Laryngoscope 2020-12-21

Geographic and Socioeconomic Factors on Survival in Esthesioneuroblastoma

Sandra T. Mikhael, Abanoob F. Tadrosse, Marina F. Tadrosse, Arsany Yassa, Mina T. Mikhael, Gregory L. Barinsky, Jordon G. Grube, Christina H. Fang, Jean Anderson Eloy

Publication date 21-12-2020


Objectives Esthesioneuroblastoma (ENB) is a rare sinonasal malignancy with little known regarding how regional and socioeconomic differences in the United States alter disease survival. The aim of this study is to explore the geographic difference in clinical features, socioeconomic factors, and survival outcomes of ENB patients.
MethodsENB cases were extracted from the Surveillance, Epidemiology, and End Results registry from 1975–2016. Patient data were stratified based on geographical location and comparative analyses of socioeconomic features, disease characteristics, and survival patterns were performed. Kaplan–Meier regression analyses were used to estimate disease‐specific survival (DSS).
ResultsA total of 987 patients were identified: 56.4% West, 14.0% South, 12.7% Midwest, and 16.6% East. The West had the highest proportion of patients with Medicaid coverage (P < .001), stage A malignancy (P < .001), and treated with surgery and adjuvant radiotherapy (P < .001). The South had the highest proportion of patients who were Black (P < .001), uninsured (P < .001), and resided in rural areas (P < .001). Five‐year DSS patterns were 81.0% (West), 79.8% (East), 67.4% (Midwest), and 72.7% (South) P = .018. Ten‐year DSS outcomes were 74.0% (West), 73.7% (East), 60.9% (Midwest), and 63.6% (South) P = .017.
Conclusion In ENB patients, survival disparity exists in the United States based on geographical region. Patients from the West and East exhibit higher survival than those from the South and Midwest.
Level of Evidence4 Laryngoscope, 2020

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Audiometric Profile of Cochlear Implant Recipients Demonstrates Need for Revising Insurance Coverage

Jason H. Barnes, Linda X. Yin, John P. Marinelli, Matthew L. Carlson

Publication date 21-12-2020


Objectives/Hypothesis To describe the pre‐implant audiometric profile of adult cochlear implant (CI) recipients to investigate whether current binaural candidacy requirements prevent access to patients who could benefit from CI.
Study Design Retrospective case series.
Methods Retrospective review from 2016 to 2018 evaluating preoperative pure‐tone thresholds and speech perception scores in the ipsilateral and contralateral ear.
ResultsA total of 252 adult CI recipients undergoing 270 implants were identified. Median age at time of implantation was 70.5 years (IQR 61.3–78.3) for those undergoing unilateral implantation and 59.0 (IQR 48.0–72.3) for those undergoing bilateral implantation (P < .01). For unilateral implantation, median pre‐implantation speech perception performance in the ear to be implanted was 8.0% (IQR 0%–26.0%) for CNC word scores, and 9.0% (IQR 0%–34.0%) for Az Bio sentence scores in quiet. Median speech perception performance in the contralateral ear was 36.0% (IQR 14.0%–60.0%) on CNC word scores, and 48.5% (IQR 17.5%–76.0%) on Az Bio sentence tests. Speech perception scores were significantly different between ears for word and sentence tests (P < .01). Patients older than age 65 were significantly less likely to undergo bilateral implantation (P = .03).
Conclusions Adult CI recipients exhibit substantially poorer pre‐implant speech perception scores than the commonly utilized ipsilateral qualifying threshold of 50% on sentence testing. Yet, existing insurance paradigms limit patients by excessively stringent binaural best‐aided requirements. This limitation likely leads to worse device performance as patients often wait years for their binaural hearing to qualify while their ear to be implanted potentially experiences an unnecessarily extended duration of deafness. Older patients also experience a unique delay in referral for cochlear implantation.
Level of EvidenceIII‐ Retrospective review Laryngoscope, 2020

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A Prospective Study of Voice, Swallow and Airway Outcomes following Tracheostomy for COVID‐19

Maral J Rouhani, Gemma Clunie, Gerard Thong, Lindsay Lovell, Justin Roe, Margaret Ashcroft, Andrew Holroyd, Guri Sandhu, Chadwan Al Yaghchi

Publication date 20-12-2020


Abstract Objective The COVID‐19 pandemic has led to unprecedented demands on healthcare with many requiring intubation. Tracheostomy insertion has often been delayed and the enduring effects of this on voice, swallow and airway outcomes in COVID‐19 tracheostomy patients are unknown. The aim of this study was to prospectively assess these outcomes in this patient cohort following hospital discharge.
Methods All COVID‐19 patients who had undergone tracheostomy insertion, and were subsequently decannulated, were identified at our institution and followed up two months post‐discharge. Patient‐reported (PROMS) and clinician‐reported outcome measures, endoscopic examination and spirometry were used to assess voice, swallow and airway outcomes.
Results Forty‐one patients were included in the study with a mean age of 56 years and male:female ratio of 28:13. Average duration of endotracheal intubation was 24 days and 63.4% of tracheostomies were performed at day 21‐35 of intubation. 53.7% had an abnormal GRBAS score and 30% reported abnormal swallow on EAT‐10 questionnaire. 81.1% had normal endoscopic examination of the larynx however positive endoscopic findings correlated with the patient self‐reported VHI‐10 (p=0.036) and EAT‐10 scores (p=0.027). 22.5% had spirometric evidence of fixed upper airway obstruction using the Expiratory‐Disproportion Index (EDI) and Spearman correlation analysis showed a positive trend between abnormal endoscopic findings and EDI scores over 50 (p<0.0001).
Conclusion The preliminary results of this study reveal a high incidence of laryngeal injury among patients who underwent intubation and tracheostomy insertion during the COVID‐19 pandemic. As these patients continue to be followed up, the evolution of these complications will be studied.

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Endoscopic Endonasal Prelacrimal Approach: Radiological Considerations, Morbidity, and Outcomes

Alberto Daniele Arosio, Marco Valentini, Frank Rikki Canevari, Luca Volpi, Apostolos Karligkiotis, Dimitris Terzakis, Paolo Battaglia, Christos Georgalas, Maurizio Bignami, Paolo Castelnuovo, Mario Turri‐Zanoni

Publication date 18-12-2020


Objective/Hypothesis This study describes a multicentric experience with the use of prelacrimal approach (PLA), focusing on preoperative radiological parameters potentially associated with surgical outcomes and postoperative morbidity.
Study Design Retrospective case‐series.
MethodsA retrospective review of patients undergoing PLA in three European referral centers was performed. The post‐operative morbidity was analyzed in relation to two radiological parameters: width of prelacrimal recess (WPR) and internal angle of pyriform notch (APN).
Results The study included 28 patients affected by Schneiderian papilloma (20 cases), inflammatory disease (6 cases), schwannoma (1 case), and osteoma (1 case). The most reported sequela was paresthesia of ipsilateral anterior superior alveolar process (25% of the cases). An association between post‐operative morbidity and APN was observed (P = .047).
Conclusions Preoperative radiological evaluation of WPR is crucial in understanding the feasibility of the approach, while APN measurement may predict postoperative morbidity, which is paramount in the patients counseling.
Level of Evidence4 case‐series Laryngoscope, 2020

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Current Status and Future Trends: Pediatric Intracapsular Tonsillectomy in the United States

Kevin C. Huoh, Yarah M. Haidar, Brandyn S. Dunn

Publication date 17-12-2020


Objectives1) To assess the current status of pediatric intracapsular tonsillectomy in the United States, and 2) To apply lessons from the scientific literature and adoption of surgical innovation to predict future trends in pediatric intracapsular tonsillectomy.
Methods This was a cross‐sectional survey study and literature review. An anonymous survey was sent to all members of the American Society of Pediatric Otolaryngology (ASPO) to determine current practices in pediatric tonsillectomy. Statistical analysis was performed to compare differences in individuals who perform intracapsular tonsillectomy as opposed to extracapsular tonsillectomy. A literature analysis of the adoption of new technological advancements and innovative surgical techniques was then performed.
Results The survey was sent to 540 pediatric otolaryngologists with a response rate of 42%. Of all respondents, 20% currently perform intracapsular tonsillectomy. The primary reason cited for not performing the procedure was concern for tonsillar regrowth. Time in practice, practice setting, and fellowship status was not associated with an increased incidence of intracapsular tonsillectomy.
Conclusions Only 20% of pediatric otolaryngologist respondents in the United States perform intracapsular tonsillectomy. Based on the documented advantages of intracapsular tonsillectomy over extracapsular tonsillectomy and an analysis of adoption of novel surgical techniques, we predict a paradigm shift in the specialty toward intracapsular tonsillectomy.
Level of Evidence3 Laryngoscope, 131:S1–S9, 2021

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Table of contents

Publication date 17-12-2020


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Masthead

Publication date 17-12-2020


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Presenting Symptom as a Predictor of Clinical course in Juvenile Onset Recurrent Respiratory Papillomatosis

Pamela Mudd, Emily Wikner, Md Sohel Rana, George Zalzal

Publication date 17-12-2020


Objective/Hypothesis Determine if the presentation of voice versus airway symptoms at the time of diagnosis of juvenile recurrent respiratory papillomatosis (JORRP) correlates with treatment and outcomes.
Study Design Original report, Retrospective review.
Methods Twenty year retrospective review of all patients with JORRP presenting at any time in treatment to a single tertiary childrens hospital between 1997 and 2017.
Results Fifty‐four patients presented with a diagnosis of JORRP during the 20 year study period. Of these, 32 were female and 22 were male. African American children made up the majority of the patients (65%), with 19% identifying as Caucasian, 9% Hispanic, and 7% Asian. Fifteen of the children presented initially to the ENT clinic (87% with hoarseness), 12 to the emergency department (92% with airway concerns), 11 to the voice clinic, and the remaining 12 at outside hospitals or clinics and care were transferred. Voice symptoms, namely hoarseness, was the presenting symptom in 31 (57%), airway symptoms, namely respiratory distress or stridor was predominate in 17 (32%), and the presenting symptom was unknown in six cases (11%). Children presenting with airway symptoms were younger at presentation (median 2.1 years, range 0.38–8.77 years) than those presenting with voice symptoms (median 6.7 years, range 0.98–15.13 years), and after adjusting for age underwent a greater number of surgeries in the first year to control disease.
Conclusions Patients who present with airway symptoms present younger and have an increased number of surgeries in the first year compared to those presenting with voice complaints.
Level of Evidence4 Laryngoscope, 2020

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Compensation Rates for Otolaryngologic Procedures Under the Medicare Physician Fee Schedule in 2018

Neil S. Kondamuri, Ashley L. Miller, Vinay K. Rathi

Publication date 17-12-2020


Objective/Hypothesis Medicare reimbursement for physician work depends on the estimated time and intensity – which encompasses technical skill, cognitive load, and stress – required to perform services. The Centers for Medicare and Medicaid Services (CMS) quantitatively expresses intensity estimates as compensation rates per unit time. This study aimed to characterize compensation rates under the Medicare Physician Fee Schedule (PFS) for operative procedures commonly performed by otolaryngologists.
Study Design This study was a retrospective, cross‐sectional analysis.
Methods This study was a retrospective, cross‐sectional analysis of fiscal year 2018 PFS specifications and publicly available Medicare Part B utilization data for the top 100 highest‐volume procedures furnished by otolaryngologists to Medicare beneficiaries in inpatient and ambulatory surgical center (ASC) settings between January 1, 2018, and December 31, 2018. Co‐primary outcomes were the estimated 1) total compensation rate ($/min) and 2) intraservice (i.e., “skin‐to‐skin” time) compensation rate ($/min) for each included procedure.
Results The analytic sample included 147 unique procedure types (settings non‐mutually exclusive): 82 inpatient procedure types (n = 33,907 procedures) and 95 ASC procedure types (n = 34,765 procedures). In the inpatient setting, median total compensation rate and intraservice compensation rates were $1.50/min (interquartile range IQR: $1.19/min–$1.65/min) and $2.27/min (IQR: $1.69/min–$2.68/min), respectively. In the ASC setting, median total compensation rate and intraservice compensation rates were $1.48/min (interquartile range IQR: $1.27/min–$1.77/min) and $2.39/min (IQR: $1.82/min–$2.91/min), respectively. At the service line level, volume‐weighted total (inpatient: $1.91/min, ASC: $1.90/min) and intraservice (inpatient: $3.84/min, ASC: $3.37/min) compensation rates were highest for rhinologic procedures.
Conclusions Compensation rates under the Medicare PFS varied widely for operative procedures commonly performed by otolaryngologists.
Level of EvidenceN/A Laryngoscope, 2020

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Increased Risk of Nasal Septal Abscess After Septoplasty in Patients with Type 2 Diabetes Mellitus

Chih‐Wei Luan, Ming‐Shao Tsai, Chia‐Yen Liu, Yao‐Hsu Yang, Yao‐Te Tsai, Cheng‐Ming Hsu, Ching‐Yuan Wu, Pey‐Jium Chang, Geng‐He Chang

Publication date 16-12-2020


Objective/Hypothesis To investigate the risk of nasal septal abscess (NSA) in patients with type 2 diabetes mellitus (T2DM) after septoplasty.
Study Design Retrospective cohort study through Taiwan National Health Insurance database.
Methods The Taiwan National Health Insurance Research Database was used to conduct this retrospective cohort study. A total of 382 patients with T2DM (DM group) diagnosed between 2000 and 2010 and 382 matched patients without a DM diagnosis (non‐DM group) were enrolled. Patients were followed up until death or December 31, 2013. NSA incidence was the main outcome.
Results After septoplasty, the cumulative incidence of NSA in the DM group was significantly higher than that in the non‐DM group (P < .001). Cox proportional hazards regression indicated a significant association between T2DM and higher NSA incidence (adjusted hazard ratio, 2.62; 95% CI, 1.44–3.61; P < .001). However, subgroup analysis and sensitivity testing demonstrated that the effect of T2DM on NSA risk was stable. In addition, the subgroup with a Diabetes Complications Severity Index (DCSI) of ≥1 had higher NSA risk than that with DCSI = 0 (adjusted hazard ratio, 3.58; 95% CI, 2.10–6.09; P < .001). The treatment type for NSA did not differ between the groups.
ConclusionsT2DM is an independent risk factor for NSA in patients undergoing nasal septoplasty, and the NSA risk is greater among patients with high DM severity.
Level of EvidenceIV Laryngoscope, 2020

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YO‐IFOS Guidelines for Pediatric ENT Surgery during COVID‐19: An Overview of Recommendations

Taseer Din, Tagwa Abdalla, Carlos Chiesa‐Estomba, François Simon, Natacha Teissier, Izaskun Thomas, Johannes Fagan, Shazia Peer

Publication date 15-12-2020


Abstract Objective To review the literature on pediatric ENT COVID‐19 guidelines worldwide, in particular, surgical practice during the pandemic, and to establish a comprehensive set of recommendations.
MethodsA comprehensive literature review through an independent electronic search of the COVID‐19 pandemic in Pub Med, Medline, Google, and Google Scholar was performed on April 26‐30, 2020. Resources identified comprised of published papers, national and international pediatric ENT society guidelines.
Results Fourteen guidelines fit the inclusion criteria.
Key statements were formulated and graded: a) Strong recommendation (reported by 9 or more/14), b) Fair recommendation (7‐8/14) c) Weak recommendation (5‐6/14) d) Expert opinion (2‐4/14). Any single source suggestion was included as a comment. Highly scored recommendations included definition of urgent/emergent cases that required surgery; surgery for acute airway obstruction; prompt diagnosis of suspected cancer and surgical intervention for sepsis following initial first‐line medical management. Other well scored recommendations included senior faculty to perform the surgery; the use of open approaches rather than endoscopic ones; and avoidance of powered instruments that would aerosolise virus‐loaded tissue. A tracheostomy should be performed on a case by case basis where key technical modifications become necessary.
Conclusion The COVID‐19 pandemic will have a profound short and long‐term impact on pediatric ENT practice. During this rapidly evolving climate, guidelines have been based on local practice and expert opinion. Until evidence‐based practice in the COVID era is established, a comprehensive set of recommendations for pediatric ENT surgical practice based on a review of currently available literature and guidelines, is therefore appropriate.
This article is protected by copyright. All rights reserved.

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Risk Factors for Postextubation Dysphagia: A Systematic Review and Meta‐analysis

Melanie McIntyre, Timothy Chimunda, Mayank Koppa, Nathan Dalton, Hannah Reinders, Sebastian Doeltgen

Publication date 15-12-2020


Objectives/Hypothesis To identify, describe, and where possible meaningfully synthesize the reported risk factors for postextubation dysphagia (PED) in critically ill patients.
Study Design Systematic review and meta‐analysis.
MethodsA systematic search of peer‐reviewed and grey literature was conducted in common scientific databases to identify previously evaluated risk factors of PED. Data extraction and risk of bias assessment used a double‐blind approach. Random effects models were used for the meta‐analyses. Meta‐analyses were conducted where sufficient study numbers allowed after accounting for statistical and clinical heterogeneity.
Results Twenty‐five studies were included, which investigated a total of 150 potential risk factors. Of these, 63 risk factors were previously identified by at least one study each as significantly increasing the risk of PED. After accounting for clinical and statistical heterogeneity, only two risk factors were suitable for meta‐analysis, gender, and duration of intubation. In separate meta‐analyses, neither gender (RR 1.00 0.71, 1.43, I2 = 0%) nor duration of intubation (RR 1.54 −0.40, 3.49, I2 = 0%) were significant predictors of PED.
ConclusionsA large number of risk factors for PED have been reported in the literature. However, significant variability in swallowing assessment methods, patient populations, timing of assessment, and duration of intubation prevented meaningful meta‐analyses for the majority of these risk factors. Where meta‐analysis was possible, gender and duration of intubation were not identified as risk factors for PED. We discuss future directions in clinical and research contexts. Laryngoscope, 2020

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Modernizing the Otolaryngology Referral Workflow: The Impact of Electronic Consultation

Eliezer C. Kinberg, Diana N. Kirke, Samuel J. Trosman

Publication date 15-12-2020


Objectives/Hypothesis To determine the impact of electronic consultation on the otolaryngology clinic workflow at our high‐volume public hospital.
Study Design Retrospective Observational Study.
Methods This is a retrospective observational analysis study. Operational data regarding clinic volume, referral patterns, and scheduling efficiency were assessed over a 9‐month period in 2018 prior to implementation of electronic consultation. The same data were collected for the 9‐month period immediately following implementation of electronic consultation in 2019.
Results During the pre‐implementation (pre‐EC) period, 3,243 otolaryngology referrals were made as compared to 4,249 post‐implementation (post‐EC). 86% of referrals were scheduled for a clinic appointment pre‐EC, compared to 61% post‐EC (P < .00001) 24.5% of patients were evaluated within 30 days pre‐EC compared to 53.6% post‐EC (P < .00001). The average time to be seen by an otolaryngology provider declined from 60.8 days pre‐EC to 42.8 days post‐EC (P = .0029). There was a 50% decline in the percentage of appointments canceled by patients in the post‐EC period as compared to pre‐EC.
Conclusions In our experience, implementation of electronic consultation significantly reduced both wait times for a clinic appointment and the percentage of no‐show or canceled appointments. Electronic consultation may be a valuable tool in improving the efficiency and yield of the modern otolaryngology clinic.
Level of Evidence4 Laryngoscope, 2020

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Temporal Artery Posterior Auricular Skin Free Flap for Secondary Oral Cavity Reconstruction

Axel Sahovaler, Ilyes Berania, Marco Ferrari, Hedyeh Ziai, Ashok Jethwa, David P. Goldstein, John R. Almeida, Ralph Gilbert

Publication date 15-12-2020


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Can Smartphone Apps Be Used to Screen for Obstructive Sleep Apnea

Camille Duggal, Kenny P. Pang, Brian W. Rotenberg

Publication date 14-12-2020


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To Vaccinate or Not to Vaccinate: Should Adults Aged 26 to 45\u2009Years Receive the Human Papillomavirus Vaccine?

Brooke M. Su‐Velez, Maie A. St. John

Publication date 14-12-2020


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No Shortage of Decibels in Music City: Evaluation of Noise Exposure in Urban Music Venues

Sarah M. Tittman, Robert J. Yawn, Nauman Manzoor, Matthew M. Dedmon, David S. Haynes, Alejandro Rivas

Publication date 14-12-2020


Objectives/Hypothesis To measure and report noise exposure at urban music venues and assess the risk of noise‐induced hearing loss by comparing these measures to the National Institute of Occupations Safety and Health (NIOSH) guidelines.
Study Design Observational study.
MethodsA commercially available smartphone and external calibrated microphone were used to measure sound levels at urban music venues. The maximum sound level, equivalent continuous sound level, and statistical noise levels (L10, L50, L75, L90) were recorded.
Results The average equivalent continuous sound level was 112.0 (±4.9) dBA, and the average maximum sound level was 127.0 (±3.2) dBA. The L90 average (sound levels at or above this loudness for 90% of measured exposure time) was 101.1 (±5.5) dBA, and the L10 average was 115.2 (±5.0) dBA. Based off of NIOSH guidelines, noise exposure duration at the L10 average should not exceed 28 seconds, and those at the L90 average should not exceed 12 minutes.
Conclusions Smartphone applications using external calibrated microphones can provide useful sound measurements. Data show that randomly sampled music venues may have noise levels that place patrons without hearing protection at risk for noise‐induced hearing loss with prolonged exposure.
Level of EvidenceNA Laryngoscope, 131:25–27, 2021

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Presbylarynx: Does Body Muscle Mass Correlate With Vocal Atrophy? A Prospective Case Control Study

Mariline Santos, Susana V. Freitas, David Dias, Joana Costa, Miguel Coutinho, Cecília A. Sousa, Álvaro M. da Silva

Publication date 14-12-2020


Objective To analyze the potential association between body muscle mass and presbylarynx.
Methods Study performed on subjects referred to the otorhinolaryngology department in a tertiary center between January and September 2019 . Based on endoscopic findings of the larynx, the patients were subdivided into two main groups: presbylarynx versus no presbylarynx. Data regarding gender, body composition, self‐assessment of vocal complaints, and functional assessment were collected.
Study Design Case control, prospective, observational and cross‐sectional.
Results The study population included a total of 115 Caucasian subjects (43 males; 72 females). Presbylarynx was identified in 43 patients (37, 39%) with no statistically predilection by gender (P = .668). The mean age of the patients with presbylarynx was slightly higher, but differences between groups were not statistically significant (P = .072). Results showed an association between functional impairment (score 4 of Katz Index and score 5 of Functional Ambulation Classification) and presence of presbylarynx (P < .001). Additionally, a positive association between the absence of presbylarynx and sport activity was also observed (P < .001). The mean value of muscle mass between presbylarynx and no presbylarynx groups was statistically different (P < .01), with a lower mean for subjects with presbylarynx.
Conclusion This case control prospective study confirms that the general age‐related degeneration of body muscle mass might play an important role in the course of presbylarynx. In the future, preventing strategies based on regular sport activities and improvements on functional status can play an important role in the management of aging voice.
Level of Evidence2b Laryngoscope, 131:E226–E230, 2021

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Variations in Surgical Outcomes of Carotid Body Tumors by Surgical Specialty

Samyuktha Melachuri, Benita Valappil, Carl Snyderman

Publication date 14-12-2020


Objectives/HypothesisA carotid body tumor (CBT) is a rare type of tumor that is divided among multiple surgical specialties. Individual surgeons may have limited experience in treating these tumors. We aim to compare different surgical specialties within a single healthcare system to detect variations in management and outcome.
Study Design Retrospective chart review.
MethodsA chart review of all patients who underwent surgery for CBT at the University of Pittsburgh Medical Center (UPMC) from 2000 to 2019 was carried out. Univariate and multivariate analysis was used for descriptive statistics, comparison of outcomes, and identification of risk factors.
Results Fifty‐eight CBT resection surgeries were performed at UPMC. Patients with advanced tumor were 6.7 (95% confidence interval CI: 1.36‐32.7) times more likely to undergo preoperative embolization and 8.53 (95% CI: 2.011‐36.19) times more likely to sustain carotid artery injury. Advanced‐stage tumor resections were associated with greater blood loss (P = .03) and longer hospitalization (P = .02). Collaborative surgeries were associated with higher rates of carotid artery injury (P = .003), residual tumor (P < .001), and longer hospitalization (P = .003), as these combined cases were generally reserved for advanced‐stage tumors (P = .02). There were no differences in outcomes between specialties. Of 22 surgeons, the median number of surgeries per surgeon was one (range = 1–12, 54.5%).
Conclusions Surgeons who completed only one surgery for CBT had a greater rate of hospital readmission and greater length of hospital stay. Collaborative surgeries had worse outcomes due to more advanced tumors requiring more complex surgeries.
Level of Evidence4 Laryngoscope, 131:E190–E195, 2021

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Lymph Node Ratio in HPV‐Associated Oropharyngeal Cancer: Identification of a Prognostic Threshold

Daniel D. Bu, Rocco Ferrandino, Eric M. Robinson, Shelley Liu, Brett A. Miles, Marita S. Teng, Mike Yao, Eric M. Genden, Raymond L. Chai

Publication date 14-12-2020


Objective To evaluate the utility of lymph node ratio (LNR) as a prognostic factor for survival and recurrence in surgically treated patients with human papillomavirus (HPV)‐related oropharyngeal squamous cell carcinoma (OPSCC).
Study Design Retrospective cohort study.
Methods In this retrospective cohort study of a tertiary healthcare system in a major metropolitan area, we reviewed 169 consecutive patients with HPV‐related OPSCC treated using transoral robotic surgery. Univariable and multivariable Cox proportional hazards regression analysis with stratified models were used to compare LNR with other traditional clinicopathologic risk factors forrecurrence and survival. An LNR cutoff was found using the minimal P approach.
Results Multivariable Cox regression models showed that each additional percentage increase in LNR corresponded to an adjusted hazard ratio (HR) of 1.04 (confidence interval CI 1.02–1.07). LNR was more significant when adjusted for adequate lymph node yield of ≥ 18 nodes (HR 5.05, 95% confidence interval CI 1.38–18.47). The minimal P generated cutoff point at LNR ≥ 17% demonstrated a HR 4.34 (95% CI 1.24–15.2) for disease‐free survival.
Conclusion For HPV‐related OPSCC, continuous LNR and an LNR threshold of 17% could be helpful in identifying recurrent disease in addition to measures such as lymph node number alone.
Level of Evidence: 4

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A Mouse Model of Dysphagia After Facial Nerve Injury

Lauren Welby, Ceisha C. Ukatu, Lori Thombs, Teresa E. Lever

Publication date 14-12-2020


Objective Dysphagia is common following facial nerve injury; however, research is sparse regarding swallowing‐related outcomes and targeted treatments. Previous animal studies have used eye blink and vibrissae movement as measures of facial nerve impairment and recovery. The purpose of this study was to create a mouse model of facial nerve injury that results in dysphagia to enhance translational research outcomes.
Study design Prospective animal study.
Methods Twenty C57BL/6J mice underwent surgical transection of the main trunk (MT) (n = 10) or marginal mandibular branch (MMB) (n = 10) of the left facial nerve. Videofluoroscopic swallow study (VFSS) assays for drinking and eating were performed at baseline and 14 days postsurgery to quantify several deglutition‐related outcome measures.
ResultsVFSS analysis revealed that MT transection resulted in significantly slower lick and swallow rates during drinking (P ≤ .05) and significantly slower swallow rates and longer inter‐swallow intervals during eating (P ≤ .05), congruent with oral and pharyngeal dysphagia. After MMB transection, these same VFSS metrics were not statistically significant (P > .05).
Conclusion The main finding of this study was that transection of the facial nerve MT leads to oral and pharyngeal stage dysphagia in mice; MMB transection does not. These results from mice provide novel insight into specific VFSS metrics that may be used to characterize dysphagia in humans following facial nerve injury. We are currently using this surgical mouse model to explore promising treatment modalities such as electrical stimulation to hasten recovery and improve outcomes following various iatrogenic and idiopathic conditions affecting the facial nerve.
Level of EvidenceNA Laryngoscope, 131:17–24, 2021

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Utilization of Computed Tomography in Temporal Bone Fractures at a Large Level I Trauma Center

Mikhaylo Szczupak, Adam Kravietz, Jaimin Patel, Ariel Grobman, Charif Sidani, Michael E. Hoffer

Publication date 14-12-2020


Objectives/Hypothesis To identify which patients with temporal bone fractures who have already undergone trauma pan‐scan computed tomography (CT) do not require an additional dedicated temporal bone CT. To determine the added cost of dedicated temporal bone CT in a lower‐risk group of patients.
Study Design Retrospective chart review.
MethodsA chart review was conducted of adult patients at a large level I trauma center with temporal bone fractures who underwent both trauma pan‐scan CT and dedicated temporal bone CT. Patients were risk stratified into lower‐ and higher‐risk groups based on imaging and physical exam findings. Imaging findings regarding five critical anatomic structures were compared between the two types of CT scans.
Results There were 180 patients who met inclusion criteria, with 120 patients stratified to the lower‐risk group. The negative predictive values of trauma pan‐scan CT within the lower‐risk group for fracture involvement with the five critical anatomic structures were as follows: otic capsule (1.000), carotid canal (0.960), facial nerve canal (1.000), ossicular chain (0.992), and tegmen (0.856). The annual out‐of‐pocket cost to patients for dedicated temporal bone CT imaging in the lower‐risk group was estimated to be approximately $34,000, for a total of $190,000 during the complete study period.
Conclusions Trauma pan‐scan CT may be sufficient in lower‐risk patients to identify temporal bone fracture involvement with critical anatomic structures of the temporal bone. Reductions in dedicated temporal bone imaging will decrease both radiation exposure to trauma patients and strain on radiology departments.
Level of Evidence4 Laryngoscope, 131:E278–E282, 2021

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Volumetric Analysis of the Vocal Folds Using Computed Tomography: Effects of Age, Height, and Gender

Nicole L. Alexander, Kevin Y. Wang, Kevin Z. Jiang, Julina Ongkasuwan, Christie M. Lincoln

