Laryngoscope 2022-09-23

The Protective Efficacy of Hesperidin and Thymol on Radiation‐Induced Submandibular Gland Damage

Muhammed Sedat Sakat, Korhan Kılıç, Abdulkadir Sahin, Hilal Kiziltunc Ozmen, Serkan Yıldırım, Esra Egilmez

Publication date 23-09-2022


The purpose of this study was to demonstrate the efficacy of hesperidin and thymol, with their powerful antioxidant and anti-inflammatory properties, in preventing radiotherapy-related submandibular gland damage using biochemical, histopathological, and immunohistochemical methods. To our knowledge, this is the first study in the literature in this field.
Objective The purpose of this study was to employ biochemical, histopathological, and immunohistochemical methods to reveal the effectiveness of hesperidin and thymol in preventing radiotherapy-associated submandibular gland injury.
MethodsA total of 48 female Sprague Dawley rats were randomly assigned into six groups of eight animals each. Group 1 represented the control group. Group 2 was regarded as hesperidin Group, and the rats received only hesperidin. Group 3 was regarded as thymol Group, and the rats received only thymol. Group 4 was regarded as a Radiotherapy Group, and the rats were exposed to radiotherapy at a dose of 15 Gy. Group 5 was regarded as hesperidin + Radiotherapy Group, and rats received hesperidin at a dose of 100 mg/kg daily for 1 week prior to radiotherapy exposition. Group 6 was regarded as thymol + Radiotherapy Group, and rats received thymol at a dose of 100 mg/kg daily for 1 week prior to radiotherapy exposition. Rats were sacrificed after radiotherapy and submandibular glands were dissected for biochemical and immunohistochemical evaluations.
Results We have shown that, thanks to their strong antioxidant and anti-inflammatory properties, hesperidin and thymol minimize the damage caused by radiation toxicity by decreasing oxidant levels and increasing antioxidant enzyme levels in the submandibular gland. We found that thymol showed more protective activity than hesperidin in terms of effectiveness on radiation toxicity.
Conclusion Hesperidin and thymol exhibit histopathological, immunochemical, and biochemical protection against radiation-related submandibular gland injury. To our knowledge, this is the first study in the literature in this field.
Level of EvidenceNA Laryngoscope, 2022

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Endoscopic Posterior Costochondral Graft with Cricoid Sutures for a Recurrent Type 3 Laryngeal Cleft

Clare Richardson, Vanessa Masco, Kaalan Johnson

Publication date 23-09-2022


A patient with a multiply recurrent tracheoesophageal fistula (TEF) after type III laryngotracheoesophageal cleft (LTEC) repair underwent endoscopic repair with a posterior costochondral graft (PCCG). The graft was parachuted into place via two sutures placed through the postero-lateral cricoid cartilage, providing a layered, rigid, and secure repair. This represents the first description of an all endoscopic revision LTEC/TEF repair with PCCG.
A patient with a recurrent connection between their trachea and esophagus underwent an endoscopic repair (through the mouth with no incisions) with a graft secured via sutures, which is the first description of fully endoscopic graft placement for this pathology. Laryngoscope, 2022

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Optimal Timing of the Salivary Pepsin Test for the Diagnosis of Laryngopharyngeal Reflux

Jinhong Zhang, Xiaoyu Wang, Jiasen Wang, Jing Zhao, Chun Zhang, Zhi Liu, Jinrang Li

Publication date 23-09-2022


Salivary pepsin testing combined waking, 1 h and 2 h after breakfast and lunch, and 1 h after dinner has almost the same diagnostic value as MTPSPT, and testing at these time points can be an effective method for diagnosing LPR.
Objective To investigate the optimal time point for diagnosing laryngopharyngeal reflux (LPR) through combining 24-h hypopharyngeal-esophageal multichannel intraluminal impedance-pH (24-h HEMII-pH) monitoring and the multi-time point salivary pepsin test (MTPSPT).
Study Design Prospective uncontrolled trial.
Method Patients with and without LPR symptoms were included as the test group and the control group, respectively. The patients in the test group underwent 24-h HEMII-pH and MTPSPT. The results of 24-h HEMII-pH were used as a diagnostic criterion for LPR, and the diagnostic value of salivary pepsin tests performed at different time points was compared by receiver operating characteristic (ROC) analysis.
ResultsA total of 153 patients were included. Based on 24-h HEMII-pH, the positive rate of LPR in the test group of patients was 84.00%. In the control group, only one person (3.57%) had a positive salivary pepsin test result. The area under the curve (AUC) of the MTPSPT was 0.827. In addition, we separately calculated the AUC of the combined salivary pepsin test at different time points, and found good diagnostic value (AUC = 0.799) when the test was combined with the waking, 1 and 2 h after breakfast and lunch, and 1 h after dinner tests. However, when the number of tests were further increased, the diagnostic value did not improve significantly.
Conclusion Salivary pepsin testing combined with waking, 1 h and 2 h after breakfast and lunch, and 1 h after dinner has almost the same diagnostic value as MTPSPT, and testing at these time points can be an effective method for diagnosing LPR.
Level of Evidence3 Laryngoscope, 2022

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Phantosmia May Predict Long‐Term Measurable Olfactory Dysfunction After COVID‐19

Jai‐Sen Leung, Valentina Paz Cordano, Eduardo Fuentes‐López, Antonia Elisa Lagos, Francisco Gustavo García‐Huidobro, Rodrigo Aliaga, Luis Antonio Díaz, Tamara García‐Salum, Erick Salinas, Adriana Toro, Claudio Andrés Callejas, Arnoldo Riquelme, James N. Palmer, Rafael A. Medina, Claudia González G

Publication date 23-09-2022


Olfactory dysfunction following COVID-19 persisted in 29% of the patients after 1 year of infection. Phantosmia at baseline and 1 month were associated with a worse evolution, but their presence may represent ongoing regeneration. Longer follow-up is required in these patients.
Objectives Persistent olfactory dysfunction (OD) after 6 months caused by SARS-CoV-2 infection has been reported with a variable prevalence worldwide. This study aimed to determine the prevalence of long-term OD and identify predisposing factors.
MethodsA prospective cohort study was conducted on 100 adults with COVID-19. Olfactory function was assessed with the University of Pennsylvania Smell Identification Test and a symptom survey at the onset of disease and 30 days later. Patients with persistent quantitative OD at the second assessment were reevaluated after 1 year. Demographic variables, symptoms, and the degree of smell loss were analyzed.
Results Participants included 100 patients. The mean age was 42.2 ± 15.6 years, 55 (55%) were female, and 56 (56%) were outpatients. Baseline smell loss was identified in 75/100 (75%) patients, decreasing to 39/95 (40%) after 1 month, and persisting in 29 patients after 1 year. Phantosmia at baseline was the only risk factor identified for persistent OD after 1 year (relative risk 2.51; 95% confidence interval 1.53–4.12; p < 0.001). Regardless of the outcome in smell function, a significant decline in olfaction was associated with the presence of phantosmia at 1 month (β = −12.39; 95% CI −19.82 to −4.95; p < 0.01).
ConclusionsSARS-CoV-2 (2019–2020 variants) produced a highly frequent OD that persisted in 29% of the patients after 1 year. The presence of phantosmia at baseline and 1 month was associated with a worse evolution, but phantosmia may interfere with the performance in an identification smell test. A longer follow-up is required in these patients.
Level of Evidence2 Laryngoscope, 2022

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Longitudinal Effects of Base of Tongue Concurrent Chemoradiation Therapy in a Pre‐Clinical Model

Peter A. Benedict, Adam Kravietz, Jackie Yang, Efstratios Achlatis, Carina Doyle, Aaron M. Johnson, Gregory R. Dion, Milan R. Amin

Publication date 22-09-2022


We present a clinically relevant animal model quantifying the effects of concurrent chemoradiation therapy (CCRT) on tongue strength and elasticity over time. This study demonstrates an increasing difference in tongue strength over time between control animals and those exposed to CCRT. Tongue elasticity was not significantly affected by CCRT, suggesting that changes in strength may not be caused by fibrosis during the time period studied.
Background/Objectives Base of tongue (BOT) dysfunction is common following oropharyngeal concurrent chemoradiation therapy (CCRT). We present a clinically relevant animal model quantifying the effects of CCRT on tongue strength and elasticity over time.
Methods Fifty-three male and 53 female Sprague–Dawley rats were randomized to control or experimental groups. Experimental animals received cisplatin, 5-fluorouracil, and 5 fractions of 7 Gy directed to the BOT. Controls received no intervention. At 2 weeks, 5 months, or 10 months after CCRT, animals underwent non-survival surgery to measure twitch and tetanic tongue strength, which were analyzed using multivariate linear mixed effects models. Tongue displacement, a surrogate for tongue elasticity, was also determined via stress–strain testing and analyzed via a multivariate linear mixed effects model.
Results Reporting the combined results of both sexes, the estimated experimental group mean peak twitch forces became more divergent over time compared to controls, being 8.3% lower than controls at 2 weeks post-CCRT, 15.7% lower at 5 months, and 31.6% lower at 10 months. Estimated experimental group mean peak tetanic forces followed a similar course and were 2.9% lower than controls at 2 weeks post CCRT, 20.7% lower at 5 months, and 27.0% lower at 10 months. Stress–strain testing did not find CCRT to have a significant effect on tongue displacement across experimental timepoints.
Conclusions This study demonstrates an increasing difference in tongue strength over time between controls and animals exposed to CCRT. Tongue elasticity was not significantly affected by CCRT, suggesting that changes in strength may not be caused by fibrosis.
Level of EvidenceNA Laryngoscope, 2022

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The Role of Sialendoscopy in Parotid Duct Stenosis in Graft‐Versus‐Host Disease

Elisabeth E. Hansen, Margaret B. Mitchell, Rahmatullah W. Rahmati

Publication date 22-09-2022


A 58-year-old man with chronic graft-versus host disease underwent left parotid duct sialendoscopy for parotid swelling and dry mouth. An area of ductal obstruction was dilated. Three-and-a-half months after the procedure, the patient had no recurrence of parotid gland symptoms.
Sialendoscopy, a minimally invasive procedure for concurrent diagnosis and treatment of salivary gland ductal pathologies, was used to alleviate recurrent left parotid gland swelling and dry mouth in a 58-year-old man with chronic graft-versus-host disease. Laryngoscope, 2022

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Tracking Occupational Voice State with a Visual Analog Scale: Voice Quality, Vocal Fatigue, and Effort

Adrián Castillo‐Allendes, Daniel Guzmán‐Ferrada, Eric J. Hunter, Eduardo Fuentes‐López

Publication date 22-09-2022


This study aimed to determine if the concurrent and construct validity of three visual analog scales (VASs) of voice quality and symptoms could be used as a screening tool in call center agents. VAS as a self-report instrument of vocal symptoms was related to psychosocial voice impairment and alterations of acoustic voice parameters in call center workers. Such instruments could be easily implemented to identify voice complaints in these populations.
Background Due to elevated vocal health risk in industries such as call centers, there is a need to have accessible and quick self-report tools for voice symptoms. This study aimed to determine if the concurrent and construct validity of three visual analog scales (VASs) of voice quality and symptoms could be used as a screening tool in call center agents.
MethodsA cross-sectional study was carried out in three call center companies. The Voice Handicap Index-10 (VHI-10) and a vocal hygiene and symptoms survey were administered to 66 call center workers. Further, acoustic parameters including harmonics-to-noise ratio (HNR), smoothed cepstral peak prominence (CPPs), L1-L0 slope, and Alpha ratio were collected. Finally, workers completed three VASs capturing self-perception of vocal effort (VAS-1), voice quality (VAS-2), and vocal fatigue (VAS-3). Linear regression models with bootstrapping evaluated the possible relationship between the three VASs measurements, self-perceived vocal symptoms, and acoustic parameters.
ResultsVAS-1 scores were associated with HNR and voice breaks, VAS-2 with voice breaks, and VAS-3 with Alpha ratio. Using the area under a receiver operating characteristic curve (AUC), the highest AUC for detecting an altered VHI-10 questionnaire score was observed for the three VASs. Also, the highest AUC for detecting altered CPPs was reached for the VAS-1.
ConclusionsVAS as a self-report instrument of vocal symptoms is related to psychosocial voice impairment and alterations of acoustic voice parameters in call center workers. Such instruments could be easily implemented to identify voice complaints in these populations.
Level of Evidence Level 2 (Diagnosis research question) Laryngoscope, 2022

