Laryngoscope 2020-09-12

Comparing Caliper versus Computed Tomography Measurements of Cranial Dimensions in Children

\nGrace T. Wu, \nJason R. Audlin, \nJeewanjot S. Grewal, \nSherard A. Tatum\n

Publicatie 12-09-2020


Objectives/HypothesisWe have found no study assessing the accuracy of caliper cranium measurements compared to computed tomography (CT) measurements of the head. The objective of this study was to assess the reliability of caliper measurements in comparison to CT measurements.Study DesignRetrospective chart review.MethodsThis study includes all patients evaluated for head shape abnormality between 2010 and 2019 at a single academic medical center. Eighty‐nine patients who had CT head scans were identified, and their caliper measurements of anterior–posterior and transverse head dimensions were documented.ResultsThere was no statistically significant difference between the CT and caliper measurements.ConclusionCaliper measurements are a simple and reliable way to assess cranial vault proportionality with growth after cranial vault reconstruction.Level of Evidence4 Laryngoscope, 2020

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Pediatric Tracheal Lobular Capillary Hemangioma: A Case Report and Review of the Literature

\nRay Y. Wang, \nNorma M. Quintanilla, \nBruno P. Chumpitazi, \nSarah Gitomer, \nEric H. Chiou, \nJulina Ongkasuwan\n

Publicatie 12-09-2020


Chronic cough is a common complaint in the pediatric population and can have many different etiologies. We present a rare case of a tracheal lobular capillary hemangioma (LCH), also known as pyogenic granuloma, causing chronic cough in a child. In this case, the tracheal LCH was managed successfully with laser ablation. A review of the literature reveals only 2 other reported pediatric cases of tracheal LCH. Laryngoscope, 2020

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Relevance of Intraparotid Metastases in Head and Neck Skin Squamous Cell Carcinoma

\nCilgia Dür, \nCinzia Salmina, \nUrs Borner, \nRoland Giger, \nLluís Nisa Nisa\n

Publicatie 12-09-2020


ObjectivesParotid lymph node metastases are common in head and neck cutaneous squamous cell carcinoma (cSCCHN). Here we evaluate the diagnostic, prognostic, and therapeutic implications of intraglandular lymph node (IGLN) metastases in cSCCHN.Study DesignRetrospective study in a tertiary referral university cancer institute.MethodsWe included patients with cSCCHN who underwent parotidectomy and neck dissection (ND), with or without synchronous resection of the skin primary, between January 1999 and January 2018. The characteristics of cSCCHN with or without IGLN involvement were compared.ResultsAltogether, 68 patients were included. Of the 29 (42.6%) patients classified as cN0, eight were upstaged pN+ and had concomitant IGLN involvement. Of 21 patients with pN0 disease, IGLN metastases were absent in only three cases, resulting in a specificity and sensitivity of parotid metastases to diagnose occult nodal neck metastases of 14.29% and 100%, respectively. The positive and negative predictive values were 14.29% and 100%, respectively. Univariate analyses only displayed a significantly higher rate of moderately and poorly differentiated primaries in patients with IGLN metastases (P = .015). Only advanced T‐stages were significantly associated with neck recurrences.ConclusionIGLN status in advanced cSCCHN is potentially predictive for occul nodal neck metastases. Our results suggest that ND in patients with histopathologically negative IGLNs and clinically negative neck lymph nodes may not be necessary given the high negative predictive value of IGLN status in this group of patients. Therefore, accurate diagnostic evaluation of IGLN involvement is mandatory.Level of Evidence4 Laryngoscope, 2020

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Endoscopic Cauterization and Sclerotherapy for Airway Obstruction by a Third Branchial Pouch Sinus

\nM. Matthijs Fockens, \nBernadette S. Bakker, \nKrijn P. Lienden, \nFrederik G. Dikkers, \nCarlijn E.L. Hoekstra\n

Publicatie 11-09-2020


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Robot‐Automated Cartilage Contouring for Complex Ear Reconstruction: A Cadaveric Study

\nCorey Smith, \nBenjamin Woerd, \nRobert Potra, \nLouis Ferreira, \nCorey Moore\n

Publicatie 11-09-2020


Objectives/HypothesisAuricular reconstruction requiring manual contouring of costal cartilage is complex and time consuming, which could be facilitated by a robot in a fast and precise manner. This feasibility study evaluates the accuracy and speed of robotic contouring of cadaver costal cartilage.MethodsAn augmented robot with a spherical burr was used on cadaveric rib cartilage. Using a laser scanner, each rib section was converted to a three‐dimensional model for preoperative planning. A model ear was also scanned to define a carving path for each piece of cartilage. After being contoured, each specimen was compared against the preoperative plan utilizing deviation maps to analyze topographic accuracy. Contouring times of the robot were compared with 13 retrospectively reviewed cases (2006–2017) by an experienced surgeon.ResultsScanning the cartilage sections took 24.8 ± 6.8 seconds. Preoperative processing took an additional 29.9 ± 8.9 seconds for the preparation of the contouring path. Once the path was prepared, the robot contoured the specimens with a root mean square error of 0.54 mm and a mean absolute deviation of 0.40 mm. The average time to contour the specimens with the robot was 13 ± 2 minutes compared to 71 ± 6 minutes for the manual contouring in the reviewed cases.ConclusionsThe accuracy of the robotic system was high, with submillimeter deviations from the preoperative plan. The robot required <20% of the contouring time compared to the experienced surgeon. This represents a fast and accurate alternative to hand‐contouring costal cartilage grafts for auricular reconstruction. Laryngoscope, 2020

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Milan System for Reporting Salivary Gland Cytopathology: Challenges to be Tackled

\nSiddhanth Jain, \nShivakumar Thiagarajan\n

Publicatie 11-09-2020


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In Response to Letter to the Editor Regarding: A Call for Universal Acceptance of the Milan System for Reporting Salivary Gland Cytopathology

\nEric Barbarite, \nWilliam C. Faquin, \nMark A. Varvares\n

Publicatie 11-09-2020


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Speech Performance after Anterolateral Thigh Phonatory Tube Reconstruction for Total Laryngectomy

\nYi‐An Lu, \nYu‐Cheng Pei, \nHsiu‐Feng Chuang, \nLi‐Yun Lin, \nLi‐Jen Hsin, \nChung‐Jan Kang, \nShiang‐Fu Huang, \nHui‐Chen Chiang, \nChung‐Kan Tsao, \nTuan‐Jen Fang\n

Publicatie 10-09-2020


ObjectiveTraditionally, after total laryngopharyngectomy (TLP), patients cannot speak without a prosthesis or an artificial larynx. In Taiwan, most patients use a commercialized pneumatic laryngeal device (PLD). Phonatory tube reconstruction with the anterolateral thigh (ALT) flap is a novel, modified version of synchronous digestive and phonatory reconstruction involving a free muscular cutaneous flap. This study reviewed and compared speech performance between patients who underwent novel flap reconstruction and conventional PLD users.MethodWe retrospectively reviewed patients with laryngeal or hypopharyngeal cancer who underwent TLP from August 2017 to September 2019. The voice handicap index (VHI), speech intelligibility, acoustic and aerodynamic analysis results, and speech range profile (SRP) were compared between patients who underwent ALT phonatory tube reconstruction (ALT group) and those using PLDs (PLD group).ResultsTwenty patients were included; 13 patients were included in the ALT group, and 7 patients were included in the PLD group. Compared to the PLD group, the ALT group had a better fundamental frequency range (P < .001) and semitone range (P < .001) during speech but showed worse jitter, shimmer, and harmonic‐to‐noise ratios. The two groups showed comparable VHI and speech intelligibility performance.ConclusionsThe ALT phonatory tube, a novel flap for reconstruction, can restore digestive and voice functions simultaneously. Compared with PLD use, ALT phonatory tube reconstruction yields an improved speech range and comparable levels of voice handicap and speech intelligibility, suggesting that the technique is a good alternative for patients after TLP.Level of Evidence4 Laryngoscope, 2020

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Anastomotic Revision in Head and Neck Free Flaps

\nMatthew Stewart, \nBrian Swendseid, \nPerry Hammond, \nIshani Khatiwala, \nJuliana Sarwary, \nTingting Zhan, \nRyan Heffelfinger, \nAdam Luginbuhl, \nLarissa Sweeny, \nMark K. Wax, \nJoseph M. Curry\n

Publicatie 10-09-2020


Objectives/HypothesisPredictors of free tissue transfer (FTT) failure and the need for postoperative revision (POR) have been extensively studied; however, there are little data evaluating outcomes when intraoperative revision (IOR) at initial surgery is required. This study seeks to better understand the impact IOR of the pedicle has on FTT outcomes.Study DesignRetrospective review of 2482 consecutive patients across three tertiary institutions.MethodsAdult patients (>18) who received a FTT and underwent anastomotic revision from 2006 to 2019 were included. Logistic regression was performed to predict revision, and recursive partitioning was performed to classify risk of failure based on type of revision and vessels revised.ResultsFailure rates for IOR (19%) and POR (27%) were higher compared to a nonrevised failure rate of 2% (P < .01 and P < .01, respectively). Intraoperative venous revision (IORv, n = 13), arterial (IORa, n = 114), and both (IORb, n = 11) were associated with failure rates of 8% (odds ratio OR 3.5, P = .23), 18% (OR = 9.0, P < .01), 45% (OR = 35.3, P = <.01), respectively. Arterial revision was most common among IOR (83%, P < .01). Postoperative venous revision (PORv, n = 35), arterial (PORa, n = 36), and both (PORb, n = 11) were associated with failure rates of 20% (OR = 15.7, P < .01), 27% (OR = 10.6, P < .01), and 39% (OR = 27.0, P < .01), respectively. Failure rate for flaps that had POR after IOR (PORi, n = 11) was 45% (OR = 18.2, P < .01). Diabetes predicted IOR (P = .006); tobacco use, heavy alcohol use, and prior radiation predicted POR (P = .01, P = .05, and P = .01, respectively).ConclusionBoth IOR and POR were associated with increased failure compared to nonrevised flaps. The risk of failure increases sequentially with intraoperative or POR of the vein, artery, or both vessels. Revision of both vessels and POR after IOR are strongly predictive of failure.Level of Evidence3 Laryngoscope, 2020

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Gender‐Based Pay Discrimination in Otolaryngology

\nRobin Lindsay\n

Publicatie 10-09-2020


Male and female otolaryngologists all attend the same accredited medical schools, complete the same accredited residency programs, and take the same board certification exams; however, female otolaryngologist are paid 77 cents on the dollar compared to their male colleagues. Even after accounting for age, experience, faculty rank, research productivity, and clinical revenue, significant gender pay gaps exist across all professor levels. The goal of this review is to improve our understanding of how and why the gender pay gap and discrimination exists, the harm caused by tolerance of policies that perpetuate gender pay inequity, and what is and can be done to correct gender‐based pay gaps and discrimination. The review presents the current status of gender pay inequity in the United States and reports on how otolaryngology compares to other professions both within and outside of healthcare. The gender pay gap is shown to have a negative impact on economic growth, institutional reputation and financial success, retention and recruitment of faculty, and patient care. Many historically incorrect reasons used to explain the causes of the gender pay gap, including that women work less, have less research productivity, or produce lower‐quality care, have been be disproved by evaluation of current research. Potential causes of gender pay inequities, such as gender bias, organization culture, fear of retaliation, promotions inequalities, lack of transparency, and senior leadership not being held accountable for equity and diversity concerns, will be explored. Finally, examples of best practices to achieve pay equity will be presented. Laryngoscope, 2020

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Differentiated Thyroid Cancer: The Role of ATA Nodal Risk Factors in N1b Patients

\nStefano Taboni, \nAlberto Paderno, \nDavide Giordano, \nDomenico Albano, \nSimonetta Piana, \nEleonora Zanetti, \nFrancesco Bertagna, \nAlberto Grammatica, \nAngelo Ghidini, \nCarlo Cappelli, \nAnna Bozzola, \nCarla Baronchelli, \nPiero Nicolai, \nDavide Lombardi\n

Publicatie 10-09-2020


Objectives/HypothesisNodal involvement is frequent in patients with differentiated thyroid cancers (DTCs), but its prognostic relevance is not univocal. Some characteristics of nodal metastases can increase the risk of recurrence. We attempted to quantify the impact on survival of nodal factors included in the American Thyroid Association (ATA) risk stratification system in N1b patients with DTC.Study DesignRetrospective study.MethodsA retrospective analysis of patients affected by DTC who underwent therapeutic lateral neck dissection (ND) was performed. The impact on the prognosis of the number of positive lymph nodes (LNs), dimension of nodal metastasis, and microscopic and macroscopic extranodal extension (miENE and maENE, respectively) was investigated.ResultsThe study included 347 N1b patients who underwent 401 therapeutic lateral NDs. Mean number of positive LNs was nine, mean nodal ratio was 0.27, and mean diameter of metastasis was 15.5 mm. ENE was detected in 25.9% of patients (22.5% miENE and 3.5% maENE). In univariate analysis, the presence of maENE had an impact on disease specific survival (DSS) (P = .023); increasing number of positive LNs affected DSS and locoregional control (LRC) (P = .009 and =.006, respectively); increasing metastatic node dimension was a risk factors for overall survival, DSS, and metastases free survival (MFS) (P = .05, =.013 and =.016). In multivariate analysis, number of positive LNs and LN dimension were independent risk factors for LRC and MFS, respectively (HR 1.1, P = .028; HR 1.1, P = .026).ConclusionsIn our analysis on a cohort of N1b patients, the number of positive LNs and LN dimension were confirmed as independent risk factors for locoregional and distant recurrence, respectively.Level of Evidence4 Laryngoscope, 2020

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Modified Posterior Pedicle Middle Turbinate Flap: An Additional Option for Skull Base Resurfacing

\nAndrea Pistochini, \nFederico Russo, \nElisa Coden, \nGiorgio Sileo, \nPaolo Battaglia, \nMaurizio Bignami, \nLuca Volpi, \nPaolo Castelnuovo\n

Publicatie 10-09-2020


Objectives/HypothesisAlthough the Hadad‐Bassagusteguy flap represents the first choice for middle and posterior skull base reconstruction and coverage of exposed bony areas, in some cases it is unavailable. The aim of this study is to describe, as an alternative option in selected cases, a modified posterior pedicle middle turbinate flap (mPPMTF) extended to the lacrimal area. Anatomical features, step‐by‐step harvesting technique, and surgical applications are presented.Study designAnatomic dissection study and case report.MethodsFour mPPMTFs were raised in two fresh‐frozen cadaver heads. A study of the vascular supply and measurements of length, width, and area of the flap were performed. The ability of the flap to cover the ventral skull base, particularly the upper clivus area, was tested. A clinical case in which an mPPMTF was used for clivus resurfacing after osteoradionecrosis is reported.ResultsThe vascular supply of the mPPMTF was identified as the middle turbinate branch of the sphenopalatine artery. The flap had a mean length of 6.92 cm, mean maximum width of 1.08 cm, and mean total area of 5.33 cm2. The flap was able to reach the upper clivus, with a clival coverage ratio of 70.66%. In the clinical case, good surgical outcomes were observed, with accelerated re‐epithelization without complications.ConclusionsThe mPPMTF represents an alternative to the Hadad‐Bassagusteguy flap for posterior cranial fossa and nasopharynx resurfacing. The main drawbacks are its technically demanding and time‐consuming harvesting.Level of Evidence4 Laryngoscope, 2020

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Differing Progression to Posterior Glottic Stenosis in Autoimmune and Idiopathic Subglottic Stenosis

\nGregory R. Dion, \nJulian S. De la Chapa, \nWhitney Bettenhausen, \nLaura M. Dominguez, \nC. Blake Simpson\n

Publicatie 09-09-2020


Objectives/HypothesisWe sought to characterize rates of progression to posterior glottic stenosis (PGS) from autoimmune or idiopathic subglottic stenosis.Study DesignThis was a retrospective review.MethodsPatients from a tertiary‐care laryngology practice over a 10‐year period with autoimmune or idiopathic subglottic stenosis (SGS) were included. Patients with a history of prolonged intubation or other causes of iatrogenic stenosis were excluded. PGS was confirmed on videostrobolaryngoscopy recordings by a fellowship‐trained laryngologist. PGS type (1–4) was also recorded. Demographic information was recorded, and if applicable, autoimmune disease type was specified. Time until PGS was recorded along with the number of interventions. Chi‐squared analysis was used to compare PGS in autoimmune and idiopathic SGS.ResultsA total of 77 patients were identified with autoimmune (32 patients) or idiopathic (45 patients) subglottic stenosis. Autoimmune pathologies included systemic lupus erythematosus, granulomatosis with polyangiitis (GPA), rheumatoid arthritis, relapsing polychondritis, and sarcoidosis, with GPA the most common (14/32). Patients with autoimmune SGS had a higher rate of PGS (10 of 32) compared to idiopathic subglottic stenosis (1 of 45) for an odds ratio of 20 (95% CI: 2.4–166.4, P = .006). Patients with idiopathic SGS were more likely to be female (all 45 compared to 29/32 autoimmune, P = .07) and older (mean 53 (range 29–75) compared to 46 (20–82), P = .02).ConclusionsIn this large patient cohort, autoimmune SGS patients were found to have a higher likelihood of developing PGS compared to their idiopathic counterparts, suggesting that counseling for this progression may be warranted.Level of Evidence4 Laryngoscope, 2020

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Correlation of Glottic Gap and Voice Impairment in Presbyphonia

\nPatrick O. McGarey, \nRyan Bitar, \nCharlotte K. Hughes, \nNoah Hodson, \nEdward A. Harris, \nLaura M. Dominguez, \nGregory R Dion, \nC. Blake Simpson\n

Publicatie 09-09-2020


Objective/HypothesisThe objective of this study was to investigate the glottic gap area as a significant marker for the severity of presbyphonia as it relates to patient‐reported outcome measures (Voice Handicap Index‐10 VHI‐10) and stroboscopic findings.Study DesignRetrospective case‐control study conducted in an academic tertiary voice center.MethodsPatients seen at a tertiary voice clinic who were diagnosed with presbyphonia without other organic laryngeal pathology from January 2014 to December 2017 were included. Clinical data and laryngeal videostroboscopy videos were collected. Still images at the point of vocal process approximation during adduction were captured, and the glottic gap area was measured using ImageJ. These were compared to a control cohort. Correlations were made using Wilcoxon rank sum test, Mann–Whitney U test, and Pearson correlation coefficients.ResultsThirty‐three patients were included. Inter‐rater reliability of glottic area measurement was strong (Intraclass correlation coefficient = 0.73, P < .001). Compared to controls, presbyphonia patients had a larger glottic gap area (P < .001) and greater open‐phase quotient on laryngeal videostroboscopy (P < .001). Larger glottic gap area did not correlate with patient‐reported vocal function as measured by VHI‐10 (P = .79) and did not correlate with presence of secondary muscle tension dysphonia (P = .99). In the presbyphonia cohort, the glottic gap area did not correlate with age (P = .29).ConclusionsGlottic gap area at the point of vocal process approximation during phonation can be reliably measured. Patients with presbyphonia have a larger glottic gap area and greater open‐phase quotient on stroboscopy, but these do not correlate with patient‐reported voice impairment or the presence of secondary muscle tension dysphonia (MTD). These data suggest that dysphonia severity in presbyphonia is not fully explained by a glottic gap or secondary MTD alone.Level of Evidence4 Laryngoscope, 2020

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How I Do It: A Novel Technique for Endoscopic Placement of Stent in Management of Anterior Glottic Webs

\nNecati Enver, \nApoorva Ramaswamy, \nMichael J Pitman\n

Publicatie 09-09-2020


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Laryngotracheal Reconstruction in a Patient With a Central Conducting Lymphatic Anomaly

\nRobert J. Macielak, \nChristopher M. Low, \nMegha M. Tollefson, \nKarthik Balakrishnan\n

