independent prognostic factors for survival. Patients with a higher CONUT score had worse overall survival (OS) (hazard ratio: 2.76, 95% confidence interval CI: 1.44–5.29, p = 0.002) and disease-free survival (hazard ratio: 2.51, 95% CI: 1.28–4.91, p = 0.007). The area under the curve of the CONUT score (0.799) to predict 5-year OS was greater than those of Preoperative Nutritional Index (0.769), platelet-to-lymphocyte ratio (0.643), neutrophil-to-lymphocyte ratio (0.565), and lymphocyte-to-monocyte ratio (0.577).
Conclusion The CONUT score is a prognostic marker for patients with resectable advanced hypopharyngeal cancer.
Level of Evidence3 Laryngoscope, 133:2613–2620, 2023
Samuel J M Hale, Christian A Lux, Raymond Kim, Kristi Biswas, Simon Tucker, Peter Friedland, Brett Wagner Mackenzie, Richard G Douglas
Publication date 19-09-2023
Nasodine nasal spray was applied to biofilms of Staphylococcus aureus grown in vitro to determine its antibiofilm efficacy. When Nasodine was applied to intact biofilm, near complete eradication was observed at 6 h exposure. When the bacterial cells were released from the biofilm prior to treatment, eradication was observed at 1 min. This shows that Nasodine is active against S. aureus biofilms in vitro and that biofilm eradication is slowed by the presence of the intact biofilm structure.
Objectives Bacterial biofilms on the sinonasal mucosa, especially biofilms of Staphylococcus aureus, are associated with greater severity and recalcitrance of chronic rhinosinusitis (CRS). There are few, if any, antibiofilm agents suitable for sinonasal application available for the management of this problem. Nasodine® Nasal Spray (Nasodine) is a 0.5% povidone-iodine-based formulation that has been developed for sinonasal application. We investigated the antibiofilm efficacy of Nasodine to determine whether it may be a candidate for the treatment of biofilm-associated CRS.
Methods Biofilms of S. aureus ATCC 6538 were grown in vitro using the Centers for Disease Control biofilm reactor. Intact biofilms were treated by immersion in 0.9% saline (control), half concentration Nasodine, or full concentration Nasodine for between 5 min and 6 h. Further biofilm cells were dispersed into suspension then treated for between 30 s and 5 min. Surviving bacteria were then enumerated by culture and counting colonies, and the log10 reduction in viable bacteria was compared with control.
Results Nasodine demonstrated time and concentration-dependent bacterial killing against intact biofilm. Statistically significant reductions in viable bacteria from intact biofilms were seen with exposures as brief as 5 min. Nasodine consistently eradicated dispersed biofilm within 1 min.
Conclusion Nasodine is highly active against biofilms of S. aureus ATCC 6538 in vitro. Biofilm killing is impeded by the presence of the intact biofilm structure.
Lay summary:In chronic rhinosinusitis (CRS), bacterial communities called biofilms are associated with more severe inflammation. An iodine-based nasal spray called Nasodine almost completely eradicates bacterial biofilms after 6 h of exposure. Nasodine may be useful for treating CRS. Laryngoscope, 133:2490–2495, 2023
Clayton Prakash Burruss, Christine Sharrer, James Zachary Porterfield, Alexandra Eva Kejner
Publication date 19-09-2023
Although American Joint Committee on Cancers 8th edition (AJCC-8) has demonstrated an improved ability to stratify OPSCCs into stages that predict overall survival, high-risk populations may be predisposed to worse outcomes. The goal of this manuscript is to validate the AJCC-8 as a better metric of survivability over AJCC-7 in a historically under-served rural population with confounding variables such as tobacco use, alcohol consumption, and poor healthcare access, and to analyze the role of extranodal extension in this population.
Objectives The American Joint Committee on Cancers 8th edition (AJCC-8) separates oropharyngeal squamous cell carcinomas (OPSCCs) into human papillomavirus-positive (HPV+) tumors and HPV-negative tumors. Although AJCC-8 improves prognostic prediction for survival for the majority of HPV+ OPSCC, outliers are still encountered. The goal of this manuscript is to validate the AJCC-8 as a better metric of survivability than the AJCC-7 in an historically under-served rural population with confounding variables, such as tobacco use, alcohol consumption, and poor health care access and to analyze the role of extranodal extension (ENE) in this population.
Design Retrospective cohort study.
Results Compared to AJCC-7, AJCC-8 had a higher odds ratio (OR) for predicting mortality of stage IV HPV+ OPSCCs versus stages I–III. On multivariate analysis, HPV+ OPSCCs with ENE had a higher OR of mortality compared to ENE- OPSCCs. In addition, HPV+ OPSCC patients with a Charlson Comorbidity Index (CCI) > 3 had a higher OR of mortality compared to those with a CCI ≤ 3. Patients with Medicaid/self-pay status had a higher OR of mortality compared to those with private insurance/Medicare. Finally, patients from rural populations had a higher OR of presenting with stage IV disease, a CCI > 3, and Medicaid/self-pay status.
Conclusions Despite not being a discrete part of the AJCC-8 staging rubric, ENE was found to have a significant impact on mortality among this population, whereas tobacco use had no effect. Rural patients were more likely to present with stage IV disease, CCI > 3, and Medicaid/self-pay status. Stage IV disease was also associated with a higher OR of mortality.
Level of Evidence4 Laryngoscope, 133:2621–2626, 2023
Neal Deot, Aleksandar Kiprovski, Adam Hatala, Ade Obayemi Jr, Amar Suryadevara, Richard O. Davila
Publication date 19-09-2023
High quality perioperative photography is imperative to good surgical planning and analysis in facial reconstructive and aesthetic surgery. In this article, we explored the utility of an add-on smartphone telephoto lens for facial photography using anthropometric measurements and a survey administered to facial plastic surgeons.
Objectives High-quality perioperative photography is imperative to good surgical planning in facial reconstructive and aesthetic surgery. We explore the utility of an add-on smartphone telephoto lens to avoid the distortions noted in prior studies using smartphone cameras.
Methods Standard perioperative photographs of the same subject were taken with three distinct cameras using a dual-ring light setup. The three camera setups i Phone 11 alone, i Phone 11 with the 58 Moment telephoto lens attachment, and a D3300 Nikon DSLR APS-C sensor camera with a 60 mm NIKKOR F2.8G ED macro lens were compared using a 47-question online survey consisting of demographic and image-specific questions sent to plastic surgeons.
Results Forty-nine facial plastic surgeons completed the survey. The i Phone 11 alone was identified as having the lowest quality for central/peripheral distortion (83%), columella/caudal septum/alar anatomy (58.3%), and skin quality (38.3%). With the addition of the telephoto lens, the ability to assess all categories was significantly improved. 53.1% (n = 26) of respondents found the i Phone 11 + 58 mm telephoto lens setup to be the most useful for perioperative surgical planning.
Conclusions Smartphone photography with the addition of a telephoto lens can offer a comparable option to the DSLR with regard to photo quality and detail.
SummaryA telephoto add-on lens is an effective solution to overcome the central distortion seen in images taken by the i Phone for perioperative photography. This photo quality was found to be comparable to that of traditional DSLR cameras in our survey study.
Level of Evidence3 Laryngoscope, 133:2590–2596, 2023
Marn Joon Park, Wonki Cho, Ji Heui Kim, Yoo‐Sam Chung, Yong Ju Jang, Myeong Sang Yu
Publication date 19-09-2023
The relatively low diagnostic sensitivity of in-office punch biopsy to detect inverted papilloma associated squamous cell carcinoma (IP-SCC) indicates the need to identify other clinical and radiological features associated with IP-SCC. IP patients with chronic systemic diseases, a history of tobacco smoking, facial pain, or epistaxis, and those with bony destruction, remodeling, or invasion of adjacent structures on preoperative radiologic imaging may be at higher risk of IP-SCC, suggesting the need for more aggressive surgical strategies.
Introduction Sinonasal inverted papillomas (IP) can undergo transformation into IP-squamous cell carcinomas (IP-SCC). More aggressive treatment plan should be established when IP-SCC is suspected. Nevertheless, inaccuracy of the preoperative punch biopsy results to detect IP-SCC from IP raises the need for an additional strategy. The present study aimed to investigate significant clinicoradiological remarks associated with IP-SCC than IP.
Material and Methods Postoperative surgical specimens obtained from patients with confirmed IP or IP-SCC at a single tertiary medical center from 1997 to 2018 were retrospectively evaluated. Patients demographic and clinical characteristics, preoperative in-office punch biopsy results, and preoperative computed tomography (CT) or magnetic resonance images were reviewed. Univariate and multivariate analyses were performed to assess the odds ratio (OR) associated with IP-SCC. The area under the curve (AUC) in the receiver Operating Characteristic (ROC) curve was calculated in the prediction model to discriminate IP-SCC from IP.
Results The study included 44 IP-SCC and 301 patients with IP. The diagnostic sensitivity of in-office punch biopsy to detect IP-SCC was 70.7%. Multivariate analysis showed that factors significantly associated with IP-SCC included tobacco smoking >10PY (adjusted-OR aOR: 4.1), epistaxis (aOR: 3.4), facial pain (aOR: 4.2), bony destruction (aOR: 37.6), bony remodeling (aOR: 36.3), and invasion of adjacent structures (aOR: 31.6) (all p < 0.05). Combining all significantly related clinicoradiological features, the ability to discriminate IP-SCC from IP reached an AUC of 0.974.
ConclusionIP patients with a history of tobacco smoking, facial pain, epistaxis, and bony destruction, remodeling, or invasion of an adjacent structure on preoperative images may be at higher risk for IP-SCC.