Publication date 14-12-2020


Objective The goal of this study was to use computed tomography (CT) volumetric analysis to assess the effect of age, gender, height, body mass index (BMI), and ethnicity on vocal fold volume in patients with normal larynges.
Study Design Retrospective cross‐sectional study.
Methods Vocal fold length, width, and height were measured in a total of 105 patients without a history of laryngeal or thyroid pathology on thin‐section soft‐tissue neck CTs. The product of the three dimensions was used to calculate vocal fold volume. Simple and multiple linear regression analyses were used to assess for an association between vocal fold volume and age, gender, height, BMI, and ethnicity. Intraclass correlation coefficients (ICCs) were estimated to evaluate the degree interobserver and intraobserver agreement.
Results Vocal fold volume was not associated with age, BMI, or ethnicity. Gender‐adjusted height (P = .002) and height‐adjusted gender (P = .016) were significantly associated with volume. Height remained significantly associated with volume after stratifying by gender (P < 0.001). There was moderate‐to‐good correlation in both interobserver (ICC = 0.690 to 0.761) and intraobserver (ICC = 0.733 to 0.873) agreement.
Conclusion Age was not associated with vocal fold volume, which is in accordance with several prior negative studies. Age‐related vocal fold atrophy may not substantially contribute to presbyphonia symptoms, but other processes such as changes in the extracellular matrix may play a larger role. However, both gender and height were independently associated with vocal fold volume.
Level of Evidence4 Laryngoscope, 131:E240–E247, 2021

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Prospective Determination of Airway Response to Upper Airway Stimulation: A New Opportunity for Advanced Device Titration

Carolyn M. Jenks, Jason L. Yu, Katherine A. Schmitt, Richard J. Schwab, Erica R. Thaler

Publication date 14-12-2020


Objectives/Hypothesis Response to upper airway stimulation (UAS) is associated with the degree of airway opening during stimulation. UAS programming may affect this opening. The objective of this study was to examine airway changes in response to five different electrode configurations programmable within the Inspire UAS system.
Study Design Prospective single‐arm cohort study.
Methods Subjects who underwent UAS implantation were recruited for a prospective single‐arm cohort study during UAS device activation. Functional thresholds were recorded for all settings. Awake nasopharyngoscopy was performed to examine the retropalatal (RP) and retroglossal (RG) regions at rest and during activation with all settings at their functional thresholds. Cross‐sectional measurements were made by two blinded reviewers and reported as percent change in airway size.
Results Sixteen patients were included. The standard setting (+‐+) resulted in the greatest change in RP area in 43.8% of patients. An alternative setting resulted in greatest change in 56.2% of patients (‐‐‐ and o‐o in 18.8% each, ‐o‐ in 12.5%, and ‐+‐ in 6.3% of patients). Average response to all five settings was utilized to classify degree of palatoglossal coupling. Most patients had some enlargement (20%–70% change in RP area, 43.8%) or no enlargement (<20% change, 43.8%), whereas a minority of patients (12.5%) had marked enlargement (>70% change). RP and RG expansion were not correlated.
Conclusion Degree of RP expansion varied among patients and settings. Although the standard setting resulted in greatest RP change in a plurality of patients, over half had a greater response to an alternative setting. Future studies should address whether choice of setting based on RP expansion results in improved outcomes.
Level of Evidence4 Laryngoscope, 131:218–223, 2021

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A Prospective Observational Study of Video Laryngoscopy Use in Difficult Airway Management

Jaime B. Hyman, David Apatov, Daniel Katz, Adam I. Levine, Samuel DeMaria

Publication date 14-12-2020


Objectives/Hypothesis Video laryngoscopy has grown tremendously in popularity over the last decade for management of the anticipated difficult airway. The use of video laryngoscopy has not been adequately studied in the head and neck pathology patient population, including those with masses, previous head and neck surgery, or radiation.
Study Design Prospective observational study.
Methods This study included 100 patients with head and neck pathology undergoing awake flexible bronchoscopic intubation for nonemergency surgery requiring general anesthesia. After the performance of awake flexible bronchoscopic intubation and induction of anesthesia, video laryngoscopy was performed with the CMAC D blade and Glidescope AVL. The primary outcome was the modified Cormack‐Lehane view obtained on video laryngoscopy.
Results One hundred patients were enrolled in the study. After exclusions, 92 patients underwent video laryngoscopy with both the CMAC D blade and the Glidescope AVL. Thirty‐seven patients (40.2%) had a Cormack‐Lehane view ≥3 with the CMAC D blade, and 28 patients (30.4%) had a Cormack‐Lehane view ≥3 with the Glidescope AVL. There were no complications from awake flexible bronchoscopic intubation or video laryngoscopy.
Conclusions There is a high incidence of inability to obtain a view of the glottis with video laryngoscopy in patients with head and neck pathology, particularly airway masses.
Level of Evidence3 Laryngoscope, 131:82–86, 2021

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Dermal Fat Grafting to Reconstruct the Parotidectomy Defect Normalizes Facial Attention

Barrett J. Anderies, Jacob K. Dey, Nelson R. Gruszczynski, Daniel L. Price, Eric J. Moore, Jeffrey R. Janus

Publication date 14-12-2020


Objectives/Hypothesis Use validated eye‐tracking technology to objectively measure 1) the attentional distraction of facial contour defects after superficial and total parotidectomy and 2) changes in attentional distraction with abdominal dermal fat graft reconstruction.
Methods Standardized frontal and oblique facial images of 16 patients who had undergone superficial or total parotidectomy with or without fat graft reconstruction; four normal controls were obtained. One hundred casual observers were recruited to view these images, and gaze data were collected using a Tobii Pro eye‐tracking system. Gaze durations for predefined facial areas of interest were analyzed using mixed‐effects linear regression to test study hypotheses.
Results For frontal images, total parotidectomy increased gaze to the operated parotid area compared to the contralateral nonoperated parotid area (92 milliseconds, 95% confidence interval CI: 48‐138 milliseconds, P < .001). Fat grafting normalized the attentional distraction, with no difference in gaze time on the operated parotid region compared to normal control faces (P = .414). For oblique images, total parotidectomy increased gaze to the operated parotid area compared to the contralateral nonoperated parotid area (658 milliseconds, 95% CI: 463‐854 milliseconds, P < .001). Fat grafting normalized this attentional distraction, with no difference in gaze time on the operated parotid region compared to normal control faces (P = .504). In both views, superficial parotidectomy demonstrated no significant attentional distractions, with or without fat grafting.
Conclusions This eye‐tracking study objectively demonstrates that total parotidectomy results in a facial contour deformity that is distracting to observers, whereas superficial parotidectomy does not. For total parotidectomy, this attentional distraction can be normalized with dermal fat graft reconstruction.
Level of Evidence3b Laryngoscope, 131:E124–E131, 2021

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"A Modern Case Sheds Light on a Classical Enigma: Beethovens Deafness"

Davide Brotto, Renato Fellin, Flavia Sorrentino, Flavia Gheller, Patrizia Trevisi, Roberto Bovo

Publication date 14-12-2020


Two hundred and fifty years have passed since the birth of Ludwig van Beethoven, and the enigma about his hearing loss and overall health status seems to be not completely solved. However, the admission to the hospital of a 64‐year‐old woman in 2018 with symptoms extremely similar to those experienced by the great composer may add further evidence to a theory previously underestimated. The health issues of the modern patient were found to be due to chronic lead intoxication. The lead was released during daily cooking using a ceramic‐coated frying pan with worn surface that poisoned her breakfast most probably for years.
Abdominal pain, asthenia, and hearing loss affecting the high frequencies with a many impact on speech intelligibility tormented the patient, as they had Beethoven.
An extensive review of the music and medical literature was performed, as well as re‐examination of manuscripts, correspondence, and autopsy reports of the famous composer; and great similarities have been found. The soundness of the most‐cited classical theories about Beethovens hearing loss will be discussed. After close scrutiny of the theories, our analysis points toward a progressive sensorineural hearing loss due to lead intoxication as the most probable cause of not only Beethovens hypoacusis but his overall health status as well. Laryngoscope, 131:179–185, 2021

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Patterns of Obstruction on DISE in Adults With Obstructive Sleep Apnea Change With BMI

Stephanie J. Wong, Martha E. Luitje, Sveta Karelsky

Publication date 14-12-2020


Objectives We describe drug‐induced sleep endoscopy (DISE) obstruction patterns in adults with obstructive sleep apnea (OSA) based on body mass index (BMI). We also evaluate subgroups of patients with clinically significant obstruction patterns at the velopharynx and oropharynx.
Study Design Retrospective chart review.
Methods Single‐institution, retrospective chart review of adults with OSA who underwent DISE with dexmedetomidine sedation from 2016 to 2018. Endoscopic findings were graded using VOTE (Velum, Oropharynx, Tongue base, Epiglottis) classification. Oropharyngeal obstruction was additionally graded with the modifier T when due to palatine tonsil tissue. Findings in patients who had BMI < 25, 25 ≤ BMI < 30, and BMI ≥ 30 were compared.
Results One hundred and eleven patients (1 underweight, 23 normal weight, 56 overweight, and 31 obese) were reviewed. Patients with lower BMI were more likely to have more severe obstruction at the level of the tongue base (χ2 = 11.52, P = .021) and epiglottis (χ 2 = 10.56, P = .032). Conversely, patients with higher BMI were more likely to have complete concentric (grade 2C) velum obstruction (χ 2 = 16.04, P < .001) and more severe oropharyngeal obstruction (χ 2= 9.65, P = .046). Patients with grade 2 oropharyngeal obstruction without tonsil obstruction had more severe concurrent velum obstruction compared to subjects with grade 2 T oropharyngeal obstruction (P = .009).
Conclusion In adults with OSA, BMI categories have significantly distinct obstruction patterns at all airway levels on DISE, and there appear to be distinct subgroups associated with certain velum and oropharynx collapse patterns. These findings may have important implications for positive airway pressure–alternative treatment.
Level of Evidence3 Laryngoscope, 131:224–229, 2021

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Rural–Urban Disparities in Otolaryngology: The State of Illinois

Matthew J. Urban, Christopher Wojcik, Michael Eggerstedt, Ashok J. Jagasia

Publication date 14-12-2020


Objectives/Hypothesis To highlight rural–urban disparities in otolaryngology, and to quantify the disparities in access to otolaryngology specialist care across Illinois. Several studies across disciplines have shown increased prevalence and severity of disease in rural communities, relative to their urban counterparts. There is very little published quantifying a disparity in rural access to otolaryngologists.
Study Design Population study.
Methods Counties in Illinois were classified based on urbanization level on a scale from I (most urban) to VI (least urban) using the 2013 National Center for Health Statistics (NCHS) Urban–Rural Classification scheme. The six urbanization levels include four metropolitan (I–IV) and two nonmetropolitan levels (V and VI). The name and practice location of all registered otolaryngologists in Illinois were collected using the American Academy of Otolaryngology website (ENTnet.org). Population data were recorded from the most recent US Census (2010).
Results Two hundred seventy‐eight academy‐registered otolaryngologists were identified in Illinois. One hundred fifty‐one of these providers were located in a single county categorized as a level I by the NCHS scheme. There are over 18,000 square miles and 600,000 persons living in NCHS level VI counties in Illinois with zero registered otolaryngologists. Overall, metropolitan counties (I–IV) averaged 1.32 otolaryngologists per 100,000 population, whereas nonmetropolitan counties (V and VI) averaged 0.46 otolaryngologists per 100,000 (P < .01).
Conclusions There is a paucity of academy‐certified otolaryngologists with primary practice locations in rural counties of Illinois. There is a significant rural population and massive land area with limited spatial access to otolaryngologic specialist care.
Level of EvidenceNA Laryngoscope, 131:E70–E75, 2021

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Eight‐Year Follow‐up of Modified Uvulopalatopharyngoplasty in Patients With Obstructive Sleep Apnea

Joar Sundman, Nanna Browaldh, Johan Fehrm, Danielle Friberg

Publication date 14-12-2020


Objective To investigate whether modified uvulopalatopharyngoplasty (UPPP) for treatment of obstructive sleep apnea (OSA) remained effective after 8 years.
Methods Prospective intervention study. Sixty‐five patients with OSA were offered re‐evaluation with polysomnography and the Epworth Sleepiness Scale (ESS) 8 years after UPPP. Results were compared with baseline and with a previous 2‐year follow‐up. Baseline predictors were analyzed with regression analyses.
Results The dropout rate at the 8‐year follow‐up was 28%. The mean decrease in apnea–hypopnea index (AHI) between baseline and the 8‐year follow‐up was significant, 14.0 events/hour (from 52.9 to 38.9), 27% (P < .001). The mean increase in AHI between the 2‐year and the 8‐year follow‐up was significant, 14.7 events/hour (from 24.2 to 38.9), 61% (P < .0001). Overweight at baseline predicted an AHI at the 8‐year follow‐up that was 22.9 events higher compared to patients with normal weight (P = .015). An increase in body mass index (BMI) of 1 kg/m2 between baseline and the 8‐year follow‐up predicted a mean AHI increase of 3.8 events/hour (P = .015). The median decrease in ESS between baseline and the 8‐year follow‐up was significant, 7 (from 13.0 to 6.0), 54% (P < .0001). The median increase in ESS between the 2‐year and the 8‐year follow‐up was not significant, 1.0 (from 5.0 to 6.0), 20%.
Conclusion Modified UPPP was effective as a long‐term treatment for OSA in selected patients, although the effect on AHI decreased over time. Daytime sleepiness remained improved even in the long term. High BMI at baseline and an increase in BMI predicted a reduced long‐term respiratory outcome.
Level of Evidence3 Laryngoscope, 131:E307–E313, 2021

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Defining Typical Acetaminophen and Narcotic Usage in the Postoperative Rhinoplasty Patient

Natalie Justicz, Shekhar K. Gadkaree, Alisa Yamasaki, Robin W. Lindsay

Publication date 14-12-2020


Objective To characterize the acetaminophen and narcotic use pattern of the postoperative rhinoplasty patient. To describe a pain level and pain medication usage pattern of the typical post‐rhinoplasty patient and identify demographic considerations.
Study Design Prospective cohort study at a tertiary care center.
Methods Rhinoplasty patients were given standardized perioperative pain instructions and narcotic medication (18 tabs oxycodone) along with a pain medication use survey. Postoperatively, survey and tracking information was collected regarding narcotic and acetaminophen use at their first postoperative appointment. Patients were asked about non‐steroidal anti‐inflammatory drug, aspirin, and chronic opioid use. Narcotic and acetaminophen use along pain levels (1–10) at time of use were recorded by patients at 4‐hour increments postoperatively until their first postoperative visit.
Results Pain medication usage (oxycodone and acetaminophen) peaked on (postoperative day 1) POD1. Pain was significantly higher in younger patients (30 years old or younger), female patients, and primary rhinoplasty patients. Pain was correlated with acetaminophen and oxycodone use for women, and acetaminophen used for men. Autologous rib grafting was not correlated with higher narcotic use.
Conclusion Describing a pain medication usage pattern for the typical post‐rhinoplasty patient provides both patients and clinicians important knowledge of postoperative pain expectations and has the potential to reduce both the amount of narcotic prescribed by providers and the amount of narcotic used by patients.
Level of Evidence4 (Case Series) Laryngoscope, 131:48–53, 2021

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Role of Adjunct Treatments for Idiopathic CSF Leaks After Endoscopic Repair

Saurin Sanghvi, Brooke Sarna, Elie Alam, Joshua Pasol, Corinna Levine, Roy R. Casiano

Publication date 14-12-2020


ObjectiveA higher incidence of recurrent cerebrospinal fluid (CSF) leaks has been reported with idiopathic CSF leaks. A growing number of institutions advocate for routine use of intracranial pressure‐lowering adjunct treatments after endoscopic repair. We report our results in a patient cohort in which only symptomatic patients are subjected to further testing and treatment.
Study Design Retrospective review.
MethodsA retrospective review of patients who underwent endoscopic transnasal repair of idiopathic CSF rhinorrhea was performed at the University of Miami, Florida, from July 2010 to July 2017. The database was queried for demographical data, surgical details, radiological findings, and postoperative outcomes. Only patients with greater than a 12‐month follow‐up were included.
Results Thirty‐three patients underwent endoscopic repair of an idiopathic CSF leak. Twenty‐six (79%) were females, with an average age of entire study population being 48 years. The average body mass index (BMI) of the cohort was 33 kg/m2, with 89% being overweight (BMI > 25 kg/m2). The skull base defect was found to be mainly at the cribriform plate (64%) and sphenoid sinus (30%). Endoscopic repair was performed successfully as a single repair in 32 patients (97%). The average follow‐up was 47 months. Postoperative adjunct medications were used on four patients (12%) with symptomatic idiopathic intracranial hypertension.
Conclusion Endoscopic repair of idiopathic CSF leaks was found to have a high rate of success in our study. Postoperatively, only four patients required additional measures to medically reduce symptomatic intracranial hypertension. Routine postoperative adjunct treatments are unnecessary and may expose patients to adverse long‐term side effects.
Level of Evidence4 Laryngoscope, 131:41–47, 2021

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Prevalence and Risk of Metastatic Thyroid Cancers and Management Outcomes: A National Perspective

Zaid Al‐Qurayshi, Christopher B. Sullivan, Nitin Pagedar, Grace S. Lee, Ralph Tufano, Emad Kandil

Publication date 14-12-2020


Objectives Examine the prevalence and risk of metastasis in thyroid cancers and management outcomes.
Study design Retrospective analysis of the National Cancer Database, 2004–2014.
Methods The study population included adult (≥ 18 years) patients with thyroid cancer. Analysis included multivariate logistic regression and Cox hazard ratio modeling.
ResultsA total of 152,979 patients were included. Distant metastasis was reported in 1,867 (1.22%) patients.
The distribution of metastatic cases based on pathology and tumor size were as follows in descending order: papillary thyroid carcinoma (PTC) 1 to 4 cm (30.53%), PTC > 4 cm (19.34%), undifferentiated (UTC) > 4 cm (14.14%), PTC < 1 cm (8.46%), follicular thyroid carcinoma (FTC) > 4 cm (7.28%), FTC 1 to 4 cm (5.52%), medullary thyroid cancer (MTC) ≤ 4 cm (3.96%), MTC > 4 cm (3.91%), UTC ≤ 4 cm (3.32%), Hürthle (HCC ) > 4 cm (2.09%), and HCC 1 to 4 cm (1.45%). Significant predictors of distant metastasis, while controlling for tumor pathology and size, included older age, male gender, non‐White minorities, presence of multiple comorbidities, minimal, gross extrathyroidal extension (ETE), lymphovascular invasion (LVI), and concomitant central and lateral lymph node metastasis (LNM) (P < .05 each). The risk of distant metastasis in the absence of nodal metastasis, ETE, and LVI was highest for FTC > 4 cm.
Conclusion Although the risk of metastasis in well‐differentiated thyroid carcinoma (WDTC) is low, the prevalence of metastatic thyroid cancer is highest in WDTC population because it is the most common type of thyroid cancer. Certain pathological features, including minimal ETE and central LNM, are associated with a higher prevalence of metastatic disease.
Level of EvidenceNA Laryngoscope, 131:237–244, 2021

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Discharge by Noon: A Checklist Initiative by the Otolaryngology Service

Akina Tamaki, Claudia Cabrera, Kathryn Hoppe, Nicole Maronian

Publication date 14-12-2020


Objectives/Hypothesis Hospital length of stay (LOS) and throughput are critical issues for hospitals. Late hospital discharges contribute to bottlenecks in the emergency department, overcrowd surgical and procedural areas, and limit patient tertiary‐care center transfers. Our goal was to increase discharge by noon (DCBN) percentage from 8% to over 50% in a sustainable manner.
Study Design Retrospective Review.
Methods We used a multiple time series design and a quality improvement approach. An interdisciplinary improvement team (IIT) identified the main causes contributing to late discharge and then developed and implemented multiple interventions to increase the percentage of DCBN. Admissions and discharge information were obtained for all patients in the otolaryngology service (January 2014–September 2017). The intervention was implemented in July 2015. The primary outcome was the percentage of DCBN per month. Secondary outcomes were LOS, case‐mix index (CMI), patient experience, and 30‐day readmissions. We analyzed the impact of our intervention and outcomes at the preintervention, peri‐intervention, and postintervention periods.
Results One thousand four hundred sixty‐four admissions to the otolaryngology service were included. Throughout the intervention period, the percentage of patients DCBN increased. Analysis of the intervention showed significant DCBN change of 15% in the first versus 42% in the last 12‐months (P < .001), and shorter LOS (−1.4 days, P < .001) and lower CMI (−0.6, P < .001) in the DCBN group. Patient satisfaction scores improved by 4% (P < .05), and no difference in 30‐day readmission rates (P = .29) was shown.
Conclusions This multifaceted intervention improved early discharge and patient experience. Our checklist of key behaviors could be applied throughout other services and hospitals with reproducible success.
Level of Evidence4 Laryngoscope, 131:E76–E82, 2021

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Self‐Perceived Hearing Status Creates an Unrealized Barrier to Hearing Healthcare Utilization

Prashant Angara, Darren C. Tsang, Michael E. Hoffer, Hillary A. Snapp

Publication date 14-12-2020


Objective To examine sociodemographic and audiometric factors associated with hearing aid (HA) uptake in adults with hearing loss (HL), and to investigate the role of self‐perceived hearing status on pursuit of hearing treatment. The relationship between self‐perceived hearing status and HA adoption has not been reported in a nationally representative sample of United States (US) adults.
Study Design Cross‐sectional analysis of nationwide household health survey.
Methods Audiometric and questionnaire data from the 2005 to 2012 National Health and Nutrition Examination Survey cycles were used to examine trends in untreated HL and HA adoption in US adults. Adjusted odds ratios for HA adoption were calculated for individuals with measured HL.
Results Of 5230 respondents, 26.1% had measurable HL, of which only 16.0% correctly self‐identified their hearing status, and only 17.7% used an HA. Age, higher education, severe hearing impairments, and recent hearing evaluations, were positively associated with HA adoption.
Conclusion Hearing loss is a global public health concern placing significant economic burden on both the individual and society. Self‐reported hearing status is not a reliable indicator for HL, and measured HL is not correlated with increased rates of treatment. Recent hearing evaluation is positively associated with increased rates of treatment. Routine hearing assessment will help to better identify those with HL and improve access to hearing treatment.
Level of EvidenceIII Laryngoscope, 131:E289–E295, 2021

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Hospitalized Patients With New‐Onset Vocal Fold Immobility Warrant Inpatient Injection Laryngoplasty

"Lindsay Reder, Caitlin Bertelsen, Varun Angajala, Karla ODell, Laurel Fisher"

Publication date 14-12-2020


Objectives To evaluate the impact of early inpatient bedside injection laryngoplasty (IL) in hospitalized patients with iatrogenic unilateral vocal fold immobility (UVFI).
Study Design Retrospective cohort study.
MethodsA retrospective review of hospitalized patients with iatrogenic UVFI undergoing IL between September 2013 and June 2017 was performed. Patients had a swallow evaluation by a speech‐language pathologist and bedside IL. Evaluated outcomes included swallow scores, return to diet, secondary events/procedures, and hospital length of stay. Outcomes related to etiology of UVFI were also examined.
Results The cohort consisted of 90 patients (61% male, 52% after cardiac/cardiothoracic surgery). Seventy‐seven percent of all patients who could improve had increased swallow scores after IL. The lowest number (40%) from the subgroup of patients with high vagal injuries as the cause of UVFI obtained improvement in swallow scores, whereas 87% of those in the cardiac surgery group improved. There were more bronchoscopies and reintubations in patients before IL than after IL.
Conclusion Hospitalized patients with UVFI are at increased risk of morbidity and mortality due to dysphagia. We advocate for early swallow evaluation and intervention with IL if there is dysphagia and risk of aspiration. Coordination of care between interdisciplinary teams is paramount to a successful inpatient IL program.
Level of Evidence2b Laryngoscope, 131:115–120, 2021

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Quality and Readability Assessment of Websites on Human Papillomavirus and Oropharyngeal Cancer

Hannah L. Schwarzbach, Leila J. Mady, Thomas M. Kaffenberger, Umamaheswar Duvvuri, Noel Jabbour

Publication date 14-12-2020


Objectives/Hypothesis The incidence of human papillomavirus–positive (HPV+) oropharyngeal cancer is rising, but public knowledge about this diagnosis remains low. This study aimed to investigate the quality and readability of online information about HPV+ oropharyngeal cancer.
Study Design Cross‐sectional website analysis.
Methods This study conducted a total of 12 web searches across Google, Yahoo, and Bing to identify websites related to HPV+ oropharyngeal cancer. The QUality Evaluation Scoring Tool (QUEST) was used to measure quality based on seven website criteria. The Flesch Reading Ease Score (FRES) and Flesch‐Kincaid Grade Level (FKGL) were used to measure readability, with scores estimating the education level a reader would require to understand a piece of text. Readability improves as FRES increases and FKGL decreases.
Results Twenty‐seven unique web pages were evaluated. The mean USA reading grade level as measured by FKGL was 10.42 (standard deviation = 1.54). There was an inverse relationship between quality and readability, with a significant positive correlation between QUEST score and FKGL (r = 0.343, P = .040) and a significant negative correlation between QUEST score and FRES (r = −0.537, P = .002).
Conclusions With a mean USA reading grade level more than four grades above the American Medical Associations recommendation and results indicating that readability suffers as quality improves, these findings suggest that the currently available online information about HPV+ oropharyngeal cancer is insufficient. Improved patient education practices and resources about this diagnosis are needed.
Level of EvidenceNA Laryngoscope, 131:87–94, 2021

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Outcome of Salvage Therapy in Isolated Regional Recurrence in Head and Neck Squamous Cell Carcinoma

Roland Giger, Raffael Fink, Marco Demattè, Miranda Visini, Olgun Elicin, Lukas Anschuetz

Publication date 14-12-2020


Objectives/Hypothesis Head and neck squamous cell carcinoma (HNSCC) has a high tendency for regional lymphatic spreading. Nevertheless, isolated regional lymph node recurrences are rare, and only limited data regarding its management are available. The aim of this study was to describe treatment modalities and outcomes, and to identify prognostic factors.
Study Design Retrospective cohort study.
Methods The records of all patients (n = 498) with tumor persistence or recurrence after curatively intended treatment for HNSCC were retrospectively reviewed. Patients with synchronous secondary tumors at initial presentation, tumor persistence, local or locoregional recurrence, and systemic metastases were excluded.
ResultsA total of 76 patients were included. The rate of occult additional metastasis in radiologically uninvolved neck compartments during salvage neck dissection was 25%. The salvaged patients showed a 37.5% 5‐year recurrence‐free survival (RFS). Multivariate analysis revealed initial stage IVA‐B (hazard ratio HR: 4.16, P < .01), extracapsular spread (HR: 3.71, P = .04), higher involved/total lymph node ratio (HR: 6.79, P < .01), and soft‐tissue infiltration (HR: 3.27, P < .01) as independent adverse prognostic factors for RFS. Moreover, univariate data analysis identified recurrent stage rcN2‐3; clinical involvement of the neck levels IV, V and/or VI; and smoking as adverse risk factors for RFS.
Conclusions This study identifies initial stage IVA‐B, extracapsular spread, higher involved/total lymph node ratio, and soft‐tissue infiltration as independent adverse prognostic factors for RFS following isolated regional recurrences. The incidence of occult additional metastasis of radiologically uninvolved levels during salvage neck dissections was high (25%). Therefore, superselective or selective neck dissection would not have been the adequate type of salvage surgery.
Level of Evidence4 Laryngoscope, 131:67–72, 2021

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"Comparison of Clinical Characteristics and Magnetic Resonance Imaging of Salivary Glands With Magnetic Resonance Sialography in Sjögrens Syndrome"

Raphaël André, Minerva Becker, Tommaso Lombardi, Samanta Buchholzer, Francis Marchal, Jorg D. Seebach

Publication date 14-12-2020


Objectives/Hypothesis To compare the results of magnetic resonance imaging with magnetic resonance sialography (MRSIAL) and the clinical and laboratory characteristics in a well‐characterized cohort of patients with primary or secondary Sjögrens syndrome (SS) meeting the American–European Consensus Group criteria.
Study Design: Retrospective, observational, monocentric study.
Methods Thirty‐six patients (81% female, mean age = 48 ± 35 years) with primary or secondary SS who underwent MRSIAL were included in the study.
ResultsMRSIAL revealed characteristic radiological signs in the parotid, sublingual, and submandibular salivary glands in 35/36 patients (97%). Patients presenting with anti‐Sjögrens syndrome–related antigen A (SSA) autoantibodies showed more often fatty infiltration, a “pepper‐and‐salt” appearance, ductal stenosis, and/or ductal dilation of the parotid gland (88%, 88%, and 72% respectively) than patients negative for anti‐SSA (12%, 4%, and 28% respectively). MRSIAL demonstrated signs characteristic of SS in all 11 patients with negative minor salivary gland biopsy. For 15 patients undergoing ultrasound examination only, 11 (73%) had SS findings, but all 15 had SS findings on MRSIAL. Two cases of parotid lymphoma were detected by MRSIAL (6%).
ConclusionsMRSIAL is a reliable technique to detect glandular anomalies in patients with SS, and seems to provide a valuable aid in the diagnosis of SS.
Level of Evidence4 Laryngoscope, 131:E83–E89, 2021

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EAT‐10 Scores and Fiberoptic Endoscopic Evaluation of Swallowing in Head and Neck Cancer Patients

Michelle Florie, Walmari Pilz, Bernd Kremer, Femke Verhees, Ghislaine Waltman, Bjorn Winkens, Naomi Winter, Laura Baijens