Publicatie 09-09-2020


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Voice‐Related Quality of Life in Idiopathic Subglottic Stenosis: Effect of Serial Intralesional Steroid Injections

\nMatthew R. Naunheim, \nElefteria Puka, \nKanittha Choksawad, \nRamon A. Franco\n

Publicatie 09-09-2020


ObjectivesSerial intralesional steroid injection (SILSI) is an emerging treatment for idiopathic subglottic stenosis (ISGS), providing improvement in both subjective symptoms and objective airflow parameters. Little is known about how this airway remodeling affects the voice. This project analyzes subjective voice changes after SILSI and correlates these with airflow parameters.MethodsAn ISGS database containing voice‐related quality of life (V‐RQOL) and spirometry (peak expiratory flow percentage %PEF) was retrospectively queried. Included were ISGS patients from 2009 to 2019 who had at least one SILSI treatment. Encounters without complete data were excluded. Differences between preprocedure and postprocedure metrics were calculated. Correlations and nonparametric bivariate analysis were performed.ResultsSix hundred and seventeen steroid injections were performed in 55 patients, with an average of 3.5 years of follow‐up. The average V‐RQOL for all patient encounters, both pre‐ and postprocedure, showed little subjective dysphonia (83.5 of 100, 95% confidence interval CI 81.6 to 85.4). Considering SILSI‐only treatments, there were 143 encounters with full data; of these, V‐RQOL improved in 70 (49.0%), did not change in 40 (28.0%), and worsened in 33 (23.0%). Average V‐RQOL improvement for the entire cohort was 1.9 points (95% CI: 0.7 to 3.2), which was small but significant (P = .0003). Across all data, there was a weak but significant correlation between PEF% and V‐RQOL (ρ = 0.22, P = .0043).ConclusionSILSI was associated with improvement in subjective voice ratings in about half of patients, and the improvement correlated with improved airflow measurements. This research adds to the growing body of data regarding SILSI and suggests that further work on functional changes to the larynx with airway remodeling is imperative.Level of Evidence4 Laryngoscope, 2020

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A New Orthotic Device for Maintaining Neck Flexion Following Tracheal and Cricotracheal Resection

\nNicole Molin, \nErin Terreson, \nAhmed M. S. Soliman\n

Publicatie 09-09-2020


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Management of the Disrupted Airway in Children

\nWei‐Chung Hsu, \nClaudia Schweiger, \nCatherine K. Hart, \nMatthew Smith, \nPatricio Varela, \nCarlos Gutierrez, \nMartin Ormaechea, \nAliza P. Cohen, \nMichael J. Rutter\n

Publicatie 09-09-2020


ObjectiveOur objective was to gather data that would enable us to suggest more specific guidelines for the management of children with airway disruption.Study DesignRetrospective case series with data from five tertiary medical centers.MethodsChildren younger than 18 years of age with a disrupted airway were enrolled in this series. Data pertaining to age, sex, etiology and location of the disruption, type of injury, previous surgery, presence of air extravasation, management, and outcome were obtained and summarized.ResultsTwenty children with a mean age of 4.4 years (range 1 day–14.75 years) were included in the study. All were evaluated by flexible endoscopy and/or microlaryngoscopy in the operating room. Twelve (60%) children had tracheal involvement; seven had bronchial involvement; and one had involvement of the cricoid cartilage. Nine children had air extravasation, and all these children required surgical repair. Of the 11 who did not have air extravasation, only one underwent surgical repair. Complete healing of the disrupted airway was seen in all cases.ConclusionThis series suggests that if there is no continuous air extravasation demonstrated on imaging studies or clinical examination, nonoperative management may allow for spontaneous healing without sequelae. However, surgical repair may be considered in those patients with continuous air extravasation unless a cuffed tube can be placed distal to the site of injury. For children in whom airway injury occurs in a previously operated area, the risk of extravasation is reduced. This risk is also diminished if positive pressure ventilation can be avoided or minimized.Level of Evidence4 Laryngoscope, 2020

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Laryngology Quality of Life Questionnaire Associations: Towards Reducing Survey Burden

\nVyVy N. Young, \nKristiana M. Jordan, \nSarah L. Schneider, \nAnn Lazar, \nChristopher D. Dwyer, \nClark A. Rosen\n

Publicatie 09-09-2020


ObjectivesOutcomes in laryngology focus primarily on patient reported outcome measures (PROMs). The increasing number of questionnaires may lead to survey fatigue. We sought to determine the relationship between the newest questionnaire, Laryngopharyngeal Universal Measure of Perceived Sensation (LUMP), and other laryngology PROMs.Study DesignCross‐sectional study.MethodsPatients undergoing laryngology multidisciplinary evaluation prospectively completed laryngology questionnaires. Average summed scores between standard laryngology PROMs (ie, VHI‐10, RSI, DI, CSI, EAT‐10) and LUMP were compared. Expert consensus panel identified the most clinically relevant statements which were then compared to LUMP summed scores, in increasingly additive fashion.ResultsFour hundred eighty patients (259 female) were assessed. Average age was 57.1 ± 17.7 years. Intraclass correlation coefficient (ICC) for each PROM in comparison to LUMP ranged from moderate to poor correlation: 0.64 (RSI), 0.55 (EAT‐10), 0.50 (DI), 0.48 (CSI), and 0.34 (VHI‐10). ICC for combinations of the five most clinically relevant individual items ranged from 0.29–0.53.ConclusionsPatients with self‐reported globus had statistically significantly higher scores across all PROMs. RSI had moderate correlation with LUMP, and the five selected expert consensus items demonstrated weaker correlation. While RSI may serve as a moderately selective clinical proxy for the LUMP questionnaire, LUMP remains a validated tool with increased specificity for quantification of globus which may be especially important in the research setting. There is continued question about the need for multiple laryngologic PROMs to evaluate patient complaints, and survey reduction remains an area of interest to decrease respondent fatigue, optimize patient care, and quantify interventional success.Level of Evidence4 Laryngoscope, 2020

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Cleft Palate Patient With Conductive Hearing Loss Due to Stapes Fixation

\nOzan Özdemir, \nOkan Övünç, \nÖzgür Yiğit\n

Publicatie 08-09-2020


Congenital stapes fixation is characterized by congenital conductive hearing loss that is not progressive. This rare disease may be accompanied by additional middle ear anomalies. However, the occurrence of congenital stapes fixation with cleft palate and oligodontia was described by Gorlin et al. in 1973, and no further cases have been reported in the literature. Congenital stapes fixation was detected after the exploratory tympanotomy operation performed on a 15‐year‐old male patient admitted to our clinic with hearing loss, more prominent on the left. The patient also had a previous operation due to cleft lip and had congenital deficiencies in the upper and lower teeth. We present the second case report in the literature which we think belongs to this syndrome, which is defined as cleft palate, stapes fixation, and oligodontia syndrome by Gorlin et al. Laryngoscope, 2020

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The Use of Negative Pressure Wound Therapy in the Management of Parotid Sialocele: A Case Report

\nAlex Oradan, \nMaximilian Muntean\n

Publicatie 08-09-2020


Parotid sialocele is an accumulation of saliva inside a subcutaneous cavity, usually as a result of trauma or iatrogenic injury of the parotid gland or duct, which can progress to other complications if left untreated. Numerous treatment options have been described before, but there is currently no evidence based consensus. We present a case of a patient treated for sialocele with the use of negative pressure wound therapy. Laryngoscope, 2020

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COVID‐19 Viral Load in the Severity of and Recovery From Olfactory and Gustatory Dysfunction

\nRyan H. W. Cho, \nZion W. H. To, \nZenon W.C. Yeung, \nEugene Y. K. Tso, \nKitty S. C. Fung, \nSandy K. Y. Chau, \nErica Y. L. Leung, \nThomas S. C. Hui, \nSteven W. C. Tsang, \nK. N. Kung, \nEudora Y. D. Chow, \nVictor Abdullah, \nAndrew Hasselt, \nMichael C. F. Tong, \nPeter K. M. Ku\n

Publicatie 08-09-2020


Objectives/HypothesisThis study investigated olfactory and gustatory dysfunction in the 2020 novel coronavirus disease (COVID‐19) patients, and their correlations with viral load evaluation.Study DesignProspective cross‐sectional cohort study.MethodsOne hundred forty‐three symptomatic patients being screened for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) were invited to participate. The clinical data of 83 confirmed COVID‐19 subjects were collected, with 60 patients who were symptomatic but negative for COVID‐19 recruited as controls. The prevalence and severity of and recovery time for olfactory and gustatory dysfunction, and cycle threshold (Ct) values from a SARS‐CoV‐2 polymerase chain reaction assay of nasopharyngeal and deep throat swabs were collected. Their correlations with Ct values were reported.ResultsThirty‐nine (47.0%) and 36 (43.4%) COVID‐19 patients reported olfactory and gustatory dysfunction, respectively. The results of one‐way analysis of variance did not show statistically significant relationships between the Ct values and severity of olfactory and gustatory dysfunction (P = .780 and P = .121, respectively). Among the COVID‐19 patients who reported smell and taste loss, 28/39 (71.8%) and 30/36 (83.3%) experienced complete recovery, respectively. The mean recovery time was 10.3 ± 8.1 days for olfactory dysfunction and 9.5 ± 6.8 days for gustatory dysfunction. The recovery time was not correlated with the Ct values (Pearson correlation coefficient, smell: −0.008, P = .968; taste: −0.015, P = .940).ConclusionsThere is a high prevalence of olfactory and gustatory dysfunction in COVID‐19. However, the severity of and recovery from these symptoms have no correlations with the viral load of SARS‐CoV‐2.Level of Evidence4 Laryngoscope, 2020

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Postoperative Analgesia Protocol: A Resident‐Led Effort to Standardize Opioid Prescribing Patterns

\nCharles Meyer, \nJessica Winters, \nRebecca G. Brady, \nJeanelle B. Riddick, \nCraig Folsom, \nDinchen Jardine\n

Publicatie 07-09-2020


ObjectivesThe combined impact of variable surgeon prescribing preferences and low resident prescribing comfort level can lead to significant disparity in opioid prescribing patterns for the same surgery in the same academic surgical practice. We report the results of a resident led initiative to standardize postoperative prescription practices within the Department of Otolaryngology at a single tertiary‐care academic hospital in order to reduce overall opioid distribution.Study DesignRetrospective cohort study.MethodsFollowing approval by the Institutional Review Board, performed a retrospective review of 12 months before (July 2016–June 2017) and after (July 2017–June 2018) implementation of the Postoperative Analgesia Protocol, which included all adults undergoing tonsillectomy, septoplasty, thyroidectomy, parathyroidectomy, tympanoplasty, middle ear exploration, stapedectomy, and ossicular chain reconstruction.ResultsSeven hundred and thirty eight procedures met inclusion criteria. Following implementation, total morphine milligram equivalents decreased by 26% (P < .0001). The number of patients requiring opioid refills decreased by 49%, and morphine milligram equivalents received as refills decreased by 16% (P < .001). Thyroid and parathyroid surgery had the greatest reduction in morphine milligram equivalents prescribed (84%, P < .001), followed by septoplasty (30%, P = .001) and tonsillectomy (18%, P < .001). The number of patients receiving refills of opioid medications decreased for all procedures (tonsillectomy 54%; septoplasty 67%; thyroid/parathyroid surgery 80%, middle ear surgery 100%).ConclusionsWhile every patient and surgery must be treated individually, this study demonstrates that a resident led standardization of pain control regimes can result in significant reductions in total quantity of opioids prescribed.Level of EvidenceIV Laryngoscope, 2020

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Blunt Versus Penetrating Neck Trauma: A Retrospective Cohort Study

\nDavid Forner, \nChristopher W. Noel, \nMatthew P. Guttman, \nBarbara Haas, \nDanny Enepekides, \nMatthew H. Rigby, \nAvery B. Nathens, \nAntoine Eskander\n

Publicatie 07-09-2020


Objectives/HypothesisDespite being common, neck injuries have received relatively little attention for important quality of care metrics. This study sought to determine the association between blunt and penetrating neck injuries on mortality and length of stay, and to identify additional patient and hospital‐level characteristics that impact these outcomes.Study DesignRetrospective cohort study utilizing the American College of Surgeons Trauma Quality Improvement Program database.MethodsAdult patients (≥18) who sustained traumatic injuries involving the soft tissues of the neck between 2012 and 2016 were eligible. Multiple imputation was used to account for missing data. Logistic regression and negative binomial models were used to analyze 1) in‐hospital mortality and 2) length of stay respectively while adjusting for potential confounders and accounting for clustering at the hospital level.ResultsIn a cohort of 20,285 patients, the crude mortality rate was lower in those sustaining blunt neck injuries compared to penetrating injuries (4.9% vs. 6.0%, P < .01), while length of hospital stay was similar (median 9.9 vs. 10.2, P = 0.06). In adjusted analysis, blunt neck injuries were associated with a reduced odds of mortality during hospital admission (odds ratio: 0.66, 95% confidence intervals 0.564, 0.788), as well as significant reductions in length of stay (rate ratio: 0.92, 95% confidence intervals 0.880, 0.954).ConclusionsBlunt neck injuries are associated with lower mortality and length of stay compared to penetrating injuries. Areas of future study have been identified, including elucidation of processes of care in specific organs of injury.Level of Evidence: Level 3 Laryngoscope, 2020

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An Experimental Model of Human Recurrent Respiratory Papillomatosis: A Bridge to Clinical Insights

\nVirgilijus Uloza, \nAlina Kuzminienė, \nJolita Palubinskienė, \nIngrida Balnytė, \nIngrida Ulozienė, \nAngelija Valančiūtė\n

Publicatie 07-09-2020


Objectives/HypothesisTo investigate the growth pattern of recurrent respiratory papilloma (RRP) implants on chicken embryo chorioallantoic membranes (CAMs) and to evaluate possible associations between the clinical course of the disease and the behavior of experimentally implanted RRP tumors.Study DesignExperimental study.MethodsFresh 172 RRP tissue samples from 12 patients were implanted onto chick embryo CAMs. Morphological and morphometric analysis of the experimental CAM and chorionic epithelium was performed. The microvascular network of the CAM with the RRP implant was investigated under the effect of fluoresceinated anionic dextran. The peculiarities of the clinical course of the disease were evaluated.ResultsThe implanted RRP tissue samples survived on CAMs in 86% of cases, retaining their essential morphologic characteristics and proliferative capacity of the original tumor. Implants induced thickening of both the CAM and the chorionic epithelium, but none of the RRP implants crossed the basement membrane of the hosting CAM. A “crawling film” of acellular material with newly formed papilloma sprouts located on the outer chorionic epithelium of the CAM was detected. Direct association between a recurrence rate of RRP and the number of newly formed papilloma sprouts around the implanted tumor on CAMs was revealed.ConclusionThe chicken embryo CAM‐based model is appropriate for investigations of RRP and facilitates the understanding of tumor biology and the clinical course of the disease, thus providing the basis for further research and acceleration of the identification and development of new specific therapeutic compounds that limit the spread and recurrence of RRP.Level of EvidenceN/A Laryngoscope, 2020

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Tracing the Origins of “Cauliflower Ear” and Its Earlier Names over Two Millenia

\nAlbert Mudry, \nRobert K. Jackler\n

Publicatie 05-09-2020


ObjectivesThe post‐traumatic ear deformity, known today as cauliflower ear, has been described since antiquity. It has long been associated with pugilistic sports (wrestling, boxing) as well as among the mentally ill. The aim of this study is to present the various terms used since antiquity to describe these traumatic deformations of the auricle and to trace the origin of the modern moniker “cauliflower ear.”MethodsHistorical study, only based on original documentation accessed through personal libraries and universities repositories, completed with online sources and etymological dictionaries.ResultsWe were able to identify no fewer than 39 names for the deformity. The term cauliflower ear is of relatively recent origin. It was coined in the first decade of the 20th century, initially in the popular press and subsequently adopted by the medical profession.ConclusionIronically, the deformity has only superficial resemblance to a cauliflower. The vegetable, which is part of the cabbage family, has a symmetrical and highly ordered fractal geometry with well‐circumscribed excrescences. Cauliflower ear, by contrast, notably lacks symmetry and its rounded protuberances flow into one another. Although somewhat a misnomer, the term is deeply rooted in both popular and medical culture.Level of EvidenceN/A Laryngoscope, 2020

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Using Augmented Reality to Reduce Fear and Promote Cooperation During Pediatric Otolaryngologic Procedures

\nThomas J. Caruso, \nMartine Madill, \nDouglas Sidell, \nKara Meister, \nEllen Wang, \nMaria Menendez, \nMadison N. Kist, \nSamuel Rodriguez\n

Publicatie 04-09-2020


This case series examines interactive AR during minor otolaryngologic procedures. Although VR has been successfully used for pediatric vascular access, removing children from comforting people in the real world has resulted in patient anxiety. AR offers a potential advantage, utilizing distracting holographic images when patients maintain eye contact with parents. The primary objective was to determine the effect of AR on fear during pediatric otolaryngologic procedures. Secondary objectives included evaluating pain; procedure compliance; and patient, parent and physician attitudes toward AR, as well as assessing the feasibility of adding AR to a busy outpatient otolaryngologic clinic. Laryngoscope, 2020

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Racial Disparities in Pediatric Endoscopic Sinus Surgery

\nPhayvanh P. Pecha, \nAlexandra Hamberis, \nTerral A. Patel, \nCathy L. Melvin, \nMarvella E. Ford, \nAnne L. Andrews, \nDavid R. White, \nRodney J. Schlosser\n

Publicatie 04-09-2020


ObjectiveTo determine the impact of race and ethnicity on 30‐day complications following pediatric endoscopic sinus surgery (ESS).Study DesignCross‐sectional cohort study.Subjects and MethodsPatients ≤ 18 years of age undergoing ESS from 2015 to 2017 were identified in the Pediatric National Surgical Improvement Program‐Pediatric database. Patient demographics, comorbidities, surgical indication, and postoperative complications were extracted. Patient race/ethnicity included non‐Hispanic black, non‐Hispanic white, Hispanic, and other. Multivariable logistic regression was performed to determine if race/ethnicity was a predictor of postoperative complications after ESS.ResultsA total of 4,337 patients were included in the study. The median age was 10.9 (interquartile range: 14.5–6.7) years. The cohort was comprised of 68.3% non‐Hispanic white, 13.9% non‐Hispanic black, 9.7% Hispanic, and 2.1% other. The 30‐day complication rate was 3.2%, and the mortality rate was 0.3%. The rate of reoperation was 3.8%, and readmission was 4.1%. Black and Hispanic patients had higher rates of urgent operations (P = .003 and P < .001, respectively), and black patients had a higher incidence of emergent operations (P < .001) compared to their white peers. For elective ESS cases, multivariable analysis adjusting for sex, age, comorbidities, and surgical indication indicated that children of Hispanic ethnicity had increased postoperative complications (odds ratio: 1.57, 95% confidence interval: 1.04–2.37).ConclusionThis analysis demonstrated that black and Hispanic children disproportionately undergo more urgent and emergent ESS. Hispanic ethnicity was associated with increased 30‐day complications following elective pediatric ESS. Further studies are needed to elucidate potential causes of these disparities and identify areas for improvement.Level of Evidence3 Laryngoscope, 2020

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Head and Neck Cancer and Social Media: The Patient Experience and Cancer Survivorship