Level of Evidence3 Laryngoscope, 133:2502–2510, 2023
Marcel Mayer, Tarik B. Isik, Lisa Nachtsheim, Philipp Wolber, Kevin K. Hansen, Maria Grosheva, Jens P. Klussmann, Sami Shabli
Publication date 19-09-2023
Our original article aims to introduce a new score, the so-called “Instructional Videos in Otorhinolaryngology by YO-IFOS (IVORY)-grading-system (GS)” derived from the IVORY Guidelines, which pose established consensus recommendations for the production of educational surgical videos in otolaryngology. We further statistically evaluate the new score and conclude that it is suitable for evaluation of educational videos showing parotidectomy in order to improve quality of these videos.
Objective The aim of this study was to evaluate the quality and the educational content of You Tube videos showing parotidectomy.
Methods We searched for videos displaying parotidectomy on You Tube. To rate parotidectomy videos, we introduced the “Instructional Videos in Otorhinolaryngology by YO-IFOS (IVORY)-grading-system (GS)” derived from the IVORY Guidelines, which pose established consensus recommendations for the production of educational surgical videos in otolaryngology. The videos were rated using the IVORY-GS, and the total score was tested for statistical association with views, likes, likes/dislikes-ratio, age, and length of the videos for validation of the IVORY-GS.
Results Overall, 50 parotidectomy videos were identified. Sixty-eight (68%) of the videos showed a superficial parotidectomy. The mean IVORY-GS total score was 24.9 (out of a maximum of 44 points). Video education quality was rated as moderate in 22% and high in 4%. There was a statistically significant correlation between the total score and the number of views (p = 0.03), the total score and the number of likes (p < 0.01), and the total score and the likes/dislikes ratio (p < 0.01). A higher total score was a significant predictor of more likes (p = 0.01) and a higher likes/dislikes ratio (p < 0.01).
Conclusion Our modification of the IVORY Guidelines is otolaryngology-specific, suitable, and recommended to evaluate parotidectomy videos. To date, most videos are of poor educational quality. Future efforts in otolaryngology surgical video education could focus on the establishment of an online video platform.
Level of EvidenceNA Laryngoscope, 133:2631–2637, 2023
Ryosuke Nakamura, Renjie Bing, Gary J. Gartling, Michael J. Garabedian, Ryan C. Branski
Publication date 19-09-2023
Steroid-based therapies are associated with variable outcomes for laryngeal disease. This study provides incremental data related to potential mechanisms of this variability including divergent effects on the glucocorticoid receptor phosphorylation.
Objective Variable outcomes of glucocorticoid (GC) therapy for laryngeal disease are putatively due to diverse interactions of the GC receptor (GR) with cell signaling pathways, limited consideration regarding concentration-dependent effects, and inconsistent selection of GCs. In the current study, we evaluated the concentration-dependent effects of three frequently administered GCs on transcription factors with an emphasis on the phosphorylation of GR at Ser203 and Ser211 regulating the nuclear translocation of GR. This study provides foundational data regarding the diverse functions of GCs to optimize therapeutic approaches.
Study design In vitro.
Methods Human vocal fold fibroblasts and THP1-derived macrophages were treated with different concentrations of dexamethasone, methylprednisolone, and triamcinolone in combination with IFN-γ, TNF-α, or IL4. Phosphorylated STAT1, NF-κB family molecules, and phosphorylated STAT6 were analyzed by Western blotting. Ser211-phosphorylated GR (S211-pGR) levels relative to GAPDH and Ser203-phosphorylated GR (S203-pGR) were also analyzed.
ResultsGCs differentially altered phosphorylated STAT1 and NF-κB family molecules in different cell types under IFN-γ and TNF-α stimuli. GCs did not alter phosphorylated STAT6 in IL4-treated macrophages. The three GCs were nearly equivalent. A lower concentration of dexamethasone increased S211-pGR/GAPDH ratios relative to increased S211-pGR/S203-pGR ratios regardless of cell type and treatment.
Conclusion The three GCs employed in two cell lines had nearly equivalent effects on transcription factor regulation. Relatively high levels of Ser203-phosphorylation at low GC concentrations may be related to concentration-dependent differential effects of GCs in the two cell lines.
Level of EvidenceNA Laryngoscope, 133:2704–2711, 2023
Christopher W. Noel, Rinku Sutradhar, Wing C. Chan, Rui Fu, Justine Philteos, David Forner, Jonathan C. Irish, Simone Vigod, Elie Isenberg‐Grzeda, Natalie G. Coburn, Julie Hallet, Antoine Eskander
Publication date 19-09-2023
We sought to understand practice patterns and identify care gaps within a large-scale depression screening program for patients with head and neck cancer. A high proportion of head and neck patients report depressive symptoms, though this triggers a referral in a small number of cases. These data highlight areas for improvement in depression screening care pathways.
Objective To understand practice patterns and identify care gaps within a large-scale depression screening program for patients with head and neck cancer (HNC).
Study Design Retrospective cohort study.
Methods This was a population-based study of adults diagnosed with a HNC between January 2007 and October 2020. Each patient was observed from time of first symptom assessment until end of study date, or death. The exposure of interest was a positive depressive symptom screen on the Edmonton Symptom Assessment System (ESAS). Outcomes of interest included psychiatry/psychology assessment, social work referral, or palliative care assessment. Cause specific hazard models with a time-varying exposure were used to investigate the exposure-outcome relationships.
Results Of 14,054 patients with HNC, 9016 (64.2%) reported depressive symptoms on at least one ESAS assessment. Within 60 days of first reporting depressive symptoms, 223 (2.7%) received a psychiatry assessment, 646 (7.9%) a social work referral, and 1131 (13.9%) a palliative care assessment. Rates of psychiatry/psychology assessment (HR 3.15 95% CI 2.67–3.72), social work referral (HR 1.83 95% CI 1.64–2.02), and palliative care assessment (HR 2.34 95% CI 2.19–2.50) were higher for those screening positive for depression. Certain patient populations were less likely to receive an assessment including the elderly, rural residents, and those without a prior psychiatric history.
ConclusionA high proportion of head and neck patients report depressive symptoms, though this triggers a referral in a small number of cases. These data highlight areas for improvement in depression screening care pathways.
Level of Evidence3 Laryngoscope, 133:2638–2646, 2023
Julia Perry, Erica Sher, Kosuke Kawai, Shelby Redfield, Tieqi Sun, Margaret Kenna
Publication date 19-09-2023
The objective of this study was to investigate the association between newborn hearing screening (NBHS) results and audiologic and clinical outcomes in a large cohort of pediatric patients with hearing loss (HL) due to enlargement of the vestibular aqueduct (EVA). We found that EVA-related HL may be identified at birth or during childhood, with nearly half the patients in this cohort passing their NBHS. Our results provide prognostic information for EVA patients who pass their NBHS and highlight the importance of regular hearing monitoring for children not suspected of having HL.
Objectives Enlarged vestibular aqueduct (EVA) is the most common anatomic abnormality contributing to permanent hearing loss (HL) in children. Although the association between EVA and HL is well-documented, the pass rate for the newborn hearing screening (NBHS) for patients with EVA-related HL is not. Our objective was to investigate the association between NBHS results and audiologic and clinical outcomes in a large cohort of pediatric patients with EVA.
Methods This was a retrospective chart review of patients seen in the Boston Childrens Hospital (BCH) Department of Otolaryngology and Communication Enhancement with confirmed HL, known NBHS results, and confirmed EVA. Demographic, clinical, audiologic, and imaging data were collected from the medical record. Frequency-specific data points from pure-tone audiograms and/or automated auditory brainstem response tests were recorded, and four-frequency pure tone average was calculated using air conduction thresholds at 500, 1000, 2000, and 4000 Hz.
Results Of the 183 patients included in the study, 84 (45.9%) passed their NBHS, whereas 99 (54.1%) did not pass. Compared with patients who did not pass, patients who passed were more likely to have unilateral EVA and unilateral HL, whereas they were less likely to undergo cochlear implantation and to have causative SLC26A4 variants.
ConclusionsEVA-associated HL may be identified at birth or during childhood, with nearly half the patients in this cohort passing their NBHS. Our results provide prognostic information for patients with EVA who pass their NBHS and highlight the importance of regular hearing monitoring for children not initially suspected of having HL.
Level of Evidence4 Laryngoscope, 133:2786–2791, 2023
Fatemeh Ramazani, Erin D Wright, Derrick R Randall, Jun R Lin, Caroline C Jeffery
Publication date 19-09-2023
Background Microlaryngoscopy is a basic technical skill in Oto-HNS. It is essential for residency programs to have a competency-based assessment tool to evaluate residents performance of this procedure. An Objective Structured Assessment of Technical Skills (OSATS) is a procedure-specific assessment, which consists of the following: (a) Operation-Specific Checklist and (b) Global Rating Scale (GRS).
Objective The objective of this study was to create an OSATS for adult microlaryngoscopy.
Methods This was a prospective study, with an initial qualitative phase for OSATS development (Phase I), and a clinical pilot phase (Phase II). In Phase I, interviews were conducted with three laryngologists to establish a stepwise description of adult microlaryngoscopy and review a previously validated GRS for relevance to microlaryngoscopy. Responses were used to create a framework for the OSATS. The OSATS was then presented to Oto-HNS residents and laryngologists in an alternating fashion, for review of clarity and relevance. A pilot study was then performed to evaluate the resident performance of adult microlaryngoscopy. Multiple regression analysis was carried out to investigate whether training level, case complexity, and previous OSATS exposure could predict participant scores.
Results Phase I of this study led to the creation of a 34-item OSATS. The pilot study (N = 28 procedures) revealed that training level was significantly correlated with increased OSATS scores. There was no statistically significant correlation between case complexity and resident scores. Assessors reported the perceived utility of the OSATS and intent for use in residency training.