Publication date 14-12-2020


Objective The purpose of this study was to determine the relationship between patient‐reported symptoms of oropharyngeal dysphagia (OD) using the Eating Assessment Tool (EAT)‐10 and the swallowing function using a standardized fiberoptic endoscopic evaluation of swallowing (FEES) protocol in head and neck cancer (HNC) patients with confirmed OD.
Methods Fifty‐seven dysphagic HNC patients completed the EAT‐10 and a FEES. Two blinded clinicians scored the randomized FEES examinations. Exclusion criteria consisted of presenting with a concurrent neurological disease, scoring below 23 on a Mini‐Mental State Examination, being older than 85 years, having undergone a total laryngectomy, and being illiterate or blind. Descriptive statistics, linear regression, sensitivity, specificity, and predictive values were calculated.
Results The majority of the dysphagic patients (N = 38; 66.7%) aspirated after swallowing thin liquid consistency. A large number of patients showed postswallow pharyngeal residue while swallowing thick liquid consistency. More specifically, 42 (73.0%) patients presented postswallow vallecular residue, and 39 (67.9%) patients presented postswallow pyriform sinus residue. All dysphagic patients had an EAT‐10 score ≥ 3. Linear regression analyses showed significant differences in mean EAT‐10 scores between the dichotomized categories (abnormal vs. normal) of postswallow vallecular (P = .037) and pyriform sinus residue (P = .013). No statistically significant difference in mean EAT‐10 scores between the dichotomized categories of penetration or aspiration was found (P = .966).
Conclusion The EAT‐10 questionnaire seems to have an indicative value for the presence of postswallow pharyngeal residue in dysphagic HNC patients, and a value of 19 points turned out to be useful as a cutoff point for the presence of pharyngeal residue in this study population.
Level of Evidence: 2b

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Compartmental Surgery for Oral Tongue Cancer: Objective and Subjective Functional Evaluation

Alberto Grammatica, Cesare Piazza, Nausica Montalto, Francesca Del Bon, Barbara Frittoli, Monica Mazza, Alberto Paderno, Davide Lancini, Milena Fior, Alberto Deganello, Davide Lombardi, Piero Nicolai

Publication date 14-12-2020


Objective To assess functional outcomes in patients treated by compartmental tongue surgery (CTS) and reconstruction for advanced oral tongue/floor‐of‐mouth cancer.
Study Design Retrospective case series.
MethodsA retrospective cohort of patients (n = 48) treated by CTS and free flap reconstruction was prospectively evaluated concerning postoperative functional outcomes at different time points (6 months and 1 year). Swallowing was studied by videonasal endoscopic evaluation (VEES) and videofluoroscopy (VFS), testing various food consistencies and grading the results with the Donzelli scale. Speech articulation, lingual strength, and endurance were studied by phone call and Iowa Oral Performance Instrument (IOPI). Subjective tests (EORTC H&N35 and UWQOL) were administered.
Results After 1 year, VEES showed a Donzelli scale of 67% level 1, 23% level 2, and 10% level 3. Vallecular pouch was present in 81% of patients. VFS showed levels 1, 2, and 3 in 42%, 25%, and 33%, respectively, with liquids (L); 48%, 19%, and 33%, with semi‐liquids (SL); and 54%, 33%, and 13%, with semi‐solids (SS). Vallecular pouch residue was present in 69% with L, 73% with SL, and 87% with SS. The mean number of words recognized at phone call was 56 of 75 (range, 27–74). IOPI showed a mean tongue strength of 19.2 k Pa (range, 0–40), and a mean endurance of 16.2 seconds (range, 0–60).
ConclusionCTS does not significantly affect speech. Sub‐clinical food aspiration and vallecular pouch are present in a significant proportion of patients, especially when adjuvant treatments are administered. Residual tongue strength is not affected when proper reconstruction is performed.
Level of Evidence4 Laryngoscope, 131:E176–E183, 2021

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The Role of Cytokines in Modulating Vocal Fold Fibrosis: A Contemporary Review

Haoyuan Xu, Guo‐Kang Fan

Publication date 14-12-2020


Objectives Vocal fold (VF) scarring and laryngeal stenosis are a significant clinical challenge. Excessive scar formation causes low voice quality or even life‐threatening obstructions. Cytokines are thought to modulate multiple steps of the establishment of VF fibrosis, but there is no systematic report regarding their role in modulating VF fibrosis. This review aims to investigate the role of cytokines in modulating vocal fold fibrosis.
Study Design Literature review.
Methods This review searched for all relevant peer publications in English for the period 2009 to 2019 in the Pub Med database using search terms: “laryngeal stenosis,” “vocal fold scarring,” and “cytokines.” A thorough investigation of the methods and results of the reviewed studies was performed.
Results Comprehensive research in various studies, including analyses of prostaglandin E2 (PGE2), granulocyte‐macrophage colony‐stimulating factor (GM‐CSF), hepatocyte growth factor (HGF), basic fibroblast growth factor (bFGF), transforming growth factor‐β3 (TGF‐β3), and interleukin‐10 (IL‐10), supports cytokine therapy for VF scarring and laryngeal stenosis to some extent. A few clinical studies on this topic support the conclusion that HGF and bFGF can be selected as effective drugs, and no serious side effects were found.
Conclusions This review describes the potential of cytokines for modulating the process of VF fibrogenesis, although cytokines are still an unproven treatment method. As no ideal drugs exist, cytokines may be considered the candidate treatment for preventing VF fibrogenesis. Laryngoscope, 131:139–145, 2021

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Peri‐Interview Communication in the Otolaryngology Residency Match: The Applicant Perspective

Maria Masciello, Sonya Malekzadeh

Publication date 14-12-2020


Objectives/Hypothesis To evaluate peri‐interview communication in the otolaryngology Match from the applicants perspective.
Study Design Cross‐sectional survey study.
MethodsA survey link was emailed to 401 otolaryngology residency applicants from the 2019 Match cycle. Survey items queried peri‐interview communication practices and applicants attitudes toward communication in the postinterview period. Data were collected anonymously. Qualitative analysis was performed for descriptive statistics. Responses from female and male participants were compared using Fisher exact tests.
Results The survey yielded a 44% (56% male, 44% female) response rate and a 100% completion rate. Of applicants, 18% were told they were ranked to match, and 19% were asked how highly they planned to rank a given program. Interview questions regarding marital status and plans for children were asked to 38% and 12%, respectively. The majority (75%) believe peri‐interview communication should be allowed. Most (65%) participants felt obligated to inform top program(s) of their high rank; however, only 45% of applicants found this to be stressful. Peri‐interview communication may have altered the rank list for 10% of applicants. Of applicants, 96% created their final rank list based on where they most wanted to match rather than where they would most likely match.
Conclusions National Resident Matching Program peri‐interview communication violations occur in the otolaryngology Match at similar rates when compared to other specialties. Although peri‐interview communication can cause significant stress, the majority of otolaryngology residency applicants believe peri‐interview communication should be allowed and do not believe it alters applicants rank lists.
Level of EvidenceNA Laryngoscope, 131:28–32, 2021

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The Internal Superior Laryngeal Nerve in Humans: Evidence for Pure Sensory Function

Laura F. Santoso, Samah Jafari, Daniel Y. Kim, David Paydarfar

Publication date 14-12-2020


Objectives To determine if the internal branch of the superior laryngeal nerve (iSLN) provides direct motor innervation to the interarytenoid muscle, a laryngeal adductor critical for airway protection. We studied the iSLN‐evoked motor response in the interarytenoid and other laryngeal muscles. If the iSLN is purely sensory, there will be no detectable short latency motor response upon supramaximal stimulation, indicating the absence of a direct efferent conduction path.
Study Design Intraoperative case series.
Methods In seven anesthetized patients undergoing laryngectomy for unilateral laryngeal carcinoma, the iSLN of the unaffected side was electrically stimulated intraoperatively with 0.1‐ms pulses of progressive intensities until supramaximal stimulation was reached. Electromyographic responses were measured in the ipsilateral interarytenoid, thyroarytenoid, and cricothyroid muscles.
Results None of the subjects exhibited short‐latency interarytenoid motor responses to iSLN stimulation.
Supramaximal electrical stimulation of the intact iSLN evoked ipsilateral motor responses with long latencies: 18.7–38.5 ms in the interarytenoid (n = 6) and 17.8–24.9 ms in the thyroarytenoid (n = 5).
Supramaximal stimulation of the recurrent laryngeal nerve evoked ipsilateral motor responses with short latencies: 1.6–3.9 ms in the interarytenoid (n = 6) and 1.6–2.7 ms in the thyroarytenoid (n = 6).
Conclusion The iSLN provides no functional efferent motor innervation to the interarytenoid muscles. The iSLN exclusively evokes an interarytenoid motor response via afferent activation of central neural circuits that mediate the laryngeal reflex arc. These findings suggest that the role of the iSLN in vital laryngopharyngeal functions, such as normal swallowing and protection of the airway from aspiration, is purely sensory.
Level of Evidence4 Laryngoscope, 131:E207–E211, 2021

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Anatomical Factors that Can Predict the Structure of Lamina Papyracea for Endoscopic Sinus Surgery

Shinya Ohira, Kentaro Matsuura, Hidehito Matsui, Mitsuto Nakamura, Kazuhisa Kamiyama, Riko Kajiwara, Akiko Inoue, Kota Wada

Publication date 14-12-2020


Objectives This study investigated morphological variations of lamina papyracea, the structure that should be carefully considered when opening posterior ethmoid sinus during endoscopic sinus surgery, to avoid injury.
Study design This study employed axial, coronal, and sagittal computed tomography.
Methods Using computed tomography images of 228 face‐sides, various anatomical parameters were determined: distances of the anterior and posterior ethmoid arteries from the skull base, and from the third lamella; changes in the angles of the lamina papyracea at the anterior and posterior ethmoid sinuses; and presence or absence of supraorbital ethmoid cell (SECs), Onodi cell, and Haller cell. The relationship between the distances which indicate the point of maximum projection by the lamina papyracea among third lamina and posterior ethmoid artery into the posterior ethmoid sinus and these anatomical factors were analyzed statistically.
Results The projection distance of lamina papyracea into the posterior ethmoid sinus was −2.6 mm to 3.4 mm, and in 41.2% of cases, projection in the direction of the nasal cavity was greater than that of the lamina papyracea at the anterior ethmoid sinus. This distance increased with increasing distance of the maximum projection point from the skull base and increasing floating distances of the anterior and posterior ethmoid arteries. The number of subjects with large projection distances was increased among those with floating posterior ethmoid arteries. In addition, subjects with SECs had significantly greater projection distances.
Conclusions Particular care should be taken to avoid injury to the lamina papyracea when opening the posterior ethmoid sinus in subjects with floating anterior or posterior ethmoid arteries, and/or SEC.
Level of Evidence4 Laryngoscope, 131:E19–E25, 2021

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Study of Rocuronium–Sugammadex as an Alternative to Succinylcholine–Cisatracurium in Microlaryngeal Surgery

Cristian Aragón‐Benedí, Sara Visiedo‐Sánchez, Ana Pascual‐Bellosta, Sonia Ortega‐Lucea, Rafael Fernández‐Liesa, Javier Martínez‐Ubieto, Research Group in Anesthesia, Resuscitation AND Perioperative Medicine of Aragón Health Research Institute (IIS Aragón)

Publication date 14-12-2020


Objectives/Hypothesis Microlaryngeal surgery (ML) is a short procedure that requires a deep neuromuscular blockade to provide optimum surgical conditions. Succinylcholine is a relaxant widely used but involves numerous complications. One valid alternative is rocuronium, with a specific antagonist, sugammadex. The primary objective was to assess the surgical conditions in ML according to the relaxant. The secondary objectives were to assess intubation conditions and intraoperative and immediate postoperative adverse events.
Study Design Prospective randomized study.
Methods This was a prospective study of patients scheduled for ML randomized into two groups according to relaxant. Neuromuscular blockade was recorded after administration and during ML surgery. Surgical conditions were assessed using the ML Rating Scale, intubation conditions, remifentanil doses, intraoperative complications, surgery time, emergence time, and complications in the postanesthesia care unit.
Results Two hundred five patients were included (rocuronium = 103, succinylcholine = 102). Train‐of‐four values were higher for rocuronium, though the otorhinolaryngology surgical conditions were significantly better in that group (rocuronium = 5.54 ± 1.39 points; succinylcholine = 9.13 ± 1.99 points). Intubation conditions were similar in both groups. Remifentanil doses were higher for succinylcholine (P < .001) (rocuronium = 0.102 ± 0.05 μg/kg/min; succinylcholine = 0.201 ± 0.05 μg/kg/min). There were no differences in the duration of surgery, but the time to awakening was significantly longer for succinylcholine (rocuronium = 3.82 ± 1.38 minutes, succinylcholine = 9.18 ± 2.04 minutes, P < .001).
Conclusions Rocuronium provides better surgical conditions and allows for the use of lower doses of remifentanil as compared to succinylcholine and cisatracurium in ML. This makes it possible to decrease the time to awakening and the complications associated with high doses of remifentanil.
Level of Evidence1b Laryngoscope, 131:E212–E218, 2021

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Natural History of the Standardized Cosmesis and Health Nasal Outcomes Survey After Rhinoplasty

Cherian K. Kandathil, Mikhail Saltychev, Priyesh N. Patel, Sam P. Most

Publication date 14-12-2020


Objectives/Hypothesis To explore the natural history of nasal obstruction and cosmesis following rhinoplasty by utilizing the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS).
Study Design Retrospective chart study.
Methods This study was carried out at a tertiary referral center, preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE), SCHNOS‐Obstruction (SCHNOS‐O), and SCHNOS‐Cosmesis (SCHNOS‐C) scores in patients who underwent rhinoplasty for functional, cosmetic, or both reasons from June 2017 to May 2019 were reviewed and analyzed. Postoperative intervals were defined as <2 months, 2 to 5 months, 5 to 8 months, 8 to 12 months, and >12 months.
ResultsA total of 302 patients (67% women), with a mean age (standard deviation SD) of 35 (13) years, who underwent rhinoplasty for functional (90, 30%), cosmetic (124, 41%), and combined functional and cosmetic (88, 29%) reasons, met inclusion criteria. The mean follow‐up period (SD, range) was 5 months (4.2 months, 13 days–1.8 years). Compared to the preoperative mean NOSE score, SCHNOS‐ O, and SCHNOS‐C scores, postoperative mean scores for the functional and combined subgroup were significantly lower (P < .05) across all five postoperative intervals. In the cosmetic subgroup, postoperative mean SCHNOS‐C scores were significantly lower (P < .05) across all postoperative intervals compared to the mean preoperative scores.
Conclusions The natural history of the SCHNOS‐O and SCHNOS‐C score in patients who underwent rhinoplasty demonstrates 1) after functional rhinoplasty, an improvement in nasal breathing symptoms is attained as early as <2 months postoperatively; and 2) after cosmetic rhinoplasty, an improvement in nasal cosmesis is seen as early as <2 months postoperatively. These improvements in nasal breathing and cosmesis are sustained through a follow‐up interval >12 months.
Level of Evidence4 Laryngoscope, 131:E116–E123, 2021

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Five‐ and 10‐Year Outcomes for Primary Endoscopic Dacryocystorhinostomy: Failure Rate and Risk Factors

Oded Cohen, Itai Amos, Doron Halperin, Yosef Bavnik, Asher Milstein, Yochai Shoshani, Hana Leiba, Meir Warman

Publication date 14-12-2020


Introduction Endoscopic dacryocystorhinostomy (eDCR) is the preferred approach for nasolacrimal duct obstruction, yet quality data on long‐term outcomes is lacking.
Study DesignA retrospective study in a single, academic institution.
Objective To assess the 5‐ and 10‐year success rates of eDCR, and its associated risks.
Patients and Methods All eDCRs conducted at Kaplan Medical Center between the years 2002–2017 were included. For long‐term follow‐up analysis, two subgroups with a minimum of documented 5‐ and 10‐year follow‐up after surgery were defined. Surgical success was defined by both anatomical (observed patent lacrimal flow) and functional (symptomatic relief) success. Data was collected from the hospitals electronic medical records and was completed by phone interviews. Pre‐, intra‐, and postoperative variables were collected and stratified by multivariate analysis.
Results After exclusions, 321, 168, and 65 patients were included for immediate, 5‐ and 10‐year outcome analysis, respectively. Overall success rates were 92.5%, 86.3%, and 80%, respectively. The anatomical success rates were 93.8%, 89.9%, and 86.1%, respectively. Multivariate analysis revealed that older age (P < .001, P = .001) previous smoking (P = .043, P = .037), and postoperative complains of epiphora (even when a successful irrigation was observed, P < .001, P = .01) were all associated with eDCR failure 5 and 10 years following surgery. Male gender was also associated with eDCR failure (5 years, P = .045; 10 years, P = .063).
Conclusions Despite decreased rates over time, eDCR is beneficial for the majority of patients also at 10 years following surgery. Older age, smoking, postoperative epiphora, and male gender are related to long‐term failure and should be discussed with the patients before surgery.
Level of Evidence3b Laryngoscope, 131:10–16, 2021

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The Accuracy of iPhone Applications to Monitor Environmental Noise Levels

Eleanor Crossley, Tim Biggs, Phillip Brown, Tahwinder Singh

Publication date 14-12-2020


Objective The Control of Noise at Work Regulations came into force in Great Britain in 2005, requiring all work environments to be monitored for potentially harmful noise exposure levels. This study evaluated the effectiveness of a number of i Phone phone applications (apps) (Apple, Cupertino, CA) to accurately measure noise exposure, which may prove effective when a specialist‐calibrated sound level meter is not readily available.
Methods Suitable apps were identified using the search terms noise and decibel through the App Store (Apple). Apps that were free to download and had at least one rating were included. Apps were evaluated using a calibrated pure tone sound field and a soundproof testing booth. A 3‐frequency audiogram (1000 Hz, 2000 Hz, and 4000 Hz) was used at 25 dB, 40 dB, 55 dB, 70 dB, and 85 dB. Linear regression was carried out to assess accuracy.
Results Nine apps were tested in total, with four out of nine providing a goodness‐of‐fit coefficient (R2 value) over 0.9. The most effective app was found to be the NIOSH (National Institute for Occupational Safety and Health) Sound Level Meter (EA LAB, Slovenia) with an R2 of 0.97. The least effective app was the Decibel Meter With Recorder (Jianhua Ming, China) with an R2 of 0.62.
Conclusion This study has shown significant variation in the ability of i Phone apps (Apple) to accurately predict environmental dB levels. However, if the correct app is used, an i Phone represents a relatively reliable means of measuring noise exposure levels when a specialist calibrated sound level meter is not readily available.
Level of EvidenceNA Laryngoscope, 131:E59–E62, 2021

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A Novel Sonographic Scoring Model in the Prediction of Major Salivary Gland Tumors

Wu‐Chia Lo, Chih‐Ming Chang, Chi‐Te Wang, Po‐Wen Cheng, Li‐Jen Liao

Publication date 14-12-2020


Objectives To create a sonographic scoring model in the prediction of major salivary gland tumors and to assess the utility of this predictive model.
Study Design Retrospective case series, academic tertiary referral center.
Methods Two hundred fifty‐nine patients who underwent ultrasound (US), US‐guided needle biopsies, and subsequent operations were enrolled. These data were used to build a predictive scoring model and the model was validated by 10‐fold cross‐validation.
Results We constructed a sonographic scoring model by multivariate logistic regression analysis: 2.08 × (boundary) + 1.75 × (regional lymphadenopathy) + 1.18 × (shape) + 1.45 × (posterior acoustic enhancement) + 2.4 × (calcification). The optimal cutoff score was 3, corresponding to 70.2% sensitivity, 93.9% specificity, and 89.6% overall accuracy. The mean areas under the receiver operating characteristic curve (c‐statistic) in 10‐fold cross‐validation was 0.90.
Conclusions The constructed predictive scoring model is beneficial for patient counseling under US exam and feasible to provide us the guidance on which kind of needle biopsy should be performed in major salivary gland tumors.
Level of Evidence3b Laryngoscope, 131:E157–E162, 2021

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Bilateral Plunging Ranulas in South Auckland: Evidence for a Genetic Basis

Tary Yin, Prabha Jain, Zahoor Ahmad, John D. Harrison, Randall P. Morton

Publication date 14-12-2020


Objectives We present a series of bilateral plunging ranula patients to examine the etiology, diagnosis, treatment, and prognosis of this condition.
MethodsA retrospective chart review was performed on all cases of plunging ranula treated at the Department of Otolaryngology–Head and Neck Surgery, Counties Manukau District Health Board, New Zealand, between 2001 and 2019.
Results There were 17 patients with bilateral plunging ranulas from a total of 187 plunging ranula patients. Eight patients were of Pacific Island descent; six were Maori; and three were Asian. There were no European patients with bilateral plunging ranulas.
There were three types of bilateral plunging ranula patients: 1) Metachronous plunging ranulas—Five patients presented with a unilateral plunging ranula with no evidence of a contralateral plunging ranula on initial imaging. Despite negative contralateral imaging findings, these patients developed a clinically evident contralateral plunging ranula 21 to 61 months later. 2) Synchronous plunging ranulas detected on imaging—Eight patients presented with a clinically evident unilateral plunging ranula but also had a contralateral plunging ranula detected on imaging. 3) Clinically evident synchronous plunging ranulas—Four patients presented with bilateral clinically evident plunging ranulas, which were also evident on imaging. Twelve patients underwent bilateral transoral sublingual gland excision and plunging ranula evacuation.
Conclusion All patients with a unilateral plunging ranula should be advised of the potential for developing contralateral disease, and this should be emphasized in patients of Pacific Island, Maori, and Asian descent.
Level of Evidence4 Laryngoscope, 131:73–77, 2021

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Effect of Intravenous Lidocaine Infusion on Postoperative Early Recovery Quality in Upper Airway Surgery

Qiao Wang, Xiaojun Ding, De Huai, Weibing Zhao, Jun Wang, Chenglan Xie

Publication date 14-12-2020


Objectives/Hypothesis Systemic infusions of lidocaine have been widely used as perioperative analgesic adjuvants. The aim of this randomized, double‐blinded, controlled trial was to investigate the effect of perioperative lidocaine infusion on postoperative early recovery quality in upper airway surgery.
Study Design Prospective, randomized, double‐blinded, placebo‐controlled trial.
MethodsA total of 99 patients were randomly assigned to the lidocaine group (group L) or the control group (group C). The patients received 2 mg/kg lidocaine completed within 10 minutes before the induction of anesthesia followed by continuous infusions of 2 mg/kg/hr lidocaine (group L) or the same volume of 0.9% normal saline (group C) intravenously during anesthesia. The Quality of Recovery‐40 (QoR‐40) survey was administered on the preoperative day (Pre) and postoperative days 1 (POD1) and 2 (POD2). The primary endpoint was QoR‐40 score on POD1 and POD2.
Results Compared with Pre, global QoR‐40 scores on POD1 and POD2 were significantly lower (P < .05). Compared with group C, global QoR‐40 scores were significantly higher in group L on POD1 and POD2 (P < .05). Among the five dimensions of QoR‐40, the scores for physical comfort, emotional state, and pain were superior in group L compared to group C (P < .05). Compared with group C, the consumption of remifentanil and diclofenac as well as the incidence of postoperative nausea and vomiting (PONV) and postoperative 48‐hour numeric rating scale (NRS) scores in group L were significantly lower (P < .05).
Conclusions Systemic lidocaine infusion can improve QoR‐40 scores in patients with upper airway surgery, reduce the dosage of intraoperative opioids, decrease the incidence of PONV and NRS scores 2 days after surgery, thus improving postoperative early recovery quality.
Level of Evidence1b Laryngoscope, 131:E63–E69, 2021

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Swallowing Pressure Variability as a Function of Pharyngeal Region, Bolus Volume, Age, and Sex

Corinne A. Jones, Michelle R. Ciucci, Suzan M. Abdelhalim, Timothy M. McCulloch

Publication date 14-12-2020


Objectives Within‐individual movement variability occurs in most motor domains. However, it is unknown how pharyngeal swallowing pressure varies in healthy individuals.
We hypothesized that: 1) variability would differ among pharyngeal regions; 2) variability would decrease with increased bolus volume; 3) variability would increase with age; and 4) there would be no sex differences.
Study Design Case series.
Methods We used pharyngeal high‐resolution manometry to measure swallowing pressure in the following regions: velopharynx, tongue base, hypopharynx, and upper esophageal sphincter. Data were collected from 97 healthy adults (41 male) aged 21 to 89 years during thin liquid swallows: 2 mL, 10 mL, and participant‐selected comfortable volume. Pressure variability was measured using coefficient of variation. Repeated measures analysis of variance was used to assess impacts of region, bolus volume, age, and sex on pressure variability.
Results There was a significant region × volume interaction (P < .001) and significant main effect of age (P = .005). Pressures in the hypopharynx region were more variable than all other regions (P ≤ .028), and pressures in the tongue base region were less variable than all other regions (P ≤ .002) except at 2 mL volumes (P = .065). Swallowing pressure variability was significantly different in the velopharynx and upper esophageal sphincter regions, with comfortable volume and 2 mL swallows having greater variability than 10 mL swallows (P ≤ .026). Pressure variability significantly increased with increasing age (P = .002). There were no effects of sex on pressure variability (P ≥ .15).
Conclusion Pharyngeal swallowing pressure variability differs according pharyngeal region, volume, and age but not sex. Abnormal swallowing pressure variability may reflect deviations in motor control in persons with swallowing impairment, and results from this study can be used as normative data for future investigations evaluating swallowing pressure generation.
Level of Evidence4 Laryngoscope, 131:E52–E58, 2021

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Melanoma of the External Auditory Canal: A Review of Seven Cases at a Tertiary Care Referral Center

Eric N. Appelbaum, Neil D. Gross, Adi Diab, Andrew J. Bishop, Marc‐Elie Nader, Paul W. Gidley

Publication date 14-12-2020


Objectives/Hypothesis Examine the presentation and management characteristics of seven patients with melanoma of the external auditory canal (EAC).
Study Design Retrospective case series and review of the relevant literature.
Methods Records of seven patients from 2003 to 2017 with melanoma of the EAC were reviewed for characteristics of presentation, subsequent management, and outcomes. A thorough review of relevant literature is presented.
Results The median age is 52 years, with four females. The average Breslow depth was 3.6 mm, with five patients having a Clark level IV or greater on presentation. Six patients underwent lateral temporal bone resection, and one patient underwent wide local excision of the cartilaginous canal. Sentinel lymph node biopsy (SLNB) was performed in three patients. Three patients experienced distant recurrence an average of 20 months following primary therapy. Median follow‐up was 21 months. At last follow‐up, four were free of disease, one had active disease, and two were deceased from melanoma.
Conclusions This is the largest series and the first to report the use of SLNB for patients with EAC melanoma in the peer‐reviewed literature. Patients with external auditory canal melanoma present with higher Breslow thickness and stage relative to all external ear melanomas. Management should include wide local excision, which entails lateral temporal bone resection when the bony ear canal is involved. SLNB has a critical role in identifying patients with early metastatic disease. Postoperative radiation therapy should be considered for patients with high‐risk features to reduce the risk of locoregional relapse. Chemotherapy, and especially immunotherapy, has an emerging role for this disease.
Level of Evidence4 Laryngoscope, 131:165–172, 2021

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Magnetic Resonance Imaging Study of the Pericranial Flap and Its Local Effects Following Endoscopic Craniofacial Resection

Xinni Xu, Sein Lwin, Eric Ting, Yew Kwang Ong

Publication date 14-12-2020


Objectives/Hypothesis To describe the magnetic resonance imaging (MRI) characteristics of the pericranial flap, changes in the pericranial flap thickness over time, presence of frontal sinus opacification, and presence of frontal lobe herniation into the nasal cavity.
Study Design Retrospective case series.
Methods Seventeen consecutive endoscopic craniofacial resections with pericranial flap reconstruction performed at a tertiary hospital from 2010 to 2019 were reviewed. Sixty‐eight serial MRI scans were evaluated.
Results All pericranial flaps consistently featured a homogenous appearance on T1‐weighted sequence and enhanced with contrast. On T2‐weighted sequence, the skull base reconstruction demonstrated four layers of alternating hypo‐ and hyperintensity, which corresponded with the inlay synthetic graft or neodura (hypointense), loose areolar tissue (hyperintense), fibrous pericranium (hypointense), and nasal mucosa or granulation tissue (hyperintense). The mean pericranial flap thickness was 9.9 mm. In thicker flaps, the loose areolar layer contributed the bulk of the thickness. Of 13 patients who underwent three or more serial MRI scans, 11 flaps (84.6%) were stable and two (15.4%) had >50% reduction in their original thickness over time. Thirteen of 17 (76.5%) patients had frontal sinus opacification on follow‐up. None developed frontal sinus mucoceles or frontal lobe herniation.
Conclusions The pericranial flap has a distinctive MRI appearance, especially on T2‐weighted sequence. The thickness of the flap remains relatively stable over time for most patients even following radiotherapy. It is a sturdy flap that is able to support the frontal lobe. Frontal sinus obstruction is common, although complications from this appear to be rare.
Level of Evidence4 Laryngoscope, 131:E90–E97, 2021

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TORS Base‐of‐Tongue Mucosectomy in Human Papilloma Virus‐Negative Carcinoma of Unknown Primary

Mark W. Kubik, Hani I. Channir, Niclas Rubek, Seungwon Kim, Robert L. Ferris, Christian Buchwald, Umamaheswar Duvvuri

Publication date 14-12-2020


Objective To analyze the role of transoral robotic base‐of‐tongue mucosectomy in a cohort of patients with human papilloma virus negative unknown primary carcinoma.
Study Design Retrospective database analysis.
MethodsA retrospective database review from 2012 to 2018 was performed at two large tertiary centers to study patients with human papilloma virus (HPV)‐negative unknown primary carcinoma who underwent transoral robotic base‐of‐tongue mucosectomy. P16 testing was used as a surrogate for HPV status. Patients were included that had squamous cell carcinoma metastatic to the lateral neck based on fine needle aspiration or open biopsy. Preoperatively, all patients were classified as having an unknown primary based on normal clinical and flexible endoscopic exam, normal operative endoscopy, nonlocalizing imaging, and tonsillectomy. All patients underwent robotic base‐of‐tongue mucosectomy. The primary outcome measure was the incidence of pathologic identification of a mucosal primary.
Results Twenty‐three patients with p16‐negative unknown primary carcinoma were identified and studied. All patients underwent transoral robotic base‐of‐tongue mucosectomy. Median age was 60 years at the time of diagnosis, and 18 of 23 (78.2%) were male. Pathologic analysis of the base‐of‐tongue specimens showed a primary tumor in only three of 23 (13.0%) of patients.
Conclusion Despite prior evidence suggesting a high rate of primary site identification in HPV‐related disease, robotic base‐of‐tongue mucosectomy may not be indicated for HPV‐negative unknown primary carcinoma based on a low likelihood of finding the primary.
Level of Evidence4 Laryngoscope, 131:78–81, 2021