\nRebecca W. Gao, \nJoshua D. Smith, \nKelly M. Malloy\n

Publicatie 04-09-2020


Objectives/HypothesisTo characterize the head and neck cancer patients lived experiences with survivorship through Instagram and examine opportunities for health professionals to provide support and outreach specifically targeting these needs.Study DesignDescriptive observational study.MethodsWe analyzed key head and neck cancer–related hashtags by querying medical and layman terminology. The top English‐language posts for #headandneckcancer underwent further content examination using thematic analysis based in grounded theory for categorization for user engagement (determined by “likes” and comments), type of content, and category of the account that created the post. Of the survivorship posts by patients, the content of posts in top user accounts was further analyzed.ResultsThere were 11,600 Instagram posts on #headandneckcancer, 1,300 posts on #headandneckcancerawareness, 1,100 posts on #headandneckcancersurvivor, and several thousand posts for additional layman terms. The majority of posts were from patients (65%), with few from head and neck surgeons or medical organizations (26%). User engagement was primarily by nonmedical accounts (95%). Posts by patients discussed medical appointments and treatments (81%), managing treatment effects and symptoms (66%), and cancer screening and prevention (23%). Specific concerns included fatigue (53%), postsurgical cosmetic appearance (27%), and weight and nutrition (34%).ConclusionsOur study suggests that Instagram accounts can be intimate records of the patient experience, and gaining a better understanding of the daily experience of survivorship may be critical for head and neck surgeons and other oncology providers to provide truly comprehensive cancer care.Level of Evidence4 Laryngoscope, 2020

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Genotype–Phenotype Correlation of Tracheal Cartilaginous Sleeves and Fgfr2 Mutations in Mice

\nAustin S. Lam, \nCarrie C. Liu, \nGail H. Deutsch, \nJoshua Rivera, \nJonathan A. Perkins, \nGreg Holmes, \nEthylin W. Jabs, \nMichael L. Cunningham, \nJohn P. Dahl\n

Publicatie 04-09-2020


ObjectivesTo characterize tracheal cartilage morphology in mouse models of fibroblast growth factor receptor (Fgfr2)‐related craniosynostosis syndromes. To establish relationships between specific Fgfr2 mutations and tracheal cartilaginous sleeve (TCS) phenotypes in these mouse models.MethodsPostnatal day 0 knock‐in mouse lines with disease‐specific genetic variations in the Fgfr2 gene (Fgfr2C342Y/C342Y, Fgfr2C342Y/+, Fgfr2+/Y394C, Fgfr2+/S252W, and Fgfr2+/P253R) as well as line‐specific controls were utilized. Tracheal cartilage morphology as measured by gross analyses, microcomputed tomography (μCT), and histopathology were compared using Chi‐squared and single‐factor analysis of variance statistical tests.ResultsA greater proportion of rings per trachea were abnormal in Fgfr2C342Y/+ tracheas (63%) than Fgfr2+/S252W (17%), Fgfr2+/P253R (17%), Fgfr2+/Y394C (12%), and controls (10%) (P < .001 for each vs. Fgfr2C342Y/+). TCS segments were found only in Fgfr2C342Y/C342Y (100%) and Fgfr2C342Y/+ (72%) tracheas. Cricoid and first‐tracheal ring fusion was noted in all Fgfr2C342Y/C342Y and 94% of Fgfr2C342Y/+ samples. The Fgfr2C342Y/C342Y and Fgfr2C342Y/+ groups were found to have greater areas and volumes of cartilage than other lines on gross analysis and μCT. Histologic analyses confirmed TCS among the Fgfr2C342Y/C342Y and Fgfr2C342Y/+ groups, without appreciable differences in cartilage morphology, cell size, or density; no histologic differences were observed among other Fgfr2 lines compared to controls.ConclusionThis study found TCS phenotypes only in the Fgfr2C342Y mouse lines. These lines also had increased tracheal cartilage compared to other mutant lines and controls. These data support further study of the Fgfr2 mouse lines and the investigation of other Fgfr2 variants to better understand their role in tracheal development and TCS formation.Level of EvidenceNA Laryngoscope, 2020

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Sialadenitis: A Possible Early Manifestation of COVID‐19

\nAlexander Chern, \nAkinrinola O. Famuyide, \nGul Moonis, \nAnil K. Lalwani\n

Publicatie 04-09-2020


Acute sialadenitis may be caused by viruses, including coronaviruses. Although there are anecdotal reports of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) salivary gland infections, there have been no well‐documented cases of sialadenitis in patients with COVID‐19 described in the literature. We report a case of parotitis and submandibular gland sialadenitis, as well as an isolated case of parotitis, in two patients with concurrent SARS‐CoV‐2 infections. Computed tomography imaging demonstrated parotid and submandibular gland enlargement with heterogenous enhancement and attenuation, consistent with sialadenitis. Medical management was sufficient for successful resolution of the acute sialadenitis. Laryngoscope, 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

\nLilun Li, \nConnie Lin, \nMaria Peña, \nChaitanya Challa\n

Publicatie 03-09-2020


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The Effects of Pass/Fail USMLE Step 1 Scoring on the Otolaryngology Residency Application Process

\nKhodayar Goshtasbi, \nMehdi Abouzari, \nTjoson Tjoa, \nSonya Malekzadeh, \nNaveen D. Bhandarkar\n

Publicatie 03-09-2020


ObjectivesTo investigate how the decision to report United States Medical Licensing Examination (USMLE) Step 1 score as pass/fail will influence future otolaryngology residency application and match processes.Study DesignSurvey study.MethodsAn anonymous and voluntary survey approved by the Otolaryngology Program Directors Organization was administered to academic faculty members from April 24, 2020 through May 19, 2020.ResultsTwo hundred fifty‐seven surveys were received from department chairs (17.5%), program directors (24.1%), associate program directors (12.5%), and department faculty (45.9%). USMLE Step 1 has been the most heavily weighted metric for offering interviews (44.0%), and it has correlated with residents medical knowledge (77.0%) and in‐service performance (79.8%) but not with surgical skills (57.6%) or patient care (47.1%). In total, 68.1% disagreed with the decision to make USMLE Step 1 pass/fail. This change is anticipated to lead to an increase in significance of USMLE Step 2 CK (89.1%), core clerkship grades (80.9%), elective rotation at the respective institutions (65.7%), Alpha Omega Alpha and other awards (64.6%), and letters of recommendation (63.8%). The new scoring is also anticipated to especially benefit students from top‐ranked schools (70.8%), increase medical students anxiety/uncertainty regarding obtaining interview invites (59.1%), and negatively affect international (51.4%), doctor of osteopathic medicine (45.9%), and underrepresented students (36.9%). Indication that USMLE Step 2 CK will significantly increase in weight varied according to department position (P = .049), geographic region (P = .047), years of practice (P < .001), and residency program size (P = .002).ConclusionMost academic otolaryngologists disagreed with changing USMLE Step 1 scoring to pass/fail and believe that it will increase other objective/subjective metrics weight and put certain student populations at a disadvantage.Level of Evidence: N/A. Laryngoscope, 2020

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An Evaluation of the Presence of Spin in the Abstracts of Tonsillectomy Systematic Reviews

\nCraig M. Cooper, \nAustin Johnson, \nHarrison Gray, \nMatt Vassar\n

Publicatie 03-09-2020


Objectives/HypothesisSpin—the practice of adding or omitting information intentionally or unintentionally to make the results of a study more favorable—may influence clinical decision making, especially when present in study abstracts. Here, we quantify and characterize the presence of spin in the abstracts of systematic reviews regarding tonsillectomy.MethodsThis study is an analysis of systematic review abstracts. Searches were conducted on September 23, 2019 on PubMed and Embase using the advanced search feature to retrieve systematic reviews regarding tonsillectomies. The nine most severe forms of spin were then evaluated. Spin was classified by two investigators in parallel, with each blinded to the classifications of the other. Study characteristics were also recorded in duplicate. Consensus meetings between investigators were held to resolve disagreements.ResultsIn the 85 included systematic reviews, at least one form of spin was present in 44.7% (38/85) of abstracts. Journals with higher impact factors were less likely to contain spin in the abstracts of systematic reviews (point biserial correlation coefficient of −0.30). No statistically significant associations were found between the presence of spin and intervention type (P = .56) or adherence to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (P = .08); however, there was a significant association between spin and funding source (P = .03).ConclusionsSpin was common in the abstracts of our sample of tonsillectomy systematic reviews. Researchers, clinicians, and peer reviewers could benefit from learning to recognize spin in medical literature. Further research is needed into the effects of spin on clinical decision making.Level of EvidenceNA Laryngoscope, 2020

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Modified Marionette Technique for Unassisted In‐Office Access to the Submandibular Duct

\nCollin F. Mulcahy, \nScott Fassas, \nAshley Lloyd, \nDavid Strum, \nChristopher Badger, \nArjun Joshi\n

Publicatie 03-09-2020


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

\nPadmanabhan Karthikeyan, \nNeelima Vijayan\n

Publicatie 03-09-2020


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Comparison of Speech Performance in Bimodal versus Bilateral Cochlear Implant Users

\nJoshua J. Sturm, \nMegan Kuhlmey, \nGeorge Alexiades, \nRonald Hoffman, \nAna H. Kim\n

Publicatie 02-09-2020


ObjectiveTo assess whether listening with two cochlear implants (bilateral) offers significant benefits in terms of speech perception over listening with one cochlear implant and one hearing aid (bimodal).MethodsRetrospective review of bilateral cochlear implant recipients (24 pediatric and 26 adult). Bimodal listening was compared to bilateral listening in terms of speech perception performance at 1‐year post second implant under three listening conditions: 50 dBHL, 35 dBHL, and 50 dBHL+5 SNR. Changes in speech performance from bimodal (before second implant) to bilateral (after second implant) listening were determined within subjects and compared to a separate control group of bimodal users matched for age of first implantation who never received a second implant (10 pediatric and 20 adult).ResultsIn the pediatric group, compared to bimodal listening prior to a second implant, speech perception scores with bilateral implants increased significantly when measured at 50 dBHL, 35 dBHL, and 50 dBHL+5 SNR. By contrast, pediatric bimodal controls who never received a second implant failed to demonstrate similar improvement over 1 years time. In the adult group, compared to bimodal listening prior to a second implant, speech perception scores with bilateral implants increased when measured at 50 dBHL, but were not significantly different at 35 dBHL and 50 dBHL + 5 SNR. Adult bimodal controls who never received a second implant failed to demonstrate significant improvement in all conditions over 1 years time.ConclusionBilateral listening with two cochlear implants improved speech perception performance relative to bimodal listening in the pediatric population. Improvement in the adult population was not as significant.Level of Evidence4, Retrospective Chart Review. Laryngoscope, 2020

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National Trends in Daily Ambulatory Electronic Health Record Use by Otolaryngologists

\nJohn Paul Giliberto, \nGregory Ator, \nThomas L. Carroll, \nTeresa Chan, \nAndrew Vahabzadeh‐Hagh\n

Publicatie 02-09-2020


ObjectiveSince their development in the 1970s electronic health records (EHRs) are now nearly ubiquitous. This study aims to characterize the daily interactions of otolaryngology providers with EHRs.MethodsThis study was a cross‐sectional review of provider efficiency profile (PEP) data, as collected by a major EHR vendor. Participating institutions had 6 months of de‐identified PEP data reviewed starting January 1, 2019. PEP data is generated for providers with scheduled patients, both attendings and advanced practice providers (APPs). Time metrics are recorded when a provider is interacting with the EHR including a 5‐second time‐out for inactivity.ResultsData on 269 otolaryngologists and 29 APPs from 10 institutions were evaluated. On scheduled ambulatory clinic days attendings spent 70 ± 36 (mean ± standard deviation) min interacting in the EHR versus 108 ± 46 min for APPs. Of the daily EHR time, mean time in notes, clinical review, in basket, orders, and schedule were 30.1 ± 19.4, 9.6 ± 6.1, 7.3 ± 5.8, and 5.8 ± 7.6 min, respectively. Per patient visit, median (interquartile range) time in notes, clinical review, and orders were 3.19 (2.2–4.9), 1.14 (0.63–1.8), and 0.70 (0.47–1.05) min, respectively. Mean progress note length was 4638 ± 2143 characters.ConclusionOtolaryngology providers spend a meaningful portion of their clinic day interacting with the EHR. PEP data may provide means to target interventions and a metric to measure the impact of those interventions on provider EHR efficiency.Level of Evidence3 Laryngoscope, 2020

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The Effect of Tonsillectomy and Adenoidectomy on Isolated Sleep Associated Hypoventilation in Children

\nCharles Saadeh, \nSeckin O. Ulualp\n

Publicatie 02-09-2020


ObjectiveSleep associated hypoventilation (SAH) is diagnosed when more than 25% of total sleep time (%TST) is spent with end tidal carbon dioxide (EtCO2) > 50 mmHg. SAH in children occurs as a single entity or combined with obstructive sleep apnea. Outcomes of surgical treatment for isolated SAH in children have not been reported.MethodsThe medical charts of children who were diagnosed with isolated SAH and did not have OSA at a tertiary childrens hospital between January 2013 and December 2019 were reviewed. Data collection included information on history and physical examination, past medical history, polysomnography (PSG) findings, and surgical management.ResultsSeventeen children (10 male, 7 female, age range: 3–14 years) were diagnosed with isolated SAH. Comorbid conditions included asthma in four children, Down syndrome in one, and seizure in two. Eight children were normal weight, four were overweight, and five were obese. Children did not have obstructive or central sleep apnea. Three children (18%) had persistent SAH as documented by PSG. All normal weight children had resolution of SAH whereas two obese children and one overweight child had residual SAH. %TST with CO2 > 50 mmHg after upper airway surgery (3.4% ± 1.6%) was significantly less than that of before TA (59.1% ± 5.5%) (P < .001).ConclusionsThe majority of children with isolated SAH had normalization of hypercapnia after TA. Further studies in larger groups of children are needed to identify the risk factors for residual isolated SAH after TA.Level of Evidence4 Laryngoscope, 2020

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Disparities in Mortality from Larynx Cancer: Implications for Reducing Racial Differences

\nSophia Chen, \nEdward Christopher Dee, \nVinayak Muralidhar, \nPaul L. Nguyen, \nMilan R. Amin, \nBabak Givi\n

Publicatie 01-09-2020


ObjectiveRace predicts overall mortality (OM) of laryngeal squamous cell carcinoma (LSCC) in the United States (US). We assessed whether racial disparities affect cancer‐specific mortality (CSM) using the Surveillance, Epidemiology, and End Results (SEER) database.MethodsAdults with LSCC from 2004 to 2015 were selected. Univariable and multivariable Cox proportional hazards and Fine‐Gray competing‐risks regression analysis adjusted for clinicodemographic factors defined hazard ratios (aHR).ResultsWe identified 14,506 patients. The median age was 63 years. Most were male (11,725, 80.8%) and white (11,653, 80.3%), followed by Black (2294, 15.8%). Most had early‐stage disease (7544, 52.0%) and received radiotherapy only (4107, 28.3%), followed by chemoradiation (3748, 25.8%). With median follow‐up of 60 months, overall 3‐ and 5‐year OM were 34.0% and 43.2%; CSM were 16.0% and 18.9%, respectively. Black patients had higher OM than white patients on univariable (HR 1.35, 95% CI, 1.26–1.44, P < .001) and multivariable (aHR 1.10, 95% CI, 1.02–1.18, P = .011) analyses. Black patients had higher CSM on univariable analysis (HR 1.22, 95% CI, 1.09–1.35, P < .001) but not on multivariable CSM analysis (aHR 1.01, 95% CI, 0.90–1.13, P = .864). On multivariable analysis, year of diagnosis, age, disease site, stage, treatment, nodal metastasis, marital status, education, and geography significantly predicted CSM.ConclusionOn multivariable analyses controlling for sociodemographic, clinical, and treatment characteristics, Black and white patients differed in OM but not in CSM. However, Black patients presented with greater proportions of higher stage cancers and sociodemographic factors such as income and marital status that were associated with worse outcomes. Efforts to target sociodemographic disparities may contribute to the mitigation of racial disparities in LSCC.Level of Evidence4 Laryngoscope, 2020

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Inferior Meatus Mucosal Flap for Septal Reconstruction and Resurfacing After Nasoseptal Flap Harvest

\nRandall Ruffner, \nMarcelo Charles Pereira, \nVarun Patel, \nMaria Peris‐Celda, \nCarlos D. Pinheiro‐Neto\n

Publicatie 01-09-2020


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Health‐Related Quality of Life Following Total Laryngectomy: A Systematic Review

\nNille B. Wulff, \nAnna Højager, \nIrene Wessel, \nSusanne O. Dalton, \nPreben Homøe\n

Publicatie 31-08-2020


ObjectiveTreatment of advanced laryngeal and hypopharyngeal cancer has shifted from total laryngectomy (TL) toward laryngeal‐preserving therapies due to a general perception that TL has a significantly negative impact on the individuals life. However, whether the physical impairments related to TL translate to a reduced health‐related quality of life (HRQoL) has not yet been determined. Therefore, the objective of this systematic review was to determine how HRQoL is affected following TL.MethodsSystematic searches were conducted in PubMed, Embase, and Cochrane. Inclusion criteria were original studies describing quality of life following TL after larynx/hypopharynx cancer using a formally developed patient‐reported questionnaire. Study quality assessment was carried out with the tool developed by the National Heart, Lung, and Blood Institute.ResultsForty‐six studies using 12 different questionnaires were included. The majority were cross‐sectional (85%), and study quality was rated poor in 30%, fair in 30%, and good in 39% of studies. When comparing results from the four most frequently used questionnaires with normative data, we found that in more than 60% of studies, differences to the reference population were of clinical importance, with only few exceptions.ConclusionsIn general, we found that people who received TL have a worse HRQoL than the male normative reference population. However, even though TL patients experience a clinically important difference in many domains when compared with normative data, their burden of symptoms is generally mild. The current review also makes it evident that despite the relatively large number of studies conducted, the strength of evidence remains weak. Laryngoscope, 2020

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Rate and Factors Associated With Change in Surgeon for Revision Endoscopic Sinus Surgery

\nAria Jafari, \nBharat A. Panuganti, \nKayva L. Crawford, \nSarek Shen, \nAdam S. DeConde\n

Publicatie 31-08-2020


Objectives/HypothesisA subset of patients will undergo revision endoscopic sinus surgery (ESS) with a different otolaryngologist than the one who performed their primary surgery. The purpose of this study is to report the incidence of and clinicodemographic factors associated with a change in surgeon for revision ESS.Study DesignRetrospective cohort study.MethodsAdult patients who underwent at least two outpatient ESS procedures between 2009 and 2014 using the State Ambulatory Surgery Database for Florida were included in the study. Change in surgeon was defined by a change in a unique provider identifier for the revision procedure. Multivariable regression analysis was used to determine characteristics associated with a change in surgeon.ResultsA total of 2,963 patients were included. For the revision procedure, 47.7% of patients changed their surgeon. On multivariable logistic regression, a medium‐ (odds ratio OR: 0.64; 95% confidence interval CI: 0.53‐0.77) or high‐volume (OR: 0.50; 95% CI: 0.42‐0.61) surgeon performing the index surgery and advanced age (≥65 years) (OR: 0.79; 95% CI: 0.63‐0.99) were associated with decreased odds of surgeon change for revision ESS. Longer time elapsed between index and revision surgery (OR: 1.15; 95% CI: 1.13‐1.17) was associated with increased odds of surgeon change.ConclusionsNearly half of patients who undergo revision ESS select a surgeon other than the one who performed their primary procedure. Surgeon volume, age, and time between surgeries affect the likelihood of a change in surgeon for revision ESS. These findings may provide introductory insights into patient preferences and decision making in the surgical management of recalcitrant chronic rhinosinusitis.Level of Evidence4 Laryngoscope, 2020

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The Benefit of Primary Tumor Surgical Resection in Distant Metastatic Carcinomas of the Thyroid

\nSamer T. Elsamna, \nPooja Suri, \nGhayoour S. Mir, \nDylan F. Roden, \nBoris Paskhover\n