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Control of Pre‐phonatory Glottal Shape by Intrinsic Laryngeal Muscles

Pranati Pillutla, Neha K. Reddy, Patrick Schlegel, Zhaoyan Zhang, Dinesh K. Chhetri

Publication date 21-09-2022


Complex interactions between intrinsic laryngeal muscles and their effects on the vocal fold pre-phonatory posture were studied. The thyroarytenoid (TA) was primarily responsible for the rectangular shape of the adducted glottis with synergistic contribution from the lateral cricoarytenoid (LCA). The cricothyroid (CT) contributed minimally to vocal fold medial shape but elongated the glottis.
Objectives Surgical manipulations to treat glottic insufficiency aim to restore the physiologic pre-phonatory glottal shape. However, the physiologic pre-phonatory glottal shape as a function of interactions between all intrinsic laryngeal muscles (ILMs) has not been described. Vocal fold posture and medial surface shape were investigated across concurrent activation and interactions of thyroarytenoid (TA), cricothyroid (CT), and lateral cricoarytenoid/interarytenoid (LCA/IA) muscles.
Study Design In vivo canine hemilarynx model.
Methods The ILMs were stimulated across combinations of four graded levels each from low-to-high activation. A total of 64 distinct medial surface postures (4 TA × 4 CT × 4 LCA/IA levels) were captured using high-speed video. Using a custom 3D interpolation algorithm, the medial surface shape was reconstructed.
Results Combined activation of ILMs yielded a range of unique pre-phonatory postures. Both LCA/IA and TA activation adducted the vocal fold but with greater contribution from TA. The transition from a convergent to a rectangular glottal shape was primarily mediated by TA muscle activation but LCA/IA and TA together resulted in a smooth rectangular glottis compared to TA alone, which caused rectangular glottis with inferomedial bulging. CT activation resulted in a lengthened but slightly abducted glottis.
ConclusionsTA was primarily responsible for the rectangular shape of the adducted glottis with synergistic contribution from the LCA/IA. CT contributed minimally to vocal fold medial shape but elongated the glottis. These findings further refine laryngeal posture goals in surgical correction of glottic insufficiency.
Level of EvidenceN/A, Basic science Laryngoscope, 2022

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Palatal Coupling Maneuvers Do Not Predict Hypoglossal Nerve Stimulator Treatment Efficacy

Bryan Renslo, Kealan Hobelmann, Emily S. Sagalow, Ashwin Ananth, Maurits Boon, Colin Huntley

Publication date 21-09-2022


Objective(s)Maneuvers during drug-induced sleep endoscopy (DISE), for patients with obstructive sleep apnea (OSA), have been used as predictors for success with oral appliances. Hypoglossal nerve stimulation (HGNS) promotes opening at the velum through palatoglossus coupling. In this study, we evaluate maneuvers during DISE as predictors for HGNS treatment efficacy.
Methods We evaluated patients undergoing HGNS between November, 2014 and February, 2021. We assessed maneuvers including jaw thrust and chin lift during preoperative DISE. The impact of tongue base and palatal opening during these maneuvers were rated from 1 to 4 (1: no improvement, 2: mild improvement, 3: moderate improvement, 4: significant improvement). Patients were grouped by a score of 1–2 (weak response) or 3–4 (strong response). Apnea hypopnea index (AHI) change was calculated from the difference between preoperative and postoperative sleep study.
Results One hundred and seventy one patients were included. With jaw thrust, there was no significant difference in AHI change between patients with weak or strong response at the palate (n = 68 vs. 94, 9.5 vs. 13.6, p = 0.21) or tongue base (n = 24 vs. 138, 16.6 vs. 11.3, p = 0.24). On chin lift, there was no significant difference at the palate (n = 82 vs. 18, 13.9 vs. 11.4, p = 0.63) or tongue base (n = 92 vs. 72, 10.8 vs. 14.6, p = 0.24). On multiple linear regression analysis, lower body mass index, higher preoperative AHI, and higher preoperative oxygen nadir were associated with a larger AHI change.
Conclusion Palatal coupling maneuvers during DISE are not predictive of AHI change with HGNS. Findings using these maneuvers should not preclude HGNS candidacy.
Level of Evidence Level III Laryngoscope, 2022

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Efficacy of Imaging Methods in the Detection and Diagnosis of Cerebrospinal Fluid Rhinorrhea

Se Hwan Hwang, Sun Won Kim, Do Hyun Kim

Publication date 20-09-2022


We assess the diagnostic efficacy of various imaging methods in patients with suspected cerebrospinal fluid (CSF) rhinorrhea. This network meta-analysis demonstrates that intrathecal gadolinium-magnetic resonance cisternography is the most useful diagnostic method to detect CSF rhinorrhea.
Objective To assess the diagnostic efficacy of various imaging methods in patients with suspected cerebrospinal fluid (CSF) rhinorrhea.
Data Sources The Pub Med, EMBASE, SCOPUS, Web of Science, Cochrane Trials, and Google Scholar databases were searched up to December 2021.
Review Methods Diagnostic accuracy was compared among seven radiological methods: computed tomography (CT), CT cisternography (CTC), magnetic resonance imaging (MRI), magnetic resonance cisternography (MRC), CT + MRI, radionuclide cisternography, and intrathecal gadolinium (Gd)-MRC. Sensitivity, specificity, and accuracy were used as outcomes of the analysis. Both a traditional pairwise meta-analysis and a network meta-analysis were performed.
Results Twenty-three trials were included in the analysis. The results of a network meta-analysis performed on a network consisting of seven diagnostic methods showed that all imaging modalities had greater diagnostic accuracy than CT, with the exception of CTC, which had lower sensitivity. Only intrathecal Gd-MRC was significantly superior to other imaging methods with regard to sensitivity and accuracy. Gd-MRC also showed the greatest surface under the cumulative ranking curve values for all of the outcomes (sensitivity: 0.9200; specificity: 0.8364; accuracy: 0.8920).
Conclusion This network meta-analysis demonstrates that intrathecal Gd-MRC is the most useful diagnostic method to detect CSF rhinorrhea. Laryngoscope, 2022

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A Partial Ossicular Replacement Prosthesis With a Concentric Ball Joint in the Headplate

Nicholas Bevis, Thomas Effertz, Dirk Beutner

Publication date 20-09-2022


This study focuses on the development of the mCLIP ARC Partial Prosthesis, a new partial middle-ear prosthesis featuring a balanced, centered ball joint. The ball joint allows the headplate to adapt to the individual anatomical features of the reconstructed tympanic membrane and facilitates intraoperative handling.
Objective In passive middle ear prosthetics, rigid implants have proven successful in reconstructing the ossicular chain. However, these cannot fully replicate the physiology of the ossicular chain. Pressure fluctuations cause high stresses in rigid passive prostheses, which can result in dislocation, protrusion, and pre-tension in the annular ligament resulting in unsatisfactory hearing results.
Methods In collaboration with MED-EL, we developed a new passive middle ear prosthesis that features a balanced, centered ball joint between the headplate and shaft of the prosthesis. We compared the sound transmission properties of this new prosthesis with those of a standard rigid prosthesis. Using Laser-Doppler-Vibrometry, we measured the sound-induced velocity of the stapes footplate relative to a given acoustic stimulus.
Results The new prosthesis showed equivalent sound transmission characteristics compared to the rigid prosthesis, whereas retaining the ability to compensate for pressure fluctuations due to its ball joint. This ensures good transmission properties even during displacements of the tympanic membrane.
Conclusion This development is a further step toward a physiological reconstruction of the ossicular chain.
Level of EvidenceN/A Laryngoscope, 2022

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CD8+ and FoxP3+ T‐Cell Cellular Density and Spatial Distribution After Programmed Death‐Ligand 1 Check Point Inhibition

Joseph Curry, Angela Alnemri, Ramez Philips, Michele Fiorella, Sarah Sussman, Robert Stapp, Charalambos Solomides, Larry Harshyne, Andrew South, Adam Luginbuhl, Madalina Tuluc, Ubaldo Martinez‐Outschoorn, Athanassios Argiris, Alban Linnenbach, Jennifer Johnson

Publication date 20-09-2022


We sought to analyze CD8+ and FoxP3+ T-cell cellular density (CD) and intercellular distances (ID) in head and neck squamous cell carcinoma samples from a window of opportunity trial of durvalumab +/− metformin. Pre-treatment CD8+ and FoxP3+ T-cell CDs were similar while IDs differed significantly between the human papillomavirus (HPV)+ and HPV− samples. A higher pretreatment CD8+ CD in the leading tumor edge and greater FoxP3+ CD8+ ID were associated with pathologic response to therapy.
Objectives To analyze CD8+ and FoxP3+ T-cell cellular density (CD) and intercellular distances (ID) in head and neck squamous cell carcinoma (HNSCC) samples from a neoadjuvant trial of durvalumab +/− metformin.
Methods Paired pre- and post-treatment primary HNSCC tumor samples were stained for CD8+ and FoxP3+. Digital image analysis was used to determine estimated mean CD8+ and FoxP3+ CDs and CD8+-FoxP3+ IDs in the leading tumor edge (LTE) and tumor adjacent stroma (TAS) stratified by treatment arm, human papillomavirus (HPV) status, and pathologic treatment response. A subset of samples was characterized for T-cell related signatures using digital spatial genomic profiling.
Results Post-treatment analysis revealed a significant decrease in FoxP3+ CD and an increase in CD8+ CDs in the TAS between patients receiving durvalumab and metformin versus durvlaumab alone. Both treatment arms demonstrated significant post-treatment increases in ID. Although HPV+ and HPV− had similar immune cell CDs in the tumor microenvironment, HPV+ pre-treatment samples had 1.60 times greater ID compared with HPV− samples, trending toward significance (p = 0.05). At baseline, pathologic responders demonstrated a 1.16-fold greater CD8+ CDs in the LTE (p = 0.045) and 2.28-fold greater ID (p = 0.001) than non-responders. Digital spatial profiling revealed upregulation of FoxP3+ and cytotoxic T-lymphocyte–associated antigen 4 (CTLA-4) in the TAS (p = 0.006, p = 0.026) in samples from pathologic responders.
Conclusions Analysis of CD8+ and FoxP3+ detected population differences according to HPV status, pathologic response, and treatment. Greater CD8+-FoxP3+ ID was associated with pathologic response. CD8+ and FoxP3+ T-cell distributions may be predictive of response to immune checkpoint inhibition. Clinical Trials.gov (Identifier NCT03618654).
Level of Evidence Level 3 Laryngoscope, 2022

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The Sommerlad–Furlow Modified Palatoplasty Technique: Postoperative Complications and Implicating Factors

Karim Ahmed Sakran, Min Wu, Khaled Alkebsi, Mubarak Ahmed Mashrah, Remsh Khaled Al‐Rokhami, Yan Wang, Abdo Ahmed Mohamed, Sadam Ahmed Elayah, Hesham Mohammed Al‐Sharani, Hanyao Huang, Bing Shi