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Adjuvant Migraine Medications in the Treatment of Sudden Sensorineural Hearing Loss

Mehdi Abouzari, Khodayar Goshtasbi, Janice T. Chua, Donald Tan, Brooke Sarna, Tina Saber, Harrison W. Lin, Hamid R. Djalilian

Publication date 14-12-2020


Objectives/Hypothesis To examine the hearing outcomes of patients with sudden sensorineural hearing loss (SSNHL) treated with oral and intratympanic (IT) steroid only or a combination of steroid and migraine treatment. Our hypothesis was that adjuvant migraine medications may improve outcomes in SSNHL.
MethodsA retrospective chart review at a tertiary otology center was conducted to identify patients with SSNHL who received oral steroid and IT dexamethasone injection(s) with or without migraine medications (a combination of nortriptyline and topiramate).
ResultsA total of 47 patients received oral steroid and IT dexamethasone injection(s) only, and 46 patients received oral steroid and IT dexamethasone injection(s) as well as migraine lifestyle changes plus a combination of nortriptyline and topiramate. There were no significant differences in demographics and baseline audiometric data between the two groups. Both groups demonstrated improvements in pure tone average (PTA) and hearing thresholds at 250 Hz and 8000 Hz posttreatment. However, compared to steroid‐only group, the adjuvant migraine medications group had significantly greater improvements in hearing thresholds at the lower frequencies (250 Hz, 500 Hz, 1000 Hz). Patients in the latter cohort also had greater improvement in PTA (P = .01) and received fewer IT injections (P = .04) PTA improvement of ≥ 10 dB was observed in 36 patients (78%) in the adjuvant migraine medications group and 22 patients (46%) in the control group (P < .001).
Conclusion In multimodal treatment of SSNHL, supplementing oral and IT steroid with migraine medications may result in greater improvements in lower frequency hearing thresholds and PTA. Furthermore, adjuvant migraine treatment can lead to decrease in number of IT injections, thus reducing procedure‐related risks and complications.
Level of Evidence3 Laryngoscope, 131:E283–E288, 2021

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The Social Perception of Microtia and Auricular Reconstruction

Brian A. Nuyen, Cherian K. Kandathil, Mikhail Saltychev, Françoise Firmin, Sam P. Most, Mai Thy Truong

Publication date 14-12-2020


Objectives To examine the social perception of microtia and quantify the effect of reconstruction on socially perceived attributes.
Methods Parental consent was obtained for peri‐reconstruction photographs in a patient with unilateral grade 3 microtia without an underlying craniofacial syndrome. With computer simulation, the normal, preoperative microtia, and postoperative reconstruction ear were isolated and blended into the oblique and lateral views of that volunteers face to isolate ear morphology as a variable against a constant facial baseline. These photographs were embedded into Web‐based surveys with visual analogue scales to capture social perception data and then were sourced to general population adults.
Results Survey respondents totaled 631. On average, the face with the microtia ear was perceived to be less friendly (P = .015), less healthy (P = .022), and less successful (P = .005) than the same face with the “normal” ear. There were no statistically significant differences in socially perceived attributes between the face with the normal ear and the face with the reconstructed ear.
Conclusion This is the first study to examine the social perception consequences of microtia and microtia reconstruction in children. These findings may explain the significant psychosocial distress experienced by these patients by exploring the social perception of specific attributes perceived. Lastly, this study may better inform microtia patients and their physicians on the impact of auricular reconstruction on third partys perception of social attributes.
Level of EvidenceN/A Laryngoscope, 131:195–200, 2021

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Cochlear Implantation in Children with Single‐Sided Deafness

Nicholas L. Deep, Steven A. Gordon, William H. Shapiro, Susan B. Waltzman, J. Thomas Roland, David R. Friedmann

Publication date 14-12-2020


Objective To describe our experience with children undergoing unilateral cochlear implantation (CI) for treatment of single‐sided deafness (SSD).
Study Design Retrospective case series.
MethodsA retrospective case review from a tertiary referral center involving 14 pediatric patients (<18 years) with SSD who underwent unilateral CI. Speech perception testing in quiet and noise in the CI‐only and bimodal conditions with at least 1 year of device use and device usage from data logs represent the main outcome measures.
Results The mean age at CI was 5.0 years (median 4.4, range 1.0–11.8 years). The mean duration of deafness was 3.0 years (median 2.4, range 0.6–7.0 years). Mean follow‐up was 3.4 years. Speech perception testing with a minimum of 1 year post‐CI was available in eight patients. The mean word recognition scores (WRS) in the CI‐only condition was 56%; a significant improvement from baseline. Testing in background noise with spatially separated speech and noise revealed that patients scored as well or better with the CI‐on versus CI‐off in all conditions and in no cases was interference from the CI noted. Data logs were reviewed for device usage which revealed an average use of 6.5 hr/d.
Conclusion Cochlear implantation is a viable treatment option for pediatric SSD in this self‐selected cohort. Open‐set speech and improvement in background noise can be achieved. Careful patient selection and thorough counseling on expectations is paramount to achieving successful outcomes.
Level of EvidenceIV Laryngoscope, 131:E271–E277, 2021

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Management and Outcomes of Button Batteries in the Aerodigestive Tract: A Multi‐institutional Study

Amber D. Shaffer, Ian N. Jacobs, Craig S. Derkay, Nira A. Goldstein, Terri Giordano, Sandra Ho, Bong J. Kim, Albert H. Park, Jeffrey P. Simons

Publication date 14-12-2020


Objectives/Hypothesis To describe the clinical presentation, management, and complications associated with button battery impaction in the aerodigestive tract in children.
Study Design Retrospective case series.
Methods This multi‐institutional study, endorsed by the American Society of Pediatric Otolaryngology research consortium, is a retrospective medical record review, including all children at five tertiary‐care institutions presenting with button batteries impacted in the aerodigestive tract between January 2002 and December 2014. Battery type/size, duration and location of impaction, presenting symptoms, treatment, complications, and outcomes were examined.
Results Eighty‐one patients were included (64.2% male), with ingestion witnessed in 20 (24.7%). Median age at presentation was 3 years (range, 1 week–14 years). Median time from diagnosis to removal was 2.5 hours (range, 0.4–72 hours). Locations included the esophagus (n = 48), hypopharynx (n = 1), stomach (n = 6), nasal cavity (n = 22), and ear canal (n = 4). Most common symptoms for esophageal/hypopharyngeal impactions included dysphagia (26.5%), nausea/vomiting (26.5%), drooling (24.5%), cough (18.4%), and fever (18.4%). Most common symptoms for nasal impactions included epistaxis (54.6%), rhinorrhea (40.9%), nasal pain (27.3%), and fever (22.7%). Almost all esophageal impactions were from 3‐V (89.5%), 20‐mm (81.8%) lithium batteries. Severe esophageal complications included stricture (28.6%), perforation (24.5%), tracheoesophageal fistula formation (8.2%), pneumothorax (4.1%), and bilateral true vocal fold paresis (4.1%). Nasal complications included necrosis (59.1%), septal perforation (27.3%), and saddle nose deformity (4.5%). Duration of impaction correlated with an increased likelihood of persistent symptoms only for nasal batteries (P = .049).
Conclusions Button batteries in the upper pediatric aerodigestive tract or ear canal should be considered a surgical emergency, requiring urgent removal and careful vigilance for complications.
Level of Evidence4 Laryngoscope, 131:E298–E306, 2021

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Prognostic Value of Tumor Staging: Predicting Nodal Metastases in Cutaneous Squamous Cell Carcinoma

Montana Upton, Ashley Kita, Jason Scapa, Maie St. John

Publication date 14-12-2020


Objectives Determine the ability of three staging systems to stratify the risk of nodal metastases in cases of cutaneous squamous cell carcinoma (cSCC). Examine differential staging of tumors across the three systems and the resulting implications for clinical decision making.
Study Design Retrospective chart review.
Methods This study included 118 patients who underwent excision of primary cSCC of the head and neck as well as elective neck dissection for the same tumor between 2006 and 2017. Tumors were staged using the 2010 7th edition American Joint Committee on Cancer (AJCC 7) staging system, the 2016 8th edition AJCC staging system (AJCC 8), and the Brigham and Womens Hospital (BWH) alternative tumor staging system published in 2013.
Results There were 28 patients (23.7%) with positive nodal metastases at the time of tumor excision. Almost all tumors staged as tumor (T)2 using AJCC 7 were upstaged to T3 or T4 using the new AJCC 8, and these two groups accounted for the majority of the nodal metastases. Similarly, the BWH‐staged T3 group contained the highest number of tumors with nodal metastases. None of the three staging systems significantly stratified tumors in a manner that predicted the presence of nodal metastases.
Conclusion Individuals with cSCC tumors staged T3 or higher in the AJCC 8 and BWH staging systems should undergo neck dissection, whereas those with lower staging should be discussed with the patient on a case‐by‐case basis.
Level of Evidence: 4

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Distinct Histopathology Characteristics in Empty Nose Syndrome

Ching‐Lung Wu, Chia‐Hsiang Fu, Ta‐Jen Lee

Publication date 14-12-2020


Objectives/Hypothesis Empty nose syndrome (ENS) is a controversial disorder and the change of histopathology has never been discussed. This study aimed to conduct a structured histological review to improve the diagnosis and understanding of ENS. Further immunohistochemical staining of transient receptor potential channel melastatin 8 (TRPM8) was performed.
Study DesignA prospective case–control study in a tertiary medical center.
Methods Consecutive patients with ENS who were diagnosed and received surgical intervention after failure of conservative management were included. Patients with benign pituitary gland tumor receiving transsphenoidal excision were enrolled as control group. Biopsy of inferior turbinate was obtained during surgery for histological review and immunohistochemical staining.
Results Seventeen patients with ENS and six patients as a control group were established for structured histological review. Patients with ENS presented significantly more squamous metaplasia, a higher rate of submucosal fibrosis, and a lower submucosal gland number grading. Additionally, a unique histological change called goblet cell metaplasia was found in the ENS group. The respiratory epitheliums of ENS were mostly intact with preservation of ciliated cells and goblet cells. The ENS group had a significantly lower expression level of TRPM8.
Conclusions The nasal mucosa of ENS experienced some airway remodeling and thermoreceptors downregulation, which contribute to clinical symptoms. The distinct histology of ENS included preserved respiratory epithelium and goblet cell metaplasia, accompanying with characteristics similar to atrophic rhinitis. Biopsy of the inferior turbinate may help diagnose ENS.
Level of Evidence4 Laryngoscope, 131:E14–E18, 2021

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The Association Between Smoking on Olfactory Dysfunction in 3,900 Patients With Olfactory Loss

Alexander W. Fjaeldstad, Therese Ovesen, Thomas Hummel

Publication date 14-12-2020


Objectives/Hypothesis The association between smoking and olfactory loss remains a conundrum. Prior studies have found negative and positive effects of smoking on olfactory function in the general population. However, smoking cessation seems to improve both rated and measured olfactory function. The purpose of this study was to investigate the olfactory function and smoking habits in patients with olfactory loss caused by different etiologies to unveil underlying patterns related to smoking.
Study Design Retrospective observational study.
Methods Patients were included from two specialized taste and smell centers. Patients underwent olfactory testing, clinical examination including rhinoscopy, and the underlying etiology was identified. Patterns of olfactory test scores, demographics, and etiologies were analyzed.
Results In total, 3,900 patients with olfactory loss were included. Of these, 521 were current smokers, and 316 were former smokers. Patients with a history of smoking did not have significantly lower olfactory function. Current smokers were more often affected by posttraumatic olfactory loss, but not sinonasal, postviral, or idiopathic olfactory loss.
Conclusions Current smoking, but not former smoking, was associated with posttraumatic olfactory loss. In relation to measured olfactory function, a history of smoking was not associated to lower olfactory scores. Our findings suggest that the general recommendations of smoking cessation for patients with olfactory loss are especially relevant for patients with posttraumatic olfactory loss. The nature of this association between current smoking and posttraumatic olfactory loss has yet to be elucidated.
Level of Evidence2b Laryngoscope, 131:E8–E13, 2021

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The Correlation Between Endolymphatic Hydrops and Clinical Features of Meniere Disease

Weidong Zhang, Lian Hui, Bo Zhang, Ling Ren, Jingyi Zhu, Fei Wang, Songbai Li

Publication date 14-12-2020


Objectives The purpose of this study was to investigate the grades of endolymphatic hydrops determined by gadolinium‐contrast magnetic resonance (MR) and correlation to the clinical features in patients with Meniere disease.
Study Design Prospective study.
MethodsA total of 24 patients suffering from unilateral Meniere disease with either definite or probable clinical diagnosis were included. The duration of vertigo, duration of tinnitus, duration of vertigo attacks, hearing thresholds, and canal paresis (CP) value of caloric tests were assessed. Three‐dimensional fluid‐attenuated inversion recovery magnetic resonance imaging (MRI) was performed 4 hours after intravenous injection of double dose of gadobutrol (Gd) to show endolymph and perilymph, and the grades of endolymphatic hydrops were measured. Additionally, the correlation between clinical features and the grades of endolymphatic hydrops of cochlea and vestibular were evaluated.
Results Different grades of the endolymphatic hydrops in the impaired ear were revealed by MRI. The Spearman correlation showed a strong correlation between the hearing thresholds of low, middle, and high tone and the grades of cochlea and vestibular hydrops (P < .05); However, no significant correlation between the duration of vertigo, duration of tinnitus, duration of vertigo attacks, CP value, and endolymphatic hydrops was determined (P > .05).
Conclusion By visualizing the endolymph and perilymph of inner ear in patients with Meniere disease assisted with intravenous injection of double doses of Gd, the grades of endolymphatic hydrops could be assessed. As a result, the grades of endolymphatic hydrops in patients with Meniere disease can be used to predict the level of hearing impairment.
Level of Evidence4 Laryngoscope, 131:E144–E150, 2021

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H+/K+ATPase Expression in the Larynx of Laryngopharyngeal Reflux and Laryngeal Cancer Patients

Caroline A. McCormick, Tina L. Samuels, Michele A. Battle, Talia Frolkis, Joel H. Blumin, Jonathan M. Bock, Clive Wells, Ke Yan, Kenneth W. Altman, Nikki Johnston

Publication date 14-12-2020


Objectives The gastric H+/K+ ATPase proton pump has previously been shown to be expressed in the human larynx, however its contribution to laryngopharyngeal reflux (LPR) signs, symptoms and associated diseases such as laryngeal cancer is unknown. Proton pump expression in the larynx of patients with LPR and laryngeal cancer was investigated herein. A human hypopharyngeal cell line expressing the proton pump was generated to investigate its effects.
Study Design In‐vitro translational.
Methods Laryngeal biopsies were obtained from three LPR and eight LSCC patients. ATP4A, ATP4B and HRPT1 were assayed via qPCR. Human hypopharyngeal Fa Du cell lines stably expressing proton pump were created using lentiviral transduction and examined via transmission electron microscopy and qPCR for genes associated with inflammation or laryngeal cancer.
Results Expression of ATP4A and ATP4B was detected in 3/3 LPR, 4/8 LSCC‐tumor and 3/8 LSCC‐adjacent specimens. Expression of ATP4A and ATP4B in Fa Du elicited mitochondrial damage and expression of IL1B, PTGS2, and TNFA (P < .0001); expression of ATP4B alone did not.
Conclusions Gastric proton pump subunits are expressed in the larynx of LPR and LSCC patients. Mitochondrial damage and changes in gene expression observed in cells expressing the full proton pump, absent in those expressing a single subunit, suggest that acid secretion by functional proton pumps expressed in upper airway mucosa may elicit local cell and molecular changes associated with inflammation and cancer.
Level of EvidenceNA Laryngoscope, 131:130–135, 2021

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Cost Utility Analysis of Dupilumab Versus Endoscopic Sinus Surgery for Chronic Rhinosinusitis With Nasal Polyps

George A. Scangas, Arthur W. Wu, Jonathan Y. Ting, Ralph Metson, Evan Walgama, Mark G. Shrime, Thomas S. Higgins

Publication date 14-12-2020


Objective Both endoscopic sinus surgery (ESS) and biologic therapies have shown effectiveness for medically‐refractory chronic rhinosinusitis with nasal polyps (CRSwNP) without severe asthma. The objective was to evaluate cost‐effectiveness of dupilumab versus ESS for patients with CRSwNP.
Study Design Cohort‐style Markov decision‐tree economic model with a 36‐year time horizon.
MethodsA cohort of 197 CRSwNP patients who underwent ESS were compared with a matched cohort of 293 CRSwNP patients from the SINUS‐24 and SINUS‐52 Phase 3 studies who underwent treatment with dupilumab 300 mg every 2 weeks. Utility scores were calculated from the SNOT‐22 instrument in both cohorts. Decision‐tree analysis and a 10‐state Markov model utilized published event probabilities and primary data to calculate long‐term costs and utility. The primary outcome measure was incremental cost per quality‐adjusted life year (QALY), which is expressed as an Incremental Cost Effectiveness Ratio. One‐way and probabilistic sensitivity analyses were performed.
Results The ESS strategy cost $50,436.99 and produced 9.80 QALYs. The dupilumab treatment strategy cost $536,420.22 and produced 8.95 QALYs. Because dupilumab treatment was more costly and less effective than the ESS strategy, it is dominated by ESS in the base case. One‐way sensitivity analyses showed ESS to be cost‐effective versus dupilumab regardless of the frequency of revision surgery and at any yearly cost of dupilumab above $855.
Conclusions The ESS treatment strategy is more cost effective than dupilumab for upfront treatment of CRSwNP. More studies are needed to isolate potential phenotypes or endotypes that will benefit most from dupilumab in a cost‐effective manner.
Level of Evidence2C Laryngoscope, 131:E26–E33, 2021

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Olfactory Cleft Width and Volume: Possible Risk Factors for Postinfectious Olfactory Dysfunction

Aytug Altundag, Dastan Temirbekov, Cemal Haci, Duzgun Yildirim, Melih Cayonu

Publication date 14-12-2020


Objectives/Hypothesis Upper respiratory tract infections are a common cause of temporary and permanent olfactory dysfunction in the general population. Postviral or postinfectious olfactory loss (PIOL) develops only in rare cases. The aim of this study was to investigate the anatomical features of olfactory cleft (OC) in patients with PIOL to shed light on possible predisposing factors for PIOL.
Study Design Retrospective study.
Methods We retrospectively evaluated paranasal sinus computed tomography (CT) scan results of patients diagnosed with PIOL. A control group consisted of normosmic individuals who underwent paranasal sinus CT scans before septoplasty surgery. We compared the olfactory fossa depth, OC width, and volume on the CT scans of the PIOL and control groups.
Results In total, 71 individuals fulfilled the study criteria (PIOL group, n = 32; control group, n = 39). There was no statistically significant difference in the olfactory fossa depth in the two groups. The OC width and volume in the PIOL group was found to be significantly increased than that in the control group (P < .001 for both).
Conclusions Patients with PIOL had increased OC width and volume than the healthy controls. An extra‐wide olfactory cleft may be a predisposing factor in the pathogenesis of PIOL.
Level of Evidence4 Laryngoscope, 131:5–9, 2021

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Fibro‐osseous Lesions of Paranasal Sinus and Craniofacial Region: A Retrospective Study of 282 Cases

Dong Dong, Yue Wang, Chang Li, Hongyan Zhang, Yulin Zhao, Jinping Lai

Publication date 14-12-2020


Objectives To compare the clinical characteristics of osteoma, ossifying fibroma (OF) and fibrous dysplasia (FD) in the paranasal sinus and craniofacial regions.
Methods Totally 282 patients (112 males, 170 females) with osteoma (161), OF (44), and FD (77) involving the paranasal sinus, skull base and orbit treated surgically from January 2012 to August 2018 were analyzed retrospectively.
Results For osteoma, OF and FD, the onset ages were 40.3 (6–75), 24.5 (5–62), and 15 (1–63) years, and the most common locations were ethmoid sinus (49.7%), maxilla (36.4%) and maxilla (49.4%), respectively. There were significant differences of the preoperative serum alkaline phosphatase (ALP) levels between patients with osteoma (65 25,184 U/L), OF (85.5 41,474 U/L), and FD (104 39,362 U/L) (Z = 44.9, P < .05). The ALP levels of OF and FD patients were comparable between monostotic and polyostotic lesions (P > .05). The recurrent rates of osteoma, OF, and FD were 0%, 13.6%, and 15.6%, respectively. The recurrent OF cases had significantly higher ALP level than the primary ones (283.5 108,474 U/L vs. 76 41,348 U/L, U = 14, P < .05).
Conclusion There are differences in the onset age, location, and recurrence rate among osteoma, OF and FD involving the paranasal sinus and craniofacial region. Osteoma most commonly occurs in the ethmoid sinus, while OF and FD involve the maxilla most and are more likely to involve the orbit and the skull base, respectively. Endoscopic surgery is currently the main method for treatment, but individualized treatment regimen should be developed for patients.
Level of EvidenceIV Laryngoscope, 131:E1–E7, 2021

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Continuous Laryngeal Adductor Reflex Versus Intermittent Nerve Monitoring in Neck Endocrine Surgery

Catherine F. Sinclair, Maria J. Téllez, Sedat Ulkatan

Publication date 14-12-2020


Objective Intraoperative neuromonitoring (IONM) techniques aim to identify and potentially prevent nerve injury during surgeries. Prior studies into the efficacy of recurrent laryngeal nerve (RLN) IONM convey mixed results, with some claiming equivalence between IONM and no monitoring at all. The goal of the current study was to compare continuous RLN monitoring using the laryngeal adductor reflex (LAR) to intermittent RLN monitoring (intermittent IONM) to determine whether continuous monitoring reduces the incidence of intraoperative RLN injury during neck endocrine surgeries.
Methods In this observational, historical case‐control study, a historical cohort of patients monitored with intermittent‐IONM (group 1, n = 130) were compared to prospectively collected data from consecutive nerves‐at‐risk monitored continuously with the LAR (LAR‐CIONM, group 2, n = 205), at a single center by a single surgeon. The test benefit ratio and relative risk reduction (RRR) for LAR‐CIONM over intermittent IONM were calculated.
Results For group 1, nine nerves at risk exhibited intraoperative LOS with transient postoperative vocal fold (VF) hypomobility (n = 2) or immobility (VFI, n = 7). For group 2, two nerves at risk (0.98%) had sudden intraoperative LAR LOS following bipolar cautery, resulting in postoperative transient VFI (P = .004). In each group, there was one case of permanent postoperative VFI. The test benefit rate ratio for LAR‐CIONM demonstrated a dramatic effect at 5.23, with an RRR of 81.0%.
ConclusionLAR‐CIONM significantly decreased rates of postoperative transient VF paralysis and paresis over intermittent IONM alone (P = .004). Surgeons should be aware of the benefits and limitations of intermittent IONM versus CIONM. Intermittent IONM, although useful in nerve mapping and intraoperative decision making, has minimal benefit for the prevention of nerve injury, whereas CIONM can potentially reduce nerve injury rates and improve patient outcomes.
Level of Evidence3 Laryngoscope, 131:230–236, 2021

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Pre‐Clinical Experience With the VITOM 3D and the ARTip Cruise System for Micro‐Laryngeal Surgery

Armando De Virgilio, Andrea Costantino, Tiziana Mondello, Valerio Conti, Francesca Pirola, Elena Russo, Giuseppe Mercante, Giuseppe Spriano

Publication date 14-12-2020


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Intralingual Thyroglossal Duct Cyst Excision

Madeleine A. Drusin, Nicola M. Pereira, Vikash K. Modi

Publication date 14-12-2020


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Identification of Viruses in Patients With Postviral Olfactory Dysfunction by Multiplex Reverse‐Transcription Polymerase Chain Reaction

Jun Tian, Jayant M. Pinto, Li Li, Sanmei Zhang, Zhifu Sun, Yongxiang Wei

Publication date 14-12-2020


Objectives/Hypothesis To investigate causative viruses in patients with postviral olfactory disorders (PVOD).
Study Design Case‐control study.
Methods One hundred fifty‐one consecutive patients diagnosed with PVOD were enrolled, and samples from 38 patients who visited the doctor within 3 months of symptom onset were collected and analyzed. Thirty‐two individuals who underwent surgery for nasal septal deviation during the same time period were collected as the control group. The Sniffin Sticks psychophysical olfactory test was used to evaluate olfactory function. Olfactory cleft specimens were collected using nasopharyngeal flocked swabs (COPAN FLOQSwabs). Eighteen viruses were tested for with the Luminex xTAG RVP FAST v2 Assay Kit.
Results Out of the 38 patients with PVOD, rhinoviruses were detected in 13 patients, and coronavirus OC43 was detected in one patient. The frequency of positive virus detection in the patients with anosmia was higher than in those with hyposmia (58.8% vs. 19.0%, P = 0.018). In control group, rhinovirus was identified in one patient (3.1%). Nasal obstruction was the most common symptom and was experienced by 71.0% of patients.
Conclusions Rhinovirus and coronavirus are more commonly identified in PVOD. Our methods represent an approach to screen for viruses that may be involved in PVOD.
Level of Evidence4 Laryngoscope, 131:158–164, 2021

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Current Management of Large Vestibular Schwannomas for NF2 Patients in a National Reference Center

Pierre‐Cyril Comes, Matthieu Peyre, Marc Sanson, Olivier Sterkers, Daniele Bernardeschi, Michel Kalamarides

Publication date 14-12-2020


Objective Recently, treatment decision making for large vestibular schwannomas (VS) in patients with neurofibromatosis type 2 (NF2) has become increasingly challenging due to the availability of multiple therapeutic options including surgery, bevacizumab (an anti‐VEGF), radiosurgery, and observation; and it often remains an arbitrary decision based on local practices without firm recommendations. Our objective is to discuss the multimodal treatment options for Koos IV VS in a national reference center for NF2.
Study Design Single‐institution retrospective cohort study.
Methods All NF2 patients with Koos IV VS who visited our center, the National Reference Center for NF2 Rare Disease in Pitié‐Salpétrière Hospital of Paris, between January 2016 and December 2018 were included. Clinical charts, radiology, operative reports, and audiograms were reviewed.
Results Among 54 NF2 patients with Koos IV VS (mean maximum extrameatal diameter: 34 mm; range:17–62 mm), 27 were operated on for 28 VS; 21 were treated with bevacizumab; and six were observed. In the surgical group, VS resections were gross total, near‐total, subtotal, or partial in 32%, 25%, 32%, and 11%, respectively; and a good (House‐Brackmann grades I–II) facial nerve function was achieved in 81.5% at 1 year. Hearing was preserved in 14%, 78%, and 66% of the surgical (n = 7), bevacizumab (n = 9), and observation (n = 3) patients, respectively.
Conclusion All therapeutic options, including surgery and/or bevacizumab and occasionally observation, should be proposed to NF2 patients with large VS in the setting of dedicated centers. A decision‐making tree is proposed for Koos IV VS management based on tumor evolution, hearing and clinical status of the patient, and contralateral VS size.
Level of Evidence4, case series study, historically controlled study Laryngoscope, 131:E98–E107, 2021

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High‐Risk Cutaneous Squamous Cell Cancer of the Head and Neck: Risk Factors for Recurrence and Impact of Adjuvant Treatment

Samuel J. Trosman, Angela Zhu, Elizabeth A. Nicolli, Jason M. Leibowitz, Zoukaa B. Sargi

Publication date 14-12-2020


Objectives The behavior of advanced cutaneous squamous cell carcinoma of the head and neck (HNcSCC) remains poorly understood, with highly variable risk factors and a paucity of data for adjuvant treatment. The objective of our study was to review the oncologic outcomes of patients with high‐risk HNcSCC treated with surgery and to identify risk factors for treatment failure.
Study Design Retrospective cohort study.
Methods Retrospective review of patients treated for HNcSCC with definitive surgery involving at least parotidectomy and neck dissection at a tertiary care academic center from 2011 to 2017 was conducted. The primary outcome was disease‐free survival (DFS).
Results One‐hundred four patients with a median age of 68 years (range = 42–91 years) were reviewed. Twenty‐one patients were treated with surgery alone, 45 patients underwent adjuvant radiotherapy (RT), and 38 patients underwent adjuvant chemoradiotherapy (CRT). The 2‐year DFS for patients treated with surgery, surgery + RT, and surgery + CRT were 71%, 65%, and 58%, respectively, with no significant difference between the groups (P = .70). On multivariate analyses, tumor size (P = .006) and perineural invasion (PNI, P = .04) independently predicted recurrence. The addition of chemotherapy did not appear to improve DFS, neither for those patients with extranodal extension and/or positive margins (P = .93) nor for the entire cohort (P = .43).
Conclusions Advanced HNcSCC has a high recurrence rate despite adjuvant treatment. Tumor size >2 cm was a strong independent risk factor for recurrence. Out of the traditional mucosal HNcSCC risk factors, PNI was most strongly associated with worse DFS. There was no observed survival benefit to the addition of chemotherapy.
Level of Evidence4. Laryngoscope, 131:E136–E143, 2021

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Laryngeal Pathologies and Their Associations With Mental Health Disorders

Krzysztof Piersiala, Lee M. Akst, Alexander T. Hillel, Simon R. Best

Publication date 14-12-2020


Objectives Mental health disorders are very common. Understanding their clinical manifestations in terms of voice and laryngeal disorders (VLD) is important because they constitute a significant proportion of all patients seen by otolaryngology‐head and neck surgery. In this study, we examine different mental disorders (MDs) and their presenting symptoms and diagnoses of VLD.
Methods Case series study, retrospective chart review of patients seen between January 2016 and December 2017 at the Johns Hopkins Voice Center. Diagnoses, demographic data, and comorbidities were collected. VLD were grouped into categories (laryngeal pathology, functional voice disorders, airway, swallowing, other) for statistical analysis.
Results Of a total 4,249 patients, 836 patients (19.7%) suffered from at least one MD. Those patients presented more frequently with swallowing problems (24.9% of all diagnoses in MD compared to 21.2% in control group; adjusted odds ratio aOR 1.280, 95% confidence interval CI 1.107–1.480, P = .001) and less frequently with vocal cord pathology (30.9% of all diagnoses in MD compared to 33.9% in control group, aOR 0.793, 95% CI 0.694–0.907, P = .001). Patients suffering from depression had significantly increased odds for dysphagia (aOR 1.570, 95% CI 1.216–2.026, P = .001). VLD clinical presentation profile was created for every MD studied.
Conclusion Patients suffering from mental health disorders present more frequently with swallowing complaints, in particular for dysphagia. Awareness of this can guide appropriate referrals. Objective laryngeal findings are common in patients with substance abuse disorders. They should be screened with careful diagnostic laryngoscopy.
Level of Evidence4 Laryngoscope, 131:E231–E239, 2021

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Differences in Flexible and Rigid Bronchoscopy for Assessment of Tracheomalacia

Erik B. Hysinger, Catherine K. Hart, Gregory Burg, Alessandro De Alarcon, Dan Benscoter

Publication date 14-12-2020


Objectives/Hypothesis Both flexible and rigid bronchoscopy can be used to assess tracheomalacia; however, there is limited evidence comparing the two techniques. The objective of this study was to compare flexible and rigid bronchoscopy for evaluating the location and severity of tracheomalacia in children.
Study Design Retrospective case series.
Methods This was a retrospective study of children with both flexible and rigid bronchoscopy under the same sedation. All bronchoscopies were reviewed by three bronchoscopists for the location and severity of tracheomalacia. The location of collapse was defined as upper, middle, or lower trachea, and the severity of collapse was defined as none (0%–25% collapse), mild/moderate (26%–75% collapse), and severe (>75% collapse).
Results Twenty‐one patients were recruited for this study with a variety of neonatal respiratory diseases. There was 94% agreement (κ = 0.64) for assessment of tracheomalacia in the upper trachea. However, agreement was only 75% (κ = 0.50) in the middle trachea and 76% (κ = 0.52) in the lower trachea. In the subset of patients without tracheostomy, agreement improved to 100%, 88%, and 82% for the upper, middle, and lower trachea, respectively. There was poor correlation for tracheomalacia severity in the middle trachea (ρ = 0.30, P = .2) and moderate in the lower trachea (ρ = 0.63, P = .002).
Conclusions Although there is moderate agreement between flexible and rigid bronchoscopy for evaluating the presence of tracheomalacia, there can be differences in the two techniques, particularly when assessing severity of airway collapse. Future studies will be needed to understand factors that result in the discordance of flexible and rigid bronchoscopy for assessing airway dynamics.
Level of Evidence4 Laryngoscope, 131:201–204, 2021

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Which Anesthesia Regimen Is Best to Reduce Pulmonary Complications After Head and Neck Surgery?