Publicatie 31-08-2020


Objectives/HypothesisThyroid cancer with distant metastasis (TCDM) at diagnosis has significantly worse survival rates when compared to localized/regional thyroid cancer. This study sought to report on the characteristics of patients presenting with TCDM and the potential survival advantage of surgical resection.Study DesignData were acquired from the Surveillance, Epidemiology, and End Results (SEER) database with cases from 2004 to 2015.MethodsTCDM cases (n = 2,558) were identified from the SEER database. The Bonferroni correction was applied for multivariate analysis. Kaplan‐Meier analysis was utilized to obtain disease‐specific survival (DSS) rates. Cox regression analysis was utilized to identify independent factors significantly associated with survival.ResultsThe average age of diagnosis of TCDM was 62.0 (±17.5) years. Patients were predominantly white (74.6%), female (54.6%), in a relationship (56.0%), and between ages 36 and 80 years (76.4%). Cases consisted of papillary (57.2%), follicular (16.0%), medullary (8.9%), anaplastic (17.9%) TCDM histological variants. Overall 1‐, 5‐, and 10‐year DSS rates were 72.0%, 56.8%, and 43.8%, respectively. Anaplastic and medullary variants had the worst 10‐year DSS (0% and 25.5%, respectively). Patients who underwent surgical resection only and surgical resection with radiation were 49% and 59% less likely to die, respectively. Treatment, age, histology, T staging, relationship status, and metastasis site were determined to be significant predictors of survival.ConclusionsSurgical resection with radiation was found to be a significant predictor of survival after applying the Bonferroni correction for all thyroid cancer variants except medullary. To increase survival, surgical intervention should be recommended in patients who are deemed to be medically tolerant of surgery.Level of Evidence4 Laryngoscope, 2020

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Transoral Robotic Surgical Proficiency Via Real‐Time Tactile Collision Awareness System

\nAbie H. Mendelsohn, \nChristine Kim, \nJonathan Song, \nAadesh Singh, \nTyler Le, \nAhmad Abiri, \nGerald S. Berke, \nRory Geoghegan\n

Publicatie 31-08-2020


ObjectivesIn 2009, the Food and Drug Administration approved the use of the surgical robotic system for removal of benign and malignant conditions of the upper aerodigestive tract. This novel application of robotic‐assisted surgery, termed transoral robotic surgery (TORS), places robotic instruments and camera system through the mouth to reach recessed areas of the pharynx and larynx. Over the successive decade, there was a rapid adoption of TORS with a surgical growth rate that continues to increase. Despite the rapid clinical acceptance, the field of TORS has not yet seen substantive changes or advances in the technical shortcomings, the lack of which has restricted objective TORS‐specific surgical skills assessment as well as subsequent skills improvement efforts. One of the primary technical challenges of TORS is operating in a confined space, where the robotic system is maneuvered within the restrictive boundaries of the mouth and throat. Due to these confined boundaries of the pharynx, instruments can frequently collide with anatomic structures such as teeth and bone, producing anatomic collisions. Therefore, we hypothesized that anatomic collisions negatively impact TORS surgical performance. Secondarily, we hypothesized that avoidance of unwanted anatomic collisions could improve TORS surgical proficiency.MethodsDesign and fidelity testing for a custom TORS training platform with an integrated anatomic collision‐sensing system providing real‐time tactile feedback is described. Following successful platform assembly and testing, validation study using the platform was carried through prospective surgical training with trial randomization. Twenty otolaryngology–head and neck surgery residents, each trainee performing three discrete mock surgical trials (n = 60), performed the initial system validation. Ten of the 20 residents were randomized to perform the surgical trials utilizing the real‐time feedback system. The remaining 10 residents were randomized to perform the surgical trials without the feedback system, although the system still could record collision data. Surgical proficiency was measured by Global Evaluative Assessment of Robotic Skills (GEARS) score, time to completion, and tumor resection scores (categorical scale ranging 0–3, describing the adequacy of resection).ResultsMajor anatomic collisions (greater than 5N of force) negatively affected GEARS robotic skills. A mixed model analysis demonstrated that for every additional occurrence of a major collision, GEARS robotic skills assessment score would decrease by 0.29 points (P = .04). Real‐time collision awareness created significantly fewer major (> 5 N) anatomic collisions with the tactile feedback system active (n = 30, mean collisions = 2.9 ± 4.2) as compared with trials without tactile feedback (n = 30, mean collisions = 12.53 ± 23.23) (P < .001). The second assessment measure of time to completion was unaffected by the presence of collisions or by the use of tactile feedback system. The third proficiency assessment was measured with tumor resection grading. Tumor resection scores was significantly (P = .02) improved with collision awareness system activated than trials without collision awareness.ConclusionIn order to test our primary hypothesis, a novel TORS training platform was successfully developed that provides collision force measurements including frequency, severity, and duration of anatomic collisions. Additionally, the platform was modulated to provide real‐time tactile feedback of the occurrence of out‐of‐field collisions. Utilizing this custom platform, our hypothesis that anatomic collisions during TORS diminishes surgical performance was supported. Additionally, our secondary hypothesis that subsequent reduction of anatomic collisions improves TORS proficiency was supported by the surgical trial. Dedicated investigation to characterize the effect size and clinical impact is required in order to translate this finding into training curriculums and into clinical utilization.Level of EvidenceII (Randomized trial) Laryngoscope, 2020

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Home Sleep Testing to Direct Upper Airway Stimulation Therapy Optimization for Sleep Apnea

\nArmin Steffen, \nInke R. König, \nPeter M. Baptista, \nNils Abrams, \nStephanie Jeschke, \nKatrin Hasselbacher\n

Publicatie 31-08-2020


Objectives/HypothesisSelective upper airway stimulation (sUAS) is a well‐established treatment option for obstructive sleep apnea (OSA). This study aimed to determine if there are benefits in performing a home sleep test (HST) to evaluate postoperative sUAS effectiveness after patient acclimatization compared to the generally used polysomnography (PSG) titration, as measured by long‐term follow‐up outcomes.Study DesignRetrospective comparative cohort analysis.MethodsWe conducted an analysis of consecutive patients at our center who had completed a 6‐month follow‐up (month 6 M6) and recorded data from M6, month 12 (M12), and month 24 (M24). After device activation, we performed an HST with the patients stimulation settings, and measured the apnea‐hypopnea index (AHI), Epworth Sleepiness Scale (ESS), and device usage. These values were compared to patients who had undergone PSG‐based device titration.ResultsBaseline values of the initial 131 patients show high ESS and moderate OSA. At the 2‐month time point of the HST, nearly half of the patients (46.2%) reached an AHI ≤15/hr, and approximately a fifth (19.2%) reached <5/hr. The PSG and HST groups differed in median ESS at M24, but no other differences were observed for ESS at M6 and M12. Both groups showed similar AHI, oxygen desaturation, and usage hours per week.ConclusionsAdjusting therapy by using the HST technique after device activation and acclimatization has clinical and economic advantages. These advantages are contingent on several conditions being met when deviating from the standard device protocol, including precise communication with the referring sleep medicine physicians, especially their role in helping with long‐term follow‐up.Level of Evidence4 Laryngoscope, 2020

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Telemedicine in Otolaryngology in the COVID‐19 Era: Initial Lessons Learned

\nJason F. Ohlstein, \nJordan Garner, \nMasayoshi Takashima\n

Publicatie 31-08-2020


Objectives/HypothesisThe COVID‐19 pandemic has led to unprecedented global changes in the delivery of healthcare over a short period of time. With the implementation of shelter‐in‐place orders, otolaryngology clinic visits at our institution were transitioned to telemedicine. This change enabled the rapid characterization of the patients who accepted and declined telemedicine.Study DesignCross‐sectional analysis.MethodsA review was conducted of 525 otolaryngology patients at a tertiary‐care referral center with scheduled visits requiring rescheduling to a future date or a telemedicine visit. Visit, demographic information, and reason for deferring telemedicine were collected for analysis.ResultsSeventy‐two percent of patients declined a telemedicine visit, with the most common reason being the lack of a physical exam (97%). There was an even distribution of demographics between those who accepted and declined visits. There was an association between declining telemedicine with older age (P = .0004) and otology visits (P = .0003), whereas facial plastics patients were more likely to accept (P < .0001). Patients scheduled earlier during the pandemic were more likely to accept a visit with a median of 28 days from onset of shelter‐in‐place orders versus 35 for those who declined (P < .0001).ConclusionsWe describe our initial experience with a transition to telemedicine, where the majority of patients would decline a virtual visit due to the lack of a physical exam. Although the future remains uncertain, telemedicine will continue to play a vital role in healthcare delivery. We believe that understanding our patient base gives critical insights that will help guide and improve virtual care to meet patients needs.Level of Evidence4 Laryngoscope, 2020

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Characterization of Fibroblasts in Latrogenic Laryngotracheal Stenosis and Type II Diabetes Mellitus

\nIoan Lina, \nHsiu‐Wen Tsai, \nDacheng Ding, \nRuth Davis, \nKevin M. Motz, \nAlexander T. Hillel\n

Publicatie 28-08-2020


ObjectivesIatrogenic laryngotracheal stenosis (iLTS) is the pathological narrowing of the glottis, subglottis, and/or trachea due to scar tissue. Patients with type 2 diabetes mellitus (T2DM) are over 8 times more likely to develop iLTS and represent 26% to 53% of all iLTS patients. In this investigation, we compared iLTS scar‐derived fibroblasts in patients with and without T2DM.Study DesignControlled ex vivo study.MethodsiLTS scar fibroblasts were isolated and cultured from subglottic scar biopsies in iLTS patients diagnosed with or without type 2 diabetes (non‐T2DM). Fibroblast proliferation, fibrosis‐related gene expression, and metabolic utilization of oxidative phosphorylation (OXPHOS) and glycolysis were assessed. Contractility was measured using a collagen‐based assay. Metabolically targeted drugs (metformin, phenformin, amobarbital) were tested, and changes in fibrosis‐related gene expression, collagen protein, and contractility were evaluated.ResultsCompared to non‐T2DM, T2DM iLTS scar fibroblasts had increased α‐smooth muscle actin (αSMA) expression (8.2× increased, P = .020), increased contractility (mean 71.4 ± 4.3% vs. 51.7 ± 16% Δ area × 90 minute−1, P = .016), and reduced proliferation (1.9× reduction at 5 days, P < .01). Collagen 1 (COL1) protein was significantly higher in the T2DM group (mean 2.06 ± 0.19 vs. 0.74 ±.44 COL1/total protein pg/μg, P = .036). T2DM iLTS scar fibroblasts had increased measures of OXPHOS, including basal respiration (mean 86.7 vs. 31.5 pmol/minute/10 μg protein, P = .016) and adenosine triphosphate (ATP) generation (mean 97.5 vs. 25.7 pmol/minute/10 μg protein, P = .047) compared to non‐T2DM fibroblasts. Amobarbital reduced cellular contractility; decreased collagen protein; and decreased expression of αSMA, COL1, and fibronectin. Metformin and phenformin did not significantly affect fibrosis‐related gene expression.ConclusionT2DM iLTS scar fibroblasts demonstrate a myofibroblast phenotype and greater contractility compared to non‐T2DM. Their bioenergetic preference for OXPHOS drives their increased contractility, which is selectively targeted by amobarbital.Level of EvidenceNA Laryngoscope, 2020

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Regionalization of ORL Boot Camps: Report of the Society of University Otolaryngologists Task Force

\nKelly M. Malloy, \nJudith E. C. Lieu, \nBrian P. Cervenka, \nEllen S. Deutsch, \nSonya Malekzadeh\n

Publicatie 28-08-2020


ObjectivesSimulation‐based boot camps have emerged as timely vehicles to help novice residents develop the skills needed to manage medical emergencies. Geographically regional boot camps provide opportunities for interaction between residents and faculty from multiple otolaryngology programs. The Society of University Otolaryngologists (SUO) Boot Camp Task Force investigated the concept of regional access to otolaryngology boot camps with the goal of making more regional boot camps available for otolaryngology residents across the United States.Study DesignInterviewsMethodsThe SUO Boot Camp Task Force assessed regional access to otolaryngology boot camps with a focus on geographic distribution, curricular content, and finances. Boot camp directors were contacted by email and telephone and interviewed to elicit information on all these areas.ResultsData were available from 10 known regional simulation‐based boot camps designed for novice residents. Individual boot camps included from 12 to 30 residents and 10 to 50 faculty members. Curricula included both technical (ie, procedural) and non‐technical (eg, communication, leadership) skills for individuals and teams. Content was heavily weighted toward a variety of airway problems and management techniques, although various conditions involving hemorrhage, and airway fires were also addressed. Funding and expense structures had the greatest variability.ConclusionsConsiderable variability was identified among the known regional boot camps in terms of numbers of participants and finances, but fewer differences in curriculum. Geographic opportunity for 9 to 10 new boot camps was identified. The SUO Task Force recommends that a consensus be developed for several individual skill and teamwork scenario objectives to be included in each boot camp. Laryngoscope, 2020

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Tracheal A‐Frame Deformities Following Airway Reconstruction

\nAimee A. Kennedy, \nAlessandro Alarcon, \nMeredith E. Tabangin, \nMichael J. Rutter, \nCharles M. Myer, \nMatthew M. Smith, \nCatherine K. Hart\n

Publicatie 26-08-2020


ObjectivesAirway reconstruction for subglottic and tracheal stenosis is often successful in achieving tracheostomy decannulation and improving airway symptoms. However, one common reason for late failure is development of a tracheal A‐frame deformity, which can necessitate additional surgery. Although knowledge of this deformity exists, the incidence and risk factors have not been reported. This study seeks to determine the incidence of A‐frame following airway reconstruction and define factors that correlate with development of this deformity.Study DesignRetrospective case series.MethodsPatients under 21 years of age undergoing open airway reconstruction at our institution between January 2005–December 2006 were retrospectively reviewed. Demographic data, comorbidities, airway history/reconstruction type, and follow‐up airway findings were examined using multivariable logistic regression. Kaplan–Meier curves were used to examine time to A‐frame repair.ResultsTwo hundred patients underwent airway reconstruction and 69 (34.5%) developed an A‐frame deformity. History of tracheostomy was the most significant contributor to A‐frame development (P < .0001). Double‐ versus single‐stage procedures were not associated with increased odds of A‐frame development (P = .94), however, patients undergoing resection procedures as opposed to laryngotracheal reconstruction (LTR) with cartilage grafts had a significantly lower chance of developing this deformity (P = .004). Of the patients with an A‐frame, 27 (39%) required further surgical intervention.ConclusionApproximately one‐third of patients undergoing airway reconstruction developed a tracheal A‐frame deformity, with a significantly higher rate among patients with a history of tracheostomy and those undergoing LTR. Patients should be followed long term to assess for the development of an A‐frame.Level of EvidenceIV Laryngoscope, 2020

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Addition of Wendler Glottoplasty to Voice Therapy Improves Trans Female Voice Outcomes

\nSarah K. Brown, \nJoseph Chang, \nShirley Hu, \nGanesh Sivakumar, \nMedha Sataluri, \nLeanne Goldberg, \nMark S. Courey\n

Publicatie 26-08-2020


Objectives/HypothesisVT is often considered the preferred treatment for vocal feminization in transgender patients. However, Wendler glottoplasty offers a surgical option for increasing fundamental frequency and perception of vocal femininity. We aimed to determine whether the addition of glottoplasty to VT results in greater fundamental frequency elevation and improvement in quality‐of‐life measures.Study DesignRetrospective case series.MethodsForty‐eight trans female patients were treated for vocal feminization. Twenty‐seven patients underwent VT, and 21 patients underwent VT with additional glottoplasty (VTWG). Pre‐ and posttreatment acoustic measures, Trans Woman Voice Questionnaire (TWVQ), and Voice Handicap Index‐10 (VHI‐10) data were compared.ResultsGlottoplasty in combination with VT elevated average speaking fundamental frequency (SF0) to a greater extent than VT alone (P < .0001). The VTWG group achieved a 42‐Hz increase in SF0, whereas the VT group achieved a 15‐Hz increase in SF0. In both the VT and VTWG groups, the lower bound of physiologic range increased by 18 Hz (P = .0008 and P = .016, respectively). The addition of glottoplasty also resulted in greater improvement in voice‐related quality of life. Improvement in TWVQ and VHI‐10 was significantly greater in the VTWG group than the VT group (P = .007 and P = .029, respectively). TWVQ showed statistically significant improvement in the VTWG group only.ConclusionsVT results in SF0 elevation and improvement in VHI‐10. The addition of glottoplasty to VT results in further improvements in SF0 and VHI‐10 and statistically significant improvement in TWVQ.Level of Evidence4 Laryngoscope, 2020

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Clinical Analysis of Type II First Branchial Cleft Anomalies in Children

\nWei Liu, \nMin Chen, \nBing Liu, \nJie Zhang, \nXin Ni\n

Publicatie 26-08-2020


Objectives/HypothesisWe aimed to analyze the clinical characteristics and introduce a new subclassification system for type II first branchial cleft anomalies (FBCAs) based on magnetic resonance imaging (MRI) findings.MethodsWe conducted an analysis of data from patients with type II FBCAs. MRI findings were used to categorize FBCAs into three subtypes. FBCAs located between the subcutaneous tissue and parotid were classified as type IIa. FBCAs located between the deep and superficial lobes of the parotid were classified as type IIb. FBCAs located between the parotid and the carotid sheath were classified as type IIc.ResultsPatients with type II FBCAs were classified as type IIa, IIb, and IIc in 14, 14, and seven cases, respectively. Type IIa lesions exhibited a close relationship with the facial nerve in 42.9% of cases. In these cases, the main trunk of the facial nerve adhered to the lesion and was located superficially to the FBCA. In all patients with type IIb lesions, the main trunk and marginal mandibular branch of the facial nerve adhered to the lesion. The main trunk of the facial nerve adhered to the lesion in one patient with a type IIc. There was no relationship between the lesion and the facial nerve in the remaining type IIc cases.ConclusionsMRI can be used to identify the locations of FBCA and the parotid, which can aid surgeons in predicting the relationship between the lesion and the facial nerve. It is feasible to classify type II FBCAs into three subtypes based on MRI.Level of Evidence4 Laryngoscope, 2020

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Does Subglottic Squamous Cell Carcinoma Warrant a Different Strategy Than Other Laryngeal Subsites?