Conclusion Application of the proposed OSATS will allow for competency-based assessment of the resident performance of microlaryngoscopy.
Level of EvidenceNA Laryngoscope, 133:2719–2724, 2023
Samir A. Ballestas, Julio Hidalgo Lopez, Adam M. Klein, Conor Steuer, Dong M. Shin, Marin Abousaud, Nicole C. Schmitt, Yong Teng, Nabil F. Saba, Andrew T. Tkaczuk
Publication date 19-09-2023
Twenty-three patients with known recurrent Respiratory Papillomatosis who have been receiving off-label systemic bevacizumab were included in this study. There appears to be a reduction in the frequency of surgery required while patients are receiving this medication.
Objective The clinical course of recurrent respiratory papillomatosis (RRP) varies from spontaneous remission to severe airway obstruction with wide variability in recurrence. Standard treatment involves debulking to improve voice and/or breathing. Non-surgical therapies are emerging in hopes of non-operative disease control. This retrospective review analyzes long-term safety, efficacy, and durability of clinical control in the largest reported series of parenteral bevacizumab in adults with RRP.
Methods Twenty-three patients with known RRP who have been receiving off-label systemic bevacizumab were included. Dosage, infusion interval, number of cycles, debulking requirements, subjective outcomes, adverse events, and reasons for treatment termination were investigated.
Results Patients have been followed for an average of 791.43 (21–1468) days. The most common starting dosing regimen was 15 mg/kg at 3 weeks in 11 followed by 10 mg/kg at 6 weeks intervals in 6 individuals. Long-term maintenance dosage varied with the least intensive regimen being 10 mg/kg at 14-week intervals. Subjective improvement of voice and/or breathing was reported in 18/23 subjects. The median time for patients that needed a procedure after treatment was 634 days. Procedures after infusions decreased from 3.08 ± 2.48 procedures in the year prior to 0.52 ± 1.12 during systemic Bevacizumab, and to 0.86 ± 2.05 after stopping bevacizumab. Therapy termination occurred in 8 subjects where only 3 were due to adverse events.
Conclusion Parenteral bevacizumab remains a well-tolerated treatment for patients with recalcitrant RRP. There appears to be a durable reduction in the frequency of debulking surgery requirements although on a maintenance regimen. Laryngoscope, 133:2725–2733, 2023
Kai Wang, Nicholas A. George‐Jones, Liyuan Chen, Jacob B. Hunter, Jing Wang
Publication date 19-09-2023
We first presented a deep-learning-based multi-task framework to predict vestibular schwannoma (VS) enlargement and segmentation mask simultaneously using the initial diagnostic MRI. The proposed model is of higher learning efficiency and achieves promising performance on tumor enlargement prediction although preserving the segmentation accuracy. It has the potential to improve VS patient management.
Objective To develop a deep-learning-based multi-task (DMT) model for joint tumor enlargement prediction (TEP) and automatic tumor segmentation (TS) for vestibular schwannoma (VS) patients using their initial diagnostic contrast-enhanced T1-weighted (ceT1) magnetic resonance images (MRIs).
Methods Initial ceT1 MRIs for VS patients meeting the inclusion/exclusion criteria of this study were retrospectively collected. VSs on the initial MRIs and their first follow-up scans were manually contoured. Tumor volume and enlargement ratio were measured based on expert contours. A DMT model was constructed for jointly TS and TEP. The manually segmented VS volume on the initial scan and the tumor enlargement label (≥20% volumetric growth) were used as the ground truth for training and evaluating the TS and TEP modules, respectively.
Results We performed 5-fold cross-validation with the eligible patients (n = 103). Median segmentation dice coefficient, prediction sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) were measured and achieved the following values: 84.20%, 0.68, 0.78, 0.72, and 0.77, respectively. The segmentation result is significantly better than the separate TS network (dice coefficient of 83.13%, p = 0.03) and marginally lower than the state-of-the-art segmentation model nnU-Net (dice coefficient of 86.45%, p = 0.16). The TEP performance is significantly better than the single-task prediction model (AUC = 0.60, p = 0.01) and marginally better than a radiomics-based prediction model (AUC = 0.70, p = 0.17).
Conclusion The proposed DMT model is of higher learning efficiency and achieves promising performance on TEP and TS. The proposed technology has the potential to improve VS patient management.
Level of EvidenceNA Laryngoscope, 133:2754–2760, 2023
Zhengcai Lou, Zihan Lou, Tian Lv, Zhengnong Chen
Publication date 19-09-2023
While 12-month graft and audiometric outcomes were comparable between EMM and ETM techniques, patients who underwent EMM had less post-operative pain, shorter operative time, faster healing, and a lower incidence of complications.
Objective Here, we aimed to compare the operation time, postoperative pain score, graft healing, graft success rate, cholesteatoma incidence, audiometric outcomes, and complications between endoscopic modified myringoplasty (EMM) and endoscopic typical myringoplasty (ETM).
Methods Patients with unilateral chronic tympanic membrane (TM) perforations undergoing myringoplasty were prospectively randomized to undergo EMM (n = 44) or ETM (n = 45). The operation time, postoperative pain score, graft healing, graft success rate, cholesteatoma incidence, audiometric outcomes, and complications were compared between these groups.
Results In total, 89 patients with unilateral chronic perforations were included (EMM group, 44; ETM group, 45). There were significant differences between the EMM and ETM groups in mean pain scores on the day after surgery (1.32 ± 0.56 vs. 2.58 ± 1.16, p < 0.001) and in the mean operation time (18.18 ± 2.43 vs. 51.53 ± 8.28 min, p < 0.001). There were no significant differences in graft success rates (93.18% vs. 88.89%, p = 0.735), pre- or postoperative air conduction pure-tone averages or air bone gaps (ABGs), or changes in ABGs between the groups. However, the difference in graft healing was significant at postoperative week 2 (33/44 vs. 24/45, p = 0.033) but was nonsignificant at postoperative week 4 and month 6. Computed tomography revealed the middle ear and mastoid to be well pneumatized at 12 months in all patients.
Conclusion While 12-month graft and audiometric outcomes were comparable between EMM and ETM techniques, patients who underwent EMM had less postoperative pain, shorter operative times, faster healing, and a lower incidence of complications.
Level of Evidence1 Laryngoscope, 133:2779–2785, 2023
Yue Ma, Joseph Kidane, Grant E. Gochman, David J. Bracken, Madeleine P. Strohl, Clark A. Rosen, VyVy N. Young
Publication date 19-09-2023
Thirty seven healthy adults recruited with 340 tactile stimuli analyzed to study laryngeal sensation. Laryngeal sensation decreases in aging, male sex, and a more lateral laryngeal subsite.
Introduction Laryngeal sensory function in healthy adults was assessed through the delivery of tactile stimuli using Cheung–Bearelly monofilaments.
Methods37 healthy adults were recruited with 340 tactile stimuli analyzed.
Four calibrated tactile stimuli were delivered to three laryngeal sites: false vocal fold (FVF), aryepiglottic fold (AEF), and lateral pyriform sinus (LPS). Primary outcome was the elicitation of laryngeal adductor reflex (LAR). Secondary outcomes were gag, patient-reported laryngeal sensation (PRLS), and perceptual strength. Analysis was performed with mixed effects logistic regression modeling.
Results Positive LAR was observed in 35.7%, 70.2%, and 91.2% of stimuli at LPS, AEF, and FVF respectively. LAR rates were significantly associated with laryngopharyngeal subsite (p < 0.001), tactile force (p = 0.001), age (p = 0.022) and sex (p = 0.022). LAR, gag, PRLS, and perceptual strength significantly increased as a more medial laryngeal subsite was stimulated and as stimulus force increased. Each of the ten years of age increase was associated with 19% reduction in odds of LAR (aOR = 0.81, 95% CI 0.68, 0.97; p = 0.022). Male gender was associated with a 55% reduction in odds of LAR (aOR = 0.45, 95% CI 0.23, 0.89; p = 0.022).
ConclusionLAR elicitation capability decreases in the male gender, aging, and a more lateral subsite. This study provides insight into the pathophysiology of hypo- and hyper-sensitive laryngeal disorders and is paramount to making accurate diagnostic assessments and finding novel treatment options for various laryngological disorders. Laryngoscope, 133:2525–2532, 2023
Tripti Brar, Chantal McCabe, Amar Miglani, Michael Marino, Devyani Lal
Publication date 19-09-2023
Transcriptomic profiling using RNA-Sequencing (RNA-Seq) has enabled the study of differential expression of genes in diseased versus non-diseased tissue. In Chronic rhinosinusitis (CRS), RNA-Seq has been utilized to understand the mechanistic pathways underpinning the disease. While CRS is commonly sub-divided by phenotype into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP), sub-classification by endotype (tissue eosinophilia) has also been used, although less commonly, in understanding pathophysiology and guiding treatment. We used both metrics to compare CRS with controls using RNA-Seq and found that endotype classification by tissue eosinophilia, agnostic of nasal polyp status, offers superior insights into understanding the pathogenetics of CRS.
ObjectiveRNA sequencing (transcriptomics) is used to study biological pathways. However, the yield of data depends on comparing well-characterized cohorts. We compared tissue eosinophilia versus nasal polyp (NP) status as the metric to characterize transcriptomic mechanisms at play in eosinophilic and non-eosinophilic chronic rhinosinusitis (CRS) versus controls.
MethodsRNA sequencing was conducted on sinonasal tissue samples of CRS and controls. Analyses were conducted based on polyp status with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP) as well as tissue eosinophil levels per high power field (eos/hpf)non-eosinophilic (<10 eos/hpf, neCRS) or eosinophilic (≥10 eos/hpf, eCRS). The yield of differentially expressed genes (DEGs) and biological pathways through Ingenuity Pathway Analysis (IPA) were compared.