Dan Zhou, Xi Zhu, Likuan Wang, Xudong Yang, Yun Liu, Xiang Zhang

Publication date 14-12-2020


Objectives/Hypothesis The differences between intravenous and inhalation anesthesia in clinical postoperative pulmonary complications (PPCs) have been studied in cardiac and lung resection surgery. Clinical evidence for the effects of these two anesthetics on PPCs in other types of surgery is still missing. We aimed to assess the impact of sevoflurane and propofol on the incidence of PPCs in patients undergoing surgery for head and neck cancer.
Study Design Double‐blind, randomized, controlled trial.
Methods We assigned 220 adults at intermediate‐to‐high risk of PPCs scheduled for head and neck cancer surgery with radial forearm or fibular flap reconstruction to either propofol or sevoflurane as a general anesthetic. The occurrence of pulmonary complications according to the Clavien‐Dindo score was defined as the primary (within 7 days after surgery) outcome.
Results The PPC incidence during 7 days after surgery was 32.4% and 18.2% in the propofol and sevoflurane groups, respectively (P = .027). The corresponding incidence of PPCs in patients who underwent tracheotomy at the end of surgery in the two groups was 44.8% and 24.5%, respectively (P = .030). In addition, the Clavien‐Dindo classification showed significant differences between groups in minor complications (grades I and II) but not in major complications (grades III–V).
Conclusions Compared with intravenous anesthesia, the administration of sevoflurane reduces the incidence of minor PPCs (grades I and II) in moderate‐ and high‐risk patients who have undergone tracheotomy after head and neck cancer surgery with radial forearm or fibular flap reconstruction.
Level of Evidence2 Laryngoscope, 131:E108–E115, 2021

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Multimodal Imaging With Positron Emission Tomography/Computed Tomography and Magnetic Resonance Imaging to Detect Extracapsular Extension in Head and Neck Cancer

Sean C. Sheppard, Roland Giger, Beat Bojaxhiu, Christos Sachpekidis, Florian Dammann, Matthias S. Dettmer, Andreas Arnold, Jan Wartenberg, Lluís Nisa

Publication date 14-12-2020


Objectives/Hypothesis To assess the ability of specific positron emission tomography/computed tomography (PET/CT) and magnetic resonance imaging (MRI) features to detect extracapsular extension (ECE) in head and neck squamous cell carcinoma (HNSCC) patients.
Study Design Retrospective study in a tertiary certified university cancer institute.
Methods We performed a review of patients with advanced HNSCC at Bern University Hospital between 2014 and 2018. Patients with pretherapeutic PET/CT and/or MRI who underwent neck dissection were included, with 212 patients fulfilling inclusion criteria. Blinded evaluation of specific PET/CT and MRI features with respect to presence of ECE was performed. Histopathological examination of neck dissection specimens was used as the gold standard to determine ECE status.
Results Out of the 212 included patients, 184 had PET/CT, 186 MRI, and 158 both modalities. Overall clinical stage IV (odds ratio OR: 2.26, 95% confidence interval CI: 2.25‐11.74), ill‐defined margins in both PET/CT and MRI (OR: 3.48, 95% CI: 1.21‐9.
98 and OR: 2.14, 95% CI: 0.94‐4.89, respectively), and a maximum standardized uptake value ≥ 10 (OR: 5.44, 95% CI: 1.21‐9.98) were all significant independent predictors of ECE. When combined, these four features led to a cumulative score able to predict ECE status with an accuracy of 91.43%.
Conclusions The current findings indicate specific features in PET/CT and MRI are potential predictors of ECE status and may help in pretherapeutic stratification in HNSCC.
Level of Evidence4 Laryngoscope, 131:E163–E169, 2021

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Effects of Neurod1 Expression on Mouse and Human Schwannoma Cells

Jennifer Kersigo, Lintao Gu, Linjing Xu, Ning Pan, Sarath Vijayakuma, Timothy Jones, Seiji B. Shibata, Bernd Fritzsch, Marlan R. Hansen

Publication date 14-12-2020


Objectives The objective was to explore the effect of the proneuronal transcription factor neurogenic differentiation 1 (Neurod1, ND1) on Schwann cells (SC) and schwannoma cell proliferation.
Methods Using a variety of transgenic mouse lines, we investigated how expression of Neurod1 effects medulloblastoma (MB) growth, schwannoma tumor progression, vestibular function, and SC cell proliferation. Primary human vestibular schwannoma (VS) cell cultures were transduced with adenoviral vectors expressing Neurod1. Cell proliferation was assessed by 5‐ethynyl‐2‐deoxyuridine (EdU) uptake.
Study Design Basic science investigation.
Results Expression of Neurod1 reduced the growth of slow‐growing but not fast‐growing MB models. Gene transfer of Neurod1 in human schwannoma cultures significantly reduced cell proliferation in dose‐dependent way. Deletion of the neurofibromatosis type 2 (Nf2) tumor‐suppressor gene via Cre expression in SCs led to increased intraganglionic SC proliferation and mildly reduced vestibular sensory‐evoked potentials (VsEP) responses compared to age‐matched wild‐type littermates. The effect of Neurod1‐induced expression on intraganglionic SC proliferation in animals lacking Nf2 was mild and highly variable. Sciatic nerve axotomy significantly increased SC proliferation in wild‐type and Nf2‐null animals, and expression of Neurod1 reduced the proliferative capacity of both wild‐type and Nf2‐null SCs following nerve injury.
Conclusion Expression of Neurod1 reduces slow‐growing MB progression and reduces human SC proliferation in primary VS cultures. In a genetic mouse model of schwannomas, we find some effects of Neurod1 expression; however, the high variability indicates that more tightly regulated Neurod1 expression levels that mimic our in vitro data are needed to fully validate Neurod1 effects on schwannoma progression.
Level of EvidenceNA Laryngoscope, 131:E259–E270, 2021

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Anti‐C1GALT1 Autoantibody Is a Novel Prognostic Biomarker for Patients With Head and Neck Cancer

Mei‐Chun Lin, Min‐Chuan Huang, Pei‐Jen Lou

Publication date 14-12-2020


Objectives The objective of this study is to determine the value of the anti‐ glycoprotein‐N‐acetylgalactosamine 3‐beta‐galactosyltransferase 1 (C1GALT1) autoantibody as a biomarker for distant metastasis and good response to immune checkpoint inhibitors in patients with head and neck squamous cell carcinoma (HNSCC).
Methods In this retrospective study with a median follow‐up of 55.7 months, 186 HNSCC patients were enrolled between July 2013 and August 2014. Data were analyzed between April 2018 and November 2019. Titers of autoantibody against the C1GALT1 peptide were measured by ELISA. Student t test, Kaplan–Meier analysis, and univariate and multivariate Cox proportional hazard models were used to evaluate the association of anti‐C1GALT1 autoantibody titer with clinicopathologic factors, survival, and response to immunotherapy.
Results Our results showed that high levels of the anti‐C1GALT1 autoantibody is an independent marker for distant metastasis and poor disease‐specific survivals in HNSCC patients. In 19 recurrent or metastatic (R/M) HNSCC patients who have received nivolumab or pembrolizumab, higher autoantibody titers are associated with a better treatment response.
Conclusion We propose that the anti‐C1GALT1 autoantibody can serve as a novel biomarker for distant metastasis in HNSCC patients. It is also useful in individualized medicine for R/M HNSCC patients who are considering immunotherapy.
Level of EvidenceIV Laryngoscope, 131:E196–E202, 2021

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An Open‐Source Computer Vision Tool for Automated Vocal Fold Tracking From Videoendoscopy

Nat Adamian, Matthew R. Naunheim, Nate Jowett

Publication date 14-12-2020


Objectives Contemporary clinical assessment of vocal fold adduction and abduction is qualitative and subjective. Herein is described a novel computer vision tool for automated quantitative tracking of vocal fold motion from videolaryngoscopy. The potential of this software as a diagnostic aid in unilateral vocal fold paralysis is demonstrated.
Study Design Case‐control.
MethodsA deep‐learning algorithm was trained for vocal fold localization from videoendoscopy for automated frame‐wise estimation of glottic opening angles. Algorithm accuracy was compared against manual expert markings. Maximum glottic opening angles between adults with normal movements (N = 20) and those with unilateral vocal fold paralysis (N = 20) were characterized.
Results Algorithm angle estimations demonstrated a correlation coefficient of 0.97 (P < .001) and mean absolute difference of 3.72° (standard deviation SD, 3.49°) in comparison to manual expert markings. In comparison to those with normal movements, patients with unilateral vocal fold paralysis demonstrated significantly lower maximal glottic opening angles (mean 68.75° ± 11.82° vs. 49.44° ± 10.42°; difference, 19.31°; 95% confidence interval CI 12.17°–26.44°; P < .001). Maximum opening angle less than 58.65° predicted unilateral vocal fold paralysis with a sensitivity of 0.85 and specificity of 0.85, with an area under the receiver operating characteristic curve of 0.888 (95% CI 0.784–0.991; P < .001).
ConclusionA user‐friendly software tool for automated quantification of vocal fold movements from previously recorded videolaryngoscopy examinations is presented, termed automated glottic action tracking by artificial intelligence (AGATI). This tool may prove useful for diagnosis and outcomes tracking of vocal fold movement disorders.
Level of EvidenceIV Laryngoscope, 131:E219–E225, 2021

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Distinct Clinical Pathology and Microbiota in Chronic Rhinosinusitis With Nasal Polyps Endotypes

Elrayah E. Abbas, Chuan Li, Ao Xie, Shan Lu, Li Tang, Yinhui Liu, Ayman Elfadil, Shu Wen

Publication date 14-12-2020


Objectives/Hypothesis Eosinophilic and noneosinophilic chronic rhinosinusitis with nasal polyps (ECRSwNP and NECRSwNP) show distinguished clinical pathology, but their underlying mechanism remains unclear. We aimed to investigate the clinical, hematological, and histopathological changes in chronic rhinosinusitis with nasal polyps (CRSwNP) endotypes and its association with microbiota.
Study DesignA comparative cross‐sectional study.
MethodsA comparative study of 46 patients with CRSwNP (34.69 ± 16.39 years old) who underwent endoscopic sinus surgery were recruited and subdivided into ECRSwNP and NECRSwNP groups based on eosinophilic tissue inflammation; 12 healthy controls were also included. A structured histopathological analysis was conducted, and complete blood count was determined in patients. Endoscopic‐guided middle meatus swabs and fecal samples were collected from the patients and controls and subsequently subjected to 16S rRNA gene sequencing on Illumina Mi Seq.
Results Compared to NECRSwNP, ECRSwNP showed a statistically significant increase in the computed tomography score, endoscopic score, blood eosinophil percentage, tissue eosinophil count, inflammation degree, subepithelial edema, and eosinophil aggregation. Airway microbiota communities differed among the three groups. The abundance of Moraxella and Parvimonas was significantly higher in the ECRSwNP group. Distinct microbiota dysbiosis in CRSwNP endotypes was found to be correlated with different clinical pathologies. Moreover, the gut microbiota in ECRSwNP and NECRSwNP showed dysbiosis, that is, significant decrease in the abundance of Actinobacteria in the former and significant increase in the abundance of Enterobacterales and several genera in NECRSwNP.
Conclusions Significant clinical pathology and microbiota changes were evident in patients with ECRSwNP and NECRSwNP. Distinct microbiota dysbiosis was correlated with different clinical pathologies. Understanding these differences may improve the prognosis and treatment of chronic rhinosinusitis.
Level of Evidence4 Laryngoscope, 131:E34–E44, 2021

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RNA Sequencing Reveals Cancer‐Associated Changes in Laryngeal Cells Exposed to Non‐Acid Pepsin

Tina L. Samuels, Michael T. Zimmermann, Atefeh Zeighami, Wendy Demos, Jessica E. Southwood, Joel H. Blumin, Jonathan M. Bock, Nikki Johnston

Publication date 14-12-2020


Objective Laryngopharyngeal reflux (LPR) is a common affliction that contributes to laryngeal inflammation, symptoms that impact quality of life, and life‐threatening illnesses such as cancer. Effective treatment strategies for LPR are lacking. Pepsin is a proinflammatory and carcinogenic element of refluxate. Investigation of molecular pathways involved in pepsin‐mediated damage may lead to identification of novel biomarkers and therapeutic targets for LPR. In this study, RNA sequencing was used to examine changes in human laryngeal epithelial cells following brief pepsin insult. Cells were immortalized to generate a model to aid future study of laryngeal injury and therapeutics.
Study Design In vitro translational.
Methods Laryngeal epithelial cells were cultured from a patient without signs or symptoms of LPR or laryngeal cancer. Cells were treated with 0.1 mg/ml pepsin for 1 hour or normal growth media (control) prior to RNA sequencing. Cells were immortalized via HPV E6/7 and characterized by microscopy, immunohistochemistry, G‐banding, and soft agar assay.
Results Three hundred ninety‐seven genes exhibited differences in expression with pepsin treatment (P < .05). Pathway analysis revealed association with cancer and related signaling processes including dysregulation of cancer‐associated molecules, Metastasis‐Associated Lung Adenocarcinoma Transcript 1 and KRT82, and the long‐noncoding RNA, lipoprotein receptor‐related protein 1 (LRP1)–AS, which regulates the putative pepsin receptor LRP1.
ConclusionsA single, brief exposure to pepsin activated cancer‐associated signaling pathways in laryngeal cells in vitro, revealing novel mechanisms by which chronic reflux may contribute to carcinogenesis. The cell line developed herein represents a novel tool in which to investigate pepsin‐dysregulated pathways identified by RNA sequencing and disparities of tumor proneness of laryngeal subsites.
Level of EvidenceN/A Laryngoscope, 131:121–129, 2021

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The Geriatric Nutritional Risk Index as a Prognostic Factor in Patients with Advanced Head and Neck Cancer

Masahiro Nakayama, Masahiko Gosho, Masahiro Adachi, Rieko Ii, Shin Matsumoto, Hidetaka Miyamoto, Yuki Hirose, Bungo Nishimura, Shuho Tanaka, Tetsuro Wada, Keiji Tabuchi

Publication date 14-12-2020


Objective The Geriatric Nutritional Risk Index (GNRI) is a simple and well‐established nutritional assessment tool and is a significant prognostic factor in various cancers. However, the role of the GNRI in predicting clinical outcomes in patients with advanced head and neck cancer (AHNC) has not been investigated. The aim of the present study was to examine the association between the GNRI and prognosis in patients with AHNC.
Study Design Retrospective cohort study.
Methods Data collected between 2002 and 2013 from Tsukuba University Hospital were reviewed. The GNRI was calculated according to the equation, 1.489 × serum albumin (g/l) + 41.7 × (body weight/ideal body weight).
Characteristics and prognosis were compared among three risk groups: high (GNRI <82); intermediate (GNRI 82–98); and normal (GNRI >98). The primary endpoint was overall survival.
ResultsA total of 248 AHNC patients were enrolled, among whom 134 (54%) exhibited no nutritional risk, 53 (21%) had an intermediate risk for malnutrition, and 61 (25%) exhibited a high risk for malnutrition. Three‐year survival rates according to the three‐group GNRI scores for normal, intermediate, and high risk were 76.6%, 56.3%, and 19.5%, respectively. As the three‐group GNRI score increased, the risk for mortality significantly increased (adjusted hazard ratio HR for intermediate to normal, 1.73 95% CI, 1.02–2.92; adjusted HR for high to normal, 4.31 95% CI, 2.71–6.84).
Conclusions The GNRI could be considered a useful prognostic factor in patients with AHNC.
Level of Evidence4 Laryngoscope, 131:E151–E156, 2021

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Clinicoradiologic Characteristics of Temporal Bone Meningioma: Multicenter Retrospective Analysis

Jae Joon Han, Doh Young Lee, Soo‐Keun Kong, Ki‐Hong Chang, Yong Joo Yoon, Hyung‐Jong Kim, Hyo‐Jeong Lee, Min‐Hyun Park, Ja‐Won Koo, Young Ho Kim

Publication date 14-12-2020


Objectives/Hypothesis Meningioma is a neoplasm arising from cells related to the arachnoid villi. The aim of the present study was to explore the clinical and radiological characteristics of temporal bone meningioma (TBM) in a multicenter cohort.
Study Design Retrospective cohort study.
Methods Thirteen patients diagnosed with TBM at eight medical institutes between 1998 and 2018 were retrospectively enrolled. The clinical procedures, symptoms, signs, and images that led to the diagnosis of TBM were investigated for all patients.
Results The most common symptom at the initial visit was hearing loss (n = 12/13, 92.3%). All patients exhibited unilateral TBMs with varied symptom durations (1–60 months). Four patients presented masses occupying the external auditory canal; the tympanic membrane (TM) could not be evaluated. The other nine patients did not show TM perforation despite the presence of inflammatory signs. The majority of patients exhibited unilateral conductive or mixed hearing loss. A retrospective review of temporal bone computed tomography (TBCT) images revealed findings suggestive of a tumor in all patients. However, three patients had been misdiagnosed with chronic otitis media and were subjected to tympanomastoidectomy (n = 3/7, 42.9%). TBCT findings that suggested TBM included diffuse trabecular hyperostosis in the middle and posterior cranial fossae and widening and destruction of the temporal bone in the jugular bulb area.
ConclusionsTBM should be suspected if patients exhibit persistent inflammatory symptoms or signs involving intact TM or unilateral conductive or mixed hearing loss with trabecular hyperostosis or destruction of the temporal bone on computed tomography images.
Level of Evidence4 Laryngoscope, 131:173–178, 2021

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3D Printed Fistula Plug: A Novel Bridge to Definitive Reconstruction

Robert J. Macielak, Michelle T. Ziebarth, Daniel L. Price

Publication date 14-12-2020


A case is presented showcasing the feasibility of three‐dimensional (3D) printing patient‐specific fistula plugs as a bridge therapy to definitive management of pharyngocutaneous fistulae. For this patient, a set of 3D printed fistula plugs was successfully used with low morbidity and positive results in the management of this postoperative issue. Utilizing 3D printed fistula plugs could represent a novel yet safe therapy for patients requiring long‐term management of similar wounds. Further studies are warranted to evaluate implementation of this practice on a widespread scale. Laryngoscope, 131:111–114, 2021

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Metachronous Bilateral Vestibular Schwannomas

Mohamed Elsayed, Baptiste Hochet, Renato Torres, Olivier Sterkers, Yann Nguyen, Ghizlene Lahlou, Michel Kalamarides

Publication date 14-12-2020


Bilateral vestibular schwannoma (BVS) is the hallmark of neurofibromatosis type 2 (NF2), both of them being present at diagnosis. We report four cases of metachronous BVS, a contralateral intracanalicular vestibular schwannomas (VS) being visible 2 to 13 years after resection of a unilateral VS. NF2 workup was negative except in one case where two NF2 gene mutations were found in tumor analysis. These cases raise the questions of whether the contralateral VS occurred by chance and how to manage it on the only hearing ear. Otologists should be aware of this rare eventuality for decision making of the first unilateral VS. Laryngoscope, 131:E250–E254, 2021

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HPV‐Related Multiphenotypic Sinonasal Carcinoma: A Case Report and Literature Review

Matthew L. Ward, Mikelle Kernig, Thomas J. Willson

Publication date 14-12-2020


Objectives Human papilloma virus‐related multi phenotypic sinonasal carcinoma (HMSC), a recently characterized sinonasal malignancy, is discussed including histology, clinical presentation, and treatment outcomes.
Study Design Case report with literature review.
MethodsA case of HMSC is reported, as well as a retrospective review of all cases of HMSC reported in the English literature from January 2000 through May 2018 in the MEDLINE, EMBASE, and Scopus databases. Case data from selected articles was pooled along with the presented case and analyzed.
Results Including the present case report, a total of 57 cases of HMSC were identified through literature review. Of the 42 cases with staging information, 25 (60%) presented as early‐stage disease (T1/T2). No nodal metastasis or disease‐specific mortalities were reported. Among the 44 cases with posttreatment follow‐up data, 16 cases (36.4%) developed local recurrence. The majority of recurrences occurred 24 to 60 months posttreatment, although reports of recurrence 10 and 29 years posttreatment exist. Local recurrence occurred in 40% and 60% of patients with perineural invasion and bone invasion, respectively. Patients who developed local recurrence had a longer disease‐free interval when treated with adjuvant radiotherapy, which approached statistical significance.
ConclusionsHMSC is a distinct entity with paradoxically aggressive morphology paired with an indolent clinical course characterized by high rates of local recurrence but no reported disease‐specific mortalities to date. Surgery with or without adjuvant radiotherapy is the most common treatment modality, and adjuvant radiotherapy may be associated with an increased disease‐free interval among patients with local recurrence.
Level of Evidence4 Laryngoscope, 131:106–110, 2021

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A Novel Technique for the Diagnosis and Management of Middle Ear Myoclonus

Michael J. Hutz, Margaret H. Aasen, Matthew Kircher

Publication date 14-12-2020


A novel technique for the diagnosis and management of middle ear myoclonus is described. A patient with middle ear myoclonus underwent a trans‐canal microscopic middle ear exploration with injection of botulinum toxin into the stapedius and tensor tympani muscles. Postoperatively, the patient noted complete resolution of symptoms. This is the first report of the use of botulinum toxin directly applied to the middle ear musculature via a trans‐canal approach for the management of middle ear myoclonus. This approach is both a useful diagnostic and therapeutic tool that allows for temporary muscle paralysis prior to offering definitive surgical management. Laryngoscope, 131:E248–E249, 2021

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In Response to “Lost in Meta‐Analysis”

Anders Sideris, Benjamin Cumming, Timothy R. Holmes, Thomas Stewart, Thomas Havas

Publication date 14-12-2020


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"In Response to Over‐the Counter Tinnitus “Cures”: Marketers Promises Do Not Ring True by Drs Vendra, Vaisbuch, Mudry and Jackler: Laryngoscope 129: August 2019; 1898–1906"

Michael D. Seidman

Publication date 14-12-2020


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"In Response to Letter to the Editor Regarding Over‐the‐Counter Tinnitus “Cures”: Marketers Promises Do Not Ring True"

Robert K. Jackler

Publication date 14-12-2020


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In Response to Letter to the Editor Regarding: Elective Neck Dissection During Salvage Laryngectomy: A Systematic Review and Meta‐Analysis

Jennifer H. Gross, Peter M. Vila, Joseph Zenga, Patrik Pipkorn

Publication date 14-12-2020


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In Response to Awake Thyroidectomy–‘Squeeze’ Technique for Nerve Monitoring

Thorsen W. Haugen, Archie B. LaMadrid

Publication date 14-12-2020


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Reflux Symptom Score and Quality of Life: Response to the Paper by Lechien JR et al.

Wen‐Jiun Lin, Chen‐Chi Wang, Sheng‐Hwa Chen, Jia‐Shiou Liao

Publication date 14-12-2020


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In Response to Validity and Reliability of the Reflux Symptom Score

Jerome R. Lechien, Francois Bobin, Vinciane Muls, Alexandra Rodriguez, Sven Saussez

Publication date 14-12-2020


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In response to: “A Systematic Review and meta‐analysis of Predictors of Airway Intervention in Adult Epiglottitis”

Sarah K. Rapoport, Nazaneen N. Grant, Ziad E. Deeb

Publication date 14-12-2020


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In Response to Letter to the Editor Regarding Over‐Under Versus Medial Tympanoplasty: Comparison of Benefit, Success, and Hearing Results

Seilesh Babu, Alexander L. Luryi, Christopher A. Schutt

Publication date 14-12-2020


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In Reference to A Randomized Controlled Trial of Adjuvant Mitomycin‐C in Endoscopic Surgery for Laryngotracheal Stenosis

Frederik G. Dikkers

Publication date 14-12-2020


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In Reply to Mitomycin‐C Is Ineffective in Laryngotracheal Surgery If Used Incorrectly

Katherine C. Yung, Joseph Chang, Mark S. Courey

Publication date 14-12-2020


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Regarding Elective Neck Dissection During Salvage Laryngectomy: A Systematic Review and Meta‐Analysis

Nagarjuna G. V. Reddy, Anand Subash, Vishal Rao

Publication date 14-12-2020


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In Reference to Awake Thyroidectomy—“Squeeze” Technique for Nerve Monitoring

Tzu‐Yen Huang, Feng‐Yu Chiang, Che‐Wei Wu

Publication date 14-12-2020


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Regarding Trigeminocardiac Reflex in Paediatric Adenotonsillectomy: A Report of Two Cases With Literature Review

Padmanabhan Karthikeyan, Neelima Vijayan

Publication date 14-12-2020


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In Response to Letter to the Editor Regarding: Trigeminocardiac Reflex in Pediatric Adenotonsillectomy: A Report of Two Cases With Literature Review

Lilun Li, Connie Lin, Maria Peña, Chaitanya Challa

Publication date 14-12-2020


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Regarding Over‐Under Versus Medial Tympanoplasty: Comparison of Benefit, Success, and Hearing Results

Zhengcai Lou

Publication date 14-12-2020


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Masthead

Publication date 14-12-2020


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Table of contents

Publication date 14-12-2020


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Voice and Swallowing Outcomes Following Airway Reconstruction in Adults: A Systematic Review

Gemma M. Clunie, Justin W. G. Roe, Caroline Alexander, Gurpreet Sandhu, Alison McGregor

Publication date 14-12-2020


Objectives Laryngotracheal stenosis is a rare condition characterized by upper airway narrowing. Reconstructive surgical treatment aims to manage the area of stenosis to improve dyspnea and can impact voice and swallowing function. This article critically evaluates the literature about voice and swallowing outcomes in adults with laryngotracheal stenosis who undergo reconstructive surgery.
Study Design Systematic review.
Methods Six databases were searched for articles referring to voice and swallowing outcome measures following reconstruction procedures in adults with laryngotracheal stenosis. Screening was completed using predefined inclusion/exclusion criteria.
ResultsA total of 143 abstracts were reviewed, with 67 articles selected for full‐text review. Twenty studies met the inclusion criteria. Data extraction was completed with the Strengthening Reporting of Observational Studies in Epidemiology checklist with Oxford Centre for Evidence‐Based Medicine Level of Evidence used to indicate quality. Risk of bias was assessed using the Risk of Bias Assessment Tool for Non‐Randomized Studies. All studies scored a high risk of bias in at least one of the domains. Selection and timing of outcome measures was heterogenous, and there was limited information provided about rationale or reliability.
Conclusions The literature acknowledges the importance of voice and swallowing outcomes following airway reconstruction. Studies show correlation between reconstructive surgery and deterioration in vocal function; there are no consistent data about swallowing outcomes. The lack of a core outcome measures set for adults with laryngotracheal stenosis limits the findings of this review. Further research is needed to establish clear criteria for robust and clinically relevant outcome measurement. Laryngoscope, 131:146–157, 2021

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Patient Safety and Quality Improvement in Otolaryngology–Head and Neck Surgery: A Systematic Review