\nMejd Jumaily, \nJames A. Gallogly, \nMatthew C. Gropler, \nFarhoud Faraji, \nGregory M. Ward\n

Publicatie 26-08-2020


Objectives/HypothesisSubglottic squamous cell carcinoma (SSCC) is a rare cancer with limited evidence‐based treatment guidelines. This study aimed to describe the treatment patterns for SSCC and to determine which treatments provide the best overall survival.Study DesignRetrospective database review.MethodsThe National Cancer Database (NCDB) was queried for patients treated for SSCC from 2004 through 2014. Overall survival (OS) rates were determined by the Kaplan‐Meier method. Clinicopathologic characteristics were assessed by univariable and multivariable Cox proportional hazards models, which corrected for age, sex, race, insurance status, income quartile, residence, Charlson‐Deyo comorbidity score, facility type providing treatment, tumor grade, and clinical N and T category.ResultsIn this cohort of 549 patients with SSCC, the 5‐year OS was 48.2%. SSCC presented at an advanced stage (American Joint Committee on Cancer stage III or IV) in 60.1% of cases; 78.3% of cases had no nodal metastases. Among only stage IV cases, multivariable analysis showed that radiotherapy (RT) (hazard ratio HR = 5.944; 95% confidence interval CI: 2.76‐12.8; P < .001) and chemoradiotherapy (CRT) (HR = 2.321; 95% CI: 1.36‐3.97; P = .002) were both associated with decreased 5‐year OS compared to a group consisting of all surgeries. When this analysis was repeated for only stage III cases, RT (HR = 1.134; 95% CI: 0.38‐3.37; P = .821) and CRT (HR = 1.784; 95% CI: 0.78‐4.08; P = .170) were equivalent to surgery.ConclusionsUsing the NCDB to study the largest cohort of SSCC with known staging and treatment, primary surgery may provide a better 5‐year OS in advanced‐stage SSCC.Level of Evidence4 Laryngoscope, 2020

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Factors Associated With the Choice of Radiation Therapy Treatment Facility in Head and Neck Cancer

\nChristopher B. Sullivan, \nZaid Al‐Qurayshi, \nCarryn M. Anderson, \nAaron T. Seaman, \nNitin A. Pagedar\n

Publicatie 26-08-2020


ObjectiveTo analyze the clinicodemographic characteristics and treatment outcomes of patients receiving postoperative radiation therapy (PORT) at a different treatment facility rather than the initial surgical facility for head and neck cancer.Study Design: Retrospective cohort analysis.MethodsUtilizing the National Cancer Data Base, 2004 to 2015, patients with a diagnosis of oral cavity/oropharyngeal, hypopharyngeal, and laryngeal squamous cell carcinoma were studied. Multivariate analysis was completed with multivariate regression and Cox proportional hazard model, and survival outcomes were examined using Kaplan‐Meier analysis.ResultsA total of 15,181 patients who had surgery for a head and neck cancer at an academic/research center were included in the study population. Of the study population, 4,890 (32.2%) patients completed PORT at a different treatment facility. Treatment at a different facility was more common among patients who were ≥65 years old, white, Medicare recipients, those with a greater distance between residence and surgical treatment facility, and with lower income within area of residence (each P < .05). Overall survival was worse in patients completing PORT at a different treatment facility versus at the institution where surgery was completed (61.9% vs. 66.4%; P = .002).ConclusionsPORT at a different facility was more common in older individuals, Medicare recipients, those with greater distance to travel, and lower‐income individuals. Completing PORT outside the hospital where surgery was performed was associated with inferior survival outcomes among head and neck cancer patients.Level of Evidence3 Laryngoscope, 2020

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Long‐term Quality of Life After Treatment of Oropharyngeal Squamous Cell Carcinoma

\nPihla Ranta, \nIlpo Kinnunen, \nLauri Jouhi, \nTero Vahlberg, \nLeif J. J. Back, \nElina Halme, \nPetri Koivunen, \nTimo Autio, \nMatti Pukkila, \nHeikki Irjala\n

Publicatie 25-08-2020


ObjectivesTo analyze the long‐term quality of life (QOL) among oropharyngeal squamous cell carcinoma (OPSCC) survivors.Study DesignRetrospective chart analysis and patient response to European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, Core Module (EORTC QLQ‐C30), Head and Neck Module (EORTC QLQ‐H&N35), and M.D. Anderson Dysphagia Inventory (MDADI) survey questionnaires.MethodsAll survivors of OPSCC diagnosed and treated between 2000 and 2009 in Finland were included. There were 263 survivors (44.2% of all curatively treated patients), of which a total of 164 participated in this study (62.4%). Median follow‐up was 11.79 years (range = 8.59–18.53 years, interquartile range IQR = 4.64 years). The mean age of the participants was 67.9 years (standard deviation = 8.0 years) at QOL follow‐up.ResultsMost survivors reported a good QOL. The EORTC QLQ‐C30 global health status median was 75.00 (IQR = 31.25). The single modality treatment group had significantly better QOL outcomes than the combined treatment group. Nonsmokers and previous smokers had significantly better QOL outcomes than patients who smoked at the time of diagnosis. A history of heavy alcohol use resulted in significantly worse QOL outcomes. The p16‐positive cancer patients had significantly better QOL outcomes than p16‐negative patients. Percutaneous endoscopic gastrostomy (PEG) tube–dependent patients reported a significantly worse QOL than patients without a PEG tube.ConclusionsLong‐term QOL in OPSCC survivors is generally good. In line with previous literature, single modality treatment was superior to combined treatment in long‐term QOL outcomes, and it should be pursued whenever possible.Level of Evidence4 Laryngoscope, 2020

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Vocal Tradeoffs in Anterior Glottoplasty for Voice Feminization

\nIngo R. Titze, \nAnil Palaparthi, \nTed Mau\n

Publicatie 25-08-2020


Objectives/HypothesisAnterior (Wendler) glottoplasty has become a popular surgery for voice feminization. However, there has been some discrepancy between its theoretical pitch‐raising potential and what is actually achievable, and downsides to shortening the glottis have not been fully explored. In addition, descriptions of the surgery are inconsistent in their treatment of the vocal ligament. This study aimed to determine 1) how fundamental frequency ( f o ) is expected to vary with length of anterior glottic fixation, 2) the impact of glottic shortening on sound pressure level (SPL), and 3) the effect of including the ligament in fixation.Study DesignComputational simulation.MethodsVoice production was simulated in a fiber‐gel finite element computational model using canonical male vocal fold geometry incorporating a three‐layer vocal fold composition (superficial lamina propria, vocal ligament, and thyroarytenoid muscle). Progressive anterior glottic fixation (0, 1/8, 2/8, 3/8, etc. up to 7/8 of membranous vocal fold length) was simulated. Outcome measures were f o , SPL, and glottal flow waveforms.Results f o increased from 110 Hz to 164 Hz when the anterior one‐half vocal fold was fixed and continued to progressively rise with further fixation. SPL progressively decreased beyond 1/8 to 1/4 fixation. Inclusion of the vocal ligament in fixation did not further increase f o . Any fixation increased aperiodicity in the acoustic signal.ConclusionsThe optimal length of fixation is a compromise between pitch elevation and reduction in output acoustic power. The simulation also provided a potential explanation for vocal roughness that is sometimes noted after anterior glottoplasty.Level of EvidenceNA Laryngoscope, 2020

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Low‐Normal Platelets and Decreasing Platelets Are Risk Factors for Hearing Impairment Development

\nYasunori Abe, \nKensuke Toyama, \nMasaya Kazurayama, \nShinji Tanaka, \nMasamitsu Yamaizumi, \nMegumi Ueno, \nJoshua M. Spin, \nNaohito Hato, \nMasaki Mogi\n

Publicatie 24-08-2020


ObjectiveIdentification of undefined risk factors will be crucial for the development of therapeutic strategies in hearing impairment. Platelets are likely to affect the development of sudden sensorineural hearing loss, which is a primary risk factor for permanent hearing impairment. This implies that abnormal platelets might contribute to long‐term hearing loss. This study investigated the role of platelets in the development of hearing impairment over a 5‐year period.MethodsThis study was a retrospective cohort study and consisted of a population‐based survey, which was performed for 1,897 participants in 2014 to 2019. To evaluate the effect of platelet level on hearing ability, the subjects were divided into two groups: a high‐normal platelet group (25 ∼ 40 × 104 cells/μL) and a low‐normal platelet group (15 ∼ 25 × 104 cells/μL). Subjects were defined as having hearing impairment when pure tone audiometry was over 25 dB HL in either ear (tested in 2017 and 2019). Incidence of hearing impairment was analyzed.ResultsIncidence of hearing impairment at low frequencies was significantly higher in the low‐normal platelet group than in the high‐normal group year over year. Low‐normal platelet count associated with low‐frequency hearing impairment (LFHI) incidence (odds ratio OR, 2.34; 95% confidence interval CI, 1.15–4.76). In the low‐normal platelet group, subjects whose counts declined from baseline developed more LFHI than those whose counts increased over time. Further, decreasing platelets appeared to be an independent risk factor contributing to the incidence of LFHI (OR, 2.10; 95%CI, 1.09–4.06) in the low‐normal platelet group.ConclusionBoth a low‐normal platelet and a declining platelet count were independently associated with the incidence of LFHI.Level of Evidence3 Laryngoscope, 2020

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Outcomes in N3 Head and Neck Squamous Cell Carcinoma and Role of Upfront Neck Dissection

\nAngela Boros, \nPierre Blanchard, \nArlette Dade, \nPhilippe Gorphe, \nIngrid Breuskin, \nCaroline Even, \nFrance Nguyen, \nEric Deutsch, \nFrançois Bidault, \nFrançois Janot, \nStephane Temam, \nHaitham Mirghani, \nYungan Tao\n

Publicatie 24-08-2020


ObjectivesWe investigated the prognostic factor of N3 head and neck squamous cell carcinoma (HNSCC), including the role of upfront neck dissection (UFND) before radiotherapy (RT).MethodsWe retrospectively reviewed the charts of consecutive N3 HNSCC patients treated with curative intent RT.ResultsIn the study, 323 N3 HNSCC patients were included. Of those, 125 patients (39%) had UFND. Median follow‐up was 3.9 years (0–14.8 years). Overall survival (OS) at 5 years was 31.2%, and progression‐free survival (PFS) was 26%. In the multivariate analysis, OS was improved in PS 0, T1‐2 tumors, patients receiving concurrent chemotherapy, never or former smokers, and UFND. UFND was strongly associated with increased OS (45.7% vs. 21.2%, P < .001), and PFS (P < .001). Regardless of neck node size, UFND improved survival (P = .001 for ≤ 7 cm and P = .004 for > 7 cm).ConclusionUFND could improve treatment outcomes in N3 HNSCC, especially for non‐oropharyngeal cancer, regardless of neck node size.Level of Evidence2B Laryngoscope, 2020

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Application of the Spider Limb Positioner to Subscapular System Free Flaps

\nAdam Bender‐Heine, \nGavin Young, \nJennifer Moy, \nSavannah Weedman, \nMark K. Wax\n

Publicatie 24-08-2020


ObjectiveTo demonstrate the application and surgical time savings of the Spider Limb Positioner for subscapular system free flaps in head and neck reconstructive surgery.MethodsSingle institution retrospective chart review and analysis of patients between 2011 and 2019 that underwent a subscapular system free flap either with or without use of the Spider Limb Positioner. One hundred five patients in total were reviewed with 53 patients in the Spider group. The surgical times were compared between the two groups. Patient‐specific information regarding average age, laterality of donor site, recipient site, gender, and flap type were reviewed.ResultsForty‐one patients in both groups underwent a latissimus free flap. Twelve of 53 in the Spider group and 11/52 in the control group underwent a scapula free flap. The average age in the Spider group at the time of surgery was 64 years. The recipient sites for the Spider groups were reviewed. The free flap was ipsilateral to the defect in 81% of cases. The mean surgical time for the 105 patients without the Spider was 568 minutes versus 486 minutes with a Spider P‐value of .003478.ConclusionUse of the Spider Limb Positioner allows for a simultaneous two‐team approach during free flap elevation of the subscapular system, which eliminates both dependence on an assistant to support the arm and time consuming positioning changes during flap elevation.Level of Evidence3 Laryngoscope, 2020

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Reducing Aerosolised Particles and Droplet Spread in Endoscopic Sinus Surgery during COVID‐19

\nHuw AS Jones, \nRami J Salib, \nPhilip G Harries\n

Publicatie 15-08-2020


AbstractObjectivesThe presence of high SARS‐Cov‐2 viral loads in the upper airway, including the potential for aerosolised transmission of viral particles, has generated significant concern amongst Otolaryngologists worldwide, particularly those performing Endoscopic Sinus Surgery (ESS). We evaluated a simple negative pressure mask technique to reduce viral exposure.MethodsTwo models simulating respiratory droplets >5‐10 μm and fine respiratory nuclei <5 μm using fluorescein dye and wood smoke respectively were utilised in a fixed cadaveric study in a controlled environment. Using Ultra‐Violet light, fluorescein droplet spread was assessed during simulated ESS with powered microdebrider and powered drilling. Wood smoke ejection was used to evaluate fine particulate escape from a negative pressure mask using digital subtraction image processing.ResultsThe use of a negative pressure mask technique resulted in a 98% reduction in the fine particulate aerosol simulation, and eliminated larger respiratory droplet spread during simulated ESS, including during external drill activation.ConclusionsAs global ENT services resume routine elective operating, we demonstrate the potential use of a simple negative pressure mask technique to reduce the risk of viral exposure for the operator and theatre staff during ESS.

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What is the Role of Transoral Thyroidectomy?

\nBrent A. Chang, \nAmeya A. Asarkar, \nCherie‐Ann O. Nathan\n

Publicatie 14-08-2020


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What Is the Appropriate Duration of Antibiotic Use After Septorhinoplasty?

\nShabnam Ghazizadeh, \nMaie A. St. John\n

Publicatie 14-08-2020


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The Relationship Between Cisplatin‐related and Age‐related Hearing Loss During an Extended Follow‐up

\nJakob Skalleberg, \nMilada Cvancarova Småstuen, \nJan Oldenburg, \nTerje Osnes, \nSophie D. Fosså, \nMarie Bunne\n

Publicatie 14-08-2020


ObjectivesCisplatin‐related hearing loss (HL) is claimed to progress after treatment. This controlled longitudinal study with extended follow‐up investigates HL in testicular cancer survivors (TCSs) after cisplatin‐based chemotherapy (CBCT).Study DesignControlled longitudinal study.MethodsEighty‐two TCSs treated with CBCT between 1980 and 1994 in Norway participated in two surveys (S1/S3), including pure‐tone audiograms (0.125–8 kHz) and self‐reported HL, 12 and 31 years after treatment, respectively. Hearing thresholds were age‐adjusted based on age‐matched hearing thresholds from the general population (controls). Hearing loss was defined as thresholds >20 dB at any frequency.ResultsBetween the two surveys, the prevalence of high‐frequency HL (4, 6, and 8 kHz) increased from 73% to 94% but approached those of the aging general population after age adjustment. In TCSs aged >40 years at first survey, HL at the subsequent survey equaled that of controls. Self‐reported HL increased from seven (9%) at S1 to 20 (26%) at S3. At S1, age‐adjusted HL was identified in all (seven) TCSs reporting decreased hearing whereas at S3, hearing thresholds did not differ from controls in seven out of 20 patients reporting HL.ConclusionCBCT‐related ototoxicity causes high‐frequency HL, but in contrast to reports from follow‐up studies from the first post‐treatment decade, no major progression was found beyond the first post‐treatment decade for frequencies 0.125–8 kHz. Importantly, with extended follow‐up, hearing thresholds of patients approach those of the general population, possibly due to a less‐than‐additive effect with age‐related hearing loss (ARHL) in CBCT‐treated patients. Age‐and sex‐matching is strongly advised in long‐term follow‐up of CBCT‐related ototoxicity. Specificity for detecting ototoxicity with self‐reported questionnaires decreases with extended follow‐up.Level of Evidence3 Laryngoscope, 130:E515–E523, 2020

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Rounded Insertion Technique for Cochlear Implantation Surgery to Treat Cystic Inner Ear Malformation

\nHao‐Chun Hu, \nWilliam Kuan‐Hua Chen, \nMei‐Jui Huang, \nChi‐Ching Lin, \nJoshua Kuang‐Chao Chen\n

Publicatie 14-08-2020


ObjectiveThis article outlines the advantages and applicability of the rounded insertion technique of cochlear implants in patients with cystic inner ear malformation. This technique enables the insertion of the maximum number of electrodes and prevents the unwanted entry of electrodes into the internal auditory canal.MethodsWe conducted a retrospective chart review of consecutive patients with cochlear hypoplasia (CH) and/or common cavity (CC) who underwent CI (cochlear implantation) via rounded insertion technique. The position of the electrode array in each patient was confirmed postoperatively via X‐ray, and the number of functional electrodes was confirmed during the mapping process.ResultsThis study included five male and two female patients (median age: 3 years; age range: 2–7 years). Among the seven patients, four received a cochlear implant on the right side, one on the left side, and two bilaterally. Of the nine ears, six were cases of CH, and three were CC. All cochlear implant surgeries via rounded insertion technique were completed without complications. The maximum number of electrode contacts with fair function in the cystic cochlea was confirmed via postoperative X‐ray and the subsequent mapping process.ConclusionThis consecutive series of patients demonstrated the safety and reliability of rounded insertion technique for CI in patients with CH and/or CC.Level of Evidence4 Laryngoscope, 130:2229–2233, 2020

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The Generalizability of the Clinical Assessment Score‐15 for Pediatric Sleep‐Disordered Breathing

\nNira A. Goldstein, \nNorman R. Friedman, \nHeather C. Nardone, \nAbdullah Aljasser, \nAllison B.J. Tobey, \nDebra Don, \nFuad M. Baroody, \nDerek J. Lam, \nSteven Goudy, \nStacey L. Ishman, \nJill M. Arganbright, \nCristina Baldassari, \nJ.B.S. Schreinemakers, \nTodd M. Wine, \nNicole J. Ruszkay, \nAhmed Alammar, \nAmber D. Shaffer, \nJeffrey A. Koempel, \nJeremy Weedon\n

Publicatie 14-08-2020


ObjectiveThe Clinical Assessment Score‐15 (CAS‐15) has been validated as an office‐based assessment for pediatric sleep‐disordered breathing in otherwise healthy children. Our objective was to determine the generalizability of the CAS‐15 in a multi‐institutional fashion.MethodsFive hundred and thirty children from 13 sites with suspected sleep‐disordered breathing were recruited, and the investigators completed the CAS‐15. Based on decisions made in the course of clinical care, investigators recommended overnight polysomnography, observation, medical therapy, and/or surgery. Two hundred and forty‐seven subjects had a follow‐up CAS‐15.ResultsMean age was 5.1 (2.6) years; 54.2% were male; 39.1% were white; and 37.0% were African American. Initial mean (standard deviation SD) CAS‐15 was 37.3 (12.7), n = 508. Spearman correlation between the initial CAS‐15 and the initial apnea‐hypopnea index (AHI) was 0.41 (95% confidence interval CI, 0.29, 0.51), n = 212, P < .001. A receiver‐operating characteristic curve predicting positive polysomnography (AHI > 2) had an area under the curve of 0.71 (95% CI, 0.63, 0.80). A score ≥ 32 had a sensitivity of 69.0% (95% CI, 61.7, 75.5), a specificity of 63.4% (95% CI, 47.9, 76.6), a positive predictive value of 88.7% (95% CI, 82.1, 93.1), and a negative predictive value of 32.9% (95% CI, 23.5, 44.0) in predicting positive polysomnography. Among children who underwent surgery, the mean change (SD) score was 30.5 (12.6), n = 201, t = 36.85, P < .001, effect size = 3.1.ConclusionThis study establishes the generalizability of the CAS‐15 as a useful office tool for the evaluation of pediatric sleep‐disordered breathing.Level of Evidence2B Laryngoscope, 130:2256–2262, 2020

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The Incidence of Laryngotracheal Stenosis in Neonates With a History of Ventilator‐Associated Pneumonia

\nAnne Sun Lowery, \nAlexander Gelbard, \nChristopher Wootten\n

Publicatie 14-08-2020


Objectives/HypothesisNeonatal patients requiring prolonged intubation are susceptible to both infection and laryngotracheal stenosis (LTS). This study investigated the effect of ventilator‐associated pneumonia (VAP) on the development of LTS in neonates.Study DesignRetrospective case–control study.MethodsThe incidence of LTS in neonates with VAP was compared with the incidence of LTS in matched intubated controls without VAP. Patients were treated at a tertiary‐care medical center from 2004 to 2014. Eligible patient records were assessed for the development of LTS. Demographics, medical comorbidities, infection characteristics, and treatment variables were compared using unpaired t test or χ2 test. Statistical significance was set a priori at P < .05.ResultsWhen comparing the VAP patients with matched non‐VAP controls, we found no significant differences in the incidence of LTS (VAP vs. non‐VAP, 8.3% vs. 6.7%; P = .73). In subgroup analysis of the VAP cohort, LTS and non‐LTS patients demonstrated similar VAP organisms on broncho‐alveolar lavage (Klebsiella pneumoniae, Pseudomonas aeroginosa, Escherichia coli, methicillin‐resistant Staphylococcus aureus, Streptococcus pneumoniae, and Enterobacter). Additionally, within the VAP cohort, LTS and non‐LTS patients showed similar gestational age (LTS vs. non‐LTS, 31.3 days vs. 28.1 days; P = .22), birth weight (LTS vs. non‐LTS, 1.6 kg vs. 1.2 kg; P = .33), and similar intubation duration (LTS vs. non‐LTS, 37.8 days vs. 27.5 days; P = .52).ConclusionsIn this neonatal cohort, VAP was not associated with an increased incidence of LTS. Given severity of the burden of LTS on the healthcare system, multi‐institutional longitudinal investigation into contributing risk factors for neonatal LTS is warranted.Level of EvidenceNA Laryngoscope, 130:2252–2255, 2020