Publication date 19-09-2022


This study was conducted to estimate the incidence of postoperative complications and investigate the impact of preselected factors on functional and quality of life outcomes following Sommerlad–Furlow modified palatoplasty technique. The Sommerlad–Furlow modified technique appears to have appropriate postoperative outcomes, even in the wide cleft palate. The older age at palatoplasty has a major impact on the overall postoperative outcomes.
Objective To explore the incidence of postoperative complications and investigate the impact of preselected factors on functional and quality of life outcomes following the Sommerlad–Furlow modified palatoplasty technique.
Study Design Retrospective cohort.
MethodsA total of 429 patients with cleft palate, who received Sommerlad–Furlow modified technique between 2011–2017 were enrolled. The postoperative complications including oronasal fistula (ONF), velopharyngeal insufficiency (VPI), and inadequate quality of life (QOL) were collected. Data of preselected factors including gender, age at palatoplasty, cleft type, cleft width, palatal width, pharyngeal cavity depth, and operation duration were also collected.
Results Among 429 patients, 40.1% were males whereas 59.9% were females. The mean age at palatoplasty was 1.23 ± 0.69 (0.42–4) years, and the average cleft width was 10.15 ± 2.95 (4–27) mm. The cleft types had recorded rates of about 6.8%, 69.5%, 17.7%, and 6.1% of Veau I, II, III, and IV, respectively. The overall incidence rates of ONF, VPI, and inadequate QOL were 2.3%, 19.4%, and 31.3%, respectively. In both the univariate and multivariate analyses, the cleft type was significantly implicated in ONF formation (p = 0.023 and 0.032, respectively) whereas the velopharyngeal function was impacted by the palatoplasty age (p ˂ 0.001). The receiver operating characteristic curve indicated that age of palatoplasty ≥1.3 years (area under the curve = 0.611, p = 0.002) was the cutoff value for predicting the incidence of VPI.
Conclusions The Sommerlad–Furlow modified technique appears to have appropriate postoperative outcomes, even in the wide cleft palate. The older age at palatoplasty has a major impact on the overall postoperative outcomes.
Level of Evidence4 Laryngoscope, 2022

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Functional Outcomes of Swallowing Following Surgery for Obstructive Sleep Apnea

Alysha Rasool, Derrick R. Randall, Jason K. M. Chau

Publication date 16-09-2022


Identification, evaluation, and management of pre-and postoperative swallowing dysfunction in patients undergoing upper airway surgery for obstructive sleep apnea (OSA) is limited. This study evaluated subjective swallowing function pre and postoperatively in patients undergoing multi-level reconstructive pharyngeal sleep surgery.
Objective Identification and evaluation of swallowing dysfunction in patients undergoing upper airway surgery for obstructive sleep apnea (OSA) is limited. This study evaluated subjective swallowing function pre and postoperatively in patients undergoing multi-level reconstructive pharyngeal sleep surgery.
MethodsA retrospective analysis of prospectively-administered Eating Assessment Tool (EAT-10) scores was conducted among adult patients undergoing surgery for OSA at a tertiary sleep surgery center. Preoperative and 1, 3, and 6-month postoperative time points were assessed. Patients were subdivided into two groups based on the degree of upper airway reconstruction performed. All patients underwent uvulopalatopharyngoplasty +/−tonsillectomy and tongue-base reduction. Patients undergoing Phase 1 reconstructive surgery additionally underwent tongue-base advancement procedures.
ResultsA total 100 patients underwent airway reconstructive surgery. Forty-one patients underwent Phase 1 surgery; 59 patients underwent Mini-Phase 1 surgery. Neither group demonstrated preoperative dysphagia. Both groups experienced significant subjective dysphagia at 1-month postoperatively, which was greater among Phase 1 patients (mean EAT-10 14.8; SD 10.4) versus Mini-Phase 1 patients (mean EAT-10 6.7; SD 7.5) (p < 0.001). Swallowing function among both groups normalized by 3 and 6 months postoperatively. Phase 1 patients with pre-operative dysphagia (mean EAT-10 9.6; SD 5) demonstrated initial worsening of their swallowing postoperatively; however, reported improved swallowing versus pre-operative levels by 6 months postoperatively (mean EAT-10 3.6; SD 4.3) (p = 0.03).
Conclusion Pharyngeal surgery resulted in no significant, persistent adverse change in swallowing function. Among both groups, significant subjective dysphagia was reported at 1 month postoperatively, yet returned to preoperative levels by 6 months postoperatively. OSA patients with pre-existing dysphagia undergoing Phase 1 surgery trended towards improved swallowing function postoperatively.
Level of Evidence2 Laryngoscope, 2022

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"Quantification of Vocal Fold Atrophy in Age‐Related and Parkinsons Disease‐Related Vocal Atrophy"

Hans C. Baertsch, Neel K. Bhatt, John P. Giliberto, Connor Dixon, Albert L. Merati, Cara Sauder

Publication date 16-09-2022


In this study, features of vocal fold atrophy were quantified and compared across dysphonia severity and between age-related and Parkinsons disease-related vocal atrophy. The results support an association between vocal fold bowing and dysphonia severity based on CAPE-V scores, and demonstrate that patients with Parkinsons-related atrophy have more significant bowing compared to those with age-related vocal atrophy.
Objective Vocal fold atrophy (VFA) is associated with aging and Parkinsons disease (PD). Clinical diagnosis of VFA depends on several visual-perceptual laryngostroboscopy findings that are inherently subjective. The purpose of this study was to use quantitative measurements to; (1) examine the relationships between VFA and dysphonia severity and (2) evaluate differences in VFA in patients with age-related VFA versus PD.
Methods Thirty-six patients >60 years of age with VFA were included in this retrospective cohort study. Demographic information, medical history, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), Voice Handicap Index-10 (VHI-10), and still images from the stroboscopic exam were obtained. Image J™ was used to measure VFA, including bowing index (BI), normalized glottal gap area, and normalized mucosal wave amplitude. Pearsons correlation was used to evaluate the relationship between VFA, CAPE-V, and VHI-10. t-Tests and multivariate linear regression were used to compare VFA measures by dysphonia severity (CAPE-V <30 vs. >30) and diagnosis (age-related vocal atrophy ARVA and PD).
ResultsBI was positively correlated with CAPE-V. Patients with CAPE-V >30 had a significantly larger BI compared to those with CAPE-V <30. Patients with PD had significantly larger BI than those with ARVA. Diagnosis of PD also predicted a larger BI after controlling for age and CAPE-V.
Conclusion Quantitative measures supported an association between bowing severity and dysphonia severity in patients with PD and ARVA. A PD diagnosis significantly predicted more severe BI. These findings demonstrate the potential utility of BI. Quantitative VFA measures might also provide insight into the mechanisms of ARVA and dysphonia.
Level of Evidence3 Laryngoscope, 2022

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Current and Temporal Trends in Otolaryngology Department Chair Appointment

Madeline Nottoli, Carina Tedesco, Lana Boladian, Khodayar Goshtasbi, Sunil Verma

Publication date 15-09-2022


This cross-sectional study aims to characterize current otolaryngology-head and neck surgery department chairs and division chiefs and evaluate whether there have been significant changes in the occupants of these positions over time. A large proportion of otolaryngology-head and neck surgery department chairs are internally recruited from their home institution. Most chairs are male, and head and neck oncologic surgery is the most common subspecialty.
Objective This cross-sectional study aims to characterize current otolaryngology-head and neck surgery department chairs and division chiefs and evaluate whether there have been significant changes in the occupants of these positions over time.
Methods All permanent department chairs or division chiefs at allopathic ACGME-accredited otolaryngology residency programs (n = 109) were identified and academic and professional information were collected using publicly available websites.
Results After excluding 12 department chairs due to interim status, 97 chairs and chiefs (81 chairs and 16 chiefs) were included with mean and median current term length of 9 ± 8 and 7 ± 5 years, respectively (range = 0–35 years). The most commonly completed fellowship in the group was head and neck oncologic surgery (42%). Seventy-seven percent of chairs previously held a faculty position within their institution. Seventy-one percent did not complete residency or fellowship training at their current institution. The average time between completing training and being appointed chair was 15.5 ± 7.7 years. Those appointed within the last 6 years (n = 47) had more years of experience than those appointed previously (18.0 ± 7.2 vs. 13.1 ± 7.4 years, p = 0.002). The number of female chairs remains low (n = 9), and despite an increasing number of women being appointed in recent years, the most recent group of appointees did not demonstrate a significant increase in female appointment (4% vs. 15%, p = 0.065).
ConclusionsA very large proportion of otolaryngology-head and neck surgery department chairs are internally recruited from their home institution. Most chairs are male, and head and neck oncologic surgery is the most common subspecialty.
Level of EvidenceN/A Laryngoscope, 2022

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Scarless Neck Feminization: Chondrolaryngoplasty Through Endoscopic Transoral Vestibular Approach

Victoria E. Banuchi, Samuel N. Helman

Publication date 15-09-2022


We present in this paper a novel approach to perform endoscopic chondrolaryngoplasty without any external visible scars. The technique involves utilizing the endoscopic transoral vestibular approach. We have modified the technique by using the placement of a suture immediately above the anterior commissure, which provides a marker for the inferior extent of cartilage resection. Laryngoscope, 2022

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Examining multi‐level immune response to determine prevalence of COVID‐19 in pediatric tonsillectomy

Pamela Mudd, Nahir Romero, Hengameh Behzadpour, Qin Xu, Md Sohel Rana, Lyuba Gitman, Diego Preciado, Maria Karkanitsa, Jacquelyn Spathies, Kaitlyn Sadtler, Heather Kalish, Pamela L. Schwartzberg, Kalpana Manthiram

Publication date 14-09-2022


Objective To determine the prevalence of COVID-19 in a cohort of children undergoing tonsillectomy through assessment of B cell immune responses to SARS-CoV-2 in both peripheral blood and tonsil tissue.
Methods In this cohort study at a tertiary pediatric hospital (Childrens National Hospital) in Washington, DC, we recruited 100 children undergoing tonsillectomy from late September 2020 to January 2021. Serum, peripheral blood cells, and tonsil tissue were collected and examined for immune reactivity to SARS-CoV-2. Parent-reported clinical histories were compared to antibody and B-cell responses.
Results Among 100 children undergoing tonsillectomy, 19% had evidence of immune responses to SARS-CoV-2 (CoV2+), indicating prior COVID-19. In all seropositive participants, we detected SARS-CoV-2 specific B cells in both peripheral blood mononuclear cells and tonsils, providing evidence for tissue-specific immunity in these children. Of the 19, 63% reported no known history of COVID-19, and an additional 3 were asymptomatic or unaware of an acute infection when detected on pre-surgery screen. Hispanic children represented 74% of CoV2+ subjects compared to 37% of the full cohort. 100% of CoV2+ children lived in a zip code with poverty level >10%.
Conclusions Nearly one-fifth of children undergoing tonsillectomy at an urban U.
S. hospital had evidence of prior COVID-19 during the early pandemic, with the majority unaware of prior infection. Our results underscore the ethnic and socio-economic disparities of COVID-19. We found concordant evidence of humoral immune responses in children in both blood and tonsil tissue, providing evidence of local immune responses in the upper respiratory tract.
Level of Evidence3 Laryngoscope, 2022

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Surfactant Protein A can Affect the Surface Tension of the Eustachian Tube and Macrophage Migration

Guodong Li, Tao Chen, Yanyan Mao, Yu Ai, Wenqing Yan, Yanqing Lu, Wenwen Liu, Haibo Wang, Li Li