ResultsCRS tissue differed from controls by 736 statistically significant DEGs. Both NP status and tissue eosinophilia were effective in differentiating CRS from controls and into two distinct subgroups. Statistically significant DEGs identified when comparing CRS by NP status were 60, whereas 110 DEGs were identified using eosinophil cutoff ≥10 and <10 eos/hpf. Additionally, heatmaps showed greater homogeneity within each CRS subgroup when analyzed by tissue eosinophilia versus NP status. On IPA, the IL-17 signaling pathway was significantly different only by tissue eosinophilia status, not NP status, being higher in CRS <10 eos/hpf.
Conclusion Tissue eosinophilia is superior to an analysis by NP status for the study of CRS transcriptome by RNA sequencing in identifying DEGs. Classification of CRS samples by eosinophil counts agnostic of NP status may offer advantageous insights into CRS pathogenetic mechanisms.
Level of Evidence3 Laryngoscope, 133:2480–2489, 2023
CM Lawlor, Sukgi S. Choi
Publication date 19-09-2023
David Myssiorek, Stephen C Scharf
Publication date 19-09-2023
Nuclear medical imaging is indicated in most, but not all, patients with suspected paragangliomas of the head and neck. Advances in technology and somatostatin receptor analogs have improved the selectivity and sensitivity of this imaging.
Pubmed PDF WebLeah Sax, Shaan Sharma, Jacob Benedict, Kevin Guy, Ian Mandybur, Michael Bittner, John Sinacori, Benjamin Rubinstein
Publication date 19-09-2023
The objective of this study is to assess the impact of two different ventilation techniques, jet ventilation and apneic anesthesia with intermittent ventilation (AAIV), on patient hemodynamics and operative time during endoscopic laryngotracheal stenosis surgery.
Objective The objective of this study is to assess the impact of two different ventilation techniques, jet ventilation and apneic anesthesia with intermittent ventilation (AAIV), on patient hemodynamics and operative time during endoscopic laryngotracheal stenosis surgery.
Methods Retrospective chart review of patients who underwent airway dilation for laryngotracheal stenosis by a single surgeon at a single institution from October 1, 2000 through January 2, 2020. Logistic regression, Mann–Whitney U tests and chi square analysis were used to determine statistical significance.
ResultsA total of 157 patients, 43 (27.4%) male and 114 (72.6%) female, and 605 total encounters were included for analysis. There were no significant differences in hemodynamic outcomes when comparing the AAIV and jet ventilation groups. Specifically, there was no significant difference in either peak end-tidal CO2 or nadir O2 saturation between the AAIV and jet ventilation groups (p = 0.4016) and (p = 0.1357), respectively. The patients in the AAIV group had a significantly higher median BMI 32.93 (27.40–39.40) compared with 28.80 (24.1–32.65) (p = 0.0001). Although not necessarily clinically significant, patients with higher BMI had lower median O2 nadirs (97.8%) than non-obese patients (99.2%) (p < 0.0001). The median total procedure time was equivalent when comparing the two ventilation techniques.
ConclusionAAIV is a safe method of ventilation for patients undergoing endoscopic laryngotracheal stenosis surgery with no significant differences in patient hemodynamics or procedure time when compared with jet ventilation. AAIV was the preferred method of ventilation for obese patients undergoing endoscopic laryngotracheal stenosis surgery.
Level of Evidence3 Laryngoscope, 2023
Seraphina Key, Nusrat Mohamed, Melville Da Cruz, Kelvin Kong, Zubair Hasan
Publication date 18-09-2023
In 14 studies with 314 patients, pooled data show that the Osia® demonstrates audiological benefit compared with the unaided state, and a good safety profile. Future research is needed in the improvement for different frequencies, quality of life measures, and sensorineural hearing loss.
Objective This review aims to quantify the pooled functional gain (FG) in different types of hearing loss with the transcutaneous hearing device, Osia (Cochlear, Sydney, Australia) in comparison with the unaided state. Secondary outcomes are patient-reported outcomes measures (PROMs) and complication rates.
Data Sources Medline, Embase, SCOPUS, Cochrane CENTRAL, PROSPERO and Cochrane Library.
Review Methods Systematic review and meta-analysis of indexed search terms relating to “Osia,” “Osseointegration,” “Cochlear Implant,” and “Bone-Anchored Prosthesis” was performed from database inception to September 20, 2022.
Results Of the 168 studies identified, 14 studies with 15 patient cohorts (n = 314) met inclusion criteria for meta-analysis. Pooled overall mean FG for all types of hearing loss was 35.0 dB sound pressure level (SPL) (95% confidence interval CI 29.12–40.97) compared against unaided hearing. Pooled FG for conductive/mixed hearing loss was 37.7 dB SPL (95% CI 26.1–49.3). Pooled single-sided deafness (SSD) FG could not be calculated due to the small patient cohort for whom SSD data was reported. There is a trend toward improvements in speech receptiveness threshold, signal to noise ratio, and some PROMs compared with baseline hearing. Early complication rates demonstrate risks similar to other transcutaneous implants, with a low predicted explantation (0.11%, 95% CI 0.00%–1.90%) and wound infection rate (1.92% 95% CI 0.00%–6.17%). No articles directly comparing transcutaneous devices were identified.
Conclusion The Osia devices demonstrate clear audiologic benefits and a good safety profile for the included patient population. Our study results indicate that frequency-specific gain, PROMs, and the audiological benefit in single-sided deafness may be areas for future prospective research. Laryngoscope, 2023
Erika Elfstrand, Christian Löfvenberg, Lars Lundman, Johan Wikström
Publication date 18-09-2023
We present a rare case of extranasopharyngeal angiofibroma (ENA) in a patient who was clinically and radiologically diagnosed as having an Endolymphatic sac tumor (ELST). Additionally, we present an overview of typical clinicopathological features regarding ELSTs.
A 30-year-old man presented with minute-long episodes of vertigo and severe autophony. CVEMP showed a decreased threshold when testing the left side, potentially indicating SSCD. A subsequent MRI demonstrated a multi-lobulated, cystic mass in the temporal bone and the radiological diagnosis at that time was ELST. Tumor excision was performed, and microscopic examination of the excised material revealed fibrovascular tissue without signs of papillary or cystic projections. The conclusion of the histological assessment rendered a diagnosis of angiofibroma. We were unable to find a previous report of ENA originating around the endolymphatic sac. Laryngoscope, 2023
Aarti Agarwal, Ramez Philips, Michele Fiorella, Dev R. Amin, Howard Krein, Ryan Heffelfinger
Publication date 15-09-2023
Background Esophageal defects can result from primary pathologies such as malignancy or stricture, or secondary ones such as perforation due to trauma or iatrogenic injury. Techniques, management, and outcomes of reconstruction in this setting are poorly understood. Herein, we aim to highlight surgical outcomes in patients undergoing local and free flap reconstruction of esophageal defects in the setting of an intact larynx.
Methods Retrospective review of patients who underwent esophageal reconstruction with an intact larynx between 2009 and 2022 at our institution was performed.
Results Ten patients met inclusion criteria. Esophageal reconstruction was performed for extruded spinal hardware (n = 8), and esophageal stricture (n = 2). Four patients underwent reconstruction with free tissue transfer, and six with local pedicled flaps. There were no cases of flap failure, esophageal fistula, hematoma, or wound dehiscence. One patient had post-operative bleeding requiring return to the operating room. Three patients had a postoperative wound infection, two of whom required washout. There were no unplanned 30-day readmissions. At three months after operation, all patients who were not tube feed-dependent prior to surgery returned to oral intake. Of the four patients who were tube feed-dependent preoperatively, three were tolerating oral intake at nine months postoperatively. Nine patients (90%) had stable flexible laryngoscopy exams pre- and postoperatively with no voice changes.
Conclusions Reconstruction of esophageal defects in the setting of an intact larynx can be challenging. In this series, surgical intervention with free tissue transfer and local pedicled flaps was effective in returning patients to oral intake with low long-term morbidity.
Level of Evidence4 Laryngoscope, 2023
Olcay Cem Bulut, Burkard M. Lippert, Frank Riedel, Michaela Plath, Ralph Hohenberger
Publication date 14-09-2023
Objectives Septorhinoplasty (SRPL) and functional endoscopic sinus surgery (FESS) are two frequently performed surgeries to improve quality of life (QoL) in patients with nasal symptoms. It has been demonstrated as a safe combination regarding complication rates, but patient satisfaction in concurrent surgery has not been adequately studied yet.
Methods Patients undergoing sole FESS due to chronic rhinosinusitis (n = 57), sole SRPL (n = 148), and concurrent surgery (n = 62) were prospectively evaluated for their disease-specific QoL before and one year after surgery. Each procedure was performed by the same surgeon (OCB). For SRPL, the patient-reported outcome measures Rhinoplasty Outcomes Evaluation (ROE) and Functional Rhinoplasty Outcome Inventory (FROI-17) were utilized, and for chronic rhinosinusitis, the Sino-Nasal Outcome Test-22 (SNOT22).
Results All three groups showed significant improvement in the postoperative QoL measurements (all p < 0.01). The postoperative improvements were slightly smaller in the concurrent surgery group compared with the single surgery groups measured with ROE (combined: +55.2 ± 9.3, single: +58.8 ± 9.8, p = 0.02), FROI total score (combined: +47.6 ± 5.2, single: +49 ± 5.4; p = 0.08) and SNOT22 (combined: +33.1 ± 6.7, single +34.5 ± 7, p = 0.26).
ConclusionsSRPL, FESS, and combined surgery improve disease-specific QoL. When applicable, surgeons may offer the benefits of a combined procedure without compromising the QoL gain.