John D. Gettelfinger, P. Barrett Paulk, Cecelia E. Schmalbach

Publication date 14-12-2020


Objective The current landscape of patient safety/quality improvement (PS/QI) research dedicated to Otolaryngology–Head and Neck Surgery (OHNS) has not been established. This systematic review aims to define the breadth and depth of PS/QI research dedicated to OHNS and to identify knowledge gaps as well as potential areas of future study.
Methods The study protocol was developed a priori using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) process. A computerized Ovid/Medline database search was conducted (January 1, 1965–September 30, 2019). Similar computerized searches were conducted using Cochrane Database, Pub Med, and Google Scholar. Articles were classified by year, subspecialty, PS/QI category, Institute of Medicine (IOM) Crossing the Chasm categories, and World Health Organization (WHO) subclass.
Results Computerized searches yielded 11,570 eligible articles, 738 (6.4%) of which met otolaryngology PS/QI inclusion criteria; 178 (24.1%) were not specific to any one subspecialty. The most prevalent subspecialty foci were head and neck (29.9%), pediatric otolaryngology (16.9%), and otology/neurotology (11.0%). Studies examining complications or risk factors (32.0%) and outcomes/quality measures (16.3%) were the most common foci. Classification by the IOM included effective care (31.4%), safety (29.9%), and safety/effective care (25.3%). Most research fell into the WHO categories of understanding causes (28.5%) or measuring harm (28.3%).
Conclusion Most OHNS PS/QI projects (32.0%) focus on reporting complications or risk factors, followed by outcomes/quality measures (16.3%). Knowledges gaps for future research include healthcare disparities, multidisciplinary care, and the WHO category of studies translating evidence into safer care.
Level of EvidenceNA Laryngoscope, 131:33–40, 2021

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The Relationship between Croup and Gastroesophageal Reflux: A Systematic Review and Meta‐Analysis

Alanna Coughran, Karthik Balakrishnan, Yifei Ma, Reza Vaezeafshar, Nicole Capdarest‐Arest, Osama Hamdi, Douglas R. Sidell

Publication date 14-12-2020


Objective The mechanism by which recurrent croup occurs is unknown. Gastroesophageal reflux is commonly implicated, although this relationship is only loosely documented. We conducted a systematic review with a meta‐analysis component to evaluate the relationship between recurrent croup and gastroesophageal reflux disease (GERD), and to assess for evidence of improvement in croup symptoms when treated.
Style Design Systematic Review and Meta Analysis.
Methods We searched five separate databases. Studies were included if they discussed the relationship between croup and GERD in children, >5 subjects, and available in English. Literature retrieved was assessed according to pre‐specified criteria. Retrieved articles were reviewed by two independent authors and decisions mediated by a third author. If there was a difference of opinion after first review, a second review was performed to obtain consensus. Heterogeneity was calculated and summarized in forest plots.
Results Of 346 initial records, 15 met inclusion criteria. These were two retrospective cohort and 13 cross‐sectional studies. Thirteen of 15 articles support an association between recurrent croup and GERD. Although heterogeneity is high among studies that reported prevalence of GERD, there is less uncertainty in results for improvement to recurrent croup after GERD treatment. Most studies lacked a control group and all carry a moderate‐to‐high risk of bias.
Conclusion There is limited evidence linking GERD to recurrent croup; Further research is needed to assess for causality as most studies are retrospective, lack a control group, and have a study design exposing them to bias. Patients treated with reflux medication appear to demonstrate a reduced incidence of croup symptoms.
Level of Evidence1 Laryngoscope, 131:209–217, 2021

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Method of Lateral Osteotomy to Reduce Eyelid Edema and Ecchymosis After Rhinoplasty: A Meta‐analysis

Ji‐sun Kim, Sun Hong Kim, Se Hwan Hwang

Publication date 14-12-2020


Objectives Although lateral osteotomy is an important part of rhinoplasty, it is known to be closely associated with postoperative eyelid edema and ecchymosis after rhinoplasty. There is no consensus on which osteotomy methods are effective in reducing morbidity from rhinoplasty. This study compared the effects of different osteotomy methods on edema and ecchymosis after lateral osteotomy using a meta‐analysis.
Study DesignA literature search using MEDLINE, SCOPUS, and Cochrane databases.
Methods Two authors independently reviewed the databases published until May 2019. Randomized controlled trials that compared lateral osteotomy methods (external approach) with different methods (internal approach), for which the outcomes of interest were mucosal injury, edema, and ecchymosis on postoperative days, were included. Sufficient data for meta‐analysis was found in six studies with a total of 224 patients.
Results In a comparison of the external approach with the internal approach, mucosal injury was significantly lower in the external approach (odds ratio = 0.41; 95% confidence interval = 0.11; 0.99, I2 = 29%). There were significant differences between the external and internal approach in eyelid ecchymosis and edema, except for eyelid ecchymosis at 7 days postoperatively. However, all significant results showed a small effect size with a standardized mean difference near 0.2.
Conclusions The external approach during lateral osteotomy had no significant advantage in edema and ecchymosis compared to the internal approach. Further studies with good research methodology should be carried out to determine the effect on the postoperative complications of different lateral osteotomy methods. Laryngoscope, 131:54–58, 2021

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Bleeding Complications After Transoral Robotic Surgery: A Meta‐Analysis and Systematic Review

William Stokes, Jad Ramadan, Georges Lawson, F. Robert L. Ferris, Floyd Christopher Holsinger, Meghan T. Turner

Publication date 14-12-2020


Objective Postoperative hemorrhage is the most common complication of transoral robotic surgery (TORS), the severity of which can range from minor bleeding treated with observation to catastrophic hemorrhage leading to death. To date, little is known about the incidence, risk factors, and management of post‐TORS hemorrhage.
Study Design Systematic Review and Metanlysis.
MethodsA systematic review of the published literature using the Cochrane Handbook for Systematic Reviews of Interventions was performed and examined TORS, postoperative hemorrhage, and the use of prophylactic transcervical arterial ligation (TAL).
ResultsA total of 13 articles were included in the analysis. To date, there have been 332 cases of hemorrhage following a total of 5748 TORS. The pooled median post‐TORS hemorrhage rate was 6.47%. The overall incidence of minor and major hemorrhage was 5.29% and 2.90%. Patients with prior radiation (relative risk RR = 1.46, 95% confidence interval CI = 1.00–2.12), large tumors (RR = 2.11, 95% CI = 1.48–2.99), and those requiring perioperative coagulation (RR = 2.25, 95% CI = 1.54–3.28) had significantly higher relative risks of hemorrhage. There was no significant difference in the relative risk of overall hemorrhage with TAL. Looking at major hemorrhage, patients undergoing TAL had a large but insignificant relative risk reduction in post‐TORS hemorrhage (RR = 0.40, 95% CI = 0.15–1.07).
Conclusion The incidence of post‐TORS hemorrhage is low (5.78%), and for major hemorrhage requiring emergent embolization, TAL, or tracheotomy to control hemorrhage it is even lower (2.90%). Large tumors, perioperative anticoagulation, and prior radiation were associated with significantly increased risk of post‐TORS hemorrhage. TAL does not reduce the overall incidence of post‐TORS hemorrhage but may lead to fewer severe hemorrhages.
Level of EvidenceIII Laryngoscope, 131:95–105, 2021

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Hair Transplantation in Frontal Fibrosing Alopecia and Lichen Planopilaris: A Systematic Review

Joshua A. Lee, Dylan A. Levy, Krishna G. Patel, Emily Brennan, Samuel L. Oyer

Publication date 14-12-2020


Objective: Evolving hair transplantation (HT) techniques have offered new possibilities for hair restoration. However, the role of HT in patients with frontal fibrosing alopecia (FFA) and lichen planopilaris (LPP) remains unclear. This study aims to evaluate the outcomes and temporal relationship of HT in this population.
Methods: A literature search of three databases was conducted. We reviewed 1) literature reporting outcomes of patients with LPP or FFA who received HT, and 2) studies reporting the development of LPP or FFA resulting from HT.
Results: Thirteen articles included 42 patients that provided data for evaluation. Fifteen patients had previously been diagnosed with FFA or LPP, and the remaining 27 patients developed disease after undergoing HT. Seven patients with FFA and eight patients with LPP received HT, with a mean sustained disease remission of 2.69 years prior to HT. In total, two of seven (29%) patients with FFA and five of eight (75%) patients with LPP experienced positive HT results over a follow‐up period of 8–72 months. Interestingly, 27 patients without evidence of previous disease developed FFA or LPP following HT after a median duration of 16 months.
Conclusions: HT for LPP and FFA is feasible but results may be less favorable compared to HT for other causes. Outcomes may be more favorable for LPP than FFA but this was not statistically significant and evidence is very limited. FFA and LPP can also develop following HT in patients without previous evidence of disease.
Level of Evidence: NA Laryngoscope, 131:59–66, 2021

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Treatment of Vestibular Migraine: A Systematic Review and Meta‐analysis

Young Jae Byun, Dylan A. Levy, Shaun A. Nguyen, Emily Brennan, Habib G. Rizk

Publication date 14-12-2020


Objective To assess the efficacy of the various therapies used for the prevention of vestibular migraine (VM).
Methods Primary studies were identified though Pub Med, Scopus, PsycINFO, and Cochrane Library by two independent investigators for articles published through April 2019. The search identified randomized comparison or observational studies pertaining to vestibular migraine treatment. Meta‐analysis was performed on pre‐ and posttreatment Dizziness Handicap Inventory, vertigo frequency, and percentage of perceived improvement.
Results Literature search identified 13 studies that reported sufficient outcome measures to be included in the analysis. Patients with VM had a mean age of 43.3 years with female‐to‐male gender ratio of 2.1:1. Classes of therapeutic agents included antiepileptic drugs, calcium channel blockers, tricyclic antidepressants, β‐blockers, serotonin and norepinephrine reuptake inhibitors, and vestibular rehabilitation. All treatment options that were analyzed demonstrated improvement in all of the outcome parameters, but due to significant heterogeneity and lack of standardized reporting on outcomes, establishment of preferred treatment modality could not be determined.
Conclusions Various treatment modalities have been evaluated for preventative treatment of VM. Physician familiarity, patient comorbidities, and the side‐effect profiles of various interventions likely influence the selection of intervention. Future randomized controlled trials with restrictive inclusion criteria and generalizable standardized outcome measures will allow for more robust meta‐analyses and for more evidence‐based treatment of vestibular migraines. Laryngoscope, 131:186–194, 2021

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Efficient Postoperative Disposition Selection in Pediatric Otolaryngology Patients: A Novel Approach

Jennifer M. Lavin, Amod Sawardekar, Lisa Sohn, Roderick C. Jones, Laurely Fusilero, Mary E. Iafelice, Laura Molenda

Publication date 14-12-2020


Objective Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate‐risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals.
Study Design Quality improvement initiative.
Methods Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level‐of‐care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2–5 hours in the post‐anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU.
Results In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability.
Conclusions Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate‐risk patients. This was achieved without compromising safety of patient care, and was financially sound in both fee‐for‐service and value‐based reimbursement models. While such a model may not be applicable in all healthcare settings, it may improve efficiency at other pediatric hospitals with high surgical volume and acuity.
Level of EvidenceN/A Laryngoscope, 131:S1–S10, 2021

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Table of contents

Publication date 14-12-2020


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Masthead

Publication date 14-12-2020


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Transoral Robotic Surgery (TORS) Versus Non‐TORS Tongue Resection for Obstructive Sleep Apnea

Jeehong Kim, Barish Poole, Steven Yong Cen, Nerses Sanossian, Eric James Kezirian

Publication date 14-12-2020


Objective To compare transoral robotic surgery (TORS) versus non‐TORS tongue resection procedures performed for obstructive sleep apnea from January 2010 to September 2015 using a national database, focusing on patient characteristics, performance of concurrent procedures, operative time, length of hospital stay, and postoperative complications.
MethodsA cohort of adults undergoing TORS and non‐TORS tongue resection procedures was identified in the Nationwide Inpatient Sample, a publicly‐available national administrative database incorporating a stratified sample of hospital discharge records. Outcomes were annual case volumes, prolonged (≥3 days) hospital stay, and complications. Statistical analyses examined potential associations between TORS and prolonged hospital stay and complications.
Results From 2010 to 2015, 5709 hospital discharges included tongue resection surgery to treat obstructive sleep apnea. There was a gradual decline and stabilization in overall volumes, with the proportion of TORS use showing an initial increase, followed by a decrease and rebound increase. TORS patients were less likely to undergo concurrent nasal surgery (15% vs. 44%, P < .01), but there was no association between the use of TORS and concurrent palatal surgery. TORS use was not associated with concurrent hypopharyngeal surgery overall, but it was associated with specific types of hypopharyngeal surgery. TORS use was associated with patient age, payor, and certain hospital characteristics. TORS use was associated with an increased risk of prolonged hospital stay (33% vs. 25%, P = .045) but was not associated with complications.
Conclusion This study provides insight into TORS use in tongue resection surgery for obstructive sleep apnea during this period of early TORS adoption.
Level of Evidence Level 3 (cohort study). Laryngoscope, 2020

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Standardized Order Set Exhibits Surgeon Adherence to Pain Protocol in Pediatric Adenotonsillectomy

Abbey Studer, Kathleen Billings, Dana Thompson, Jonathan Ida, Jeff Rastatter, Manisha Patel, Patricia Huetteman, Erin Hoeman, Sarah Duggan, Sukhraj Mudahar, Patrick Birmingham, Michael King, Jennifer Lavin

Publication date 14-12-2020


Objectives/Hypothesis To produce a sustained reduction in opioid prescriptions in patients <5 years of age undergoing T&A through utilization of standardized algorithms and electronic health record (EHR) automation tools.
Study Design Prospective quality improvement initiative.
Methods Plan‐do‐study‐act (PDSA) methodology was used to design an age‐based postoperative pain regimen in which children <5 years of age received a non‐opioid pain regimen, and option to prescribe oxycodone for additional pain relief was given for children >5 years of age. Standardized discharge instructions and automated, age‐specific order sets were created to facilitate adherence. Rate of discharge opioid prescription was monitored and balanced against post‐discharge opioid prescriptions and returns to the emergency department (ED).
Results In children <5 years of age undergoing T&A, reduction in opioid prescription rates from 65.9% to 30.9% after initial implementation of the order set was noted. Ultimately, reduction of opioid prescribing rates to 3.7% of patients was noted after pain‐regimen consensus and EHR order set implementation. Opioid prescriptions in patients >5 years of age decreased from 90.6% to 58.1% initially, and then down 35.9% by the last time point analyzed. Requests for outpatient opioid prescriptions did not increase. There was no significant change in returns to the emergency ED for pain management, or in the number opioids prescribed when patients returned to the ED.
Conclusions Iterative cycles of improvement utilizing standardized pain management algorithms and EHR tools were effective means of producing a sustained reduction in opioid prescriptions in postoperative T&A patients. Such findings suggest a framework for similar interventions in other pediatric otolaryngology settings.
Level of Evidence4 Laryngoscope, 2020

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Prognostic Significance of Pain in Parotid Gland Malignancy

Sophia Colevas, James Thompson, Tiffany Glazer, Gregory Hartig

Publication date 12-12-2020


Objectives/Hypothesis To better understand the significance of pain as a predictor of disease severity in parotid gland malignancy.
Study DesignA retrospective chart review of patients treated for primary parotid gland malignancy at our institution between 1991 and 2020 was performed.
Methods Patient records were retrospectively reviewed and relevant clinical parameters were collected. Patients were stratified into low stage (I and II) disease and high stage (III and IV) disease groups to analyze the independent effect of pain at initial presentation on disease recurrence rate and disease‐free survival using Kaplan–Meier survival curves and an independent two‐sample t‐test.
Results Of 154 patients evaluated, there were 69 patients in the low stage group and 80 patients in the high stage group. Thirty‐seven high stage patients presented with pain. High stage patients with pain were significantly more likely to develop disease recurrence than high stage patients without pain (58.5% 22/37 versus 33.3% 13/39, P = .022). High stage patients with pain also had significantly decreased disease‐free survival time compared to high stage patients without pain (P = .027).
Conclusion Pain on presentation appears to be a poor prognostic factor for patients with parotid gland malignancy. For patients with demonstrated high stage disease, pain is independently associated with increased risk of recurrence and decreased disease‐free survival time.
Level of Evidence4 Laryngoscope, 2020

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Healthcare Disparities in Laryngology: A Scoping Review

Noah Z. Feit, Zhaorui Wang, Michelle R. Demetres, Sotirios Drenis, Katerina Andreadis, Anaïs Rameau

Publication date 12-12-2020


Objectives/Hypothesis This scoping review aims to map out existing disparities research within the subspecialty of laryngology in order to highlight gaps in knowledge and guide future research.
Study Design Scoping Review.
Methods We completed a scoping review of Pub Med, Ovid Embase, and the Cochrane Library for primary research focused on evaluating the existence and impact of disparities in race/ethnicity, sex/gender, insurance status, education level, income, geography, and LGBTQ identity in the context of various laryngological conditions. Publications of any design and date, performed in the United States, and focusing on the adult population exclusively were included.
Results Of the 4,999 unique abstracts identified, 51 articles were ultimately included. The most frequently examined condition in relation to disparities was laryngeal cancer (27 of 51), followed by voice disorders (15 of 51), deglutitive disorders (eight of 51), and airway disorders (one of 51). Sources of inequity evaluated from most common to least common were race/ethnicity (43 of 51), sex/gender (39 of 51), insurance status (23 of 51), geography (23 of 51), income (21 of 51), and education level (16 of 51). No study examined the association of LGBTQ identity with inequity.
Conclusions This scoping review highlights the limited extent of disparities research in laryngology and establishes the need for further scholarship on the impact of disparities in laryngology care. The pathologies studied were, in decreasing order of frequency: laryngeal cancer, voice disorders, deglutitive disorders, and airway disorders. Race/ethnicity and sex/gender were the most common disparities examined, with no evaluation of LGBTQ‐related care inequity.
Level of EvidenceNA Laryngoscope, 2020

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Expression of ACE2, TMPRSS2, and Furin in Mouse Ear Tissue, and the Implications for SARS‐CoV‐2 Infection

Tsukasa Uranaka, Akinori Kashio, Rumi Ueha, Taku Sato, Han Bing, Gao Ying, Makoto Kinoshita, Kenji Kondo, Tatsuya Yamasoba

Publication date 11-12-2020


Objectives/Hypothesis Intracellular entry of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) depends on the interaction between its spike protein with the cellular receptor angiotensin‐converting enzyme 2 (ACE2) and depends on Furin‐mediated spike protein cleavage and spike protein priming by host cell proteases, including transmembrane protease serine 2 (TMPRSS2). As the expression of ACE2, TMPRSS2, and Furin in the middle and inner ear remain unclear, we analyzed the expression of these proteins in mouse ear tissues.
Study Design Animal Research.
Methods We performed immunohistochemical analysis to examine the distribution of ACE2, TMPRSS2, and Furin in the Eustachian tube, middle ear spaces, and cochlea of mice.
ResultsACE2 was present in the nucleus of the epithelium of the middle ear and Eustachian tube, as well as in some nuclei of the hair cells in the organ of Corti, in the stria vascularis, and the spiral ganglion cells. ACE2 was also expressed in the cytoplasm of the stria vascularis. TMPRSS2 was expressed in both the nucleus and cytoplasm in the middle spaces, with the expression being stronger in the nucleus in the mucosal epithelium of the middle ear spaces and Eustachian tube. TMPRSS2 was present in the cytoplasm in the organ of Corti and stria vascularis and in the nucleus and cytoplasm in the spiral ganglion. Furin was expressed in the cytoplasm in the middle ear spaces, Eustachian tube, and cochlea.
ConclusionsACE2, TMPRSS2, and Furin are diffusely present in the Eustachian tube, middle ear spaces, and cochlea, suggesting that these tissues are susceptible to SARS‐CoV‐2 infection.
Level of EvidenceNA Laryngoscope, 2020

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Effectiveness of Injection Laryngoplasty for Aspiration in Acute Iatrogenic Vocal Fold Paralysis: A Systematic Review

Sabrina Pan, Babak Sadoughi

Publication date 11-12-2020


Objective/Hypothesis To review current evidence on effectiveness of injection laryngoplasty on aspiration outcomes in acute unilateral vocal fold paralysis.
Study Design Systematic review.
MethodsA literature search was performed on MEDLINE, Embase, Scopus, and the Cochrane Library from inception of each database to May 2019. Inclusion criteria included case series, case–control studies, prospective cohort studies, and randomized controlled trials assessing the outcomes of early injection laryngoplasty on aspiration in unilateral vocal fold paralysis, in the acute setting. Only English articles with adult study populations were included. Two independent investigators screened all abstracts and manuscripts. Data on study design, patient demographics, interventions, and outcome measures were systematically extracted by both authors for included studies.
Results Fourteen case series studies comprising 582 patients were included. Results were not quantitatively synthesized due to the heterogeneity of outcome measures. Eleven studies reported that a majority (ranging 50%–100%) of patients in each respective study showed improvement in diet intake (progression from nil per os to oral) or Penetration‐Aspiration Scale (PAS) scores after injection laryngoplasty. However, none of the investigations used a control group, and therefore, did not account for the possibility of improvement of function related to placebo or Hawthorne effects rather than attributed to intervention.
Conclusions No robust evidence was found to support injection laryngoplasty as an effective measure to improve aspiration outcomes in acute iatrogenic vocal fold paralysis. Current practices rely on empirical observations and scarce expert opinions. Further prospective investigations with controlled objective measures are necessary to definitively demonstrate the effectiveness of IL for aspiration management. Laryngoscope, 2020

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Comparison of Autofluorescence With Near‐Infrared Fluorescence Imaging Between Primary and Secondary Hyperparathyroidism

Mika Takeuchi, Takeshi Takahashi, Ryusuke Shodo, Hisayuki Ota, Yushi Ueki, Keisuke Yamazaki, Arata Horii

Publication date 11-12-2020


Objectives To examine the role of autofluorescence (AF) monitoring with near‐infrared fluorescence imaging (NIFI) in identifying parathyroid lesions in primary or secondary hyperparathyroidism (P‐HPT or S‐HPT) surgeries.
Study Design Prospective study.
Methods Twelve lesions each were resected from 12 and 3 patients with P‐HPT and S‐HPT, respectively. The mean and maximum AF intensities of the lesions normalized to that of the thyroid tissue for in situ and ex vivo preparations were compared between P‐HPT and S‐HPT. Subjective visual classifications of AF intensity were compared with postoperative quantitative assessments. The unevenness of AF distribution inside the lesions was assessed by determining the ratio of maximum to mean AF intensity and comparing them with the corresponding ratio for normal parathyroid glands (PGs).
Results In all quantitative comparisons (in situ/ex vivo, mean, and maximum AF), AF intensities of P‐HPT were stronger than those of S‐PHT. The AF‐positive rate in in situ subjective visual classification was higher for P‐HPT (100% vs. 33%). Subjective visual classifications showed a positive correlation with AF intensities. The ratio of maximum to mean AF was higher in P‐HPT and S‐HPT than in normal PGs.
Conclusions For P‐HPT, AF intensity in both in situ and ex vivo preparations was sufficiently high and correlated with the subjective visual classification, suggesting that NIFI may be useful for confirming P‐HPT lesions. In contrast, NIFI may have only a minor role in S‐HPT surgeries owing to the weak‐AF of S‐HPT lesions. HPT lesions show an uneven AF intensity distribution compared with normal PGs.
Level of Evidence3 Laryngoscope, 2020

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National Database Outcomes of Esophageal Dilations

Michael B. Mullen, Michael Andrew Witt, Arnold J. Stromberg, Mark A. Fritz

Publication date 11-12-2020


Objectives/Hypothesis To better assess rates of postoperative complications and mortality following esophageal dilation, and to identify factors associated with adverse outcomes.
Study Design Observational, retrospective cohort study.
Methods We queried a national database of insurance claims for Current Procedural Terminology (CPT) codes representing esophageal dilation performed between 2011 and 2017. Patients aged 18 to 100 who were continuously enrolled with their insurance provider were included. Demographic information, additional CPT codes, concomitant diagnoses, and anticoagulant medication data were collected for all patients included. Postoperative mortality was assessed and International Classification of Diseases (ICD)9/10 codes for complications, including esophageal perforation, hemorrhage, mediastinitis, and sepsis were flagged.
Results We identified 202,965 encounters for esophageal dilation. Of these procedures, 193 were performed on a patient who underwent percutaneous endoscopic gastrostomy (PEG) during the study period and was analyzed separately. Another 244 dilations were excluded due to repeat entries. Of the remaining 202,528 procedures remaining, 42,310 were repeat dilations in the same patient. Data analysis was confined to each patients initial dilation. 160,218 initial dilations remained. Of these, 62,107 were performed on male patients and 98,111 were performed on female patients. The average age was 57.7 years. There were 12 mortalities within 30 days postoperatively, representing 0.0075% of all dilations. Esophageal perforation and esophageal hemorrhage were the most common reported complications, with 139 and 110 occurrences, respectively. The overall per‐dilation complication rate was 0.215%.
Conclusions Evidence from a national insurance claim database suggests that esophageal dilation is a safe procedure with a low rate of serious complications and a 30‐day all‐cause mortality rate of less than 1 per 10,000 dilations.
Level of EvidenceIV Laryngoscope, 2020

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Health Literacy and Hearing Healthcare Use

Emma D. Tran, Yona Vaisbuch, Z. Jason Qian, Matthew B. Fitzgerald, Uchechukwu C. Megwalu

Publication date 11-12-2020


Objective To assess whether health literacy is associated with: 1) degree of hearing loss at initial presentation for audiogram and 2) hearing aid adoption for hearing aid candidates.
Methods We identified 1376 patients who underwent audiometric testing and completed a brief health literacy questionnaire at our institution. The association between health literacy and degree of hearing loss at initial presentation was examined using linear regression, adjusted for age, gender, marital status, education level, race, language, employment status, and insurance coverage. The association between health literacy and hearing aid adoption was examined in the subset of patients identified as hearing aid candidates using logistic regression, adjusted for demographic factors and insurance coverage.
Results Patients with inadequate health literacy were more likely to present with more severe hearing loss (adjusted mean pure‐tone average PTA difference, 5.38 dB, 95% confidence interval CI 2.75 to 8.01). For hearing aid candidates (n = 472 41.6%), health literacy was not associated with hearing aid adoption rate (odds ratio OR 0.85, 95% CI 0.40 to 1.76). Hearing aid coverage through Medicaid (OR 2.22, 95% CI 1.13 to 4.37), and moderate (OR 2.70, 95% CI 1.58 to 4.69) or moderate–severe (OR 2.23, 95% CI 1.19 to 4.16) hearing loss were associated with hearing aid adoption.
Conclusions In our population, patients with low health literacy are more likely to present with higher degrees of hearing loss, but no less likely to obtain hearing aids compared with patients with adequate health literacy. Hearing loss severity and hearing aid coverage by insurance appear to be the main drivers of hearing aid adoption.
Level of Evidence3 Laryngoscope, 2020

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"Otolaryngology Residency Programs Rising Social Media Presence During the COVID‐19 Pandemic"

Khodayar Goshtasbi, Kotaro Tsutsumi, Michael H. Berger, Edward C. Kuan, Tjoson Tjoa, Yarah M. Haidar

Publication date 10-12-2020


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Antibiotic Prescribing for Acute Rhinosinusitis: In‐Person Versus Virtual Visits During Covid‐19

Lauren E. Miller, Neil Bhattacharyya

Publication date 10-12-2020


Objectives/Hypothesis Determine if antibiotic prescribing patterns differ for in‐person versus virtual clinic visits for acute rhinosinusitis (ARS).
Study Design Cross sectional study.
Methods All adult virtual clinical encounters from March to May 2020 with a principal diagnosis of ARS were reviewed for demographic data and the presence or absence of an antibiotic prescription during the coronavirus shut down in Massachusetts. In‐person clinical encounters from March to May 2019 were similarly examined as a control. The rate of antibiotic prescription was compared between virtual (2020) and in‐person (2019) visits for ARS diagnoses.
Results There were 2,075 patients in March to May 2020 and 3,654 patients March to May 2019 who received an ARS principal diagnosis at their virtual and in‐person outpatient visits, respectively. There was a statistically significant lower rate of antibiotic prescriptions for ARS in 2020 (72.1%) versus 2019 (76.7%).
The odds ratio for an antibiotic prescription for ARS was 0.783 (95% confidence interval, 0.693–0.86; P < .001) for patients seen in the 2020 cohort versus the 2019 cohort. The compared rates for antibiotic prescribing for 2020 versus 2019 were not different in individual month‐to‐month comparisons. When stratified by otolaryngology providers there was no statistically significant difference of antibiotic prescriptions between the 2019 and 2020 cohort (P = .781).
Conclusions During the massive transition to virtual visits for March to May 2020 due to the coronavirus pandemic shut down in Massachusetts, the total rate of outpatient antibiotic prescribing for ARS was lower in the virtual visit environment compared to the traditional in‐person visit. In this scenario, telemedicine did not result in an increase in antibiotic prescribing despite the lack of an in‐person physical exam.
Level of EvidenceIV Laryngoscope, 2020

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Rigid Video Laryngoscopy for Intubation in Severe Pierre Robin Sequence: A Retrospective Review

Joseph D. Peterson, Michael D. Puricelli, Ahmed Alkhateeb, Aaron D. Figueroa, Steven L. Fletcher, Richard J. H. Smith, Deborah S. F. Kacmarynski

Publication date 10-12-2020


Objectives/Hypothesis The anatomy of children with severe Pierre Robin sequence can present a challenge for direct laryngoscopy and intubation. Advanced techniques including flexible fiberoptic laryngoscopic intubation have been described but require highly specialized skill and equipment. Rigid video laryngoscopy is more accessible but has not been described in this population.
Study Design Retrospective cohort study.
MethodsA retrospective review was completed at a tertiary care center of all children between January 2016 and March 2020 with Pierre Robin sequence who underwent a mandibular distraction osteogenesis procedure. Intubation events were collected, and a descriptive analysis was performed. A univariate logistic regression model was applied to direct laryngoscopy and flexible fiberoptic laryngoscopy with rigid video laryngoscopy as a reference.
Results Twenty‐five patients were identified with a total of 56 endotracheal events. All patients were successfully intubated. Direct laryngoscopy was successful at first intubation attempt in 47.3% (9/19) of events. Six direct laryngoscopy events required switching to another device. Rigid video laryngoscopy was successful at first intubation attempt in 80.5% (29/36) of events. Two cases required switching to another device. Flexible fiberoptic laryngoscopy was found successful at first intubation attempt in 88.9% (8/9) of events. Direct laryngoscopy was 4 times more likely to fail first intubation attempt when compared to rigid video laryngoscopy (P < .05). There was no significant difference between rigid video laryngoscopy and flexible fiberoptic laryngoscopy for intubation.
Conclusions For children with Pierre Robin sequence rigid video laryngoscopy should be considered as a first attempt intubation device both in the operating room and for emergent situations.
Level of Evidence4 Laryngoscope, 2020