Publication date 14-09-2022


Surfactant protein A (SPA) can change the surface tension of secretions from the eustachian tube (ET) and affect the migration ability of macrophages to alter the function of the ET. Although research in this field of otitis media with effusion (OME) is nascent, initial work suggests that SPA likely plays an important role in OME progression.
Objective To assess the role and possible mechanism of surfactant protein A (SPA) in the pathogenesis of otitis media with effusion (OME).
Methods This was a multi-part study with both an in vivo mouse model study as well as an in vitro study. The control and study groups (OME group) received phosphate-buffered saline and inactivated Streptococcus pneumoniae, respectively, via external auditory meatus injections. Changes in the surface tension of secretions from the eustachian tube (ET) and SPA expression were measured in both groups. A transwell assay was performed to observe the effect of different concentrations of SPA on the migration ability of macrophages. We examined the differentially expressed genes related to SPA-treated macrophages using RNA-seq analysis.
Results On Day 3, the surface tension of the OME group was higher than that of the control group (p = 0.014). The variation intensity of SPA in the ET of the OME group was significantly lower than that of the control group (p < 0.001). Surface tension was correlated with SPA (r = −0.525, p = 0.037). The expression of SPA and macrophages in the ET was different between the two groups. In vitro experiments revealed that macrophages showed different migration abilities with SPA concentration changes (p < 0.05). RNA-seq and western blotting were performed after macrophages were treated with SPA. The results showed that RhoA and Rac1/2/3 were differentially expressed.
ConclusionsSPA can change the surface tension of secretions from the ET and affect macrophage migration to alter the function of the ET. Although research in this field of OME is nascent, initial work suggests that SPA likely plays an important role in OME progression.
Level of EvidenceNA Laryngoscope, 2022

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Cricopharyngeus Muscle Dysfunction and Hypopharyngeal Diverticula (e.g., Zenker): A Multicenter Study

Rebecca J. Howell, Dale Ekbom, Jan Kasperbauer, Meredith Tabangin, Mekibib Altaye, Shaun Wahab, Peter Belafsky, Gregory Postma, Prospective OUtcomes of Cricopharyngeal Hypertonicity (POUCH) Collaborative

Publication date 14-09-2022


This serves as the seminal work from the prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeal Hypertonicity Surgery (POUCHS) Collaborative. Of the 250 persons enrolled, 85% had a Zenker diverticula (ZD), 9% had evidence of cricopharyngeus muscle dysfunction (CPMD) without diverticula and 4% had a Killian Jamieson diverticula (KJD). Patients with isolated CPMD appear to be more symptomatic than persons with ZD or KJD.
Objective To describe demographics and imaging and compare findings and symptoms at presentation in a large cohort of persons with cricopharyngeus muscle dysfunction (CPMD) with and without hypopharyngeal diverticula.
Methodology Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeal Hypertonicity (POUCH) Collaborative. Patient survey, comorbidities, radiography, laryngoscopy findings, and patient-reported outcome measures (e.g., Eating Assessment Tool EAT-10) data were abstracted from a REDCap database and summarized using means, medians, percentages, and frequencies. Diagnostic categories were compared using analysis of variance.
ResultsA total of 250 persons were included. The mean age (standard deviation SD) of the cohort was 69.0 (11.2). Forty-two percent identified as female. Zenker diverticula (ZD) was diagnosed in 85.2%, 9.2% with CPMD without diverticula, 4.4% with a Killian Jamieson diverticula (KJD), and 1.2% traction-type diverticula. There were no differences between diagnostic categories in regard to age, gender, and duration of symptoms (p = 0.25, 0.19, 0.45). The mean (SD) EAT-10 score for each group was 17.1 (10.1) for ZD, 20.2 (9.3) for CPMD, and 10.3 (9.4) for KJD. Patients with isolated CPMD had significantly greater EAT-10 scores compared to the other diagnostic groups (p = 0.03).
ConclusionZD is the most common, followed by CPMD without diverticula, KJD, and traction-type. Patients with isolated obstructing CPMD may be more symptomatic than persons with ZD or KJD.
Level of Evidence Level 4 Laryngoscope, 2022

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Prevalence of New‐Onset Tinnitus after COVID‐19 Vaccination with Comparison to Other Vaccinations

Ian Dorney, Lukas Bobak, Todd Otteson, David C. Kaelber

Publication date 13-09-2022


Objective To investigate how often patients are diagnosed with new-onset tinnitus within 21 days after COVID-19 vaccination in comparison to after three other common vaccinations: influenza, Tdap (tetanus, diphtheria, and acellular pertussis), and polysaccharide pneumococcus.
Methods The Tri NetX Analytics Network, a federated health research network that aggregates the de-identified electronic health record (EHR) data of over 78 million patients, was queried for patients receiving each vaccination. Instances of new-onset tinnitus within 21 days of vaccination were recorded and reported.
Results Out of 2,575,235 patients receiving a first dose of the mRNA COVID-19 vaccine without any prior tinnitus diagnosis, 0.038% (95% CI: 0.036%–0.041%) of patients had a new diagnosis of tinnitus within 21 days. There was a higher risk of a new tinnitus diagnosis after the influenza vaccine (RR: 1.95, 95% CI: 1.72–2.21), Tdap vaccine (RR: 2.36, 95% CI: 1.93–2.89), and pneumococcal vaccine (RR: 1.97, 95% CI: 1.48–2.64) than after the first dose of the COVID-19 vaccine. There was a lower risk of a new tinnitus diagnosis after the second dose of COVID-19 than after the first dose (RR: 0.80, 95% CI: 0.71–0.91).
Conclusion The rate of newly diagnosed tinnitus acutely after the first dose of the COVID-19 vaccine is very low. There was a higher risk of newly diagnosed tinnitus after influenza, Tdap, and pneumococcal vaccinations than after the COVID-19 vaccine. The present findings can help to address COVID-19 vaccine hesitancy during the ongoing pandemic.
Level of Evidence Level 3 Laryngoscope, 2022

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Rapid Additive Manufacturing of a Superlight Obturator for Large Oronasal Fistula in Pediatric Patient

Yichen Xu, Hanyao Huang, Min Wu, Yuting Tian, Qianbing Wan, Bing Shi, Tao Hu, Sebastian Spintzyk

Publication date 13-09-2022


This study developed a novel digital workflow to fabricate a 3D printed hollow obturator for the prosthetic reconstruction of palatal fistula. It will provide cleft surgeons and therapists a choice for treating children with large palatal fistula before the appropriate age for surgical reconstruction. Laryngoscope, 2022

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Can Hyperbaric Oxygen Salvage a Compromised Local/Regional Skin Flap?

Andrew Yousef, Isaac Solomon, David B. Hom

Publication date 12-09-2022


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When is Antibiotic Prophylaxis for Nasal Packing Indicated?

Michelle K. Hong, Daniel M. Beswick, Marilene B. Wang

Publication date 12-09-2022


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A Comprehensive Assessment of Blood Transfusions in Elective Thyroidectomy Based on 180,483 Patients

Usama Waqar, Javeria Tariq, Ahmad Areeb Chaudhry, Haissan Iftikhar, Hasnain Zafar, Syed Akbar Abbas

Publication date 12-09-2022


Objectives To assess the incidence, risk factors, and complications of blood transfusions (BTs) in elective thyroidectomy patients.
MethodsA retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program. Adult patients who underwent elective thyroidectomy from 2005 to 2019 were divided into two cohorts based on whether they received BT or not. Multivariable binary logistic regression models were used to identify risk factors of BT and its impact on postoperative complications.
Results Of 180,483 patients, 0.13% received BT. Risk factors for BT included underweight body mass index (BMI) (adjusted odds ratio OR 3.179, 95% confidence interval CI 1.444–6.996), bleeding disorders (OR 2.121, 95% CI 1.149–3.913), anemia (OR 4.730, 95% CI 3.472–6.445), preoperative transfusion (OR 7.230, 95% CI 1.454–35.946), American Society of Anesthesiology physical statuses 3–5 (OR 3.103, 95% CI 2.143–4.492), operative time >150 min (OR 4.390, 95% CI 1.996–9.654), and inpatient thyroidectomy (OR 5.791, 95% CI 3.816–8.787). In addition, transfusion was independently associated with any postoperative complication, non-infectious, cardiac, pulmonary, renal, vascular, or infectious complications, surgical site infection, sepsis, septic shock, wound disruption, pneumonia, unplanned reoperation, prolonged length of stay, and mortality.
Conclusion Recognition of risk factors of BT is imperative to identify at-risk patients and reduce transfusions by controlling modifiable risk factors such as anemia, operative time, and BMI. In cases where transfusions are still indicated, surgeons should optimize care to prevent or adequately manage transfusion-associated complications.
Level of Evidence3 Laryngoscope, 132:2078–2084, 2022

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Outcomes After Oral Cavity and Oropharyngeal Salvage Surgery

Bhavya K. Sharma, Kevin J. Contrera, Xuefei Jia, Christopher Fleming, Robert R. Lorenz, Shlomo A. Koyfman, Chengetai Mahomva, Khashayar Arianpour, Brian B. Burkey, Michael Fritz, Jamie A. Ku, Eric D. Lamarre, Joseph Scharpf, Brandon L. Prendes

Publication date 12-09-2022


Objectives Investigate outcomes following oral cavity and oropharyngeal salvage surgery.
Methods Adult patients who underwent salvage surgery for recurrent squamous cell carcinoma of the oral cavity and oropharynx from 1996 to 2018 were analyzed using multivariable Cox proportional hazards regression. Disease-free survival (DFS), overall survival (OS), associated factors, and basic quality measures were analyzed.
Results One hundred and eight patients (72% oral cavity, 28% oropharynx) were followed for a median of 17.9 months. Median DFS and OS were 9.9 and 21 months, respectively. Surgery with adjuvant chemoradiotherapy compared to surgery alone (hazard ratio HR = 0.15, 95% confidence interval CI: 0.03–0.78) and negative margins (HR = 0.36, 95% CI: 0.14–0.90) were associated with better DFS, while lymphovascular space invasion (LVSI) (HR = 2.66, 95% CI: 1.14–6.19) and higher stage (III vs. I–II, HR = 3.94, 95% CI: 1.22–12.71) were associated with worse DFS. Higher stage was associated with worse OS (HR = 3.79, 95% CI: 1.09–13.19). Patients were hospitalized for a median of 8 days with 24% readmitted within 30 days. A total of 72% and 38% of patients, respectively, underwent placement of a feeding tube or tracheostomy.
Conclusions After oral cavity and oropharyngeal salvage surgery, adjuvant chemoradiotherapy, negative margins, negative LVSI, and lower stage were associated with a lower risk of recurrence. Only lower-stage disease was associated with improved survival. The majority of patients had feeding tubes, half underwent free tissue transfer, a third required tracheostomy, and a quarter was readmitted.
Level of Evidence3 Laryngoscope, 132:1984–1992, 2022

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Smell Impairment in Stage I‐II Obesity: Correlation with Biochemical Regulators and Clinical Aspects

Alessandro Micarelli, Simona Mrakic‐Sposta, Beatrice Micarelli, Sandro Malacrida, Ilaria Misici, Valentina Carbini, Ilaria Iennaco, Sara Caputo, Alessandra Vezzoli, Marco Alessandrini

Publication date 12-09-2022


Olfactory perception changes across obesity stages. Biochemical regulators are related to smell performance along the obesity stages. The in-depth analysis of olfactory behavior may change strategies of diagnosis, treatment and prevention of obesity.
Objective To evaluate the differences in olfactory sensitivity, nutritional habits, levels of modulators of feeding and smell, bioelectrical impedance analysis (BIA) measures and metabolic assays between two groups of participants with stage I and II obesity and reciprocal relationships between these parameters.
Methods Eighteen participants with stage I (11 female; mean age = 54.3 ± 13.1 years) and 20 participants with stage II (10 female; mean age = 54.5 ± 11.9) obesity underwent a food frequency questionnaire and Sniffin Sticks® test battery, anthropometric parameters, and BIA measurements as well as metabolic assays (including plasma levels of leptin, insulin, ghrelin, glucose, insulin-like growth factor-1 IGF-1 and usual laboratory parameters).
Results The stage II obesity participants demonstrated significant higher levels of insulin and leptin and lower levels of ghrelin and IGF-1, a reduction in odor identification (OI) and in total olfactory score, and an increase in visceral and total fat percentage. Among a mosaic of multiple correlations, ghrelin was found to positively correlate with OI and leptin negatively with odor discrimination.
Conclusion The present study expands the notions positing the olfactory perception – and its connections with metabolic cues, foods habits and BIA measures – changes across the two most important obesity stages. This could ameliorate clinical and research deepening of obesity-related olfactory behavior with possible consequences on diagnosis, treatment and prevention of onset and development of obesity, thus opening possible future strategies involving multidisciplinary contributions.
Level of Evidence3 Laryngoscope, 132:2028–2035, 2022