Level of Evidence Level 3 Laryngoscope, 2023
Sachi S. Dholakia, David Grimm, Rachel Daum, Dawn T. Bravo, Nicole Salvi, David Zarabanda, Jonathan B. Overdevest, Andrew Thamboo, Tsuguhisa Nakayama, Jayakar V. Nayak
Publication date 13-09-2023
We have identified novel radiographic and endoscopic imaging findings specific to patients with empty nose syndrome. These findings provide objective measurements highly specific to this group of patients and can help aid in the diagnosis of this challenging pathology.
Objective Empty nose syndrome (ENS) is a relatively uncommon disease that greatly impacts the quality of life and presents diagnostic challenges. We sought to identify objective clinical findings unique to patients with ENS, and in doing so identified compensatory mucosal hypertrophy in an alternating, undulating swelling on endoscopy and coronal computerized tomography (CT) that we have termed the “Serpentine Sign.” Here, we investigated whether this radiographic finding is a reliable manifestation in ENS patients.
Methods Retrospective review was undertaken to identify ENS patients with past turbinoplasty, an ENS6Q score of at least 11/30, and symptomatic improvement with the cotton placement test. Control patients without complaints of ENS symptoms (ENS6Q < 11) were identified for comparison. ENS and control patients had coronal CT imaging available to evaluate for the Serpentine Sign, as well as ENS6Q scores, and histologic analysis of nasal tissue.
Results34 ENS and 74 control patients were evaluated for the presence of the Serpentine Sign. Of the 34 patients with ENS, 18 exhibited this radiographic finding on CT imaging (52.9%) compared to 0 of the 74 control patients (p < 0.0001). Further analysis demonstrated that ENS patients with the Serpentine Sign had lower median scores on ENS6Q than ENS patients without (17.5 vs. 22, p = 0.033). Histology revealed disorganized subepithelium rich in seromucinous glands similar to the nasal septum swell body.
Conclusion The “Serpentine Sign” is a unique presentation of hypertrophic change to the nasal septum soft tissue that is specific to ENS patients and may serve as a reliable radiographic and endoscopic finding in diagnosis.
Level of EvidenceIV Laryngoscope, 2023
Meena Easwaran, Chloe Santa Maria, Joshua D. Martinez, Barbara Hung, Xuan Yu, Joanne Soo, Akari Kimura, Eric R. Gross, Elizabeth Erickson‐DiRenzo
Publication date 12-09-2023
Objectives The effects of electronic cigarettes (e-cigarettes) on the larynx are relatively unknown. This study examined the short-term effects of e-cigarette inhalation on cellular and inflammatory responses within the mouse laryngeal glottic and subglottic regions after exposure to pod-based devices (JUUL).
Methods Male C57BL6/J mice (8–9 weeks) were assigned to control (n = 9), JUUL flavors Mint (JMi; n = 10) or Mango (JMa; n = 10). JUUL mice were exposed to 2 h/day for 1, 5, and 10 days using the in Expose inhalation system. Control mice were in room air. Vocal fold (VF) epithelial thickness, cell proliferation, subglandular area and composition, inflammatory cell infiltration, and surface topography were evaluated in the harvested larynges. Mouse body weight and urinary nicotine biomarkers were also measured. Chemical analysis of JUUL aerosols was conducted using selective ion flow tube mass spectrometry.
ResultsJUUL-exposed mice had reduced body weight after day 5. Urinary nicotine biomarker levels indicated successful JUUL exposure and metabolism. Quantitative analysis of JUUL aerosol indicated that chemical constituents differ between JMi and JMa flavors. VF epithelial thickness, cellular proliferation, glandular area, and surface topography remained unchanged after JUUL exposures. Acidic mucus content increased after 1 day of JMi exposure. VF macrophage and T-cell levels slightly increased after 10 days of JMi exposures.
Conclusions Short-term e-cigarette exposures cause minimal flavor- and region-specific cellular and inflammatory changes in the mouse larynx. This work provides a foundation for long-term studies to determine if these responses are altered with multiple e-cigarette components and concentrations.
Level of EvidenceN/A Laryngoscope, 2023
Jo Omata, Yushi Ueki, Yuto Takahashi, Ryoko Tanaka, Yusuke Yokoyama, Takeshi Takahashi, Ryusuke Shodo, Keisuke Yamazaki, Takafumi Togashi, Hiroshi Matsuyama, Nao Takahashi, Ryuichi Okabe, Arata Horii
Publication date 12-09-2023
This study analyzed the treatment outcome and prognostic factors of patients with head and neck cell carcinoma with initial metastasis disease. Multivariate analysis revealed that the administration of locoregional radiation therapy, use of ICIs, and radiation therapy/surgery for distant metastasis were the independent overall survival prognostic factors.
Objective Recurrent/metastatic head and neck squamous cell carcinoma (HNSCC) treatment has changed dramatically with the introduction of immune checkpoint inhibitors (ICIs). However, there are few reports of treatment outcomes on HNSCC with distant metastasis (M1) at initial diagnosis, and its treatment strategy has not been standardized. We aimed to analyze the treatment outcome and prognostic factors of patients with HNSCC with initial M1 disease.
Methods In this multi-institutional retrospective study, 98 patients with HNSCC were initially diagnosed with M1 disease between 2007 and 2021. The patients were divided into the non-palliative (received any systemic chemotherapy, n = 60) and palliative (did not receive systemic chemotherapy, n = 38) groups. Overall survival (OS) was compared between the groups. In the non-palliative group, predictors of OS were explored based on patient characteristics and treatment details.
Results The median OS in the non-palliative group was 15 months (95% confidence interval CI, 10–20), which was significantly longer than that in the palliative group (3 months, 95% CI, 2–5) (p < 0.001). Multivariate analysis revealed that administration of locoregional radiation therapy (RT) (hazard ratio HR 0.407 95% CI 0.197–0.844; p = 0.016), ICIs (HR 0.216 95% CI 0.088–0.532; p < 0.001) and RT/surgery for distant metastasis (HR 0.373 95% CI 0.150–0.932; p = 0.034) were the independent prognostic factors of OS.
Conclusion An intensive treatment strategy combining systemic therapy using ICIs with RT/surgery for locoregional or distant metastasis may yield a survival benefit for patients with HNSCC with M1 disease.
Level of Evidence4 Laryngoscope, 2023
Stefanie Seo, Sarek Shen, Andy S. Ding, Francis X. Creighton
Publication date 12-09-2023
This paper is the first to describe the long-term outcomes of cochlear implants in patients with Neurofibromatosis type 2. We found that larger lifetime VS tumor size is significantly correlated with the odds of becoming a non-user of CI (p = 0.028). While failure of CI function and profound hearing loss are frequent in the course of NF2, patients may still experience long-term benefits from cochlear implants.
Objective Cochlear implants (CIs) are a well-established treatment modality for hearing loss due to neurofibromatosis type 2 (NF2). Our aim is to investigate variables that affect longitudinal performance of CIs among patients with NF2.
Study Design Retrospective review at a single academic institution consisting of patients who have received cochlear implants following hearing loss due to NF2.
Methods The primary outcome examined was CI disuse or explantation. Associated clinical and surgical variables were analyzed using descriptive statistics. These included postoperative pure tone average (PTA) at 500, 1000, and 2000 Hz, tumor size, previous surgery, and comorbid depression.
ResultsA total of 12 patients and 14 cochlear implants received at our institution from 2001 to 2022 were included. Notably, 35.7% of CIs (5 out of 14 cases) resulted in disuse or explantation. The average interval until explant was 9.4 years (range 3–14 years). In explanted CI cases, 20% had previous surgery and 80% had a diagnosis of comorbid depression as compared to 22.2% and 22.2%, respectively, in intact CI cases. Maximum tumor diameter was the only variable found to impact CI usage outcome (p = 0.028). Long-term data showed that on average, patients benefit from 13.85 years of CI utility and a maximum PTA improvement of 45.0 ± 29.0 dB.
Conclusion Despite the recurrent nature of NF2, patients continue to receive audiological benefit from cochlear implants. We found that larger tumor size may be associated with longitudinal CI failure.
Level of Evidence Level 4 Laryngoscope, 2023
Dante J. Nicotera, Aseeyah A. Islam, Yupeng Liu, Kate Dunsky, Judith E. C. Lieu
Publication date 12-09-2023
Among pediatric patients presenting with retropharyngeal abscess, Black patients were less likely to receive surgical management, and less likely to have presented to care having already received antibiotics. These findings suggest potential disparities in access to primary and urgent care that result in increased presentation care without prior treatment, resulting in higher rates of trial of medical management prior to surgery.
Objectives Differences in management and outcomes of otolaryngologic diseases may reflect inequities driven by social determinants of health. This study aimed to investigate disparities in presentation and outcomes of retropharyngeal abscess (RPA) among 231 pediatric patients.
Methods Medical records were searched for pediatric patients with RPA from 2010 to 2021. Charts were reviewed for demographics, clinical features, and treatment decisions. Area deprivation index (ADI) scores for patient zip codes were determined. Chi-square analysis independent samples t-test, and regression analyses were used to investigate associations between variables.
Results Among patients presenting for RPA, Black patients were less likely to undergo surgical management than non-Black patients (53.2% vs. 71.6%, p = 0.009). Black patients had a lower rate of treatment with antibiotics prior to hospital admission (19.4% vs. 54.4%, p < 0.001). Among patients who received surgery, Black patients had higher cross-sectional abscess area on CT (6.4 ± 8.4 cm2 > vs. 3.8 ± 3.3 cm2, p = 0.014), longer length of stay (5.4 ± 3.3 days vs. 3.2 ± 1.5, p < 0.001), and longer time between admission and surgery (2.3 ± 2.1 vs. 0.83 ± 1.1, p < 0.001). Increased ADI was correlated with increased rate of trismus.