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Suture Knot Externalization Modification of the Fasanella‐Servat Technique for Involutional Ptosis

Ameer Ghodke, Mark M. Mims, William W. Shockley, J. Madison Clark

Publication date 10-12-2020


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Olfactory Dysfunction is not a Determinant Of patient‐Reported Chronic Rhinosinusitis Disease Control

Adam C. McCann, Michal Trope, Victoria L. Walker, Tazheh A. Kavoosi, Marlene M. Speth, Isabelle Gengler, Katie M. Phillips, Ahmad R. Sedaghat

Publication date 10-12-2020


Objectives/Hypothesis As a cardinal symptom of chronic rhinosinusitis (CRS), hyposmia has been recommended to be assessed as a component of CRS disease control. Herein we determine the significance of hyposmia in CRS in the context of nasal obstruction and drainage symptoms.
Study Design Prospective, cross‐sectional Methods Cross‐sectional study of 308 CRS patients (102 CRSwNP, 206 CRSsNP) without prior endoscopic sinus surgery. The burden of nasal obstruction and hyposmia were assessed using the corresponding item scores on the 22‐item Sinonasal Outcome Test (SNOT‐22). Burden of nasal discharge was assessed using the mean of “thick nasal discharge” and “thick post‐nasal discharge” SNOT‐22 item scores. Patients were all asked to rate their CRS symptom control as “not at all,” “a little,” “somewhat,” “very,” or “completely.”Results In CRSwNP, only 4.9% had a hyposmia score > 1 with nasal obstruction and drainage scores less than or equal to 1. In CRSsNP, only 1.9% had a hyposmia score > 1 with nasal obstruction and drainage scores less than or equal to 1. On univariate association, CRS symptom control was significantly associated with nasal obstruction, hyposmia, and drainage in both CRSwNP and CRSsNP (P < .05 in all cases). Using multivariable regression to account for all nasal symptoms, only nasal obstruction and nasal discharge scores (but not hyposmia) were significantly associated with CRS symptom control.
Conclusions Hyposmia rarely occurs without nasal obstruction or nasal drainage, and may therefore be redundant to assess for CRS disease control. Moreover, hyposmia was not associated with patient‐reported CRS symptom control when accounting for the burden of nasal obstruction and drainage.
Level of Evidence3 Laryngoscope, 2020

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Absent Posterior Belly of Digastric Muscle

Sonia N. Yuen, Isabelle Gengler, Arvind K. Badhey, Alice L. Tang, Chad Zender

Publication date 10-12-2020


Objective Report a unique case of absent posterior belly of digastric muscle, with a literature review and discussion of its clinical importance.
Methods Present a case report and review the current literature including PUBMED search terms; “absent posterior digastric”, “digastric muscle”, “posterior belly”.
Results While there were multiple reports of accessory anterior and posterior bellies and absence of anterior belly, there is a paucity of literature on absence of posterior belly of digastric muscle.
Conclusion To our knowledge, this is the first report of an absent posterior belly of the digastric muscle. The posterior belly of the digastric muscle is an important landmark in neck dissection, and its absence makes knowledge of other anatomic landmarks critically important. Laryngoscope, 2020

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MRI Texture Features are Associated with Vestibular Schwannoma Histology

Nicholas A. George‐Jones, Rati Chkheidze, Samantha Moore, Jing Wang, Jacob B. Hunter

Publication date 10-12-2020


Objectives/Hypothesis To determine if commonly used radiomics features have an association with histological findings in vestibular schwannomas (VS).
Study Design Retrospective case‐series.
Methods Patients were selected from an internal database of those who had a gadolinium‐enhanced T1‐weighted MRI scan captured prior to surgical resection of VS. Texture features from the presurgical magnetic resonance image (MRI) were extracted, and pathologists examined the resected tumors to assess for the presence of mucin, lymphocytes, necrosis, and hemosiderin and used a validated computational tool to determine cellularity. Sensitivity, specificity, and positive likelihood ratios were also computed for selected features using the Youden index to determine the optimal cut‐off value.
ResultsA total of 45 patients were included. We found significant associations between multiple MRI texture features and the presence of mucin, lymphocytes, hemosiderin, and cellularity. No significant associations between MRI texture features and necrosis were identified. We were able to identify significant positive likelihood ratios using Youden index cut‐off values for mucin (2.3; 95% CI 1.2–4.3), hemosiderin (1.5; 95% CI 1.04–2.1), lymphocytes (3.8; 95% CI 1.2–11.7), and necrosis (1.5; 95% CI 1.1–2.2).
ConclusionsMRI texture features are associated with underlying histology in VS.
Level of Evidence3 Laryngoscope, 2020

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Do Patients With Dementia Benefit From Cochlear Implantation?

Nabil F. Darwich, Tiffany P. Hwa, Michael J. Ruckenstein

Publication date 09-12-2020


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Hearing Status and Aural Rehabilitative Profile of 878 Patients With Sporadic Vestibular Schwannoma

Robert J. Macielak, John P. Marinelli, Samuel A. Spear, Debbie L. Hahs‐Vaughn, Michael J. Link, Chad Nye, Matthew L. Carlson

Publication date 09-12-2020


Objectives/Hypothesis To examine the hearing status and aural rehabilitative profile in a national cohort of patients with sporadic vestibular schwannoma (VS).
Study Design Cross‐sectional survey MethodsA cross‐sectional survey of Acoustic Neuroma Association members diagnosed with sporadic VS was performed from February 2017 through January 2019. Self‐reported results were used to determine the aural rehabilitative profile of respondents.
Results Among survey respondents, 62.2% (546/878) were not using any hearing‐assistive device at time of survey. For the 37.8% (332/878) that were utilizing hearing‐assistive devices, 32.8% (109/332) reported using a behind‐the‐ear hearing aid, 23.8% (79/332) used a contralateral routing of signal (CROS) hearing aid, and 21.7% (72/332) used a bone conduction device. Notably, 41.9% (278/663) of patients who previously underwent tumor treatment reported utilizing a hearing rehabilitation device at some point during VS management compared to 27.0% (58/215) of those undergoing observation with serial imaging (P < .001). Of 275 patients with functional hearing in the ipsilateral ear, 26.5% (73/275) reported having used at least one type of hearing device; 24.0% (66/275) reported use of a conventional hearing aid, 0.7% (2/275) a CROS aid, and 0.4% (1/275) a bone conduction device. Among respondents reporting ipsilateral nonfunctional hearing, 44.9% (258/575) reported having used at least one type of hearing device; 13.0% (75/575) a CROS aid, and 12.3% (71/575) a bone conduction device.
Conclusions Even among a cohort with presumably elevated literacy surrounding hearing rehabilitation options, few patients with a history of unilateral vestibular schwannoma ultimately use hearing assistive devices long‐term, suggesting that most patients sufficiently adjust to unilateral hearing loss or are unsatisfied with the benefits achieved with current device options.
Level of EvidenceIV Laryngoscope, 2020

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Hypoglossal Nerve Stimulation: Outcomes in Veterans with Obstructive Sleep Apnea and Common Comorbid Post‐traumatic Stress Disorder

Reena Dhanda Patil, Kathleen M. Sarber, Madison V. Epperson, Meredith Tabangin, Mekibib Altaye, Franklin Mesa, Stacey L. Ishman

Publication date 09-12-2020


Objectives/Hypothesis Veterans have an increasing prevalence of obstructive sleep apnea (OSA) and high levels of intolerance to positive airway pressure (PAP). The hypoglossal nerve stimulator (HNS) is a promising alternative surgical treatment for OSA in these patients, many of whom suffer from mental health conditions such as post‐traumatic stress disorder (PTSD) that may negatively affect their ability to use PAP.
Our aims were: 1) to assess postoperative changes in OSA severity and sleepiness in a veteran only population after HNS; 2) to compare postoperative changes in OSA severity, sleepiness and HNS adherence between veterans with and without PTSD; and 3) to compare HNS adherence in our population to HNS adherence in the current literature as well as published PAP adherence data.
Study Design Retrospective and prospective case series.
Methods Clinical data on consecutive patients undergoing HNS in a Veterans Affairs hospital were examined for demographic data as well as medical, sleep, and mental health comorbidities. The overall cohort as well as subsets of patients with and without PTSD were examined for postoperative changes in OSA severity (apnea hypopnea index AHI, lowest oxygen saturation (LSAT), and sleepiness (Epworth sleepiness scale ESS), as well as for device adherence. PTSD and depression symptomatology were measured using the PTSD Checklist 5 (PCL‐5) and Patient Health Questionnaire 9 (PHQ‐9).
Results Forty‐six veterans were included. Forty‐four patients were male (95.6%), 45 were white (97.8%), and the mean age was 61.3 years. Twenty‐six patients met PCL‐5 criteria for PTSD and 17 did not. OSA severity and sleepiness improved significantly in the overall cohort after HNS; median (IQR) AHI decreased from 39.2 (24.0, 63.0) to 7.4 (1.2, 20.8) events/hour (P < .0001), mean LSAT increased from 81% to 88% (P < .0001) and mean ESS decreased from 10.9 to 6.7 (P < .0001). These improvements were similar between patients with and without PTSD (P = .434–.918). Overall device adherence was 6.1 hours/night for the overall cohort and was not significantly different between patients with and without PTSD (P = .992).
ConclusionsHNS is an efficacious therapy in a veteran population, providing patients with significant improvements in OSA severity and sleepiness. Veterans with and without PTSD benefited similarly from HNS when comparing improvements in sleep apnea severity and sleepiness as well as device usage. Adherence was similar to previously published HNS adherence data and better than PAP adherence reported in the literature.
Level of Evidence4 Laryngoscope, 2020

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"In Reference to Is Expecting the Emergency Department to Adhere to AAO‐HNS Bells Palsy Guidelines Unrealistic?"

Sina J. Torabi, David A. Kasle, Douglas Hildrew

Publication date 07-12-2020


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Prevalence of Olfactory Dysfunction in Coronavirus Disease 2019 (COVID‐19): A Meta‐analysis of 27,492 Patients

Jeyasakthy Saniasiaya, Md Asiful Islam, Baharudin Abdullah

Publication date 05-12-2020


Objectives/Hypothesis Olfactory dysfunction has been observed as one of the clinical manifestations in COVID‐19 patients. We aimed to conduct a systematic review and meta‐analysis to estimate the overall pooled prevalence of olfactory dysfunction in COVID‐19 patients.
Study Design Systematic review and meta‐analyses.
Methods Pub Med, Scopus, Web of Science, Embase, and Google Scholar databases were searched to identify studies published between 1 December 2019 and 23 July 2020. We used random‐effects model to estimate the pooled prevalence with 95% confidence intervals (CIs). Heterogeneity was assessed using the I 2 statistic and Cochrans Q test. Robustness of the pooled estimates was checked by different subgroup and sensitivity analyses This study is registered with PROSPERO (CRD42020183768).
Results We identified 1162 studies, of which 83 studies (n = 27492, 61.4% female) were included in the meta‐analysis. Overall, the pooled prevalence of olfactory dysfunction in COVID‐19 patients was 47.85% 95% CI: 41.20–54.50. We observed olfactory dysfunction in 54.40% European, 51.11% North American, 31.39% Asian, and 10.71% Australian COVID‐19 patients. Anosmia, hyposmia, and dysosmia were observed in 35.39%, 36.15%, and 2.53% of the patients, respectively. There were discrepancies in the results of studies with objective (higher prevalence) versus subjective (lower prevalence) evaluations. The discrepancy might be due to false‐negative reporting observed in self‐reported health measures.
Conclusions The prevalence of olfactory dysfunction in COVID‐19 patients was found to be 47.85% based on high‐quality evidence. Due to the subjective measures of most studies pooled in the analysis, further studies with objective measures are advocated to confirm the finding.
Level of Evidence2 Laryngoscope, 2020

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Reduced Asthma Medication Use after Treatment of Pediatric Paradoxical Vocal Fold Motion Disorder

Ryan Ivancic, Laura Matrka, Gregory Wiet, Amy Puckett, Jennifer Haney, Brad deSilva

Publication date 04-12-2020


Objectives/Hypotheses The primary objective of this study was to determine whether the diagnosis and treatment of pediatric Paradoxical Vocal Fold Motion Disorder (PVFMD) leads to decreased asthma medication use. Our secondary objective was to determine dyspnea outcomes following diagnosis and treatment for PVFMD.
Study Design Prospective observational study.
Methods Patients with newly diagnosed PVFMD between the ages of 11 and 17 were recruited at a single pediatric institution. A medication questionnaire and Dyspnea Index (DI) were completed at the initial visit, at the first return visit, and at greater than 6 months post‐diagnosis and therapy. Laryngeal Control Therapy (LCT) consisted of teaching breathing techniques and identifying emotional, physical, and environmental contributing factors and strategies to reduce them.
Results Twenty‐six patients were recruited to the study. There were 19/26 (73%) patients diagnosed with asthma prior to a diagnosis of PVFMD, and 26/26 (100%) patients were using an inhaler prior to the enrollment visit. Twenty‐two (85%) patients completed follow‐up questionnaires. Five patients participated in no therapy, seven patients in partial therapy, and 14 patients in full therapy. Significant reduction in asthma medication use was seen in the full therapy group (P < .05) and in those with exercise as their only trigger (P < .05). Furthermore, symptoms as scored by the DI decreased overall from 25.5 to 18.8 (P < .001).
Conclusions Diagnosis and treatment of pediatric PVFMD leads to a decline in asthma medication use in those patients who participate in at least two LCT sessions and in those with exercise‐induced PVFMD. LCT for pediatric PVFMD leads to a significant decrease in symptoms as measured by the DI.
Level of Evidence4 Laryngoscope, 2020

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Factors Related to Extralaryngeal Spread in Juvenile Recurrent Respiratory Papillomatosis

Geraldine Labedz, María Laura Scatolini, Silvina Ruvinsky, Hugo Anibal Rodriguez

Publication date 04-12-2020


Objectives/Hypothesis To identify factors associated to increased risk of extra‐laryngeal spread in pediatric patients with recurrent respiratory papillomatosis (RRP).
Study Design Retrospective chart review.
MethodsA retrospective study was conducted evaluating the clinical charts of patients younger than 16 years with histopathologically confirmed RRP treated between January 2014 and December 2018. Characteristics of patients with and without extra‐laryngeal disease dissemination were compared. Odds ratios were calculated and multivariate logistic regression analysis was performed.
Results Data from 82 patients were analyzed. Mean age at symptom onset was 42 months. Fifteen (18.29%) patients had extra‐laryngeal spread (ELS) at time of diagnosis and in four, the disease continued to spread to other sites. Of 67 patients with disease restricted to the larynx, 17 (25.37%) developed ELS during the disease course. Human papilloma virus (HPV) typing was performed in 49 (59.8%) patients; in 28 (57.1%) HPV subtype 6 was identified and in 21 (42.9%) HPV subtype 11. ELS was found in 11 patients with serotype 11 (52.38%) and in seven patients with serotype 6 (25%) (P = .048). Statistically significant differences for ELS were also found for age at diagnosis younger than 5 years (P = .045), presence of tracheostomy (P = .031), and need for adjuvant therapy (P = .010).
Conclusions Age at diagnosis of RRP younger than 5 years and presence of tracheostomy were factors related to ELS. A statistically significant association between infection with HPV subtype 11 and ELS were also observed. Adjuvant medication might be considered a protective factor against ELS. Laryngoscope, 2020

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Laryngeal Pathologies Associated with the Genre of Singing and Professional Singing Status in a Treatment‐Seeking Population

Janine Rotsides, Sophia Chen, Arianna Winchester, Milan R. Amin, Aaron M. Johnson

Publication date 03-12-2020


Objectives/Hypothesis Singers have high vocal demands and are at increased risk of developing voice disorders. Different singing genres place different technical demands on the voice. However, differences in laryngeal pathology based on genre have not been well‐researched. The purpose of this study was to determine the prevalence of laryngeal pathology in different genres of professional and amateur singers who present with a voice complaint.
Study Design Retrospective review.
Methods Retrospective review of patients seen at a tertiary laryngology practice. Self‐identified singers who reported their primary singing genre and categorized their singing as a full‐time job, part‐time job, or amateur involvement were included. Type and prevalence of pathology were calculated based on genre and professional status.
Results Of the 302 self‐identified singers, 54% (n = 164) had laryngeal pathology. Among those with pathology, the most common finding was fibrotic lesion (38.4%, 63/164). Genres in which a majority of singers had pathology were other (69.2%, 9/13), choral (64.7%, 11/17), pop (63.2%, 12/19), musical theater (61.4%, 43/70), country (100%, 4/4), and Latin (100%, 2/2). The highest prevalence of pathology was seen in part‐time professional singers (62.2%, 41/66) and full‐time professionals (60.8%, 62/102), compared to amateurs (45.1%, 60/133).
Conclusions Laryngeal pathology is prevalent in singers presenting with a voice complaint. Regardless of genre or professional status, fibrotic lesions were the most common pathological finding. This study provides preliminary data on the prevalence of different laryngeal pathologies found in singers by genre and degree of professional involvement.
Level of Evidence4 Laryngoscope, 2020

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Perceptual Voice and Speech Analysis after Supraglottic Laryngeal Closure for Chronic Aspiration in Head and Neck Cancer

Peter K. M. Ku, Alexander C. Vlantis, Zenon W. C. Yeung, Osan Y. M. Ho, Ryan H. W. Cho, Alex K. F. Lee, Thomas S. C. Hui, Erin P. L. So, Thomas K. T. Law, Victor Abdullah, Andrew Hasselt, Michael C. F. Tong

Publication date 02-12-2020


Objectives/Hypothesis To evaluate the voice and speech outcomes after tubed supraglottic laryngeal closure (TSLC) surgery to treat chronic aspiration after radiotherapy for head and neck cancer.
Study DesignA retrospective case‐control study.
Methods The data of patients who underwent radiotherapy for head and neck cancer and who later required total laryngectomy or TSLC for chronic aspiration between 2004 and 2017 were retrieved from a dysphagia clinic. Preoperative and postoperative voice and speech were assessed by the GRBAS and INFVo rating scales. Control subjects who underwent radiotherapy alone or total laryngectomy with a tracheoesophageal prosthesis for other indications were recruited for comparison.
Results Of 15 patients who underwent a TSLC with a mean age of 57.3 years (45–75 years), 13 were male and 2 female. All patients had a history of nasopharyngeal carcinoma. The success rate of speech production using their own larynx following an intact TSLC was 64%. There was no statistically significant difference in voice and speech ratings between preoperative and TSLC subjects on the GRBAS (P = .32) and INFVo scales (P = .57), although the quality of voice appeared to deteriorate after TSLC. However, the INFVo scale for impression, intelligibility and unsteadiness of the voice after TSLC was statistically significantly better than for laryngectomy with tracheoesophageal speech.
ConclusionsA tubed supraglottic laryngeal closure controls chronic aspiration while preserving the larynx for phonation, and results in a better voice and speech quality than a laryngectomy with a voice prosthesis.
Level of Evidence4 Laryngoscope, 2020

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Survival of Young Versus Old Patients With Oral Cavity Squamous Cell Carcinoma: A Meta‐Analysis

David S. Lee, Ricardo J. Ramirez, Jake J. Lee, Carla V. Valenzuela, Jose P. Zevallos, Angela L. Mazul, Sidharth V. Puram, Michelle M. Doering, Patrik Pipkorn, Ryan S. Jackson

Publication date 02-12-2020


Objective/Hypothesis To assess whether young patients with oral cavity squamous cell carcinoma (OCSCC) demonstrate worse oncologic outcomes than older patients after definitive therapy.
Study Design Systematic review and meta‐analysis.
MethodsA medical librarian composed a search strategy to identify relevant studies in Medline, Embase, Scopus, and other major databases (Prospero registration number CRD42019127974). Inclusion criteria were adults with histologically diagnosed OCSCC that underwent treatment, comparator groups with an age cutoff of 40 years old, and reported survival outcomes. Articles were excluded if they contained patients with oropharyngeal squamous cell carcinoma or patients treated for palliative intent. Overall survival hazard ratios were analyzed with a meta‐analysis.
Results There were 23,382 patients with OCSCC that were treated with definitive therapy from 22 included studies. The pooled cohort contained 2,238 (10%) patients ≤40 years of age. Oral tongue was the most common subsite in both the younger (n = 1,961, 91%) and older (n = 18,047, 88%) cohorts. The majority of OCSCCs were either T1 or T2, representing 859 (80%) malignancies in younger patients and 8,126 (77%) malignancies in older patients. A meta‐analysis of nine studies demonstrated that younger patients did not experience worse survival outcomes than older patients (hazard ratio = 0.97, 95% confidence interval = 0.66–1.41).
Conclusions Young adults with OCSCC experienced similar oncologic outcomes as older patients with OCSCC after definitive treatment. Until compelling evidence demonstrates clinically relevant differences between these two cohorts, their approach to management should be similar. Future studies should consider comorbidities and using age 40 as a standard age cutoff to provide more uniform data moving forward. Laryngoscope, 2020

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Awake Laser Laryngeal Stenosis Surgery

Nicole T. Jiam, Christopher D. Dwyer, Clark A. Rosen

Publication date 02-12-2020


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Redefining Success by Focusing on Failures After Pediatric Hypoglossal Stimulation in Down Syndrome

Phoebe K. Yu, Asitha D. L. Jayawardena, Matthew Stenerson, Margaret B. Pulsifer, Julie A. Grieco, Leonard Abbeduto, Raj C. Dedhia, Ryan J. Soose, Allison Tobey, Nikhila Raol, Stacey L. Ishman, Sally R. Shott, Michael S. Cohen, Brian G. Skotko, Thomas B. Kinane, Donald G. Keamy, Christopher J. Hartnick

Publication date 02-12-2020


Objectives/Hypothesis Patients with Down syndrome have a high incidence of obstructive sleep apnea (OSA) and limited treatment options. Hypoglossal stimulation has shown efficacy but has not yet been approved for pediatric populations. Our objective is to characterize the therapy response of adolescent patients with down syndrome and severe OSA who underwent hypoglossal stimulation.
Study Design Prospective longitudinal trial.
Methods We are conducting a multicenter single‐arm trial of hypoglossal stimulation for adolescent patients with Down syndrome and severe OSA. Interim analysis was performed to compare objective sleep and quality of life outcomes at 12 months postoperatively for the first 20 patients.
Results The mean age was 15.5 and baseline AHI 24.2. Of the 20 patients, two patients (10.0%) had an AHI under 1.5 at 12 months; nine patients of 20 (45.0%) under five; and 15 patients of 20 (75.0%) under 10. The mean decrease in AHI was 15.1 (P < .001). Patients with postoperative AHI over five had an average baseline OSA‐18 survey score of 3.5 with an average improvement of 1.7 (P = .002); in addition, six of these patients had a relative decrease of apneas compared to hypopneas and seven had an improvement in percentage of time with oxygen saturation below 90%.
Conclusions Patients with persistently elevated AHI 12 months after hypoglossal implantation experienced improvement in polysomnographic and quality of life outcomes. These results suggest the need for a closer look at physiologic markers for success beyond reporting AHI as the gold standard.
Level of Evidence4 Laryngoscope, 2020

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Cancellous Tibial Bone Graft for Malunion after Mandibular Reconstruction in Head and Neck Cancer

Chelsea S. Hamill, Christopher M. Maatouk, Kate Clancy, Chad A. Zender, Rod P. Rezaee

Publication date 02-12-2020


Objectives/Hypothesis While nonunion after mandibular reconstruction for head and neck surgery is rare, literature exploring management is scarce. Our primary objective was to determine success rates of tibial bone graft (TBG) in achieving mandibular union. Secondary objectives include determining factors that contribute to failure of TBG.
Study Design Retrospective Chart Review.
Methods Retrospective chart review between January 1, 2008 and December 31, 2018. Patients who underwent a mandibulotomy or mandibulectomy with osteocutaneous free flap reconstruction were identified. Patients who were pursuing dental rehabilitation, subsequently diagnosed with mandibular nonunion and received a cancellous TBG were assessed.
Results The 15 patients meeting inclusion criteria were mostly male (67%), white (87%), and nonsmokers (67%) with a median age of 64 (IQR = 60–73). Successful union occurred in 13 of 18 (72%) TBGs and the majority (63%) had a partial union documented at the time of surgery. Five patients (83%) who initially had a mandibulotomy achieved union compared to 78% of those with osteocutaneous reconstruction (P = 1.0).
Postoperative radiation did not affect rates of union: 80% for both (P = 1.0). Patients with osteoradionecrosis (ORN) achieved union in 67% of cases compared to 75% of cases who did not have ORN (P = .86). There were similar rates of union for those who required perioperative antibiotics for infection and those without infection (67% vs. 75%, P = .86). Dental rehabilitation was achieved in 55% of patients, most commonly dentures.
Conclusions This study shows that TBG can be used to achieve union for patients with malunion after head and neck cancer reconstruction. We show its successful use within the reconstructive algorithm for patients regardless of postoperative radiation for very small defects.
Level of EvidenceIII Laryngoscope, 2020

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Superior Thyroid Cornu Syndrome: A Novel Laryngeal Etiology of Chronic Cough

Jesse L. Schmid, Tabitha L. I. Galloway, Craig A. Bollig

Publication date 02-12-2020


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Obesity as a Possible Risk Factor for Pediatric Sensorineural Hearing Loss

Andrew Bluher, Kosuke Kawai, Alicia Wang, Derek Stiles, Greg Licameli

Publication date 02-12-2020


Objectives/Hypothesis Childhood hearing loss impacts linguistic, academic, social, and psychologic development, and may have lasting implications for future workforce performance. Current evidence for obesity as a pediatric sensorineural hearing loss (SNHL) risk factor is intriguing but equivocal. We hypothesized that obesity is associated with a higher risk of SNHL. We additionally examined whether underweight is associated with a higher risk of SNHL.
Study Design Retrospective database review.
MethodsA single‐institution audiologic database from 2015 to 2020 was queried for audiograms with type‐A tympanograms from children aged 5 to 18 years old. Comorbidities known to be associated with hearing loss were excluded. We then examined both for sub‐clinical (≥15 dB) high‐ or low‐frequency hearing loss, and for clinical (≥21 dB) hearing loss, with the aim of examining the association between obesity and SNHL. Multivariable logistic regression was performed to adjust for age, gender, diabetes mellitus, attention deficit hyperactivity disorder, and autism.
ResultsA total of 3,142 children were included. Obesity was not associated with risk of SNHL (adjusted OR 0.82; 95% CI: 0.60, 1.12). Underweight children had a higher risk of SNHL than normal weight children (adjusted OR 1.78; 95% CI: 1.08, 2.95). Autism was significantly associated with increased risk of sub‐clinical SNHL only (adjusted OR 2.00; 95% CI 1.34, 2.98).
Conclusions No association was found between obesity and pediatric SNHL. Underweight children may represent a higher‐risk population for SNHL. There appears to be an increasing risk of SNHL as children approach adolescence. Further study of systemic risk factors for SNHL is indicated.
Level of Evidence3 Laryngoscope, 2020

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Reconstruction of Anterior Table Frontal Sinus Defects with Pericranial Flap and Titanium Mesh

John R. Craig, Robert H. Deeb

Publication date 01-12-2020


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Lingual Hamartomas: Clinical Characteristics, Diagnostic Evaluation, Treatment, and Outcomes

Yi‐Chun Carol Liu, Michael Shih, M. John Hicks, Matthew S. Sitton

Publication date 01-12-2020


Objectives/Hypothesis To further clinically characterize lingual hamartomas, and to consolidate literature by analyzing clinical presentation, diagnostic evaluation, treatment, and outcomes.
Study Design Retrospective chart review and literature review.
Methods Case series from 1989 to 2020 at a tertiary pediatric center; follow‐up ranging from 2 months to 12 years. Patient demographics, clinical presentations, physical examination findings, surgical pathology, operative methods, pre‐operative imaging, and follow‐up. A review of English‐language literature from 1945 to 2020 was conducted.
Results Seven patients (four male, three female) with nine lingual hamartomas were identified. Average age at surgical excision was 7.9 months (SD 3.5 months, range 3 to 14 months). Follow‐up ranged from 2 months to 12 years, with all patients having no recurrence. Physical examination identified five pedunculated hamartomas and two sessile hamartomas. One patient had a neck CT, one had neck ultrasound, and two had facial MRIs. CT and ultrasounds confirmed presence of cervical thyroid. MRI suggested no muscular invasion for one patient, whereas motion artifact obscured findings for the other patient. Most patients who presented with dysphagia or poor weight gain achieved post‐surgical improvement. The present cases combined with the literature review identified 57 patients with 63 lingual hamartomas.
Conclusions Lingual hamartomas appear as hypovascular pedunculated masses near the foramen cecum. There is no demographic predisposition, and most are identified during infancy. Imaging is not necessary, unless there is concern for lingual thyroid, in which case thyroid ultrasound should be performed. Surgical excision is curative, with dysphagia resolution and low likelihood for recurrence.
Level of Evidence4 Laryngoscope, 2020

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Preserved Cochlear Implant Function After Multiple Electroconvulsive Therapy Treatments

Nicole T. Jiam, Descartes Li, Kurt Kramer, Charles J. Limb

Publication date 30-11-2020


This case report presents the successful use of multiple treatments of electroconvulsive therapy (ECT) in a patient with a cochlear implant (CI). A 60‐year‐old man with a left‐sided CI and bipolar disorder presented with severe depression. A total of 9 separate sessions of unilateral ECT was administered to the contralateral side of the existing CI. We collected subjective, clinical, and audiological assessment of the patient and the CI prior, during, and after ECT therapy. The patient tolerated ECT well and there were no complications. Unilateral ECT was performed contralateral to the CI without any harm to the patient or implant. Laryngoscope, 2020

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Laryngeal Reconstruction Using Tissue‐Engineered Implants in Pigs: A Pilot Study

Sarah Brookes, Lujuan Zhang, Theodore J. Puls, John Kincaid, Sherry Voytik‐Harbin, Stacey Halum