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COVID‐19 and the Otolaryngology Residency Match: Rising Incidence of Home Matches

Jeffrey D. Bernstein, Matthew Harmon, Deborah Watson

Publication date 12-09-2022


Objectives/Hypothesis To quantify the effect of the coronavirus disease 2019 (COVID-19) pandemic upon the 2020 to 2021 residency match for Otolaryngology-Head and Neck Surgery (OHNS).
Study Design Retrospective cohort design.
Methods Residency match outcomes for all applicants to our institution during 2020 to 2021 were collected from the National Residency Matching Program including medical school of origin and matched program. Matches were categorized as to home-program, within-region, or out-of-region and sorted by US geographic region. Matches from the 2020 to 2021 cycle were compared to those from 2019 to 2020, as well as averages and trends from match cycles 2016 to 2020. Statistical analysis included descriptive statistics and chi-square testing.
Results During 2020 to 2021, there were 436 applicants to our single OHNS program. From 2019–2020 to 2020–2021, the match rate decreased significantly for groups studied, including: All applicants (72.0% 268/372 to 64.7% 282/436; P = .025); all US MD Senior applicants (76.5% 254/332 to 68.9% 262/380; P = .024); and US MD Seniors specifically without a home program (77.5% 31/40 to 56.4% 22/39; P = .046). The match rate for US MD Seniors with a home program did not change significantly (76.4% 223/292 to 70.4% 240/341; P = .09). From 2019–2020 to 2020–2021, the proportion of US MD seniors who matched to home-program increased significantly (22.0% 49/223 to 30.0% 72/240; P = .05).
Conclusion The COVID-19 pandemic saw high volumes of OHNS applicants with an overall decreased rate of matching compared to previous years. These changes particularly affected applicants without home programs. Home-program matching increased significantly, likely as a consequence of the limitations placed on in-person away experiences including interviews. Laryngoscope, 132:1934–1938, 2022

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Postoperative Radiation Therapy in Oral Cavity Verrucous Carcinoma

Akash N. Naik, Dustin A. Silverman, Chandler J. Rygalski, Songzhu Zhao, Guy Brock, Chen Lin, Sidharth V. Puram, James W. Rocco, Sujith Baliga, Kyle K. VanKoevering, Matthew O. Old, Nolan B. Seim, Stephen Y. Kang

Publication date 12-09-2022


Objectives/Hypothesis We investigate the clinicopathologic and treatment factors associated with the use of postoperative radiation therapy (PORT) and its effect on overall survival (OS) for patients with oral cavity verrucous carcinoma (VC).
Study Design Retrospective cohort study.
MethodsA retrospective cohort study of the National Cancer Database (NCDB) from 2006 to 2015 was performed. Multivariable logistic regression was used to identify independent predictive factors associated with the use of PORT. Cox Regression survival and propensity score analyses were used to evaluate the effect of PORT on mortality.
ResultsA total of 356 adult patients with primary oral cavity VC who underwent definitive surgical resection were identified. A total of 10.7% of patients underwent definitive surgical resection followed by PORT. Variables associated with PORT included distance to the hospital per 10 miles (adjusted odds ratio aOR, 0.81 95% confidence interval (CI), 0.70–0.95) and stage III–IV disease (aOR, 12.13 and 23.92, respectively). Multivariable Cox regression survival analysis indicated no evidence of survival benefit in patients undergoing PORT compared to surgery alone (adjusted hazard ratio 1.50 0.74–3.05, P = .23). Propensity score analysis also showed no OS benefit with the use of PORT (P = .41).
Conclusions Variables associated with the use of PORT on multivariable analysis included closer distance to hospital and stage III–IV disease. No clear survival benefit with PORT was identified on either multivariable survival analysis or propensity score analysis. These results suggest that surgery alone with negative margins may be the optimal treatment for patients with oral cavity VC.
Level of Evidence4 Laryngoscope, 132:1953–1961, 2022

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Systemic Bevacizumab Treatment for Recurrent Respiratory Papillomatosis: Long‐Term Follow‐Up

Ryan Ruiz, Naomi Balamuth, Luv R. Javia, Karen B. Zur

Publication date 12-09-2022


Objectives/Hypothesis Systemic bevacizumab is a new adjuvant therapy for recurrent respiratory papillomatosis (RRP) that has shown promising preliminary results in children. The objective of this study was to report the largest series to date that includes long-term follow-up data on bevacizumab treatment.
Study Design Retrospective chart review.
Methods Retrospective review of seven pediatric patients treated within the past 6 years with systemic bevacizumab for RRP refractory to traditional debridement.
Results All seven patients had a significant reduction in disease burden after initiation of systemic bevacizumab. There have been no major complications associated with systemic therapy so far. Median duration of bevacizumab treatment was 2.13 years. Three of the seven patients have been on treatment for over 3 years with the longest duration of treatment in our first patient now at 5.5 years. One patient experienced significant disease recurrence on two occasions when therapy was temporarily discontinued and was recently diagnosed with squamous cell carcinoma of the lung.
Conclusion Systemic bevacizumab is an effective therapy for cases of severe RRP with promising results both in short-term and long-term follow-up. Side effects are minimal. Patients must be followed closely to determine appropriate dosing intervals to control disease and to screen for disease progression.
Level of Evidence4 Laryngoscope, 132:2071–2075, 2022

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Patterns of Opioid Usage and Predictors of Utilization Following Endoscopic Skull Base Surgery

Edward C. Kuan, Jack L. Birkenbeuel, Alexander J. Kovacs, Arash Abiri, Khodayar Goshtasbi, Brandon M. Lehrich, Kiarash Golshani, Jefferson W. Chen, Gilbert Cadena, Frank P.K. Hsu

Publication date 12-09-2022


Objective Pain control is an important topic that has not been extensively studied in patients undergoing endoscopic skull base surgery (ESBS). The purpose of this study is to identify opioid requirements after ESBS and the risk factors predictive of increased use.
Methods This study was a retrospective review of all patients undergoing ESBS at a tertiary academic skull base surgery program between July 2018 and August 2020. The primary outcome variable was total morphine equivalent dose (MED) requirements after surgery, calculated as the sum of all morphine milligram equivalents over a 24-h period, and summated across the duration of each participants hospital course.
Results94 patients were included in this review. Average daily MED requirements were 14.00 ± 6.79 mg. Average total MED requirements were 83.78 ± 92.99 mg during hospitalization. Average length of stay (LOS) was 5.71 ± 4.42 days, with 22 (23.4%) patients not requiring opioid use upon discharge. On multivariate analysis, female sex (β = 49.62; 95% CI 13.53, 85.71, p = 0.008), nasoseptal flap (NSF) reconstruction (β = 49.56; 95% CI 13.51, 85.61, p = 0.008) and LOS (β = 4.02; 95% CI 0.001, 8.04, p = 0.050) were independently associated with higher total MED requirements.
Conclusions We report average total MED requirements of 83.78 mg after ESBS, with female sex, intraoperative use of an NSF, and increased LOS as predictors of higher MED use. This data indicates a subset of patients who may benefit from more aggressive pain control strategies upfront, including consideration of non-opioid, multimodal pain regimens.
Level of Evidence3 Laryngoscope, 132:1939–1945, 2022

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The Effects of Amniotic Membrane Transplantation on Vocal Fold Regeneration

Machiko Ogawa, Shigeyuki Mukudai, Yoichiro Sugiyama, Hiroki Matsushita, Shota Kinoshita, Satomi Ozawa, Keiko Hashimoto, Shinya Fuse, Mami Kaneko, Yosuke Nakanishi, Tomokazu Yoshizaki, Chie Sotozono, Shigeru Hirano

Publication date 12-09-2022


Objectives/Hypothesis Vocal fold (VF) scar and sulcus cause severe vocal problems, but optimal methods have not been established. Total replacement of the mucosa is required particularly for cases in which the whole lamina propria is occupied by severe fibrosis and vibratory function is totally lost. The amniotic membrane (AM) has been proven to have regenerative potential, as it contains stem cells and growth factors. The current study investigated the biocompatibility and effects of AM for regeneration of the VF mucosa.
Study Design In vitro and in vivo studies.
Methods Vocal fold fibroblasts (VFFs) from 13 Sprague–Dawley rats were seeded on AM and subjected to histology and immunohistochemistry, and gene expressions in the VFFs on AM were examined in in vitro study. Twelve New Zealand White rabbits were used in in vivo study. VFs were stripped down and were reconstructed with AM. The regenerative effects were examined 3 months later by histological examination.
Results In vitro study indicated VFFs survived on AM and stained positively for Ki67, vimentin, and fibronectin. Gene expressions of Has1, Has2, and Hgf were significantly increased in the VFFs on AM compared with the other groups. The in vivo study indicated AM-transplanted VFs showed a significantly higher density of hyaluronic acid and lower density of collagen compared with sham VFs.
Conclusions The current preliminary study suggests biocompatibility and possible regenerative effects of AM for VFs.
Level of EvidenceNA Laryngoscope, 132:2017–2025, 2022

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Pain at the Cochlear Implant Site Requiring Device Removal in Pediatric Patients

A. Eliot Shearer, Alicia Wang, Maranda Lawton, Catherine Lachenauer, Jacob R. Brodsky, Dennis Poe, Margaret Kenna, Greg Licameli

Publication date 12-09-2022


Objectives Idiopathic pain at the cochlear implant (CI) site outside of the immediate postoperative period is an uncommon occurrence but may necessitate device explantation. Our objective was to describe the clinical course for pediatric patients with CI site pain who ultimately required device explantation.
Study Design Retrospective chart review.
Methods We performed a retrospective database review of CIs performed at a tertiary referral center for pediatric cochlear implantation. We specifically evaluated pediatric patients who presented with pain at or near the CI device site and ultimately required explantation.
Results Fifteen patients (16 CIs) had pain at or near the CI site requiring device explantation. Cultures taken during site exploration or device explantation identified bacteria in 86% and 81% of procedures, respectively. Propionibacterium acnes and Staphylococcus non-aureus were the most commonly identified organisms.
Conclusions The majority of patients with idiopathic pain in this cohort ultimately requiring CI explantation had chronic bacterial colonization.
Level of Evidence4 (Case series) Laryngoscope, 132:2044–2049, 2022

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Bilateral Cochlear Implantations in Temporal Bone Fracture: A Viable Treatment Option

Medhat F. Yousef, Rami Theyab, Soha N. Garadat, Abdulrahman Hagr

Publication date 12-09-2022


Objectives/Hypothesis Although it is surgically more challenging, patients with bilateral temporal bone fractures (TBFs) are potential candidates for successful bilateral cochlear implantation (CI). This study aimed to investigate the feasibility of bilateral implantation in patients with sustained bilateral TBFs.
Study Design Retrospective database study.
Methods Seven patients with bilateral cochlear implants who were diagnosed with TBFs were included in this study. Preoperative radiological and audiological evaluations were performed. The outcomes of the CI were also investigated.
Results Hearing levels were restored to the mild–moderate range (<40 dB) for nearly all patients and they reported an improved quality of life.
ConclusionsCI in patients with TBF is safe and offers a solution for the restoration of hearing in a population who may experience sudden bilateral deafness. However, preoperative confirmation of intact auditory nerves and patent cochlea is essential to maximize the success of CI in this population.
Level of Evidence4 Laryngoscope, 132:2050–2055, 2022

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Establishing an Endoscopic Chronic Subglottic Stenosis Rabbit Model