Conclusions Lower rates of pre-admission antibiotics and larger abscess area on CT imaging among Black patients may suggest disparities in access to primary care, resulting in presentation to tertiary care at later stages of disease and higher rates of medical management trial prior to surgical intervention.
Level of Evidence Three (retrospective cohort study) Laryngoscope, 2023
Jonna Kuuskoski, Jaakko Vanhatalo, Jami Rekola, Leena‐Maija Aaltonen, Pia Järvenpää
Publication date 11-09-2023
Water swallow test is more accurate than the Eating Assessment Tool (EAT-10) questionnaire in predicting dysphagia findings in videofluoroscopy. Coughing and drinking bolus size are the most important variables in water swallow test.
Background Videofluoroscopy (VFS) is the gold standard in evaluating dysphagia. Water swallow tests (WST) and the Eating Assessment Tool (EAT-10) are commonly used in dysphagia screening. We aimed to determine the feasibility of WST and EAT-10 as screening tools for referral to VFS.
Methods Patients (n = 150, median age: 70.0 years, range: 19–92 years, 58.7% female) referred to VFS completed the WST and EAT-10 before the examination. In the WST, we evaluated both the qualitative parameters (coughing, possible change in voice) and quantitative parameters (average drinking bolus size, swallowing speed). Correlations of EAT-10 total scores and WST parameters to the VFS findings were analyzed both individually and combined.
Results In the WST, the most specific (89.7%) predictor of normal VFS findings was the absence of coughing, and the most sensitive (79.1%) parameter to predict abnormal findings was a bolus size of ≤20 mL. Using a combination of coughing and a bolus size ≤20 mL (simplified WST), the sensitivity of predicting abnormal findings increased to 83.5%. The most sensitive (84.6%) predictor of penetration/aspiration was failing any parameter in the WST. Lack of coughing indicated an absence of penetration/aspiration with an 82.5% specificity. Swallowing speed or combining the EAT-10 results with the WST results did not enhance the sensitivity or specificity of the WST for predicting the VFS results.
Conclusions Coughing and average drinking bolus size are the most important parameters in WST when screening for referral to VFS, whereas the swallowing speed does not seem to be useful. The WST is superior to EAT-10 in predicting VFS findings.
Level of Evidence4 Laryngoscope, 2023
Saangyoung E. Lee, Elizabeth Ritter, Tuong T. Nguyen, Princess C. Onuorah, Charles S. Ebert Jr., Brent A. Senior, Brian D. Thorp, Adam J. Kimple
Publication date 11-09-2023
Utilization of mass spectrometry to quantify in vivo absorption of fluticasone at different anatomic locations in the sinonasal cavity. Our study shows that sinonasal fluticasone absorption is significantly higher than estimated by previous computational fluid dynamic models.
Background Intranasal corticosteroids (INCS) are a treatment mainstay of chronic rhinosinusitis and allergic rhinitis. Current computational models demonstrate that >90% of INCS drug deposition occurs on the head of the inferior turbinate and nasal valve, rather than the actual sinuses. These models do not consider mucociliary clearance which propels mucus posteriorly, nor do they consider the absorption of the drug. The purpose of this study is to better understand the exact anatomical location where INCS are absorbed.
Methods Patients with chronic rhinosinusitis and allergic rhinitis taking fluticasone pre-operatively who were scheduled for functional endoscopic sinus surgery and inferior turbinate reduction, respectively, were recruited. Intra-operative tissue samples were obtained from predetermined locations within the sinonasal cavity. Mass spectrometry was then used to quantify the amount of absorption in each specific anatomic location to determine the largest amount of absorption.
Results Eighteen patients were included in our study. The greatest fluticasone absorption levels across the sinonasal anatomy were at the anterior inferior turbinate (5.7 ngl/mL), ethmoid sinus, (4.4 ng/mL), posterior inferior turbinate (3.7 ng/mL), maxillary sinus (1.3 ng/mL), and the sphenoethmoidal recess (0.72 ng/mL) respectively. Absorption was significantly higher in revision surgery compared to surgically naïve patients.
Conclusions Computation fluid dynamic models of the nasal passage are useful models to help predict intranasal particle flow. However, these models do not incorporate or consider the important mucociliary clearance system, leading to absorption of fluticasone throughout the sinonasal cavity far beyond that predicted by these models.
Level of Evidence2 Laryngoscope, 2023
"Tayla Razmovski, Kate M. Brody, Dimitra Stathopoulos, Dongcheng Zhang, Ellie Cho, Amy J. Hampson, Aaron Collins, Christofer Bester, Stephen OLeary"
Publication date 11-09-2023
This manuscript examines the feasibility of an intra-cochlear flushing protocol for the removal of blood during cochlear implantation. The results from a chronic animal study showed that intra-cochlear flushing reduced the tissue response in the basal half of the cochlea, even when compared with the control group.
Introduction Intraoperative trauma leading to bleeding during cochlear implantation negatively impacts residual hearing of cochlear implant recipients. There are no clinical protocols for the removal of blood during implantation, to reduce the consequential effects such as inflammation and fibrosis which adversely affect cochlear health and residual hearing. This preclinical study investigated the implementation of an intra-cochlear flushing protocol for the removal of blood.
Methods Three groups of guinea pigs were studied for 28 days after cochlear implantation; cochlear implant-only (control group); cochlear implant with blood injected into the cochlea (blood group); and cochlear implant, blood injection, and flushing of the blood from the cochlea intraoperatively (flush group). Auditory brainstem responses (ABRs) in addition to tissue response volumes were analyzed and compared between groups.
Results After implantation, the blood group exhibited the highest ABR thresholds when compared to the control and flush group, particularly in the high frequencies. On the final day, the control and blood group had similar ABR thresholds across all frequencies tested, whereas the flush group had the lowest thresholds, significantly lower at 24 k Hz than the blood and control group. Analysis of the tissue response showed the flush group had significantly lower tissue responses in the basal half of the array when compared with the blood and control group.
Conclusions Flushing intra-cochlear blood during surgery resulted in better auditory function and reduced subsequent fibrosis in the basal region of the cochlea. This finding prompts the implementation of a flushing protocol in clinical cochlear implantation.
Level of EvidenceN/A Laryngoscope, 2023
Diane Majerus Brewer, Claire Marcus Bernstein, Dominique Calandrillo, Nancy Muscato, Kailey Introcaso, Cassandra Bosworth, Anne Olson, Rachel Vovos, Gina Stillitano, Sarah Sydlowski
Publication date 09-09-2023
This RCT study provides evidence of improved speech recognition and psychosocial outcomes, with large effect sizes, following 6 weeks of TeleAR intervention. For adult postlingually deafened CI users, TeleAR treatment can leverage neuroplasticity to maximize outcomes.
Objective(s)This randomized controlled study evaluated the effectiveness of a Telehealth Aural Rehabilitation (TeleAR) training protocol to improve outcomes for adult cochlear implant (CI) users.
Methods This was a multisite clinical study with participants randomized to either an AR treatment or active control group. The AR protocol consisted of auditory training (words, sentences, and speech tracking), informational counseling, and communication strategies. The control group participants engaged in cognitive stimulation activities (crosswords, sudoku, etc.). Each group completed 6 weekly 90-min individual treatment sessions delivered remotely. Twenty postlingually deafened adult CI users participated. Assessments were completed pretreatment and 1 week and 2 months posttreatment.
Results Repeated-measures ANOVA and planned contrasts were used to compare group performance on Az Bio Sentences, Hearing Handicap Inventory (HHI), Client Oriented Scale of Improvement (COSI), and Glasgow Benefit Inventory (GBI). The two groups were statistically equivalent on all outcome measures at pre-assessment. There was a statistically significant main effect of time for all measures. Improvement over time was observed for participants in both groups, with greater improvement seen for the AR than the CT group on all outcome measures. The AR group showed medium to large effect sizes on all measures over time, suggesting clinically significant outcomes.
Conclusion This randomized controlled study provides evidence of improved speech recognition and psychosocial outcomes following 6 weeks of TeleAR intervention. For adult post-lingually deafened CI users, including those >3 months post-activation, AR treatment can leverage neuroplasticity to maximize outcomes.
Level of Evidence2 Laryngoscope, 2023
Nick J. I. Hamilton, Angela Tait, Ben Weil, Julie Daniels
Publication date 08-09-2023
Exploring the use of cord-derived mesenchymal stem cells embedded within a collagen matrix as a method to restore vocal cord viscoelastic tissue.
Objectives Fibrosis of the vocal fold lamina propria reduces vocal cord vibration resulting in a chronically hoarse voice. We describe a novel approach using umbilical cord-derived mesenchymal stem cells in a dehydrated collagen matrix (cellogen) to reconstruct the delicate balance of extracellular matrix within the vocal fold lamina propria whilst limiting the host inflammatory response to the implant.
Methods Human umbilical cord-derived mesenchymal stem-cells were embedded in bovine type I collagen hydrogel and dehydrated using the RAFT™ 3D culture system. The extracellular matrix, cellular viability and composition, paracrine profile, and genomic profile were assessed and the scaffold engrafted onto the hind muscle of NUDE mice.
Results The cells retained stem-cell markers following fabrication and secreted collagen III, fibronectin, and glycosaminoglycans within the scaffold. Electron microscopy showed the scaffold consisted of single strands of protein with interspersed bundles of a similar size to native vocal fold lamina propria. The use of the dehydration step improved cell viability and upregulated the expression of genes important in wound healing and matrix organization compared with unmodified collagen hydrogel carriers. The cells were shown to secrete exosomes and cytokines and, following engraftment within an immunocompromised mouse model, appeared to modulate the host inflammatory response compared with controls.