Publication date 28-11-2020


Objective/Hypothesis There are currently no treatments available that restore dynamic laryngeal function after hemilaryngectomy. We have shown that dynamic function can be restored post hemilaryngectomy in a rat model. Here, we report in a first of its kind, proof of concept study that this previously published technique is scalable to a porcine model.
Study Design Animal study.
Methods Muscle and fat biopsies were taken from three Yucatan minipigs. Muscle progenitor cells (MPCs) and adipose stem cells (ASCs) were isolated and cultured for 3 weeks. The minipigs underwent a left laterovertical partial laryngectomy sparing the left arytenoid cartilage and transecting the recurrent laryngeal nerve. Each layer was replaced with a tissue‐engineered implant: 1) an acellular mucosal layer composed of densified Type I oligomeric collagen, 2) a skeletal muscle layer composed of autologous MPCs and aligned oligomeric collagen differentiated and induced to express motor endplates (MEE), and 3) a cartilage layer composed of autologous ASCs and densified oligomeric collagen differentiated to cartilage. Healing was monitored at 2 and 4 weeks post‐op, and at the 8 week study endpoint.
Results Animals demonstrated appropriate weight gain, no aspiration events, and audible phonation. Video laryngoscopy showed progressive healing with vascularization and re‐epithelialization present at 4 weeks. On histology, there was no immune reaction to the implants and there was complete integration into host tissue with nerve and vascular ingrowth.
Conclusions This pilot study represents a first in which a transmural vertical partial laryngectomy was performed and successfully repaired with a customized, autologous stem cell‐derived multi‐layered tissue‐engineered implant.
Level of EvidenceN/A Laryngoscope, 2020

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Autofluorescence and Indocyanine Green in Thyroid Surgery: A Systematic Review and Meta‐Analysis

Diego Barbieri, Pietro Indelicato, Alessandro Vinciguerra, Federico Marco, Anna Maria Formenti, Matteo Trimarchi, Mario Bussi

Publication date 28-11-2020


Objectives/Hypothesis To estimate the impact of optical techniques on prevention of post‐operative hypocalcemia and hypoparathyroidism after total thyroidectomy.
Study Design Systematic review and meta‐analysis.
MethodsA literature search was conducted in Pubmed, EMBASE, SCOPUS, and Cochrane databases. The main inclusion criteria for eligible articles for meta‐analysis were patients with benign or malignant thyroid pathologies who underwent total thyroidectomy, utilization of optical techniques to support PGs preservation, the availability of calcium and/or PTH levels. The primary outcome was to evaluate the variation of calcium and PTH levels when adopting optical technologies compared to standard naked‐eye surgery.
Results In total, 13 papers with 1484 procedures were included. Pooled proportion for short‐ and medium‐term hypocalcemia rates were 8% (95% CI, 5%:11%) and 1% (95% CI, 0%:4%) for optical techniques, while for naked‐eye surgery were 15% (95% CI, 9%:23%) and 5% (95% CI, 2%:9%), respectively.
Conclusions Optical technologies reduced short and medium term hypocalcemia compared to conventional surgery.
Level of EvidenceNA Laryngoscope, 2020

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Reduced Tearing With Stable Quality of Life After Vidian Neurectomy: A Prospective Controlled Trial

Eric W. Wang, Paul A. Gardner, Shannon Fraser, S. Tonya Stefko, Juan C. Fernandez‐Miranda, Carl H. Snyderman

Publication date 28-11-2020


Objectives/Hypothesis Although vidian neurectomy (VN) is associated with decreased lacrimation, its impact on dry eye quality‐of‐life is not well‐defined. Endoscopic endonasal transpterygoid approaches (EETA) may require vidian nerve sacrifice.
Study DesignA prospective cohort trial.
MethodsA prospective trial evaluating VN during EETA on lacrimation by phenol red thread testing and dry eye severity by the five‐item Dry Eye Questionnaire (DEQ‐5) was performed. Preservation of the contralateral vidian nerve allowed comparison between the eye subjected to VN and the control eye postoperatively.
Results Twenty‐one subjects were enrolled with no preoperative difference in lacrimation between eyes (P = .617) and overall mild dry eye severity. Although the control eye had no difference in lacrimation pre‐ and postoperatively, decreased tearing was noted in the VN eye at 1 month (20.8 mm vs. 15.8 mm, P = .015) and at 3 months (23.2 mm vs. 15.8 mm, P = .0051) postoperatively. Overall, no difference was noted in the DEQ‐5 score for dry eye severity between the pre‐ and postoperative measures. However, six patients were noted to have moderate to severe dry eye severity postoperatively and five of these six had decreased lacrimation (<20 mm) preoperatively. Patients with decreased tearing preoperatively demonstrated significantly worse postoperative DEQ‐5 scores when compared to patients with normal tearing (P < .0056).
ConclusionsVN during EETA results in decreased tearing but is not associated with increased dry eye severity overall. However, patients with decreased tearing preoperatively are at risk for increased dry eye severity and should be counseled for this risk.
Level of Evidence2 Laryngoscope, 2020

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Early Postoperative Magnetic Resonance in the Diagnosis of Persistent Juvenile Angiofibroma

Alberto Schreiber, Marco Ravanelli, Marco Ferrari, Davide Mattavelli, Vittorio Rampinelli, Andrea Bolzoni Villaret, Giacomo Bertazzoni, Michele Tomasoni, Tommaso Gualtieri, Ivan Zorza, Davide Farina, Roberto Maroldi, Piero Nicolai

Publication date 27-11-2020


Objectives/Hypothesis Despite improvements in the treatment of juvenile angiofibroma (JA), the rate of persistence (pJA) is still not negligible. In the present study, we assessed the value of early postoperative magnetic resonance imaging (MRI) in depicting unintentional pJAs and designed a MRI‐driven decisional flow‐chart for pJA management and follow‐up.
Study Design Observational study.
Methods Patients undergoing early postoperative MRI after endoscopic resection of JA in the Unit of Otorhinolaryngology – ASST Spedali Civili, University of Brescia from 2007 to 2017 were enrolled. MRI was defined as negative or positive based on defined radiological criteria. The diagnostic performance of MRI was evaluated.
Results The analysis included 26 patients, with a mean age of 16.5 years (range, 11–25). Early MRI was negative for pJA in 21 (80.8%) patients and positive in five (19.2%). No patient with a negative finding was found positive at subsequent follow‐up MRIs. The accuracy of a positive finding was confirmed by pathologic examination (three cases) or follow‐up MRIs (two cases). The diagnostic performance of MRI was excellent with sensitivity and specificity of 100%. An MRI‐driven flow‐chart for pJA management and follow‐up was designed.
Conclusions Early postoperative MRI demonstrated a high diagnostic accuracy in the detection of unintentional pJA. Our MRI‐driven strategy and decisional flow‐chart could aid in the decision‐making process in the management of pJA and definition of postoperative surveillance.
Level of evidence4 Laryngoscope, 2020

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Phonation Threshold Pressure/Flow for Reflecting Glottal Closure in Unilateral Vocal Fold Paralysis

Jung Hsuan Jen, Roger W. Chan, Chia‐Hsin Wu, Chi‐Te Wang

Publication date 24-11-2020


Objective Previous theoretical analysis predicted that phonation threshold flow (PTF) could be a more sensitive aerodynamic measure than phonation threshold pressure (PTP) for reflecting glottal incompetence. This study investigated the feasibility of whether PTP and PTF may differentiate subjects with unilateral adductor vocal fold paralysis and paresis (UAVFP) from those without, and whether PTP and PTF could reflect the extent of incomplete glottal closure associated with UAVFP.
MethodsPTP and PTF were quantified for 13 subjects with UAVFP and 21 control subjects with normal voice, and the normalized glottal gap area (NGGA) based on videostroboscopic image analysis was quantified for subjects with UAVFP.
Results Significant differences in both PTP and PTF were found between subjects with UAVFP and control subjects. Receiver operating characteristic analysis indicated a higher discriminatory ability of PTP for differentiating subjects with UAVFP from those without (area under the curve of 0.905 for PTP, 0.678 for PTF), yet a significant positive correlation was found between PTF and NGGA (Spearmans ρ = 0.571) but not between PTP and NGGA (ρ = −0.364).
Conclusion Results supported the feasibility of using PTP and PTF as potential diagnostic indicators for reflecting glottal closure in UAVFP, with PTP potentially more sensitive for differentiating subjects with and without incomplete glottal closure. These preliminary findings were limited by the small sample size, with further studies needed to verify whether PTF could be more sensitive for reflecting the extent of incomplete glottal closure, as predicted theoretically.
Level of Evidence3 Laryngoscope, 2020

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The Effect of Dupilumab on Intractable Chronic Rhinosinusitis with Nasal Polyps in Japan

Shigeharu Fujieda, Shoji Matsune, Sachio Takeno, Mikiya Asako, Makiko Takeuchi, Hiroyuki Fujita, Yoshinori Takahashi, Nikhil Amin, Yamo Deniz, Paul Rowe, Leda Mannent

Publication date 23-11-2020


Objectives/Hypothesis Dupilumab, which blocks the shared receptor component for interleukin‐4 and interleukin‐13, reduced polyp size, sinus opacification, and symptom severity, and was well tolerated in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) in the SINUS‐52 study (NCT02898454). We assessed dupilumab in patients enrolled at Japanese centers.
Methods Patients on a background of mometasone furoate nasal spray, received dupilumab 300 mg every 2 weeks (q2w) for 52 weeks (Arm A); dupilumab 300 mg q2w for 24 weeks, followed by every 4 weeks (q4w) for 28 weeks (Arm B); or placebo (Arm C). Co‐primary endpoints were week 24 nasal polyp score (NPS), nasal congestion (NC) score, and sinus Lund–Mackay CT (LMK‐CT) scores. Symptoms, sense of smell, health‐related quality of life, and safety were assessed during the 52‐week treatment period.
Results Of 49 patients enrolled in Japan, 45 completed the study. Week 24 least squares (LS) mean improvement versus placebo were as follows: NPS (Arm A: −3.1, P < .0001; Arm B: −2.1, P = .0011); NC score (Arm A: −1.2, P < .0001; Arm B: −0.9, P < .0001); and LMK‐CT (Arm A: −5.1, P = .0005; Arm B: −2.8, P = .0425). The most common treatment‐emergent adverse event in dupilumab and placebo‐treated patients was nasopharyngitis.
Conclusion Dupilumab provided rapid, significant, and clinically meaningful improvements for patients with CRSwNP in Japan. Dupilumab was well tolerated, and safety and efficacy were consistent with the overall study population.
Level of Evidence2. Laryngoscope, 2020

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"Crumleys Classification of Laryngeal Synkinesis: A Comparison of Laryngoscopy and Electromyography"

Gerhard Foerster, Rosa Podema, Orlando Guntinas‐Lichius, Roger L. Crumley, Andreas H. Mueller

Publication date 21-11-2020


Objectives/Hypothesis Applying the principles of misdirected nerve regeneration to the larynx, Roger Crumley in 1989 coined the term laryngeal synkinesis (LS) which he later (2000) classified into 4 types (type I – good voice, type II – involuntary twitches and poor voice, type III – adduction during inspiration, type IV – abduction during phonation). Neurophysiological data were not available for all LS patients at that time. The current study was undertaken to utilize and test the Crumley classification for a clinical interrater comparison and, secondly, compare predicted with actual laryngeal electromyography (LEMG) results.
Study Design Descriptive study Methods Laryngoscopic and LEMG data of patients with unilateral vocal fold paralysis (VFP) of 6 months duration or longer were combined for retrospective evaluation. Forty‐five data sets were available for laryngoscopic classification by two local laryngologists and by Roger Crumley. Twenty‐three data sets with complete thyroarytenoid (TA) and posterior cricoarytenoid (PCA) – EMG data were used to compare predicted with actual LEMG results.
Results Local laryngologists were able to classify 24 of 45, Crumley 30 of 45 cases into one of the 4 synkinesis types. There was substantial agreement between examiners (Cohens Kappa 0.66 P < .001). Comparison of predicted and actual LEMG data showed only moderate agreement. EMG sykinesis rates were lower in TA than in PCA and highest in Crumley type I cases.
Conclusion The Crumley classification is helpful in describing and understanding synkinesis. It does not always correlate predictably with actual LEMG data. A complete LEMG mapping of all intrinsic muscles may improve understanding of chronic VFP.
Level of Evidence4. Laryngoscope, 2020

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Deep Learning for Voice Gender Identification: Proof‐of‐concept for Gender‐Affirming Voice Care

Yael Bensoussan, Jeremy Pinto, Matthew Crowson, Patrick R. Walden, Frank Rudzicz, Michael Johns

Publication date 21-11-2020


Objectives/Hypothesis The need for gender‐affirming voice care has been increasing in the transgender population in the last decade. Currently, objective treatment outcome measurements are lacking to assess the success of these interventions. This study uses neural network models to predict binary gender from short audio samples of “male” and “female” voices. This preliminary work is a proof‐of‐concept for further work to develop an AI‐assisted treatment outcome measure for gender‐affirming voice care.
Study Design Retrospective cohort study.
Methods Two hundred seventy‐eight voices from male and female speakers from the Perceptual Voice Qualities Database were used to train a deep neural network to classify voices as male or female. Each audio sample was mapped to the frequency domain using Mel spectrograms. To optimize model performance, we performed 10‐fold cross validation of the entire dataset. The dataset was split into 80% training, 10% validation, and 10% test.
Results Overall accuracy of 92% was obtained, both when considering the accuracy per spectrum and per patient metric. The accuracy of the model was higher for recognizing female voices (F1 score of 0.94) compared to male voices (F1 score of 0.87).
Conclusions This proof of concept study shows promising performance for further development of an AI‐assisted tool to provide objective treatment outcome measurements for gender affirming voice care.
Level of evidence3 Laryngoscope, 2020

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Opioid Usage and Prescribing Predictors Following Transoral Robotic Surgery for Oropharyngeal Cancer

Nicholas B. Abt, Andrew J. Holcomb, Allen L. Feng, Krish Suresh, Tara E. Mokhtari, Christopher I. McHugh, Anuraag S. Parikh, Daniel L. Faden, Daniel G. Deschler, Mark A. Varvares, Derrick T. Lin, Jeremy D. Richmon

Publication date 19-11-2020


Objective/Hypothesis Pain management following transoral robotic surgery (TORS) varies widely. We aim to quantify opioid usage following TORS for oropharyngeal squamous cell carcinoma (OPSCC) and identify prescribing predictors.
Study Design Retrospective cohort study.
MethodsA consecutive series of 138 patients undergoing TORS for OPSCC were reviewed from 2016 to 2019. Opioid usage (standardized to morphine milligram equivalents MME) was gathered for 12 months post‐surgery via prescribing record cross‐check with the Massachusetts Prescription Awareness Tool.
Results Of 138 OPSCC TORS patients, 92.8% were human papillomavirus (HPV) positive. Adjuvant therapy included radiation (XRT;67.4%) and chemoradiation (cXRT;6.5%). Total MME usage from start of treatment averaged 1395.7 MMEs with 76.4% receiving three prescriptions or less. Categorical analysis showed age <65, male sex, overweight BMI, lower frailty, former smokers, HPV+, higher T stage, and BOT subsite to be associated with increased MMEs. Adjuvant therapy significantly increased MMEs (TORS+XRT:1646.2; TORS+cXRT:2385.0; TORS alone:554.7 P < .001) and 12‐month opioid prescription totals (TORS+XRT:3.2; TORS+cXRT:5.5; TORS alone:1.6 P < .001). Adjuvant therapy increased time to taper (total MME in TORS alone versus TORS+XRT/cXRT: 0 to 3 months:428.2 versus 845.5, 4 to 6 months:46.8 versus 541.8, 7 to 9 months:12.4 versus 178.6, 10 to 12 months:11.0 versus 4.4,P < .001). Positive predictors of opioid prescribing at the 4‐ to 6‐month and 4‐ to 12‐month intervals included adjuvant therapy (odds ratio OR:5.56 and 4.51) and mFI‐5 score ≥3 (OR:36.67 and 31.94). Following TORS at 6‐, 9‐, and 12‐month, 15.7%, 6.6%, and 4.1% were still using opioids.
Conclusions In OPSCC treated with TORS, opioid use tapers faster for surgery alone versus with adjuvant therapy. Opioid prescribing risks include adjuvant therapy and higher frailty index.
Level of Evidence4 Laryngoscope, 2020

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SARS‐CoV‐2 Presence in the Saliva, Tears, and Cerumen of COVID‐19 Patients

Fatih M. Hanege, Esra Kocoglu, Mahmut T. Kalcioglu, Serdal Celik, Yasemin Cag, Fehim Esen, Eray Bayindir, Sadrettin Pence, Emine Alp Mese, Canan Agalar

Publication date 19-11-2020


Objectives/Hypothesis The emergence of a new coronavirus strain (SARS‐CoV‐2) in December 2019 from China led to a global pandemic. The lack of herd immunity against this virus and the possibility of viral spread from asymptomatic individuals is still a major challenge for the prevention of viral transmission. The aim of this study was to evaluate the presence of the virus in different bodily secretions as a potential source of viral spread among patients infected with SARS‐CoV‐2.
Study Design Cross Sectional Study.
Methods The study included 38 COVID‐19 patients with a positive real‐time polymerase chain reaction (RT‐PCR) test result for SARS‐CoV‐2, obtained from the combined nasopharyngeal–oropharyngeal swab samples. Saliva, tear, and cerumen samples were taken from the patients within 72 hours of the first RT‐PCR test. SARS‐CoV‐2 N1 and N2 gene regions were studied with single‐step RT‐PCR in all samples.
Results Among the studied samples, the highest positivity rate was in saliva (76.3%) followed by tears (55.3%) and cerumen (39.5%). Viral load in saliva was also significantly higher compared to tears and cerumen (P < .001), while there was no significant difference between tears and cerumen. Higher viral load in combined nasopharyngeal–oropharyngeal swab samples was associated with higher viral load in tears, but not in saliva or cerumen. Half of the saliva, tear, and cerumen samples obtained from asymptomatic patients contained SARS‐CoV‐2 genome.
Conclusions The virus was detected in the saliva, tears, and cerumen samples of both symptomatic and asymptomatic patients. The potential role of these bodily fluids on viral spread needs to be studied.
Level of Evidence4 Laryngoscope, 2020

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Long‐Term Stability and Safety of the Soundbridge Coupled to the Round Window

Georg Mathias Sprinzl, Philipp Schoerg, Stefanie Muck, Max Jesenko, Sophie Speiser, Marlene Ploder, Stefan Herwig Edlinger, Astrid Magele

Publication date 19-11-2020


Objective The objective of the study was to demonstrate the long‐term outcomes of patients implanted with the active middle ear implant (AMEI) Vibrant Soundbridge (VSB) through coupling the floating mass transducer (FMT) to the round window (RW).
Methods This retrospective study evaluated the short‐ and long‐term clinical performance (audiological outcomes) and safety (revisions/explantations) of the VSB coupled to the RW between 2013 and 2019 at the St. Pölten University Hospital, Austria. For the outcome analysis, the sample was divided into a short‐term examination group followed up for less than 12 months (<12 months) and a long‐term examination group followed up for more than 12 months (>12 months). Cumulative survival outcomes were separately analyzed for subjects with and without cholesteatoma.
Results46 patients with an average long‐term follow‐up period of 31.43 months (13–75 months) were investigated. Complications requiring revision surgery were reported in total in seven patients with cholesteatoma (15.2%) and none in subjects without cholesteatoma (0%). Residual hearing was not affected by VSB surgery. Word understanding on the Freiburger monosyllabic speech test improved significantly at 65 dB (P < .0001) and 80 dB (P < .0001), and these outcomes were stable for long‐term follow up.
Conclusion The VSB coupled to the RW is a safe implantation method for patients with conductive or mixed hearing loss. Hearing improvement was stable for the long‐term follow‐up up to 74 months. The revision rates are directly related to the underlying pathology of cholesteatoma (with radical cavity); thus, this special cohort requires additional counseling on potential complications.
Level of Evidence4 (Case‐series) Laryngoscope, 2020

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Parosmia is Associated with Relevant Olfactory Recovery After Olfactory Training

David T. Liu, Maha Sabha, Michael Damm, Carl Philpott, Anna Oleszkiewicz, Antje Hähner, Thomas Hummel

Publication date 19-11-2020


Objective/Hypothesis This study aims to determine the association between parosmia and clinically relevant recovery of olfactory function in patients with post‐infectious olfactory dysfunction (PIOD) receiving olfactory training.
Study Design Retrospective cohort study.
Methods This was a retrospective cohort study of patients with PIOD that received olfactory training. Adult patients with the major complaint of quantitative smell loss were recruited and treated at several ENT clinics in German between 2008 and 2018. The outcome was based on the association between smell‐loss related factors (including parosmia and phantosmia) and clinically relevant changes in overall and subdimension olfactory function of threshold, discrimination, and identification using binary logistic regression analysis.
ResultsA total of 153 participants with PIOD were included. Clinically relevant improvements in overall olfactory function were more likely in those that had lower baseline olfactory function. Relevant improvements in discrimination function were more likely in those that had lower baseline olfactory function and those that had parosmia at the initial visit. Similarly, relevant improvements in odor identification were more likely in those that had a lower baseline olfactory function and in those who had parosmia at the first visit. Clinically significant improvements in odor threshold were more likely in those who were older in age.
Conclusions This study demonstrated that the presence of parosmia is associated with clinically relevant recovery in olfactory discrimination and identification function in patients with PIOD receiving olfactory training.
Level of Evidence4 Laryngoscope, 2020

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Sialographic Analysis of Radioiodine‐Associated Chronic Sialadenitis

Ryan K. Thorpe, Megan J. Foggia, Kathryn S. Marcus, Bruno Policeni, Joan E. Maley, Henry T. Hoffman

Publication date 17-11-2020


Objectives/Hypothesis To apply a novel sialography classification system to identify parotid and submandibular ductal findings following I‐131 therapy and to assess correlates to dose and duration of symptoms.
Study Design Retrospective single‐center case series.
Methods Patients who underwent sialography between February 2008 and February 2019 after previously receiving I‐131 treatment were identified via a retrospective chart review. Their sialograms were systematically evaluated and scored by applying the Iowa parotid sialogram scale to also include submandibular gland analysis.
Results From 337 sialograms, 30 (five submandibular, 25 parotid) underwent analysis. Ductal stenosis was identified in all sialograms and was graded as moderate (>50%–75%) in 7/30 cases and severe (>75%) in 15/30 cases. The distal (main) duct was narrowed in 23/30 cases. No association was identified between degree of ductal stenosis and I‐131 dose (P = .39), age (P = .81), or time from I‐131 therapy to sialogram (P = .97).
Conclusions The Iowa parotid sialogram scale was successfully applied to report abnormalities of the parotid and submandibular ductal system. The most common manifestation of I‐131‐associated sialadenitis was a severe stenosis within the distal salivary duct. No statistically significant association was found between degree of ductal stenosis and dose of I‐131, age, or duration of symptoms.
Level of Evidence4 Laryngoscope, 2020

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Internal Auditory Canal Diverticula in Children: A Congenital Variant

Thomas J. Muelleman, Hannah Kavookjian, Julia Asmar, Kirang Patel, David Nielsen, Kyle Summers, Meghan Tracy, Janelle Noel‐MacDonnell, Hinrich Staecker, Luke Ledbetter, Robert Weatherly

Publication date 17-11-2020


Objectives/Hypothesis Internal auditory diverticula in adults have been found to exist independent of otosclerosis, and in the presence of otosclerosis. We sought to determine the prevalence of internal auditory canal (IAC) diverticula in a pediatric cohort, to assess whether IAC diverticula are a risk factor for hearing loss, and the co‐occurrence of otic capsule hypoattenuation.
Study Design Retrospective review.
MethodsA single‐site retrospective review of high‐resolution temporal bones computed tomography (CT) scans including the presence and size of diverticula and hypoattenuation of the otic capsule. Demographic, imaging, and audiometric data were collected and descriptively analyzed. Bivariate analysis of collected variables was conducted. Comparisons between sides in unilateral cases were also performed.
Results16/600 (2.7%; 95% CI 2.0%, 3.4%) were found to have IAC diverticula. Six were bilateral. Thirty‐one patients (5.2%) were found to have hypoattenuation of the otic capsule. There were no coincident cases of IAC diverticulum and hypoattenuation of the otic capsule. There was no association between the presence of IAC diverticula and age (P = .13). In six patients with unilateral diverticula, pure tone average (P = .42), and word recognition (P = .27) scores were not significantly different when compared to the normal, contralateral side.
Conclusions The prevalence of IAC diverticula in children is lower than the prevalence in adults. IAC diverticula in children likely represent congenital variants of temporal bone anatomy. Similar to adult populations, there is evidence that IAC diverticula in children are likely not an independent risk factor for hearing loss.
Level of Evidence4 Laryngoscope, 2020

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Management of Laryngopharyngeal Reflux Around the World: An International Study

Jerome R. Lechien, Jacqueline E. Allen, Maria R. Barillari, Petros D. Karkos, Huan Jia, Fabio P. Ceccon, Rui Imamura, Osama Metwaly, Carlos M. Chiesa‐Estomba, Jonathan M. Bock, Thomas L. Carroll, Sven Saussez, Lee M. Akst

Publication date 17-11-2020


Objective To investigate worldwide practices of otolaryngologists in the management of laryngopharyngeal reflux (LPR).
Methods An online survey was sent on the management of LPR to members of many otolaryngological societies.
The following aspects were evaluated: LPR definition, prevalence, clinical presentation, diagnosis, and treatment.
ResultsA total of 824 otolaryngologists participated, spread over 65 countries. The symptoms most usually attributed to LPR are cough after lying down/meal, throat clearing and globus sensation while LPR‐related findings are arytenoid erythema and posterior commissure hypertrophy. Irrespective to geography, otolaryngologists indicate lack of familiarity with impedance pH monitoring, which they attribute to lack of knowledge in result interpretation. The most common therapeutic regimens significantly vary between world regions, with a higher use of H2 blocker in North America and a lower use of alginate in South America. The duration of treatment also significantly varies between different regions, with West Asia/Africa and East Asia/Oceania otolaryngologists prescribing medication for a shorter period than the others. Only 21.1% of respondents are aware about the existence of nonacid LPR. Overall, only 43.2% of otolaryngologists believe themselves sufficiently knowledgeable about LPR.
ConclusionsLPR knowledge and management significantly vary across the world. International guidelines on LPR definition, diagnosis, and treatment are needed to improve knowledge and management around the world.
Level of EvidenceN.
A. Laryngoscope, 2020

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Pain Experience and Tolerance of Awake In‐Office Upper Airway Procedures: Influencing Factors

Chad W. Whited, Jonathan Lubin, Nicholas Marka, Ian J. Koszewski, Matthew R. Hoffman, Stephen Schoeff, Seth H. Dailey

Publication date 16-11-2020


Objectives/Hypothesis Awake, unsedated in‐office upper airway procedures are performed frequently and have high completion rates, yet less is known about the patients pain experience and potentially influencing factors. It is also unclear if patients pain experiences become worse with repeated procedures. We identified procedure‐ and patient‐related factors that might influence procedural completion and pain scores.
Study Design Retrospective chart review.
Methods Pre‐, intra‐, and post‐procedure pain scores were collected prospectively for awake unsedated upper airway procedures performed at a single institution over a 5‐year period. Patient factors reviewed were demographics, body mass index, psychiatric and/or pain diagnosis, and related medications. Procedure factors reviewed were procedure type, route, side, and performance of the same procedure multiple times. Patients reported their pain level before, during, and after the procedure using a standard 0 to 10 scale. Maximum pain score change (PΔmax), or the difference between highest and lowest reported pain levels, was calculated. Descriptive and multivariate analyses were performed.
Results Procedure completion was 98.7% for 609 first time patients and 99.0% in 60 patients undergoing 292 repeat procedures. PΔmax did not covary with age, gender, or BMI. PΔmax covaried with pain and psychiatric conditions and associated medications. PΔmax was highest for injection medialization and lowest for tracheoscopy. PΔmax decreased over time for those undergoing multiple identical procedures.
Conclusions Procedures were performed with a very high completion rate and low pain scores. Age, sex, and BMI did not affect pain experience. A combination of pain and psychiatric conditions did. Injection medialization had the highest PΔmax and tracheoscopy the lowest.
Level of Evidence4 Laryngoscope, 2020

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Rising Costs of Otic Drops: Review of a National Database

Andrew E. Bluher, Stephanie Moody‐Antonio

Publication date 16-11-2020


ObjectivesUS prescription drug prices have increased substantially during the past decade and now account for approximately 17% of total US health expenditures. Otic drop prices are of particular interest given their common use in otolaryngologic clinical practice. We hypothesized that otic drop prices increased at a rate significantly higher than the overall inflation rate. We considered potential causes for otic drop price fluctuations during this period and whether they could be correlated with corporate restructuring events.
Methods Publicly available data on otic antibiotic drop pricing was assessed from 2012 to 2020 and were correlated with contemporaneous publicly available information about corporate and political events.
Results CiproHC (Alcon Laboratories, Inc., Fort Worth, TX, US), Ciprodex (Alcon Laboratories, Inc., Fort Worth, TX, US), Cortisporin‐TC (Endo Pharmaceuticals, Dublin, Ireland), Coly‐Mycin S (JHP Pharmaceuticals, LLC, Rochester, MI, US), generic neomycin‐polymixin‐HC otic drop, ciprofloxacin otic drop, and ofloxacin otic had overall change in cost between January 2014 and January 2020 of 69.9%, 63%, 268.9%, 219.5%, 232.5%, 13%, and 62.4%, respectively. Generic ofloxacin otic drop showed the most price fluctuation, temporarily rising 945% from July 2015 to its peak price of $26/mL in October 2016.
Conclusion Otic drop prices have been volatile, with overall price increases higher than overall inflation. Drug pricing is not transparent, making it difficult for prescribers and patients alike to be cost conscious when choosing the best therapy. We outline six factors that contribute to high US medication prices and also highlight two examples of otic drops that underwent significant price fluctuation during the studied period.
Level of EvidenceV Laryngoscope, 2020

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