Orna K. Kadosh, Ivanna Nebor, Matthew M. Smith, Catherine K. Hart, Meredith E. Tabangin, Kaulini Burra, Jennifer L. Kasten, Debora I. Sinner, Alessandro Alarcon

Publication date 12-09-2022


Objectives/Hypothesis To develop a reproducible and consistent chronic subglottic stenosis (SGS) in an endoscopic animal model.
Study Design Prospective study.
Methods We conducted a prospective study using New Zealand white rabbits. Chronic SGS was induced endoscopically by Bugbee electrocautery to 50% to 75% of the subglottic areas circumference, followed by 4-hour endotracheal intubation. The rabbit airways were endoscopically assessed and sized with uncuffed endotracheal tubes (ETTs) before the injury, during follow-up, and at the endpoints.
There were four endpoints: 2, 4, 6, and 8 weeks post SGS induction. Animals were humanely euthanized for histopathological examination of the subglottic injury site and microscopic measurement of the cricoid lumen.
Results Twenty-two rabbits reached the endpoints, and 18 rabbits developed chronic SGS. ETT size significantly decreased by 0.5 from preinjury to the endpoint in all groups, P < .001. Control median cricoid lumen measurements were 20.48 mm2, the median cricoid lumen measurement for the 2 weeks endpoint was 14.3 mm2, 4 weeks 11.69 mm2, 6 weeks 16.03 mm2, and 8 weeks endpoint median was 16.33 mm2. Histopathological examination showed chronic scar tissue and new cartilage formation at the cricoid level, mainly at the posterior subglottic injury site starting from 4 weeks postinjury. Collagen staining revealed substantial amounts of organized collagen and different collagen orientation starting 4 weeks postinjury lasting until 8 weeks postinjury.
Conclusion We developed an animal model to study chronic SGS. This model will be utilized to compare different endoscopic treatment interventions in acute SGS versus chronic SGS and further define the molecular basis of SGS.
Level of EvidenceNA Laryngoscope, 132:1909–1915, 2022

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Practical Implementation of Sleep Endoscopy with Positive Airway Pressure in Clinical Practice

Michael J. Hutz, Phillip LoSavio

Publication date 12-09-2022


Drug-induced sleep endoscopy with positive airway pressure (DISE-PAP) is a new technique that allows for both the visualization of upper airway collapse as well as to evaluate the degree of airway collapsibility. This DISE-PAP protocol provides an affordable and clinically efficient manner in which to immediately implement this technique in clinical practice. Laryngoscope, 132:2076–2077, 2022

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Analysis of Systematic Reviews in Clinical Practice Guidelines for Head and Neck Cancer

Jaydeep Dhillon, Taimoor Khan, Bilal Siddiqui, Trevor Torgerson, Ryan Ottwell, Austin L. Johnson, Mason Skinner, Patrick Buchanan, Micah Hartwell, Matt Vassar

Publication date 12-09-2022


Objective Clinical practice guidelines (CPGs) are essential to clinical decision-making as their recommendations are supported by published literature. Systematic reviews are considered the highest quality of evidence used to underpin these guidelines. However, research to support these recommendations may lack compliance to quality reporting among systematic reviews (SRs). Here, we aim to evaluate the quality of SRs underpinning CPG recommendations for the management of head and neck cancer (HNC).
Study Design Retrospective cross-sectional analysis.
Methods Using Pub Med, we searched for CPGs pertinent to the management of head and neck cancer published between January 2017 and May 2021. Relevant guidelines were analyzed for all SRs. Cited SRs in CPGs were evaluated using A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR-2) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) instruments. Study characteristics were extracted in a masked triplicate fashion.
ResultsA total of 16 CPGs and 142 unique SRs were included in our study. PRISMA completion ranged from 67.15% to 87.65% across CPGs with a mean of 76.41% (SD = 16.9). AMSTAR-2 completion ranged from 34.38% to 84.38% across CPGs with a mean of 67.55% (SD = 20.9) among all SRs. The lowest rated items included funding sources and publication bias. A higher score was achieved in SR done by Cochrane group and it was only 2.11% (3/142) of all SRs quoted in CPG.
Conclusion Adherence to AMSTAR-2 and PRISMA items exhibits a variation among SRs cited in CPGs for the management of HNC. The mature underpinning CPG recommendation of SRs cited as supportive evidence could be enhanced in reporting quality.
Level of EvidenceNA Laryngoscope, 132:1976–1983, 2022

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Applications of Artificial Intelligence to Office Laryngoscopy: A Scoping Review

Peter Yao, Moon Usman, Yu H. Chen, Alexander German, Katerina Andreadis, Keith Mages, Anaïs Rameau

Publication date 12-09-2022


Objectives/Hypothesis This scoping review aims to provide a broad overview of the applications of artificial intelligence (AI) to office laryngoscopy to identify gaps in knowledge and guide future research.
Study Design Scoping Review.
Methods Searches for studies on AI and office laryngoscopy were conducted in five databases. Title and abstract and then full-text screening were performed. Primary research studies published in English of any date were included.
Studies were summarized by: AI applications, targeted conditions, imaging modalities, author affiliations, and dataset characteristics.
Results Studies focused on vocal fold vibration analysis (43%), lesion recognition (24%), and vocal fold movement determination (19%). The most frequently automated tasks were recognition of vocal fold nodules (19%), polyp (14%), paralysis (11%), paresis (8%), and cyst (7%). Imaging modalities included high-speed laryngeal videos (45%), stroboscopy (29%), and narrow band imaging endoscopy (7%). The body of literature was primarily authored by science, technology, engineering, and math (STEM) specialists (76%) with only 30 studies (31%) involving co-authorship by STEM specialists and otolaryngologists. Datasets were mostly from single institution (84%) and most commonly originated from Germany (23%), USA (16%), Spain (9%), Italy (8%), and China (8%). Demographic information was only reported in 39 studies (40%), with age and sex being the most commonly reported, whereas race/ethnicity and gender were not reported in any studies.
Conclusion More interdisciplinary collaboration between STEM and otolaryngology research teams improved demographic reporting especially of race and ethnicity to ensure broad representation, and larger and more geographically diverse datasets will be crucial to future research on AI in office laryngoscopy.
Level of EvidenceNA Laryngoscope, 132:1993–2016, 2022

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Association Between Insurance Type and Outcomes of Reconstructive Head and Neck Cancer Surgery

Derek H. Liu, Alison J. Yu, Li Ding, Mark S. Swanson

Publication date 12-09-2022


Objectives/Hypothesis Although the benefits of expanding health insurance coverage are clear, there are limited studies comparing the different types of insurance. This study aims to determine the association between insurance type and outcomes in patients with head and neck cancer undergoing reconstructive surgery in the United States.
Methods Population-based cross-sectional study of the 2012–2014 National Inpatient Sample. We identified 1,314 patients with head and neck cancers undergoing tumor ablative surgery followed by pedicled or free flap reconstruction of oncologic defects. Insurance type was classified as private, Medicare, Medicaid, self-pay, or other. The primary outcome was extended length of stay (LOS), defined as greater than 14 days, which represented the 75th percentile of the study sample. Secondary outcomes included acute medical complications, surgical complications, morbidities, and costs. Analyses were adjusted for gender, geographic location, and various medical comorbidities.
Results In univariate analysis, insurance type was associated with extended LOS (P = .001), medical complications (P = <.001), and mortalities (P = .020). After controlling for other covariates in the multivariate analysis, compared to private insurance, Medicare and Medicaid were both associated with significantly higher odds of extended LOS (adjusted odds ratio OR 95% confidence interval (CI) = 1.73 1.09–2.76 and 2.22 1.38–3.58, respectively). Medicare was associated with significantly higher odds of medical complications, but Medicaid was not (adjusted OR 95% CI = 1.53 1.02–2.31 and 1.64 0.97–2.78, respectively).
Conclusions Medicaid and Medicare were independently associated with extended LOS after reconstructive head and neck cancer surgery. Medicare was associated with higher rates of medical complications. Efforts to address LOS should target care planning and coordination.
Level of EvidenceNA Laryngoscope, 132:1946–1952, 2022

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Timing of Acoustic Hearing Changes After Cochlear Implantation

Megan J. Jensen, Heba Isaac, Helin Hernandez, Jacob Oleson, Camille Dunn, Bruce J. Gantz, Marlan R. Hansen

Publication date 12-09-2022


Objectives/Hypothesis To determine the timing of acoustic hearing changes among hearing preservation Cochlear implant (CI) recipients. To determine differences in hearing outcomes based on device type and demographic factors. To determine if there is a relationship between the extent of early hearing loss after CI and the subsequent rate of continued hearing loss.
Study Design Prospective, single subject study.
Methods Two hundred and eleven subjects who received a hearing preservation CI were included in the study—80 Nucleus Hybrid L24 (Cochlear), 47 422/522 (Cochlear), 24 S8 (Cochlear), 14 S12 (Cochlear), 6 SRW (Cochlear), 21 SLIM J (Advanced Bionics), and 19 Flex (Med-EL). Of these, 127 were included in the subsequent analyses. Audiometric thresholds (low frequency pure-tone-averages) were collected and compared pre and postoperatively.
Results Long-term hearing preservation rates were 65% (52/80) for L24, 83% (20/24) for S8, 79% (11/14) for S12, 83% (5/6) for SRW, 54% (25/47) for 422/522, 91% (21/23) for SLIM J, and 84% (16/19) for Flex. Hearing loss was not related to device type (P = .9105) or gender (P = .2169). Older subjects (age ≥65) had worse hearing outcomes than younger subjects after initial device activation (age <65, P = .0262). There was no significant difference in rate of hearing loss over time between older and younger patients (P = .0938). Initial postoperative hearing loss was not associated with the rate of long-term hearing loss.
Conclusions Long-term low frequency hearing preservation is possible for CI recipients and is not associated with gender or device type. Rate of hearing loss over time is not dependent on patient age. Early hearing loss after CI does not predict the rate of long-term hearing loss.
Level of Evidence3 Laryngoscope, 132:2036–2043, 2022

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A Novel Adenoidectomy Training System

Nicole Molin, Nigel Wang, Glenn Isaacson

Publication date 12-09-2022


Objectives/Hypothesis Young residents find mirror-guided adenoidectomy difficult. Inexperienced trainees must learn to focus a headlight beam, work upside-down and backward in a small space and thoroughly ablate adenoid tissue—all new skills. We present an adenoidectomy training system that is low-cost, easy to construct, and is focused on these basic adenoidectomy skills.
Study Design Prospective experimental study.
Methods This training suite includes three stations each targeting a different skill. The first employs a mannequin head with exposed nasopharynx. It trains the student to coordinate a headlight and mirror while touching a series of targets with a curved probe. At the second station participants electrodessicate (or microdebride) an anchored piece of veal thymus. The third station combines both sets of skills as participants ablate thymus in a simulated nasopharynx (30 mm rectangular aluminum tube) constrained within a Crow-Davis retractor, using a headlight, mirror, and suction electrosurgical electrode (or microdebrider). To evaluate the training systems efficacy, we assessed the performance of 10 surgically naïve medical student volunteers before and after 15 minutes of practice using a validated rating scale used for adenoidectomy.
Results There was significant improvement in adenoidectomy skill scores after practicing. Overall scores were higher, time taken to touch a series of targets with a headlight and mirror was less and amount of tissue ablated at the final station was greater (P < .05).
Conclusion This novel adenoidectomy training system is inexpensive and easy to build. Practice with the model resulted in statistically significant improvement in adenoidectomy skill scores for inexperienced student surgeons.
Level of Evidence3 Laryngoscope, 132:2056–2062, 2022

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Bereavement Practices Among Head and Neck Cancer Surgeons

Roberto N. Solis, Nicole I. Farber, Nathan Fairman, Nuen T. Yang, Sandra L. Taylor, Marianne Abouyared, Arnaud F. Bewley, D. Gregory Farwell, Andrew C. Birkeland