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The Natural History of Vocal Fold Cysts

\nDiana N. Kirke, \nLucian Sulica\n

Publicatie 14-08-2020


ObjectiveTo determine the natural history of vocal fold cysts, by undertaking a retrospective analysis of data from a single clinical institute.MethodsAll patients diagnosed with vocal fold cysts were identified from January 2006 to June 2018. A total of 87 patients that elected not to have surgery or who had an interval of observation greater than 90 days prior to surgical intervention were further analyzed. The primary outcome was whether the cyst enlarged, reduced in size, resolved or ruptured. The secondary outcome measures were whether cyst characteristics (translucent or opaque by gross appearance and/or the presence of inflammation), voice therapy or duration of follow up (≤/> 300 days) had an impact upon natural history.ResultsThere were 65 females and 22 males (47 years ±17). The mean duration of follow up was 589 days (Range 21 – 4523 days). The majority of cysts did not change (70.11%). The rest enlarged (12.64%), reduced in size (13.79%), resolved (1.15%) or ruptured (1.15%). There was no statistically significant relationship between the presence or absence of clinical signs of inflammation (P = .633) or voice therapy (P = .785) on natural history. There was an equivocal relationship between gross cyst appearance and natural history (P = .054), however there was a statistically significant relationship between the duration of follow up (P = .006) and natural history.ConclusionMost vocal fold cysts appear to remain static in size over time. About 30% change, with half of these enlarging and half shrinking. In addition to some possibility of change in size, there is a small chance of resolution or spontaneous rupture with potentially serious consequences to the voice.Level of Evidence4. Laryngoscope, 130:2202–2207, 2020

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Sulcus Vocalis: Results of Excision Without Reconstruction

"\nKaterina Andreadis, \nKatherine Hoffman, \nDebra DAngelo, \nLucian Sulica\n"

Publicatie 14-08-2020


ObjectiveSulcus is an epithelial invagination of the membranous vocal fold. Its phonatory effects are usually attributed to fibrosis, thinning, and/or the absence of the superficial lamina propria (SLP). Surgical treatment is typically focused on reconstruction of the SLP. The purpose of this study is to assess the effects of excision without SLP reconstruction or replacement.MethodsRecords of patients who underwent surgical treatment of sulcus vocalis (Ford type 3) by excision without reconstruction were reviewed for demographic and historical information. Pre‐ and postoperative stroboscopic examinations were evaluated blindly by fellowship‐trained laryngologists using a modified Voice‐Vibratory Assessment with Laryngeal Imaging assessment. A Wilcoxon signed‐rank test was used to compare pre‐ and postoperative amplitude, mucosal wave, nonvibrating portion, regularity, erythema, and vascularity.ResultsExaminations of 16 vocal folds in 13 patients (8 females:5 males; mean age = 30 years, range 13 to 48 years) were evaluated by six raters each, yielding 168 sets of observations. Statistically significant improvement was seen in amplitude (95% confidence interval CI 3.6,14.3), mucosal wave (95% CI 6.1, 17.9), nonvibrating portion (95% CI −19.6, −2.7), erythema (95% CI −19.9, −3.3), and vascularity (95% CI −19.0, −0.75). The parameter of regularity, although improved, did not prove to be significant.ConclusionExcision alone appears to be an adequate and generally successful treatment for sulcus vocalis (Ford type 3). In contrast to established paradigms, restoration of the SLP does not appear to be essential to meaningful clinical improvement. Significant pathologic effects of sulcus vocalis may result from epithelial abnormalities alone.Level of Evidence4 Laryngoscope, 130:2208–2212, 2020

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Robotic Tongue‐Base Resection Combined With Tongue‐Base Suspension for Obstructive Sleep Apnea

\nMurat Turhan, \nAsli Bostanci\n

Publicatie 14-08-2020


Objectives/HypothesisOur primary objective was to evaluate the feasibility, morbidity, and efficacy of transoral robotic surgery (TORS) tongue‐base resection (TBR) combined with tongue‐base suspension (TBS) for obstructive sleep apnea (OSA) with tongue‐base collapse. Our secondary objective included evaluation of factors influencing treatment success.Study DesignSingle‐arm, prospective, observational cohort study.MethodsPatients were eligible if they had moderate‐to‐severe OSA (apnea hypopnea index AHI > 15) or positional OSA, had a tongue‐base collapse and glossoptosis identified by drug‐induced sleep endoscopy (DISE), and failed continuous positive airway pressure. All patients underwent TORS‐TBR combined with TBS. Additionally, concomitant epiglottoplasty, uvulopalatopharyngoplasty, or expansion pharyngoplasty were performed based on DISE findings.ResultsIn total, 64 patients were enrolled in the trial. The mean age was 45.9 years, mean body mass index was 30.5 kg/m2, and mean AHI was 41.7 events/hour. The mean robotic surgical time, total volume of tongue‐base tissue removed, and the length of hospital stay were 21.4 minutes, 15.16 mL, and 6.5 days, respectively. Postoperatively, almost all polysomnographic metrics improved significantly (AHI = 41.72 vs. 18.82 events/hour, lowest oxygen saturation = 80.43% vs. 85.14%, Epworth Sleepiness Scale = 10.49 vs. 4.09). The procedure provided an overall success rate of 75%, with minor morbidity. All patients experienced varying degrees of temporary lingual edema postoperatively. Tracheotomy was not required for any patient. Although no independent predictor of treatment success was determined, patients with more severe disease tend to exhibit lower response to the treatment.ConclusionsTORS‐TBR combined with TBS is a feasible, safe, and efficient procedure for OSA with tongue‐base collapse.Level of Evidence4 Laryngoscope, 130:2285–2291, 2020

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A Novel Tablet‐Based Approach for Hearing Screening of the Pediatric Population, 516‐Patient Study

\nLin Xiao, \nBin Zou, \nLi Gao, \nMeiling Weng, \nMatthew Lando, \nAnn E. Smith, \nWayne Barber, \nHongbing Yao\n

Publicatie 14-08-2020


ObjectiveAssess a tablet hearing game as a screening instrument for pediatric hearing loss.MethodsAll children age 3 to 13 presenting to the ENT clinic of a tertiary hospital clinic over a 3‐month period were eligible for study. Five hundred sixteen were entered by completing the tablet screen with calibrated tablet/headphones. All had full standard audiometry or otoacoustic emission testing to assess hearing status. Tablet game data was analyzed to find the best correlation to the air conduction audiogram. The appropriate pass threshold of the tablet game was established and the statistical accuracy of the tablet game versus the air conduction audio was assessed.ResultsThe overall rate of hearing loss was 29.7% (153 subjects). Conductive hearing loss predominated and was present in 128 children. The tablet game pure tone average from 500– 4000 Hz correlated best with the air conduction audiogram, and was most predictive of hearing loss. Setting the pass level at 20 dB for the tablet screen prioritized detection of hearing loss, yielding a sensitivity of 91% and corresponding specificity of 73.5% for ages 4 and older. Specificity progressively improved with increasing age and was over 90% for all ages 7 and older.ConclusionTablet game audiometry as a screening tool performs well in a controlled setting. Based on these results, it can be considered as a reliable screening method for school‐age children and to monitor resolution of otitis media.Level of Evidence4, case series Laryngoscope, 130:2245–2251, 2020

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Positional Awake Endoscopy Versus DISE in Assessment of OSA: A Comparative Study

\nSherif M. Askar, \nAmal S. Quriba, \nElham M. Hassan, \nAli M. Awad\n

Publicatie 14-08-2020


ObjectiveTo compare awake endoscopy with Müllers maneuver (MM) during both sitting and supine positions, with drug‐induced sleep endoscopy (DISE) as regard determination of different levels, patterns, and degrees of collapse of the upper airway in adult patients with obstructive sleep apnea (OSA).MethodsThe study included adult patients with OSA symptoms, who had apnea hypopnea index (AHI) > 15. Patients were examined by MM in a sitting position, then during supine position; DISE then followed. Site, pattern, and degree of obstruction were assessed by experienced examiners according to the nose oropharynx hypopharynx and larynx classification.ResultsEighty‐one adult subjects were included. The most common pattern of collapse at the retro‐palatal level was the concentric pattern, while the predominant pattern at the hypopharyngeal level was the lateral wall collapse. The analysis of the pattern of collapse of the study group revealed that the individual pattern did not change (for the same patient at the same level) in the majority of patients whatever the maneuver or the position.ConclusionThis study demonstrates the feasibility of positional awake endoscopy for providing valuable surgical information as regard level, pattern, and degree of severity in OSA. The data of positional awake endoscopy were comparable to those gained from DISE with less morbidity and costs. The idea and results of this work provide a useful foundation for future research in this area. Multicenter studies are encouraged to obtain more reliable conclusions and more clear standards aiming at a better surgical planning.Level of Evidence4 Laryngoscope, 130:2269–2274, 2020

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Association Between Orthonasal Olfaction and Chemosensory Perception in Patients With Smell Loss

\nDavid T. Liu, \nGerold Besser, \nBernhard Prem, \nGunjan Sharma, \nMartin Koenighofer, \nBertold Renner, \nChristian A. Mueller\n

Publicatie 14-08-2020


ObjectivesSelf‐ratings seem to be the most effortless strategy for assessment of patients chemical senses. Notably, although flavor perception strongly relies on olfaction, the relationship between self‐reported flavor perception and orthonasal olfactory tests have hitherto not been considered. The aim of this study was to investigate the relationship between self‐perceived olfactory function (SO), taste (ST), and flavor perception (SF) and smell test results in patients with olfactory dysfunction (OD).MethodsWe included 203 patients with quantitative OD. Group comparison, bivariate correlation, and ordinal logistic regression were employed to quantify the relationships between predictor variables (age, gender, reason for OD, and orthonasal olfaction—summed scores of threshold, discrimination, and identification TDI) and outcomes of SO and SF (“impaired,” “average,” or “good”).ResultsGroup comparison revealed significant differences between SO and SF (P < .001). Stronger correlations were found between SO and TDI (r = 0.64), compared to SF and TDI (r = 0.27). No relevant correlation was found between ST and TDI (r = 0.10). Higher TDI was associated with odds of higher SO in univariate (odds ratio = 1.25) and multivariable analyses (adjusted odds ratio = 1.23), and both models showed good fit of data. Conversely, regression models on the associations between TDI and changes in SF did not meet the assumption of goodness of fit.ConclusionWe found that higher orthonasal olfactory performance was associated with odds of higher SO in patients with OD, even after controlling for olfactory‐relevant factors. To the contrary, similar models based on flavor perception failed to describe these relationships. This indicates for SF and ST to be less represented by the TDI compared to SO.Level of Evidence4 Laryngoscope, 130:2213–2219, 2020

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Analysis of Abdominal Dermal‐Fat Grafting to Repair Parotidectomy Defects: An 18‐Year Cohort Study

\nNelson R. Gruszczynski, \nBarrett J. Anderies, \nJacob K. Dey, \nDaniel L. Price, \nEric J. Moore, \nJeffrey R. Janus\n

Publicatie 14-08-2020


ObjectivesTo assess the outcomes of abdominal dermal‐fat grafting following superficial and total parotidectomy.MethodsA retrospective chart review of parotidectomy patients was performed. Patients were divided into four groups based on surgical extent and grafting status: superficial parotidectomy (SP), superficial parotidectomy with grafting (SPg), total parotidectomy (TP), and total parotidectomy with grafting (TPg). Complication rates and operative times were then compared between surgically matched groups (SP vs. SPg, TP vs. TPg). Complications included graft necrosis, gustatory sweating, first‐bite syndrome, infection, hematoma, sialocele, and seroma. Data was analyzed via chi‐square and two‐sample t testing, logistic regression, and one‐way analysis of variance.ResultsThe cohort consisted of 330 patients: 106 SP (32.12%), 61 SPg (18.48%), 82 TP (24.85%), and 81 TPg (24.55%). No donor site complications occurred. TPg resulted in seven graft necroses (8.64%), and 22 reported gustatory sweating (27.20% vs. 10 TP patients (12.2%), P = 0.016); SPg resulted in two necroses (3.28%). There were no other statistically significant differences in complication rates. Graft recipients receiving adjuvant radiation were more likely to develop necrosis (odds ratio OR 4.60, 95% confidence interval CI, 1.16–18.27, P = .0194). Patients who developed gustatory sweating were 8.38 years younger (95% CI 2.66–14.10, P = 0.002, follow‐up time > 48 days). Grafting did not increase operative times (TP/TPg: mean = 275.91/263.65 minutes, standard error of the mean = 41.96/33.75, P = 0.822).ConclusionAn abdominal dermal‐fat graft is an excellent reconstructive choice for a parotidectomy defect and is not associated with increased complication rates or prolonged operative time.Level of Evidence4 Laryngoscope, 130:2144–2147, 2020

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Does Salivary Function Decrease in Proportion to Radioiodine Dose?

\nJi Won Kim, \nJeong Mi Kim, \nMi Eun Choi, \nSeok‐Ki Kim, \nYoung‐Mo Kim, \nJeong‐Seok Choi\n

Publicatie 14-08-2020


ObjectivesThis study was conducted to investigate the dose‐response characteristics of radioiodine on salivary glands and to investigate the mechanism responsible for radioiodine‐induced salivary glands toxicity.MethodsTwenty‐four mice were divided into six groups: 0, 0.05, 0.10, 0.20, 0.40, and 0.80 mCi/20 g mouse, administered orally. Mortalities were noted 12 months after radioiodine administration. Body weights, gland weights, salivary lag times, flow rates, and changes in 99mTc pertechnetate were recorded. Histopathological changes and mRNA expressions were also evaluated, and immunohistochemical analysis and apoptotic assays were performed.ResultsSurvival rates, body weights, gland weights, and flow rates decreased, and lag times increased on increasing radioiodine dose. Animals administered radioiodine showed acinar atrophy, striated duct dilations, and lymphocytic infiltration in glands and irregular destruction of epithelial surfaces of tongue. The uptake and excretion of 99mTc pertechnetate were impaired by radioiodine. Immunohistochemical analysis showed that numbers of salivary epithelial, myoepithelial, and endothelial cells decreased and that numbers of ductal cells increased with radioiodine dose. Oxidative stress biomarker levels increased; reactive oxygen species scavenger levels decreased; and numbers of apoptotic cells increased in animals exposed to higher radioiodine doses.ConclusionThese dose‐related, long‐term effects on salivary gland should be taken into account when determining radioiodine doses.Level of EvidenceNA Laryngoscope, 130:2173–2178, 2020

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Primary Laryngectomy Versus Salvage Laryngectomy: A Comparison of Outcomes in the Chemoradiation Era

\nChristopher Blake Sullivan, \nKatharine L. Ostedgaard, \nZaid Al‐Qurayshi, \nNitin A. Pagedar, \nSteven M. Sperry\n

Publicatie 14-08-2020


ObjectiveTo compare primary total laryngectomy (TL) versus salvage TL and analyze the functional outcomes, complications, recurrence rates, and survival.Study DesignCase series with chart review.SettingTertiary care center.Subjects and MethodsFifteen‐year retrospective analysis of 208 patients with laryngeal squamous cell carcinoma treated by TL was completed. Outcome measures included survival, swallowing rehabilitation, speech rehabilitation, complications, and assessment of comorbidity. Survival estimates were analyzed with Kaplan‐Meier method, and regression analysis utilized the Cox proportional hazards model.ResultsAlaryngeal speech was not significantly different between primary TL and salvage TL, 68% versus 82% (P = 0.14). Comparing primary and salvage TL, the perioperative complication rate was 33% versus 48% (P = 0.036). Thirty‐six percent of primary TL patients had recurrence compared to 26% of salvage patients. Five‐year overall survival rates between primary TL and salvage TL were not significantly different (P = 0.68). Comorbidity was an independent predictor of survival.ConclusionsDevelopment of a functional voice was not significantly different between salvage and primary TL patients, with a majority achieving alaryngeal speech. Perioperative complications were more prevalent in the salvage TL group. Recurrence and survival are significantly associated with comorbidity status.Level of Evidence4 Laryngoscope, 130:2179–2185, 2020

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Optimizing Survival Predictions of Hypopharynx Cancer: Development of a Clinical Prediction Model

\nCoralie R. Arends, \nJapke F. Petersen, \nVincent Noort, \nAdriana J. Timmermans, \nC. René Leemans, \nRemco Bree, \nMichiel W.M. Brekel, \nMartijn M. Stuiver\n

Publicatie 14-08-2020


ObjectivesTo develop and validate a clinical prediction model (CPM) for survival in hypopharynx cancer, thereby aiming to improve individualized estimations of survival.MethodsRetrospective cohort study of hypopharynx cancer patients. We randomly split the cohort into a derivation and validation dataset. The model was fitted on the derivation dataset and validated on the validation dataset. We used a Coxs proportional hazard model and least absolute shrinkage and selection operator (LASSO) selection. Performance (discrimination and calibration) of the CPM was tested.ResultsThe final model consisted of gender, subsite, TNM classification, Adult Comorbidity Evaluation‐27 score (ACE27), body mass index (BMI), hemoglobin, albumin, and leukocyte count. Of these, TNM classification, ACE27, BMI, hemoglobin, and albumin had independent significant associations with survival. The C Statistic was 0.62 after validation. The model could significantly identify clinical risk groups.ConclusionsACE27, BMI, hemoglobin, and albumin are independent predictors of overall survival. The identification of high‐risk patients can be used in the counseling process and tailoring of treatment strategy or follow‐up.Level of Evidence4 Laryngoscope, 130:2166–2172, 2020

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Elevated Troponin: A Marker for Noncardiac Complications After Resection of Head and Neck Cancers

\nTobial McHugh, \nHan Zhang, \nMichael Xie, \nMichael K. Gupta\n

Publicatie 14-08-2020


ObjectiveTo examine if troponin positivity (TP) in patients who undergo head and neck cancer mucosal resections (HNS) predicts noncardiac complications (NCC).BackgroundMajor HNSs are arduous operations that place stress on the patients hemodynamic system. TP after noncardiac surgery previously has been shown in up to 25% of patients, which may signal cardiac complications (CC) or NCC. Although CC after HNS has been observed, no study has investigated the relationship of TP to NCC.MethodsAll patients who underwent HNS at a tertiary‐care cancer center from July 2014 to July 2016 were included and underwent postoperative troponin measurements as part of an institutional cardiac protocol. Comparative and multivariate regression analysis were used to compare TP and troponin‐negative (TN) patients for NCC.ResultsOne hundred seventy‐two patients underwent HNS. Of those, 15% developed TP during the postoperative period. There was no significant difference between TP and TN for gender, tumor‐node‐metastasis staging, Charlson comorbidity index, and smoking status. Risk of NCC in TP was 73.1% versus 28.1% in TN (P < 0.001). A significant difference (P < 0.05) in wound complications, length of hospital stay (LOHS), and incidence of pneumonia was found between both groups. Nonparametric testing confirmed significant difference in pneumonia (Z = −3.469, P = 0.001) and LOHS (−3.110, P = 0.002). Multivariate regression analysis confirmed a significant difference in LOHS independent of CC (R2 = 0.122, P < 0.0001).ConclusionTP is not an uncommon occurrence after HNS and is associated with statistically significant increases in wound complications, LOHS, and pneumonia. However, the overall significance of these findings remains unclear, and further research is warranted to determine if outcomes may be improved by closely monitoring these patients for TP.Level of Evidence4 Laryngoscope, 130:2148–2152, 2020