Conclusion This article provides a scalable cell-protein scaffold that with further modifications could provide a replacement for lost or damaged vocal fold mucosa. Further investigations are required to assess the mechanical properties of the scaffold and inhibit the differentiation of the umbilical cord-derived stem-cells following implantation. Laryngoscope, 2023
Jordan K. Simmons, Wasiq Nadeem, Marcel M. Maya, Arthur W. Wu, Wouter I. Schievink, Adam N. Mamelak, Dennis M. Tang
Publication date 08-09-2023
A 12-year-old male, who had suffered a motor vehicle trauma seven years prior, was diagnosed with a rare cerebrospinal fluid (CSF)-venous fistula (CVF) causing orthostatic, exertional headache and intracranial hypotension. The CVF was treated via a unique trans-nasal endoscopic approach after MRI and CT imaging failed to detect it, but digital subtraction myelography (DSM) confirmed the diagnosis. This case suggests the need for considering CVFs in the differential diagnosis of spontaneous intracranial hypotension, and the potential utility of DSM in diagnosing CVFs when traditional radiology results are inconclusive.
An adolescent male presented with orthostatic headaches following head trauma. MRI showed cerebellar tonsil displacement and a bony defect in the clival skull base. Digital subtraction myelography (DSM) confirmed a cerebrospinal fluid-venous fistula (CVF). This was repaired endoscopically. CVFs cause uncontrolled flow of CSF into the venous system resulting in symptoms of intracranial hypotension. Theyre often difficult to identify on initial imaging. This is the first reported CVF originating in the central skull base, and the first treated via endoscopic trans-nasal approach. CVFs may elude initial imaging, making DSM crucial for unexplained spontaneous intracranial hypotension. Laryngoscope, 2023
Maie M. Zagloul, Jonathan M. Bock, Joel H. Blumin, David R. Friedland, Jazzmyne A. Adams, Ling Tong, Kristen I. Osinksi, Masoud Khani, Jake Luo
Publication date 08-09-2023
African American patients and those with public insurance had significantly higher utilization of subsequent testing and intervention in dysphagia care in our tertiary academic care network, while no significant differences were seen in dysphagia evaluation modalities based on zip code analysis.
Objectives Limited research exists evaluating the impact of social determinants of health in influencing care pathways for patients with dysphagia. A better understanding of whether these determinants correlate to altered care and resource utilization is essential as it relates to patient outcomes.
Study Design Retrospective chart review.
Methods All adult patients seen at a tertiary midwestern hospital were screened for ICD codes of dysphagia diagnoses from 2009 to 2019. Demographic information was collected from these patients with dysphagia including sex, race, ethnicity, and insurance status. Subgroup analysis was performed to assess referral pattern rates and types of diagnostic interventions ordered (none, videofluoroscopic swallow study, esophagram, and esophagogastroduodenoscopy).
ResultsA total of 31,858 patients with dysphagia were seen at our institution during the study period, with a majority being female (56.36%), Caucasian (79.83%), and publicly insured (63.16%), at a median age of 60.35 years. There were no significant care delivery pattern differences based on geography/zip code analyses. African American patients were significantly more likely to have imaging or interventions performed (odds ratio OR 1.463, p = 0.005). Patients with public insurance also had higher rates of diagnostic study utilization (OR 1.53, p = 0.01). Only 3% of all patients with dysphagia were seen by laryngologists.
Conclusion No significant differences were seen in dysphagia evaluation modalities based on zip code analyses surrounding this tertiary care facility. African American patients and those with public insurance had significantly higher utilization of subsequent testing and intervention for dysphagia care. Further studies are necessary to delineate causes and outcome differences for these measurable differences in dysphagia care pathways.
Level of EvidenceIV Laryngoscope, 2023
Pedro Plou, Simona Serioli, Alex Y. Alexander, Luciano C. P. C. Leonel, Maria Peris‐Celda, Carlos D. Pinheiro‐Neto
Publication date 07-09-2023
Frontal sinus surgery still represents a challenge due to its complex and highly variable anatomy. In this manuscript, we present a detailed anatomical description of an eyebrow approach that allows full exposure of the frontal sinus with a large osteoplastic bone flap and preservation of the supraorbital nerve. Laryngoscope, 2023
Pubmed PDF WebSul Gi Kim, Deanna C. Menapace, Mark M. Mims, William W. Shockley, J. Madison Clark
Publication date 07-09-2023
Non-cadaveric histological exploration of nasal and auricular cartilages showed a decline in glycosaminoglycans with age but an increase in collagen with age for nasal cartilages. For auricular cartilage, there was a decline in elastin with age.
Objective Analyze age-related changes in histologic features and biochemical properties of human auricular cartilage and two subsites of nasal cartilages (quadrangular cartilage and dorsal septal articulation with upper lateral cartilages).
Study Design Prospective cross-sectional study of nasal and auricular cartilages from seventy-three (73) live donors.
Methods Auricular cartilage (AC), quadrangular cartilage (QC), and dorsal septal cartilage articulation (DSA) with the upper lateral cartilage (ULCs) were collected intraoperatively.
Histochemical staining was used: Safranin O for glycosaminoglycans (GAGs), Verhoeffs for elastin, and Massons trichrome for collagen. ImageJ2 software was used to calculate cell count and percent stained for each cartilage type. R studio “ggplot” package was used to visualize age versus cell count or percent stained.
Results Participant ages ranged from 20 to 77 years, average 46.5 years. There was a significant decline in GAGs with age for the DSA subsite, (n = 64, p < 0.001). Significant increase in collagen content with age was observed for DSA subsite (n = 66, p < 0.001) and the QC subsite (n = 64, p < 0.05). There was a statistically insignificant decline in elastin with age (n = 41, p = 0.309) for AC. Cell count declined with age at all cartilage subsites.
Conclusion Our findings confirm that there were age-related decreases in cartilage glycosaminoglycan content, and chondrocyte cell count in both auricular and nasal cartilages. We have also confirmed that collagen content increases with age for both auricular and nasal cartilage. The histologic findings while not statistically significant in all comparisons, provides additional evidence that there is some loss of structural integrity and flexibility in nasal and auricular cartilage with aging.
Level of EvidenceNA Laryngoscope, 2023
"William Z. Gao, Marcus F. Paoletti, Yael Bensoussan, Neel K. Bhatt, Elizabeth A. Shuman, Nazaneen Grant, Karla ODell, Michael M. Johns III"
Publication date 07-09-2023
We prospectively studied 17 patients treated with silk microparticle-hyaluronic acid vocal fold injection medialization for unilateral vocal fold paralysis. Seven of 12 patients with 12+ months follow-up experienced notable clinical response to treatment that was sustained based on patient-reported outcomes and blinded expert assessments of laryngeal exams. This supports the ability of silk-HA to achieve durable clinical effect related to laryngeal tissue remodeling, but predictive clinical factors remain to be elucidated.
Objective Vocal fold injection medialization (VFIM) is widely used as an initial treatment for unilateral vocal fold paralysis (UVFP). Current practices employ materials that share the limitation of temporary clinical effect from variable resorption rates. A novel silk protein microparticle-hyaluronic acid-based material (silk-HA) has demonstrated cellular infiltration and tissue deposition that may portend a durable medialization effect. We report on ≥12 months outcomes after VFIM with silk-HA.
Methods Prospective open-label study of patients with UVFP that elected treatment with VFIM with silk-HA. Blinded experts rated laryngeal stroboscopic exams.
Results Seventeen patients with UVFP underwent VFIM with silk-HA. Twelve of the 17 patients have ≥12 months follow-up. Seven patients demonstrated durable treatment benefit ≥12 months after injection with median improvement of 19 (p = 0.0156) in VHI-10. There was no significant change in VHI-10 between 1 and 12 months for these patients. Blinded ratings indicated that 5/7 patients with sustained improvements in VHI-10 exhibited complete or touch glottal closure at 12 months. Two of the seven patients exhibited a small (<1 mm) glottal gap at 12 months. Seven patients experienced initial benefit with later regression 3–4 months after injection.
ConclusionVFIM with silk-HA can offer durable improvement in voice-related outcomes for UVFP past 12 months. A subset of patients treated with silk-HA experienced early loss of effect around 3–4 months postinjection. Clinical factors predictive of sustained treatment response to silk-HA injection require further exploration.
Level of Evidence3 Laryngoscope, 2023
R. Jun Lin, Michael C. Munin, Michael Belsky, Brandon Smith, Elysia Grose, Rosane Nisenbaum, Clark A. Rosen, Libby J. Smith
Publication date 07-09-2023
Background/Objective Laryngeal electromyography (LEMG) is a useful diagnostic test in the evaluation of vocal fold paralysis (VFP). This study investigates factors that can make LEMG challenging to perform.
Methods Patients with subacute unilateral VFP presented for LEMG were prospectively enrolled. Demographic data including BMI, previous neck surgery, and anatomic factors were collected. Patient-reported pain related to the procedure was recorded on a visual analogue scale (VAS). Electromyographer and otolaryngologist recorded a consensus rating of the perceived difficulty in performing the test and confidence in using the results for clinical decision-making.
ResultsA total of 111 patients (56.8% female) were enrolled between August 2015 and August 2018. The mean age was 55 ± 14 years, and the average body mass index (BMI) was 28.5 ± 6.4. The mean patient-reported VAS score for pain was 35 ± 24. Notably, 31.2% of the tests were considered “very easy,” 32.1% were considered “mildly challenging” and 23.9% and 12.8% were considered “moderately challenging” and “extremely challenging,” respectively, by the clinicians. Common factors affecting LEMG difficulty included poorly palpable surface anatomy (50.5%) and patient intolerance (15.6%). Clinicians felt confident in 76.1% of the test findings. Bivariate analyses showed that prior neck surgery is associated with elevated VAS (p = 0.02), but clinician-perceived difficulty of performing the test is not associated with elevated VAS scores (p = 0.55).