Publication date 12-09-2022


Objectives Head and neck cancer surgeons frequently interact with dying patients with advanced disease and their families, but little is known about their bereavement practices after a patients death. The aim of this study is to elucidate the frequency of common bereavement practices, cited barriers to bereavement, and predictive physician factors that lead to an increase in bereavement practices among head and neck cancer surgeons.
MethodsA 20-item survey was sent to 827 active surgeons of the American Head and Neck Society. Approval was obtained and the survey was distributed through the American Head and Neck Society. Demographics, frequency of common bereavement practices, empathy, and barriers were assessed. Multiple linear regression was performed to determine physician factors associated with more frequent bereavement follow-up.
Results There were 156 respondents (18.9% response rate). Overall, surgeons were more likely to usually/always call (48.5%) or send a letter (42.4%) compared with other practices such as attending funerals (0%), offering family meetings (18.6%), or referring family members to counseling (7.7%).
Many barriers were cited as being at least somewhat important: being unaware about a patients death (67.3%) was the most cited, whereas 51.3% cited a lack of mentorship/training in this area. Scoring higher on empathy questions (P ≤ .001) was associated with more frequent surgeon bereavement follow-up with the family of deceased patients.
Conclusion There is substantial practice variation among surgeons suggesting a lack of consensus on their roles in bereavement follow-up. Having higher empathy was predictive of higher engagement.
Level of EvidenceNA Laryngoscope, 132:1971–1975, 2022

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Trends in Positive Surgical Margins in cT1‐T2 Oral Cavity Squamous Cell Carcinoma

Emily M. Robinson, Austin S. Lam, Isaac Solomon, Jacob S. Brady, John Pang, Farhoud Faraji, Jeffrey J. Houlton, Neal D. Futran, Brittany R. Barber

Publication date 12-09-2022


Objectives/Hypothesis To evaluate trends in contemporary positive surgical margin incidence in cT1-T2 oral cavity squamous cell carcinoma and to evaluate factors associated with surgical margin status.
Study Design Retrospective analysis of large dataset.
Methods Retrospective analysis of the National Cancer Database.
Results Between 2004 and 2016, 39,818 patients with cT1 or cT2 oral cavity squamous cell carcinoma received primary curative-intent surgery. Positive surgical margins were present in 7.95% of patients, and univariable adjusted probability of positive surgical margins over the study period declined by 1% per year (odds ratio OR, 0.99; 95% confidence interval CI, 0.98–1.0; P = .049). Multivariable regression revealed the annual rate of positive surgical margins declined significantly (OR, 0.95 per year; 95% CI, 0.92–0.97; P < .001). Factors associated with increased odds of positive surgical margins included cT2 disease, subsite, understaged disease, lymphovascular invasion, tumor grade, and positive lymph nodes. Race and socioeconomic status were not associated with surgical margin status. Treatment at an academic center was associated with increased time to definitive surgery (median 35 days IQR 22–50 vs. median 27 days IQR 14–42; P < .001) and a 20% reduction in positive surgical margin rate (OR, 0.80; 95% CI, 0.71–0.90; P < .001). Treatment at high-volume centers was less likely to be associated with positive surgical margins (OR, 0.85; 95% CI, 0.74–0.98; P = .02).
Conclusion Surgical subsite, clinical T and N category, presence of lymphovascular invasion, and histologic grade were independent predictors of positive surgical margins. Patients are increasingly being treated at high-volume and academic centers. Overall, the rate of positive surgical margins in cT1-T2 oral cavity squamous cell carcinoma is decreasing.
Level of Evidence4 Laryngoscope, 132:1962–1970, 2022

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Is Diet Sufficient as Laryngopharyngeal Reflux Treatment? A Cross‐Over Observational Study

Jerome R. Lechien, Lise Crevier‐Buchman, Lea Distinguin, Giannicola Iannella, Antonino Maniaci, Lisa G. De Marrez, Sven Saussez, Stéphane Hans

Publication date 12-09-2022


Objectives/Hypothesis To investigate the efficacy of low-fat, low-quick-release sugar, high-protein, alkaline, and plant-based diet as single treatment for patients with laryngopharyngeal reflux (LPR).
Study Design Cross-over observational study.
Methods Patients with LPR diagnosis at the hypopharyngeal-esophageal multichannel intraluminal impedance-pH-monitoring were prospectively recruited from the reflux clinic of three University Hospitals. Patients were instructed to follow low-fat, low-quick-release sugar, high-protein, alkaline, and plant-based diet for 6 to 12 weeks. Pre- to post-treatment symptom and finding changes were evaluated with reflux symptom score (RSS) and reflux sign assessment. Findings were compared to those of a control period where patients did not receive any treatment or diet. Diet was evaluated with refluxogenic diet score (REDS).
Results Fifty patients completed the study (19 males). Otolaryngological, digestive, and total RSS scores significantly improved from baseline to 6-week post-diet, while there were no significant changes during the control period. At 6-week post-diet, 37 (74%) patients reported significant symptom improvement or relief. Among them, symptoms continued to improve from 6 to 12 weeks in 27 cases, corresponding to a diet success rate of 54%. The REDS was predictive of the baseline RSS (P = .031).
Conclusion Low-fat, low-quick-release sugar, high-protein, alkaline, and plant-based diet is an alternative cost-effective therapeutic approach for patients with LPR. Patients with higher REDS reported higher baseline symptom score.
Level of Evidence3 Laryngoscope, 132:1916–1923, 2022

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Management of Nasopharyngeal Cyst of Second Branchial Cleft Origin: Case Series and Systematic Review

Alessandro Vinciguerra, Benjamin Verillaud, Rachid Kaci, Jean‐Pierre Guichard, Philippe Herman

Publication date 12-09-2022


Branchial cyst of the second pouch is the most common lesion of the nasopharyngeal lateral wall, generally localized between the pharyngeal wall and internal carotid artery.
Cases consistent with such lesion, were collected. Symptomatic patients were treated with endoscopic trans-nasal marsupialisation, asymptomatic cases were followed-up. Among the 10 patients included, 4 were symptomatic and accordingly treated. In the literature, 36 cases were found, all of which were treated, most commonly with a total excision.
Considering the benign nature of branchial nasopharyngeal cyst, its treatment should be tailored to each patient: endoscopic marsupialization in symptomatic lesion, follow-up in asymptomatic one. Laryngoscope, 132:1904–1908, 2022

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Laryngeal, Pharyngeal and Respiratory Involvement in Palatal Tremor

Corina Din‐Lovinescu, Andrew Blitzer

Publication date 12-09-2022


Objective To present cases of atypical palatal tremor (PT) and showcase the variable phenomenology of this condition.
Study Design Retrospective case series.
ResultsPT, or palatal myoclonus, is a movement disorder characterized by brief, involuntary rhythmic muscular contractions of the soft palate. Variants of PT have been described and include synchronous tremors in other branchial arch derivatives including the larynx, pharynx, neck, face, jaw, ocular and also respiratory and trunk muscles. We present 3 cases, including clinical videos, of atypical PT with extra-palatal manifestations, in addition to a brief discussion of the pathophysiology and management of this condition.
Conclusion Variations of PT are of interest to the practicing otolaryngologist as the clinical spectrum of this condition is wide and can present with laryngeal, pharyngeal, respiratory and other head and neck manifestations.

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Reply to “In Reference to: Non‐Squamous Cell Malignancies of the Larynx”

Janine M. Rotsides, Alex Gordon, Jamie R. Oliver, Evan Patel, Cheng Liu, Babak Givi

Publication date 12-09-2022


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In reference to Non‐Squamous Cell Malignancies of the Larynx

Lara Alessandrini, Leonardo Franz, Gino Marioni

Publication date 12-09-2022


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Table of contents

Publication date 12-09-2022


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Masthead

Publication date 12-09-2022


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Three‐Dimensional Endoscopic Endonasal Surgery: A Systematic Review

Abdul Nassimizadeh, Hannah Lancer, James Hodson, Shahzada Ahmed

Publication date 12-09-2022


Objectives To compare participant performance and preference in the use of three-dimensional (3D) endoscopy compared to traditional two-dimensional (2D) endoscopy.
Methods Pub Med, Embase, Medline, Clinical Key, BMJ Case Reports, and the Cochrane library were systematically searched for English-language articles published between 2005 and 2020. Studies reporting comparisons of outcomes between 3D and 2D endoscopes were identified. Data relating to performance-related outcomes, as well as the participants preferred endoscope were extracted, and pooled using meta-analysis models.
Results Ten studies were included in the qualitative synthesis. Six studies reported results of participants completing simulated tasks with endoscopes, while four reported full procedures. Peg transfer tasks (n = 4 cohorts) were found to be completed significantly faster with the 3D versus 2D endoscope (pooled mean difference 6.8 seconds, 95% confidence interval CI: 2.3–11.3), while no significant difference in times taken was observed for touch tasks (n = 4; pooled mean difference 3.7 seconds, 95% CI: −1.9 to 9.2). The secondary outcome of participant preference was reported by five studies, in which a significant preference for the 3D endoscope was observed (P = .010), with a pooled total of 72% (95% CI: 59–83) of participants preferring this to the 2D endoscope.
Conclusions There is a growing body of evidence in support of 3D visualization in endoscopy. We have demonstrated 3D endoscopy to be associated with a significantly shorter time to performing simulated, reproducible and controlled tasks, and to be the preference of participants. This study provides grounds for further evaluation of the technology, and the potential for a greater widespread use. Laryngoscope, 132:1895–1903, 2022

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A Systematic Review and Meta‐Analysis: Timing of Elective Removal of Tympanostomy Tubes

Grace X. Tan, Andrew Hamilton, Carol J. MacArthur

Publication date 12-09-2022


Objective(s)Tympanostomy tube (TT) placement is the most common surgical procedure in children. Less than 10% of TT do not self-extrude. This study is a systematic review (SR) on elective TT removal in the pediatric population: timing, perforation rates, and role of simultaneous repair. A PICOTS (population, intervention, comparison, outcome, timing, setting) question was formulated: In pediatric patients who have retained TT, what is the preferred time to elective removal of such tubes, and what are the outcomes in terms of perforation rates? Does an intervention at the time of TT removal improve perforation rates?Study Design Systematic review and meta-analysis.
Methods We searched four major electronic databases: EMBASE, MEDLINE, CDSR, CCRCT for articles published prior to 02/19/20. End Note® was used to gather references, review abstracts, and obtain full text articles. Inclusion criteria were studies reporting patients aged 0 to 18 years undergoing elective TT removal with follow-up greater than 3 months. Exclusion criteria included patients >18 years, duplicate patient series, or case series with fewer than five patients. Articles that were not available in English, not available in full text, and those that only addressed long-acting TT were excluded.
Data were pooled and meta-analysis was conducted to examine how timing of TT removal, patching of the tympanic membrane, or any TM intervention at TT removal affected outcomes.
ResultsA total of 1,064 references were found. We identified 63 unique studies for full text review. Of these, 17 were selected for SR. MINORS (Methodological Index for Nonrandomized Studies) scores were low-revealing high bias among the studies. Reported perforation rates after elective TT removal ranged from 0% to 57%. Four studies had data suitable for comparative meta-analysis, which showed a significant increase in perforation rates after elective removal of TT after 3 years compared to removal prior to 3 years (OR 2.89; CI 1.78–4.69). No difference in perforation rates were identified when TM intervention vs. no intervention at time of TT removal was performed (six studies: OR 1.21; CI 0.71–2.07). No difference in perforation rates was identified when the type of TM intervention was compared, including freshening of TM edges, to patching with various materials (paper, fat, gelfoam®/gelfilm®, Trichloroacetic acid) (three studies: OR 1.07; CI 0.52–2.19).
Conclusion From the data reviewed in this SR and meta-analysis, elective TT removal at or prior to 3 years retention showed decreased perforation rates. However, TM intervention at the time of TT removal was not shown to lower perforation rates. In the absence of tube complications such as granuloma formation, nonfunctional tube, or chronic tube otorrhea, it may be reasonable to wait up to 3 years to electively remove a retained TT. Laryngoscope, 132:2063–2070, 2022