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Surgical Treatment of Paranasal Sinus Osteomas: A Single Center Experience of 58 Cases

\nAxel Wolf, \nBettina Safran, \nJakob Pock, \nPeter Valentin Tomazic, \nHeinz Stammberger\n

Publicatie 14-08-2020


ObjectivesOsteomas are osseous tumors that primarily occur at the skull, in particular the paranasal sinus system. Surgical tumor resection is the “gold standard” treatment in symptomatic osteomas. The aim of this study was to investigate the use of surgical approaches (endoscopic, open, combined) and to provide a step‐by‐step approach for patients’ management.MethodsFifty‐eight patients (31 m, 27 f, 42.1 ± 15.3 years) that were treated between 2001 and 2015 at our department were included in this retrospective, single center study.ResultsIn almost half of cases (n = 28, 48.3%) endoscopic, endonasal approaches were used for tumor resection while open (n = 11, 19%) or combined (n = 19, 32.8%) approaches were used in the rest of the cohort. Open or combined approaches were applied in patients suffering from osteomas localized in the maxillary or frontal sinuses only.ConclusionBeside interviews, clinical examination, nasal endoscopy, and computed tomography are crucial for diagnosis of paranasal sinus osteomas. Magnet resonance imaging can be useful in extensive pathologies. The preoperative selection of the optimal approach for osteoma resection might be most challenging in patients’ management. Although useful recommendations regarding the use of surgical approaches have been published, technical requirements and surgical experience of surgeons have to be considered in the limitations of endoscopic approaches. If there are doubts about the resectability of an osteoma by an endoscopic approach, the surgical procedure may be started endoscopically, and, if necessary, it can be combined with an external approach.Level of EvidenceIV Laryngoscope, 130:2105–2113, 2020

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Increased Expression of Estrogen Receptor Beta in Idiopathic Progressive Subglottic Stenosis

\nEdward J. Damrose, \nRoss David Campbell, \nSonja Darwish, \nElizabeth Erickson‐DiRenzo\n

Publicatie 14-08-2020


Background/ObjectivesIdiopathic progressive subglottic stenosis (IPSS) predominantly affects females in perimenopause. It has, therefore, been hypothesized that estrogen is involved in its pathogenesis. There are two main types of estrogen receptors: ER‐α and ER‐β. Abnormal variants of ER‐β have previously been shown to be associated with poor wound healing. Estrogen receptors have recently been identified in subglottic tissue samples, with elevated levels of ER‐α and progesterone receptors, and no expression of ER‐β, in stenotic specimens reported in one study. The objective of this study was to confirm the presence of estrogen receptors in the subglottis and investigate levels of expression and types of estrogen receptors in normal and stenotic subglottic tissue.MethodsSubglottic tissue was obtained from three female and one male cadaver without laryngotracheal pathology to serve as controls. Subglottic tissue specimens from five female patients with IPSS were also analysed. Immunofluorescence stains for ER‐α and ER‐β were performed on specimens. Staining patterns were compared qualitatively and semi‐qualitatively between control and IPSS specimens.ResultsImmunofluorescence stains demonstrated the presence of both ER‐α and ER‐β in subglottic tissue. IPSS specimens demonstrated significantly greater staining intensity of ER‐α in the epithelium and ER‐β in glands and ducts compared to controls.ConclusionsThis study confirms the presence of estrogen receptors in the subglottis. Increased expression of ER‐α in the epithelium and ER‐β in glands and ducts in IPSS compared to controls may help to explain the predisposition to stenosis in these individuals.Level of Evidence3b Laryngoscope, 130:2186–2191, 2020

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Effect of Vocal Fold Implant Placement on Depth of Vibration and Vocal Output

\nSimeon L. Smith, \nIngo R. Titze, \nClaudio Storck, \nTed Mau\n

Publicatie 14-08-2020


ObjectiveMost type 1 thyroplasty implants and some common injectable materials are mechanically stiff. Placing them close to the supple vocal fold mucosa can potentially dampen vibration and adversely impact phonation, yet this effect has not been systematically investigated. This study aims to examine the effect of implant depth on vocal fold vibration and vocal output.Study DesignComputational simulation.MethodsVoice production was simulated with a fiber‐gel finite element computational model that incorporates a three‐layer vocal fold composition (superficial lamina propria, vocal ligament, thyroarytenoid muscle). Implants of various depths were simulated, with a “deeper” or more medial implant positioned closer to the vocal fold mucosa and replacing more muscle elements. Trajectories of surface and within‐tissue nodal points during vibration were produced. Outcome measures were the trajectory radii, fundamental frequency ( F 0), sound pressure level (SPL), and smoothed cepstral peak prominence (CPPS) as a function of implant depth.ResultsAmplitude of vibration at the vocal fold medial surface was reduced by an implant depth of as little as 14% of the total transverse vocal fold depth. Increase in F 0 and decrease in CPPS were noted beyond 30% to 40% implant depth, and SPL decreased beyond 40% to 60% implant depth.ConclusionsCommonly used implants can dampen vibration “from a distance,” ie, even without being immediately adjacent to vocal fold mucosa. Since implants are typically placed at depths examined in this study, stiff implants likely have a negative vocal impact in a subset of patients. Softer materials may be preferable, especially in bilateral medialization procedures.Level of EvidenceN/A Laryngoscope, 130:2192–2198, 2020

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Direct‐To‐Consumer Advertising of Over‐the‐Counter Sinonasal Remedies: A History of Mixed Messages

\nEdward D. McCoul\n

Publicatie 14-08-2020


Sinus, cold, and allergy remedies comprise the most widely used sector of the over‐the‐counter (OTC) drug market. Direct‐to‐consumer advertising (DTCA) of pharmaceutical products has increased over the past 30 years, including the promotion of OTC drugs. The influence of DTCA on OTC sinonasal remedies comprises several positive and negative effects. Favorable aspects of this influence include empowerment and promotion of autonomy among patients, avoidance of low‐value clinical encounters, self‐directed education, and decreased healthcare expenditures. This is balanced by potential concerns, including the lack of rigorous regulation of OTC drugs, the burden of self‐diagnosis, the risk of unsupervised use resulting in adverse effects or drug interactions, and redistribution of pharmacy costs to the consumer. Despite the proliferation of product options and consumer‐directed information, healthcare utilization and cost of treating sinonasal disease remains high. Moreover, the availability of OTC sinonasal remedies and exposure to DTCA has had mixed effects without apparent overall benefit to patient and consumer health. Laryngoscope, 130:2114–2119, 2020

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Risk Factors Affecting Length of Stay in Patients with Deep Neck Space Infection

"\nKaitlin July OBrien, \nKaitlin R. Snapp, \nAdam J. Dugan, \nPhilip M. Westgate, \nNikita Gupta\n"

Publicatie 14-08-2020


ObjectivesAnalyze risk factors affecting length of stay (LOS) for patients presenting with deep neck space infections including care by medical versus surgical team.MethodsThis is a retrospective chart review from January 2005 through May 2018 at the University of Kentucky analyzing factors related to deep neck space abscesses. Patients included adults >18 years old admitted for deep neck space infections undergoing surgical intervention. This study compared effects of treatment on a medical versus surgical service on LOS while accounting for patient confounders. Independent variables included age, gender, tobacco use, medical comorbidities, Charlson comorbidity index, American Society of Anesthesiology (ASA) classification, presence of drain, readmissions, and repeat surgical interventions. Univariate and multivariate analysis were performed.ResultsOne hundred sixty‐three patients were included in the analysis. LOS was significantly longer for those on medicine services (P < .001). Patients on medicine services had a higher incidence of diabetes (P = .011), higher Charlson comorbidity score (P = .001), and higher incidence of repeat interventions (P = .005). Postoperative LOS remained lower for patients on a surgical service (P = .009) after adjusting for Charlson comorbidity scores. Presence of a drain or tobacco use was not significant between service management (P = .89; P = .63) or LOS (P = .366; P = .225).ConclusionIncreased postoperative LOS was associated with age, diabetes, ASA class, Charlson comorbidity index, and repeat procedures. Patients on a medicine service had longer LOS and higher comorbidity indices. Patients had shorter hospital stays on surgical services after adjusting for comorbidity indices. Use of a drain or presence of tobacco use did not affect LOS.Level of Evidence3 Laryngoscope, 130:2133–2137, 2020

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Gastrostomy Utilization by Oropharyngeal Cancer Patients Is Partially Driven by Swallowing Function

\nKarishma Chhabria, \nSagar Kansara, \nHoda Badr, \nCarol Stach, \nMadeline Vernese, \nAllison Lerner, \nAaron Harms, \nDavid J. Hernandez, \nAndrew T. Huang, \nGeorge Chen, \nRobert B. Parke, \nScott Charnitsky, \nVlad C. Sandulache\n

Publicatie 14-08-2020


ObjectiveOropharyngeal squamous cell carcinoma (OPSCC) incidence is rapidly increasing, as are survival rates, in large part due to the human papillomavirus (HPV). Treatment intensity, however, has remained unchanged, making treatment‐related toxicity (i.e., dysphagia) a critical problem for an increasing number of patients. The primary objective of this study was to determine whether pretreatment objective swallowing measures can predict percutaneous fluoroscopic guided gastrostomy tube (PFG) utilization during OPSCC treatment.MethodsForty‐one newly diagnosed OPSCC patients treated with radiation underwent evaluation of swallow function with modified barium swallow study (MBSS) prior to and at completion of radiation treatment using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST); a subset of patients were evaluated using the MD Anderson Dysphagia Inventory (MDADI).ResultsPatients were male (100%), primarily Caucasian (85.4%) and p16 positive (85.4%) with mean age of 65.7 years. PFG were placed in 70.7% patients (n = 29) and used by 63.4% (n = 26). Pre‐ and post‐treatment DIGEST scores were associated with T‐classification (t = −2.9, p = .001, t = −2.7, p = .01) and indicated deteriorating swallow function during treatment (mean change = 0.46 t = −2.7, p = .01). DIGEST and MDADI scores were generally not associated with patient PFG utilization. DIGEST and MDADI scores were significantly correlated prior to, but not following completion of treatment.ConclusionPre‐treatment DIGEST and patient reported swallowing outcomes (MDADI) can be useful in identifying patients with unsafe and/or grossly inefficient swallowing function. However, objectively measured swallow function was not associated with PFG utilization. Development of PFG placement algorithms (reactive vs. prophylactic) therefore require additional inputs/metrics.Level of Evidence4 Laryngoscope, 130:2153–2159, 2020

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Obstructive Sleep Apnea: Do Positional Patients Become Nonpositional Patients With Time?

\nArie Oksenberg, \nVlada Goizman, \nEdith Eitan, \nKitham Nasser, \nNatan Gadoth, \nTimo Leppänen\n

Publicatie 14-08-2020


ObjectivesObstructive sleep apnea (OSA) patients with breathing abnormalities only or mainly in the supine posture are designated positional patients (PPs), whereas nonpositional patients (NPPs) have many breathing abnormalities in both lateral and supine postures. Positional therapy (PT), the avoidance of the supine posture during sleep, is the obvious treatment for PPs. The stability over time of being PP and leading factors that are involved in converting a PP to an NPP are addressed.MethodsWe analyzed polysomnographic (PSG) recordings of 81 consecutive adult patients with OSA who were judged to be PPs at the first PSG evaluation, and their follow‐up PSGs were obtained after an average period of 6.6 years.ResultsThe follow‐up PSGs indicated that 57 PPs (70.4%) remained PPs, whereas 24 (29.6 %) converted to NPPs. Among PPs and NPPs, body mass index (P ≤ 0.05), overall Apnea–Hypopnea Index (AHI, P ≤ 0.087), and lateral AHI (P ≤ 0.046) increased and minimum SpO2 during rapid eye movement (REM) sleep (P ≤ 0.028) decreased significantly during the follow‐up. However, among patients who became NPPs, the changes in these parameters were significantly (P ≤ 0.05) more pronounced compared to the patients who remained PPs.ConclusionAfter an average of 6.6 years, 70.4% of PPs remained PPs. Therefore, if adherence for PT is good, they could continue to benefit from this therapy. For those who turned to NPPs, PT will not be the optimal treatment anymore; thus, these patients should be frequently monitored. Furthermore, an early treatment of PPs with PT would be highly beneficial to prevent worsening of their OSA.Level of Evidence2b Laryngoscope, 130:2263–2268, 2020

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Metformin Effects on FOXP3+ and CD8+ T Cell Infiltrates of Head and Neck Squamous Cell Carcinoma

\nDev Amin, \nTony Richa, \nMehri Mollaee, \nTingting Zhan, \nPatrick Tassone, \nJennifer Johnson, \nAdam Luginbuhl, \nDavid Cognetti, \nUbaldo Martinez‐Outschoorn, \nRobert Stapp, \nCharalambos Solomides, \nUlrich Rodeck, \nJoseph Curry\n

Publicatie 14-08-2020


ObjectivesAlterations of cellular metabolism have been implicated in immune dysfunction in the tumor microenvironment (TME) of head and neck squamous cell carcinoma (HNSCC). Metformin has recently emerged as a candidate of interest for combination with immunotherapy in HNSCC. This study investigated the effect of metformin on immune cell infiltrates of HNSCC.MethodsRetrospective analysis of T cell infiltrates in primary tumor specimens from patients enrolled in a clinical window of opportunity trial of presurgical metformin. Metformin was titrated to a standard diabetic dose (2000 mg/day) for a minimum of 9 days (mean 13.6 days) prior to surgical resection. Pre and posttreatment surgical specimens from 36 patients (16 HPV+, 20 HPV−) were comparatively analyzed. FOXP3+ and CD8+ immune cell infiltrates in the tumor and peritumoral stroma of pre and posttreatment HNSCC specimens were quantified by digital image analysis using Visiopharm software.ResultsMetformin treatment was associated with a 41.4% decrease in FOXP3+ T cells in intratumor regions of interest (P = .004) and a 66.5% increase in stromal CD8+ T cells at the leading edge of the tumor (P = .021) when compared to pretreatment biopsies. This was reflected in increased CD8+/FOXP3+ cell ratios within the tumor (P < .001) and stromal compartments (P < .001). The effects of metformin occurred independently of HPV status.ConclusionMetformin treatment may favorably alter the immune TME in HNSCC independent of HPV status.Level of Evidence1b. This study is most accurately described as a non‐randomized controlled trial and therefore may reflect a level of evidence below 1b but above 2a from the provided “levels of evidence” chart. Laryngoscope, 130:E490–E498, 2020

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Peak Sinus Pressures During Sneezing in Healthy Controls and Post–Skull Base Surgery Patients

\nZhenxing Wu, \nJohn R. Craig, \nGuillermo Maza, \nChengyu Li, \nBradley A. Otto, \nAlexander A. Farag, \nRicardo L. Carrau, \nKai Zhao\n

Publicatie 14-08-2020


Objectives/HypothesisPatients are frequently advised to sneeze with an open mouth and avoid nose‐blowing following an endoscopic endonasal approache (EEA) to the skull base, despite a lack of quantitative evidence. This study applies computational fluid dynamics (CFD) to quantify sinus pressures along the skull base during sneezing.Study DesignCase–control series.MethodsComputed tomography or magnetic resonance imaging scans of four post‐EEA patients and four healthy controls were collected and analyzed utilizing CFD techniques. A pressure drop of 6,000 Pa was applied to the nasopharynx based on values in the literature to simulate expiratory nasal airflow during sneezing. Peak pressures along the skull base in frontal, ethmoid, and sphenoid sinuses were collected.ResultsSignificant increases in skull base peak pressure was observed during sneezing, with significant individual variations from 2,185 to 5,685 Pa. Interestingly, healthy controls had significantly higher pressures compared to post‐EEA patients (5179.37 ± 198.42 Pa vs. patients 3,347.82 ± 1,472.20 Pa, P < .05), which could be related to higher anterior nasal resistance in unoperated healthy controls (0.44 ± 0.22 vs. 0.31 ± 0.16 Pa/mL/sec for patients, P = .38). The sinus pressure buildup may be due to airway resistance functioning as a valve preventing air from being released quickly. Supporting this theory, there was a strong correlation (r = 0.82) between peak skull base pressure and the ratio of anterior resistance to total resistance. Within‐subject variation in pressures between different skull base regions was much lower (average = ~5%).ConclusionsThis study provided the first quantitative analysis of air pressure along the skull base during sneezing in post‐EEA patients through CFD, suggesting that pressure buildup may depend on individual anatomy.Level of Evidence3b Laryngoscope, 130:2138–2143, 2020

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Reporting of Clinical Trial Interventions Published in Leading Otolaryngology–Head and Neck Surgery Journals

\nTrevor Torgerson, \nAustin L. Johnson, \nSam Jellison, \nMargo Tanghetti, \nJean‐Maria Langley, \nLily H. P. Nguyen, \nMatt Vassar\n

Publicatie 14-08-2020


Objectives/HypothesisRandomized controlled trials (RCTs) play a crucial role in advancing patient care within otolaryngology–head and neck surgery (OTL‐HNS), yet studies have shown the reporting of these trials needs improvement. Here, we evaluate the completeness of intervention reporting of RCTs in OTL‐HNS and evaluate whether the publication of the Template for Intervention Description and Replication (TIDieR) checklist has influenced intervention reporting.Study DesignRetrospective Cross‐Sectional Analysis.MethodsWe searched PubMed for RCTs published in top OTL‐HNS journals in two cohorts, one before the release of the TIDieR and one afterward. A sample of 300 RCTs was randomly selected and screened for inclusion. Once the dataset was finalized, we extracted trial characteristics and assessed each trials adherence to the TIDieR checklist. We then used descriptive characteristics, a generalized estimated equation, time‐series analysis, and a two‐sample t test to analyze our data.ResultsAfter screening was completed, 173 RCTs were included in our analysis. Of these RCTs, 103 (59.5%) showed <60% adherence to the TIDieR checklist. We found a slight increase in adherence to TIDieR items after the checklist was released, although this was not statistically significant (P = .91). In addition, we found that trials with a crossover study design or multiple interventions and those that provided a Consolidated Standards for Reporting Trials statement were associated with greater adherence to the TIDieR checklist.ConclusionsThe majority of OTL‐HNS RCTs included in our analysis showed suboptimal reporting factors related to the TIDieR checklist. Requiring a TIDieR statement and automating the journal requirements process for all OTL‐HNS clinical trials would be a worthwhile, efficient approach to improving research quality and ultimately patient care within OTL‐HNS.Level of EvidenceNA Laryngoscope, 130:E507–E514, 2020

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Esophageal Manometry, pH Testing, Endoscopy, and Videofluoroscopy in Patients With Globus Sensation

\nDouglas J. Van Daele\n

Publicatie 14-08-2020


Objectives/HypothesisCombine techniques commonly employed in the clinical workup of patients with isolated globus sensation to identify the most common pharyngoesophageal abnormality. The primary aim was to retrospectively review high‐resolution manometry, pH probe testing, contrast videofluoroscopy, and endoscopy studies in patients with a primary complaint of globus sensation. The specific hypothesis was esophageal high‐resolution manometry identifies the most significant proportion of abnormalities compared to all other modalities.Study DesignRetrospective cohort study.MethodsAn inclusive retrospective chart review was performed for patients evaluated between 2009 and 2016 with the primary complaint of globus sensation. Age at testing, self‐identified gender, associated diagnoses, and results from each modality were collected. Descriptive statistics and pairwise comparisons were performed as well as sensitivity and specificity calculations.ResultsOne hundred seventy‐two patients met inclusion criteria. The cohort had an age range of 22.7 to 88.5 years and was predominantly female. Esophageal manometry identified abnormalities in 62.8% of patients, and pH testing identified abnormal acidification in approximately 20%. The esophagram identified abnormalities in 24% of patients, and esophagogastroduodenoscopy identified abnormalities in 22%. Modified barium swallows were normal in 93% of patients. Measures of sensitivity and specificity of other modalities were poor compared to esophageal manometry and pH testing.ConclusionsPatients with isolated globus sensation have evidence of esophageal dysmotility and laryngopharyngeal and gastroesophageal reflux disease in high proportions. Esophageal high‐resolution manometry testing identifies the greatest proportion of abnormalities of the investigated modalities.Level of Evidence4 Laryngoscope, 130:2120–2125, 2020