Conclusions Majority of LEMG tests are well tolerated by patients. Physicians reported more confidence using LEMG for clinical decision-making when the test was easier to perform. Difficult surface anatomy and patient intolerance affects clinician confidence in integrating the test results with clinical care.
Level of Evidence Level 3 Laryngoscope, 2023
Hye Rhyn Chung, Yoonjeong Lee, Neha K. Reddy, Zhaoyan Zhang, Dinesh K. Chhetri
Publication date 07-09-2023
Although thyroarytenoid (TA) muscle activation plays a crucial role in regulating VF vibration, how TA activation asymmetry relates to voice acoustics and perception is unclear. We evaluated the relationship between TA activation asymmetry and the resulting acoustics and perception. We found that whereas increasing vibratory asymmetry is correlated with decreased perceptual ratings, mild asymmetries are perceptually tolerated.
Introduction Asymmetry of vocal fold (VF) vibration is common in patients with voice complaints and also observed in 10% of normophonic individuals. Although thyroarytenoid (TA) muscle activation plays a crucial role in regulating VF vibration, how TA activation asymmetry relates to voice acoustics and perception is unclear. We evaluated the relationship between TA activation asymmetry and the resulting acoustics and perception.
Methods An in vivo canine model of phonation was used to create symmetric and increasingly asymmetric VF vibratory conditions via graded stimulation of bilateral TA muscles. Naïve listeners (n = 89) rated the perceptual quality of 100 unique voice samples using a visual sort-and-rate task. For each phonatory condition, cepstral peak prominence (CPP), harmonic amplitude (H1-H2), and root-mean-square (RMS) energy of the voice were measured. The relationships between these metrics, vibratory asymmetry, and perceptual ratings were evaluated.
Results Increasing levels of TA asymmetry resulted in declining listener preference. Furthermore, only severely asymmetric audio samples were perceptually distinguishable from symmetric and mildly asymmetric conditions.
CPP was negatively correlated with TA asymmetry: voices produced with larger degrees of asymmetry were associated with lower CPP values. Listeners preferred audio samples with higher values of CPP, high RMS energy, and lower H1-H2 (less breathy).
Conclusion Listeners are sensitive to changes in voice acoustics related to vibratory asymmetry. Although increasing vibratory asymmetry is correlated with decreased perceptual ratings, mild asymmetries are perceptually tolerated. This study contributes to our understanding of voice production and quality by identifying perceptually salient and clinically meaningful asymmetry.
Level of EvidenceN/A (Basic Science Study) Laryngoscope, 2023
Riccardo Di Micco, Rolf Salcher, Anke Lesinski‐Schiedat, Thomas Lenarz
Publication date 07-09-2023
Microsurgical extirpation combined with cochlear implantation offers good hearing rehabilitation results and satisfying recurrence control rate even in the long term for intracochlear schwannomas. Speech recognition scores offer a valid clinical tool in the follow-up. Indications, results, and limits of the technique are discussed.
Objectives The aim was to analyze the long-term hearing results after simultaneous microsurgical extirpation via enlarged cochleostomy and cochlear implantation in intracochlear schwannoma as compared with non-tumor single-side deafness patients.
Methods Microsurgical extirpation via enlarged cochleostomy with simultaneous cochlear implantation was performed in 15 cases of intracochlear schwannoma between 2014 and 2021. Speech recognition tests in German language and impedance performances were collected over 36 months of observation and compared with an internal cohort of 52 age matched non-tumor single-side deafness patients. Retrospective cohort study in a tertiary referral center.
Results The surgery proved feasible and uneventful in all cases. In the case of intracochlear schwannoma, the hearing rehabilitation results were highly satisfactory and comparable to those of the non-tumor single-side deafness cohort. The speech recognition performance improved steadily in the first 12 months; afterward, it remained stable, providing indirect evidence against tumor recurrence during the follow-up. One patient required implant revision surgery related to device failure, but no recurrence was registered in the 36 months of observation.
Conclusions Cochlear implantation is the strategy of choice for hearing rehabilitation in case of intracochlear schwannomas in the long term. In particular, the combination of tumor extirpation via cochleostomy with a cochlear implantation in the same surgical time offers a viable therapy for intracochlear schwannoma, granting a sufficient degree of radicality without compromising the cochlear integrity. This technique allows for revision surgery if required.
Level of Evidence4 Laryngoscope, 2023
Patrick Schlegel, Hye Rhyn Chung, Michael Döllinger, Dinesh K. Chhetri
Publication date 06-09-2023
We analyzed vocal fold vibration as a function of neuromuscular stimulation and airflow levels. Oscillation patterns such as figure-eight and bent trajectories were linked to high nerve activation and flow. Further studies investigating longer sections of 3D reconstructed oscillations are needed to validate our findings.
Introduction Analysis of medial surface dynamics of the vocal folds (VF) is critical to understanding voice production and treatment of voice disorders. We analyzed VF medial surface vibratory dynamics, evaluating the effects of airflow and nerve stimulation using 3D reconstruction and empirical eigenfunctions (EEF).
Study Design In vivo canine hemilarynx phonation.
Methods An in vivo canine hemilarynx was phonated while graded stimulation of the recurrent and superior laryngeal nerves (RLN and SLN) was performed. For each phonatory condition, vibratory cycles were 3D reconstructed from tattooed landmarks on the VF medial surface at low, medium, and high airflows. Parameters describing medial surface trajectory shape were calculated, and underlying patterns were emphasized using EEFs. Fundamental frequency and smoothed cepstral peak prominence (CPPS) were calculated from acoustic data.
Results Convex-hull area of landmark trajectories increased with increasing flow and decreasing nerve activation level. Trajectory shapes observed included circular, ellipsoid, bent, and figure-eight. They were more circular on the superior and anterior VF, and more elliptical and line-like on the inferior and posterior VF. The EEFs capturing synchronal opening and closing (EEF1) and alternating convergent/divergent (EEF2) glottis shapes were mostly unaffected by flow and nerve stimulation levels. CPPS increased with higher airflow except for low RLN activation and very dominant SLN stimulation.
Conclusion We analyzed VF vibration as a function of neuromuscular stimulation and airflow levels. Oscillation patterns such as figure-eight and bent trajectories were linked to high nerve activation and flow. Further studies investigating longer sections of 3D reconstructed oscillations are needed.
Level of EvidenceN/A, Basic Science Laryngoscope, 2023
Amir Hamud, Alexander Brodsky, Riad Khnifes
Publication date 06-09-2023
This report documents a rare case of toxoplasmosis mimicking an oropharyngeal neoplasm in an otherwise healthy patient. An asymptomatic 28-year-old woman presented with an ulcerative tonsillar lesion and cervical lymphadenopathy unresponsive to initial antibiotic treatment, arousing suspicions of malignancy. However, high positive IgM antibodies with low IgG avidity indicated recent primary toxoplasma infection. The report emphasizes the importance of considering infectious etiologies in differential diagnoses of oropharyngeal lesions, particularly in unusual presentations.
This case report elucidates an uncommon manifestation of toxoplasmosis characterized by an ulcerative oropharyngeal lesion and cervical lymphadenopathy, which intriguingly simulated a tonsillar neoplasm. The patient, a 28-year-old immunocompetent woman, reported symptoms such as a persistent sore throat, unilateral neck pain, and otalgia. Despite the initial clinical impressions, a diagnostic left subtotal tonsillectomy revealed no malignancy but marked acute and chronic inflammation. A comprehensive investigation subsequently indicated a recent primary infection with Toxoplasma gondii, as evidenced by the presence of high IgM antibodies and low IgG avidity. This unique case underlines the significance of incorporating toxoplasmosis into the differential diagnosis of oropharyngeal lesions, thereby necessitating a meticulous approach to laboratory testing. Laryngoscope, 2023
Siddhi Hegde, Shreya Sreeram, Isaac L. Alter, Chaya Shor, Tulio A. Valdez, Kara D. Meister, Anaïs Rameau
Publication date 06-09-2023
Cough sound analysis holds the promise of an accessible disease biomarker. We survey efforts in using cough sounds in adult, pediatric, and animal populations and examine evolution in hardware and analytics. Rapid acceleration is noted in the past decade, though with limitations.
Objective The aim of the study was to examine applications of cough sounds towards screening tools and diagnostics in the biomedical and engineering literature, with particular focus on disease types, acoustic data collection protocols, data processing and analytics, accuracy, and limitations.
Data Sources Pub Med, EMBASE, Web of Science, Scopus, Cochrane Library, IEEE Xplore, Engineering Village, and ACM Digital Library were searched from inception to August 2021.
Review MethodsA scoping review was conducted on screening and diagnostic uses of cough sounds in adults, children, and animals, in English peer-reviewed and gray literature of any design.
Results From a total of 438 abstracts screened, 108 articles met inclusion criteria. Human studies were most common (77.8%); the majority focused on adults (57.3%). Single-modality acoustic data collection was most common (71.2%), with few multimodal studies, including plethysmography (15.7%) and clinico-demographic data (7.4%). Data analytics methods were highly variable, with 61.1% using machine learning, the majority of which (78.8%) were published after 2010. Studies commonly focused on cough detection (41.7%) and screening of COVID-19 (11.1%); among pediatric studies, the most common focus was diagnosis of asthma (52.6%).
Conclusion Though the use of cough sounds in diagnostics is not new, academic interest has accelerated in the past decade. Cough sound offers the possibility of an accessible, noninvasive, and low-cost disease biomarker, particularly in the era of rapid development of machine learning capabilities in combination with the ubiquity of cellular technology with high-quality recording capability. However, most cough sound literature hinges on nonstandardized data collection protocols and small, nondiverse, single-modality datasets, with limited external validity. Laryngoscope, 2023