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Gender Trends in Authorship of Original Otolaryngology Publications: A Fifteen‐Year Perspective

\nAnnie E. Arrighi‐Allisan, \nDevki C. Shukla, \nAnnika M. Meyer, \nSarah M. Kidwai, \nSharon H. Barazani, \nMaura K. Cosetti, \nMarita S. Teng\n

Publicatie 14-08-2020


ObjectiveTo examine trends in female author representation within original otolaryngology research between 2000 and 2015.MethodsOriginal research articles published in 11 otolaryngology journals were analyzed for 2000, 2003, 2006, 2009, 2012, and 2015. The genders of the first and last authors for each article were recorded. Overall female authorship was calculated by summing the numbers of the first, last, and both first and last female‐authored articles. Student t test and Cochran‐Armitage trend test were utilized to determine significance between years and groups.ResultsOf the 9,623 research articles published during 5 representative years, 223 were excluded due to one or more gender‐indeterminate authors. Female first authorship exhibited a significant upward trend from 2000 to 2015 (P < 0.0001), as did the proportion of literature with female first and last authors (P < 0.0001). Although female senior authorship in literature with an impact factor (IF) greater than 2 did not increase significantly (10.0% in 2000 to 10.1% in 2015; P = 0.738), this metric did increase significantly just within journals with an IF between 1 and 2 (9.7%–12.3%, P = 0.036). The proportion of articles with a female author in the first, last, or both positions increased from 28% to 39% (P < 0.0001).ConclusionIncreasing female representation in otolaryngology literature may reflect the rising proportion of women within otolaryngology as well as greater mentorship availability. Despite these auspicious strides, female‐authored articles nonetheless represent a smaller proportion of the literature, and female senior authors remain a stark minority. Future studies should identify the barriers to female access and advancement within the field.Level of EvidenceIII Laryngoscope, 130:2126–2132, 2020

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Respiratory Epithelial Adenomatoid Hamartoma is Frequent in Olfactory Cleft After Nasalization

\nDuc Trung Nguyen, \nRoger Jankowski, \nAyoub Bey, \nGuillaume Gauchotte, \nJean Matthieu Casse, \nPedro Augusto Gondim Teixeira, \nPatrice Gallet, \nCécile Rumeau\n

Publicatie 14-08-2020


ObjectivesTo assess the site and histopathology of polyps at the first revision surgery for recurrent nasal polyposis (NP) after radical ethmoidectomy (nasalization).Study DesignRetrospective study.MethodsBetween January 2008 and December 2015, a total of 62 patients having undergone revision surgery for recurrent NP after nasalization were included. The site and histology of the recurrence of polyps were analyzed according to operative and pathological reports.ResultsHistology showed classical inflammatory nasal polyps (CINP) in 91% of nasal cavities at primary surgery versus respiratory epithelial adenomatoid hamartoma (REAH) or REAH associated to CINP in 54.8% at revision surgery (P < .0001). Polyps were principally observed in the ethmoidal complex in 70% of nasal cavities during primary surgery and in the olfactory clefts in 88.7% during revision surgery (P < .0001). The mean interval between nasalization and first revision surgery was 8.8 ± 4.4 years (0.4–21.7 years). This interval was significantly shorter for grade 3 polyps, polyps removed from both ethmoidal complex and olfactory cleft at primary surgery, association of CINP and REAH at primary surgery, and when primary surgery had preserved the middle turbinates.ConclusionPolyp recurrences after nasalization were mainly observed in the olfactory clefts and can be different histological features: inflammatory polyps, respiratory epithelial adenomatoid hamartoma, or a combination of both.Level of Evidence4 Laryngoscope, 130:2098–2104, 2020

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"Risk of Alzheimers Disease in Obstructive Sleep Apnea Patients With or Without Treatment: Real‐World Evidence"

\nMing‐Shao Tsai, \nHsueh‐Yu Li, \nChung‐Guei Huang, \nRobert Y.L. Wang, \nLi‐Pang Chuang, \nNing‐Hung Chen, \nChi‐Hung Liu, \nYao‐Hsu Yang, \nChia‐Yen Liu, \nCheng‐Ming Hsu, \nWen‐Nuan Cheng, \nLi‐Ang Lee\n

Publicatie 14-08-2020


ObjectiveTo assess the risk of Alzheimers disease (AD) in patients with obstructive sleep apnea (OSA) with or without treatment based on real‐world evidence.Study DesignRetrospective cohort study.MethodsPatients newly diagnosed with OSA during 1997–2012 were identified using the National Health Insurance Research Database of Taiwan. Patients without OSA were randomly selected and matched in a 1:4 ratio by age, sex, urbanization level, and income. All patients were followed up until death or the end of 2013. The primary outcome was AD occurrence.ResultsThis study included 3,978 OSA patients and 15,912 non‐OSA patients. OSA was independently and significantly associated with a higher incidence of AD in an adjusted Cox proportional hazard model (adjusted hazard ratio: 2.12; 95% confidence interval CI, 1.27–3.56). The average period of AD detection from the time of OSA occurrence was 5.44 years (standard deviation: 2.96). Subgroup analyses revealed that the effect of OSA remained significant in patients aged ≥60 years, male subgroups, patients without CPAP or surgical treatment, and patients without pharmacological therapies. Patients with OSA who received treatment (continuous positive airway pressure or surgery) exhibited a significantly reduced risk of AD compared with those without treatment (incidence rate ratio 0.23, 95% CI, 0.06–0.98).ConclusionOSA is independently associated with an increased risk of AD. Treatment for OSA reduces the AD risk in OSA patients. AD irreversibility renders OSA as a potential modifiable target for slowing or preventing the process of AD development.Level of EvidenceIV Laryngoscope, 130:2292–2298, 2020

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Impact of Obesity and Obstructive Sleep Apnea in Lateral Skull Base Cerebrospinal Fluid Leak Repair

\nKristen L. Yancey, \nNauman F. Manzoor, \nPatrick D. Kelly, \nRobert J. Yawn, \nMatthew O’Malley, \nAlejandro Rivas, \nDavid S. Haynes, \nMarc L. Bennett\n

Publicatie 14-08-2020


ObjectiveTo investigate the prevalence and impact of obstructive sleep apnea (OSA) and obesity in lateral skull base cerebrospinal fluid leak repair (LSBR) of various etiologies.MethodsRetrospective case review at a tertiary skull base center was conducted of consecutive adults undergoing LSBR via transmastoid, middle cranial fossa, or combined approach between 2013–2018. The following data were collected: demographics, comorbidities, radiology and intraoperative findings, and surgical outcomes including complications and need for revision surgery or shunt placement. Patients with incomplete data or leaks following skull base surgery, trauma or chronic ear disease were excluded.ResultsNinety‐four patients (67.4% female, mean age 53.5 ± 12.9 years) underwent repair forspontaneous (sCSFL, 44%) and other etiology (nsCSFL) leaks. nsCSFL served as a comparisongroup consisting of leaks status‐post lateral skull base surgery, temporal bone fractures, andchronic ear disease. Class III obesity (P = .02), OSA (P = .03), and imaging findings of empty sella (OR = 3.32, P = .02), and skull base thinning including contralateral tegmen thinning (31%, OR = 4.3, P = .02), arachnoid granulations (26%, OR = 4.35, P = .02), and superior canal dehiscence (15.8%, OR = 8.57, P = .04) were more common in sCSFL. Four patients (4.2%) required surgical revision for recurrence, and another four (4.2%) resolved with shunting. Evidence of elevated intracranial hypertension was present in nine patients with sCSF leaks and was predictive of need for revision or shunt procedures (P < .01).ConclusionObesity, OSA, and imaging consistent with elevated intracranial pressures were more common among patients with sCSFL. Elevated intracranial pressure predicted outcomes following multilayer repair of spontaneous CSF leaksLevel of Evidence4 Laryngoscope, 130:2234–2240, 2020

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Hypoglossal Nerve Stimulation in Veterans with Obstructive Sleep Apnea

\nKathleen M. Sarber, \nKatherine W. Chang, \nMadison V. Epperson, \nMeredith E. Tabangin, \nMekibib Altaye, \nStacey L. Ishman, \nReena Dhanda Patil\n

Publicatie 14-08-2020


ObjectivesThe hypoglossal nerve stimulator (HNS) is an effective treatment for obstructive sleep apnea (OSA) in a relatively healthy subset of the population. Our aim was to determine the efficacy of HNS in a veteran population with a high incidence of chronic disease and mental health disorders. Our secondary aim was to compare subjective outcomes and adherence between veterans with and without mental health disorders.MethodsWe included all patients who underwent HNS at our institution to date. Veterans were divided into two groups based on whether or not they carried a diagnosis of anxiety, depression, and/or post‐traumatic stress disorder. Demographics, comorbidities, previous OSA treatments, adverse events, and adherence to therapy were recorded. Baseline and treatment outcome data were collected and analyzed including polysomnographic parameters, Epworth sleepiness scale score (ESS), and body mass index.ResultsThirty‐one patients were identified: 93.5% male, median age = 63.0 years. Median apnea hypopnea index (AHI) decreased from 30.0 to 3.0 events/hour (P < .001) and median ESS dropped from 11.0 to 6.5 (P < .001). There was no difference between groups with regard to change in AHI or ESS (P = .31 and .61). Twenty‐six (89.7%) patients achieved surgical success (decrease in AHI > 50% and AHI < 20 events/hour) and 21 (72.4%) had AHI < 5 events/hour. The mean device usage was 5.4 hours/night which was not significantly different between groups (P = .55).ConclusionOur cohort exhibited similar declines in AHI and ESS compared to published studies with adequate adherence to HNS. There were no significant differences in ESS or adherence to therapy between veterans with and without mental health disorders.Level of Evidence4 Laryngoscope, 130:2275–2280, 2020

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Social Determinants of Health and Oral Cavity Cancer Treatment and Survival: A Competing Risk Analysis

\nPratima Agarwal, \nRavi R. Agrawal, \nEric A. Jones, \nAnand K. Devaiah\n

Publicatie 14-08-2020


ObjectiveCompeting risk analysis is a powerful assessment for cancer risk factors and covariates. This method can better elucidate insurance status and other social determinants of health covariates in oral cavity cancer treatment, survival, and disparities.Study DesignRetrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) database.MethodsData regarding patient characteristics, clinical stage at diagnosis, treatment, and survival data for 20,271 patients diagnosed with oral cavity cancer was extracted from the SEER 18 Regs Research Data including Hurricane Katrina Impacted Louisiana Cases from 1973 to 2014. All statistical analyses were performed using SAS 9.5 (SAS Institute Inc., Cary, NC). The Fine‐Gray method for assessing impact, risk, and covariates was employed.ResultsMedicaid patients presented with later stage disease, larger tumor size, more distant metastases, and more lymph node involvement at diagnosis compared to insured patients. Medicaid patients were less likely to receive cancer‐directed surgery. Medicaid status was also associated with worse cancer‐specific survival (subhazard ratios 1.87, 95% confidence interval 1.72–2.04, P < .0001) after adjustment for all covariates.ConclusionThis is the first study examining specifically how Medicaid status and social determinants of health covariates impact oral cavity cancer treatment and outcomes and is the first using methods validated for complex covariates. Patients with Medicaid present with more extensive oral cavity disease burden are less likely to receive definitive therapy and have significantly worse overall survival than those with other forms of insurance. This better identifies disparities and the need for improving health literacy, specifically for the at‐risk Medicaid population, and can guide clinicians.Level of EvidenceNA Laryngoscope, 130:2160–2165, 2020

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Long‐term Complications of Palate Surgery: A Multicenter Study of 217 Patients

\nKenny P. Pang, \nClaudio Vicini, \nFilippo Montevecchi, \nOttavio Piccin, \nSudipta Chandra, \nHyung C. Yang, \nVikas Agrawal, \nJoseph C. K. Chung, \nYiong H. Chan, \nScott B. Pang, \nKathleen A. Pang, \nEdward B. Pang, \nBrian Rotenberg\n

Publicatie 14-08-2020


Objectives/HypothesisTo investigate long‐term complications of newer reconstructive palate surgery techniques.Study DesignRetrospective case‐series analysis.MethodsRetrospective six‐country clinical study of OSA patients who had nose and palate surgery.ResultsThere were 217 patients, mean age = 43.9 ± 12.5 years, mean body mass index = 25.9 ± 4.7, mean preoperative apnea‐hypopnea index AHI = 30.5 ± 19.1, follow‐up 41.3 months. A total of 217 palatal procedures were performed, including 50 expansion sphincter pharyngoplasties (ESP), 34 functional expansion pharyngoplasties (FEP), 40 barbed reposition pharyngoplasties (BRP), 64 modified uvulopalatopharyngoplasties (mUPPP), 11 uvulopalatal flap procedures (UPF), nine suspension pharyngoplasties (SP), eight relocation pharyngoplasties (RP), and one z‐pharyngoplasty (ZPP). Complications included were constant and/or felt twice per week; dry throat (7.8%), throat lump feeling (11.5%), throat phlegm (10.1%), throat scar feeling (3.7%), and difficulty swallowing (0.5%). Of the 17 patients who had a dry throat complaint, two were constant (one SP, one RP), 15 were occasional (10 mUPPP, three SP, two BRP). Of the 25 patients with the throat lump feeling, four were constant (three RP, one ZPP), 21 were occasional (10 mUPPP, five SP, five UPF, one BRP). Of the 22 patients with the throat phlegm feeling, four were constant (two SP, two RP), 18 were occasional (10 mUPPP, four BRP, two FEP, two SP). Of the eight patients with throat scar feeling, eight were occasional (four SP, two mUPPP, one FEP, one RP), none were constant. One patient had difficulty swallowing (RP procedure). There was no velopharyngeal incompetence, taste disturbance, nor voice change. Highest symptom complaints were mUPPP, SP, and RP, whereas the lowest symptom complaint was ESP.ConclusionsNewer palatal techniques have shown to have less long‐term complications compared to the older ablative techniques.Level of Evidence4 Laryngoscope, 130:2281–2284, 2020

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Thirty‐Day Readmission and Prolonged Length of Stay in Malignant Otitis Externa

\nZachary G. Schwam, \nRocco Ferrandino, \nVivian Z. Kaul, \nGeorge B. Wanna, \nMaura K. Cosetti\n

Publicatie 14-08-2020


ObjectivesTo determine independent risk factors for 30‐day readmission, prolonged length of stay (PLOS), and discharge to a rehabilitation facility for those with malignant otitis externa.MethodsRetrospective cohort study of patients hospitalized with malignant otitis externa (International Classification of Diseases, 9th edition, code 380.14) in the Nationwide Readmissions Database (2013–2014). Overall and disease‐specific complication and mortality data were analyzed using chi‐squared and multivariate analysis.ResultsThere were 1267 cases of malignant otitis externa extracted. A PLOS of ≥8 days (90th percentile) was found in 14.2% (n = 180) of patients, and 13.7% (n = 174) were discharged to a facility. Patients were readmitted within 30 days at a rate of 12.5% (n = 159). The overall rates of uncomplicated and complicated diabetes were found to be 42.1% and 17.8%, respectively. Factors independently associated with PLOS included undergoing a surgical procedure (odds ratio OR 2.08, P < .001), and having central nervous system complications (OR 3.21, P < .001). Independent risk factors for disposition to a facility included nutritional deficiency (OR 1.91, P = .029), PLOS (OR 4.61, P < .001), and age 65–79 years (OR 6.57, P = .001). Readmission was independently linked to PLOS (OR 3.14, P < .001). Diabetes was not an independent risk factor for any outcome.ConclusionsThirty‐day readmission, PLOS, and ultimate discharge to a rehabilitation facility were common and closely intertwined. Despite the classic association between diabetes and malignant otitis externa, diabetes was not an independent risk factor for any of our outcomes.Level of Evidence4 Laryngoscope, 130:2220–2228, 2020

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Management of a Laryngeal Venous Malformation With Nd:YAG Laser and Bleomycin Sclerotherapy

\nSayan Manna, \nAnnika Meyer, \nTomoyoshi Shigematsu, \nAlejandro Berenstein, \nMark Courey\n

Publicatie 14-08-2020


Literature describing neodymium:yttrium‐aluminum‐garnet (Nd:YAG) photocoagulation and sclerotherapy for laryngeal venous malformations (VMs) is sparse. Here we present a case in which an extensive laryngeal VM in a 28‐year‐old female was managed through a combination of four serial Nd:YAG laser photocoagulation sessions and four bleomycin injections over the course of 2 years. The treatment plan resulted in resulted in noticeable lesion ablation, mucosalization, and significant improvement in symptoms. To our knowledge, this case is the first instance of bleomycin injection specifically into a laryngeal VM reported in the English medical literature. Laryngoscope, 130:2199–2201, 2020

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Management of Benign Paroxysmal Positional Vertigo in an Adult With Severe Osteogenesis Imperfecta

\nCarrie W. Hoppes, \nBrooke N. Klatt, \nPamela M. Dunlap, \nBeth Jacks, \nSusan L. Whitney\n

Publicatie 14-08-2020


The purpose of this case report was to describe the evaluation and management of atypical benign paroxysmal positional vertigo (BPPV) in an adult with severe osteogenesis imperfecta. A 29‐year‐old male was referred to a physical therapist with extensive experience in vestibular rehabilitation who provided horizontal canal BPPV treatment with a canalith repositioning maneuver over two treatment sessions. The individuals symptoms had reduced by 65% and his nystagmus during the roll test was reduced. Extreme care is needed to safely reposition individuals living with severe osteogenesis imperfecta, but the repositioning can reduce symptoms and improve quality of life. Laryngoscope, 130:2241–2244, 2020

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Response to Letter to Editor for Islanded Pedicled Nasolabial Flap

\nSwagnik Chakrabarti, \nDevendra K. Gupta\n

Publicatie 14-08-2020


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In Reference to Versatility and Reliability of Islanded Pedicled Nasolabial Flap in Head and Neck Cancer Reconstruction

\nAbhijeet Singh, \nAnand Subash\n

Publicatie 14-08-2020


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Regarding Versatility and Reliability of Islanded Pedicled Nasolabial Flap in Head and Neck Cancer Reconstruction

\nDharma R. Poonia, \nKinjal Mujumdar, \nRajkumar K. Seenivasasgam, \nRajneesh Galwa, \nSP Agrawal\n

Publicatie 14-08-2020


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In Reference to Anosmia and Ageusia: Common Findings in COVID‐19 Patients

\nPranav Ish, \nManas K. Sen, \nNitesh Gupta\n

Publicatie 14-08-2020


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In Reference to Anosmia and Ageusia: Common Findings in COVID‐19 Patients

\nJerome R. Lechien, \nCarlos M. Chiesa‐Estomba, \nNicolas Fakhry, \nTareck Ayad, \nSven Saussez\n

Publicatie 14-08-2020


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In Response to Isolated Anosmia and Ageusia in COVID‐19 With Spontaneous Recovery

\nLuigi A. Vaira, \nGiovanni Salzano, \nGiovanna Deiana, \nGiacomo De Riu\n

Publicatie 14-08-2020


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In Response to: In Reference to Anosmia and Ageusia: Common Findings in COVID‐19 Patients

\nLuigi A. Vaira, \nGiovanni Salzano, \nGiovanna Deiana, \nFrancesco A. Salzano, \nGiacomo De Riu\n

Publicatie 14-08-2020


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Masthead

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Table of contents

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Erratum

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Erratum

Publicatie 14-08-2020


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