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Effects of Carbonation on Swallowing: Systematic Review and Meta‐Analysis

Ayano Nagano, Keisuke Maeda, Akio Shimizu, Kenta Murotani, Naoharu Mori

Publication date 12-09-2022


Objectives The effectiveness of the use of carbonation in preventing penetration/aspiration or enhancing swallowing function in adults remains unclear. This systematic review aimed to evaluate the effectiveness of carbonation on improving swallowing function in adult subjects.
Methods Literature published before March 2021 was inspected using MEDLINE, CINAHL, Web of Science Core Collection, The Cochrane Library, Cochrane Central Register of Controlled Trials, and Ichushi-web databases. We searched for intervention studies or randomized control trials considering the effects of carbonated liquids on swallowing function. The risk of bias was assessed using the Cochrane tool for assessing the risk of bias for randomized controlled trials and the Risk of Bias Assessment Tool for Nonrandomized Studies.
Results The systematic review identified 19 studies with a total of 586 participants. The effects of carbonation on swallowing function are diverse. Overall, most studies showed that carbonation promotes swallowing function compared to other liquids. Five studies were included in the quantitative synthesis. Meta-analysis showed that carbonated liquids prevent aspiration (risk difference RD −0.27%, 95% confidence interval CI −0.44 to −0.10; I2 = 0%; number needed to treat 3.8, 95% CI 2.2 to 15.0; moderate quality of evidence) when compared to noncarbonated thin liquids. Carbonated liquids also increased the duration of swallowing apnea than did noncarbonated liquids (standardized mean difference 0.25 (mean difference 0.36 seconds), 95% CI 0.03 to 0.47; I2 = 0%; low quality of evidence).
Conclusions Carbonation had favorable effects on swallowing function. Further in-depth studies are needed to clarify the benefits of carbonation.
Level of EvidenceNA Laryngoscope, 132:1924–1933, 2022

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Hearing Loss in Exfoliation Syndrome: Systematic Review and Meta‐Analysis

Michael C. Shih, Tamar M. Gordis, Paul R. Lambert, Shaun A. Nguyen, Ted A. Meyer

Publication date 10-09-2022


This systematic review and meta-analysis shows that hearing loss (HL) is associated with exfoliation syndrome (XFS). A sensorineural component to HL is confirmed, and mixed HL is possible. Given the high prevalence and infrequent diagnosis of XFS, the authors hypothesize that the current understandings of presbycusis might be improved by further investigation in XFS.
Objective To determine if exfoliation syndrome (XFS) is associated with hearing loss (HL) or vestibular dysfunction.
Data Sources Pub Med, Scopus, CINAHL, and Cochrane Library through April 1, 2022.
Review Methods Two reviewers independently screened abstracts, selected articles for inclusion, and extracted data. Studies included for qualitative analysis conducted audiometric, tympanometric, or vestibular evaluations on all subjects.
Results Twenty-one publications (1148 patients with XFS and 1212 controls) were included in the systematic review, and 16 publications (968 patients with XFS and 1147 controls) in the meta-analysis. Greater severity of HL was seen for patients with XFS compared to controls across all frequencies (odds ratio OR 8.8 7.3–10.2). Patients with XFS were more likely to have moderate to profound sensorineural HL (OR 1.8 1.3–2.5), and less likely to have none to mild HL (OR 0.34 0.17–0.67) or no HL (OR 0.37 0.28–0.50). Three studies found patients with XFS had lower tympanometric peaks. Two studies found that abnormal vestibular testing results could be more common for patients with XFS.
ConclusionsHL is associated with XFS. A sensorineural component to HL is confirmed, and mixed HL is possible. Given the high prevalence and infrequent diagnosis of XFS, the authors hypothesize that the current understandings of presbycusis might be improved by further investigation in XFS. Laryngoscope, 2022

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Cochlear Implantation in Far Advanced Otosclerosis: A Systematic Review and Meta‐Analysis

Mickey Kondo, Kartik Vasan, Nicholas Emmanuel Jufas, Nirmal P. Patel

Publication date 09-09-2022


Cochlear implantation in far advanced otosclerosis presents challenges with regards to speech perception outcomes and complications. This review gathers data that shows its efficacy and unique complication profile.
Objective To evaluate speech outcomes and facial nerve stimulation (FNS) rates in patients with far advanced otosclerosis (FAO) after cochlear implantation.
MethodsA systematic review was performed using standardized methodology of Medline, EMBASE, Pub Med, Cochrane, and Web of Science databases. Studies were included if adults with FAO underwent cochlear implantation. Exclusion criteria included concurrent otologic history (e.g., Menieres disease, superior canal dehiscence), non-English-speaking implant users, case reports, abstracts, and letters/commentaries. Bias was assessed using the Newcastle-Ottawa Scale for cohort studies and the National Institute of Health Scale for case series. The primary outcome measure was speech discrimination and the secondary outcomes were rates of partial insertion and FNS.
Results Twenty-seven studies evaluated cochlear implantation in FAO. Due to the heterogeneity of testing methods, statistical pooling of speech discrimination was not feasible, but qualitative synthesis indicated a positive effect of implantation. Pooled rates of FNS were 18% (95% confidence interval, CI 12%–27%) and the rate of partial insertion was 10% (95% CI 7%–15%).
Conclusion Cochlear implantation in FAO demonstrates significant gains in speech discrimination scores with higher rates of FNS and partial insertion. Laryngoscope, 2022

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Development and Implementation of the Cochlear Implant Quality of Life (CIQOL) Functional Staging System

Theodore R. McRackan, Brittany N. Hand, Cochlear Implant Quality of Life Development Consortium, Craig A. Velozo, Judy R. Dubno

Publication date 09-09-2022


The purpose of this study was to develop and implement a functional staging system using the Cochlear Implant Quality of Life (CIQOL) framework to improve the interpretation of real-world outcomes for adult cochlear implant users. Using a mixed-methods approach that engaged primary stakeholders (CI users) and clinicians, the CIQOL functional staging system was created and used to monitor improvement from pre-CI to 6-months post-CI activation. Results from this study can be used during discussions of expectation with potential CI users to provide enhanced insight regarding realistic outcomes and the anticipated timing for improvements.
Objectives The purpose of this study is to develop and implement a functional staging system using the Cochlear Implant Quality of Life (CIQOL) framework. The CIQOL-35 Profile was developed and validated following a rigorous research design and found to be more comprehensive and psychometrically sound than previous patient-reported outcome measures (PROMs) applied to adult CI users. However, interpreting the CIQOL-35 Profile (and all PROMs) relative to real-world functioning remains difficult for patients and clinicians, which limits the capacity of PROMs to direct clinical care. To address this limitation, a functional staging system based on PROM scores was developed to provide detailed descriptions of patients self-reported abilities (clinical vignettes) without sacrificing the inherent value of the psychometrically derived scores. The current study (1) creates an evidence-based CIQOL functional staging system using advanced psychometric techniques, (2) confirms the clarity and meaningfulness of the staging system with patients, and (3) implements the staging system to measure CIQOL stage progression using data from a longitudinal study design.
Methods Item response theory (IRT) analyses of CIQOL-35 Profile data from 705 experienced adult CI users and expert opinion were used to determine the cut-scores that separated adjacent stages for the six CIQOL-35 domains (communication, emotional, entertainment, environment, listening effort, and social). The research team then created clinical vignettes based on item response patterns for each stage. Semi-structured key informant interviews were conducted with 10 adult CI users to determine the clarity and meaningfulness of the CIQOL stages and associated clinical vignettes. Finally, we prospectively collected CIQOL-35 Profile scores from 42 CI users prior to cochlear implantation and then at 3- and 6-months post-CI activation to measure CIQOL stage progression.
Results Psychometric analyses identified five statistically distinct stages for the communication domain and three stages for all other domains. Using IRT analysis results for guidance, research team members independently identified the cut-scores that represented transitions between the functional stages for each domain with excellent agreement (κ = 0.98 95% confidence interval 0.96–0.99). Next, the key informant interviews revealed that CI users found the clinical vignettes to be clear and only minor changes were required. Participants also agreed that stage progression represented meaningful improvements in functional abilities. Finally, 88.1% of 42 patients in the prospective cohort (n = 37) improved from pre-CI functional stage by at least one functional stage in one or more domains. The communication domain had the greatest number of patients improve by one or more stages (59.5%) and the social domain the fewest (25.6%). There was also a trend for less improvement at 3- and 6-months post-CI activation for patients at higher pre-CI functional stages, even though higher stages were achievable.
Conclusion The new CIQOL functional staging system provides an evidence-based understanding of the real-world functional abilities of adult CI users from pre-CI to 3- to 6-months post-CI activation across multiple domains. In addition, study results provide the proportion of CI users in each stage at each timepoint. Results can be used during discussions of expectations with potential CI users to provide enhanced insight regarding realistic outcomes and the anticipated timing for improvements. The use of the CIQOL functional staging system also presents an opportunity to develop individualized goal-based rehabilitation strategies that target barriers to stage advancement faced by CI users.
Level of Evidence2 Laryngoscope, 2022

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Mixed Reality Enhanced Otolaryngology Case‐Based Learning: A Randomized Educational Study

Rukhnoor Malik, Jonathan R. Abbas, Ceyon Jayarajah, Iain A. Bruce, Neil Tolley

Publication date 08-09-2022


The COVID-19 pandemic has caused unprecedented disruptions to medical education. Educators are turning to technological advancements to deliver effective remote medical education. In this randomized educational design study, by comparing student engagement, knowledge transfer and student experience we investigate how mixed reality technology can enhance remote case-based learning.
Introduction The COVID-19 pandemic has caused unprecedented disruptions to medical education. Education in medical specialties, such as otolaryngology faces multiple challenges, including reduced bedside and “hands-on” training opportunities at all levels. Educators are turning to technological advancements to deliver effective remote medical education. This study investigated the value of enhancing traditional remote case-based teaching with the Holo Lens2™.
Methods We present a randomized educational design study. All educational content, media, and learning outcomes were identical. Primary outcome measures included student performance as measured with pre- and post-intervention quizzes and student engagement as measured by a tally-mark system. Secondary outcome measures, collected using feedback questionnaires, included perceived enjoyment, engagement, and opinions regarding the educational role of this technology.
Results The undergraduate medical students were randomized to either conventional or Holo Lens2™ enhanced remote case-based teaching (n = 56). Holo Lens2™ enhanced teaching improved student performance by an average of 3 marks of 15% (p < 0.001). It was engaging and encouraged questions 4-fold per session (p < 0.05) when compared to conventional remote case-based teaching. There was no significant difference in overall objective measurements of engagement. Students taught using Holo Lens2™ agreed that the teaching was enjoyable, effective in concept demonstration, and encouraged engagement.
Conclusions Remote teaching has allowed for the continuation of medical education in uncertain times. Beyond COVID-19, we predict that there will be a paradigm shift toward remote learning as new technological advancements emerges. These novel technologies may prove invaluable in the future potentially enabling education to be delivered between different hospitals, universities, and even overseas.
Level of EvidenceNA Laryngoscope, 2022

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An Ex Vivo Model of Posterior Tracheomalacia With Evaluation of Potential Treatment Modalities

Angela Cao, Pooja Swami, Rachel Kaye, Todd Goldstein, Daniel A. Grande, Lee P. Smith

Publication date 08-09-2022


We developed an ex vivo mechanical model of posterior tracheomalacia using porcine trachea. Several potential repair interventions were evaluated with the model.
Objective Posterior tracheomalacia (TM) is characterized by excessive intraluminal displacement of the tracheal membranous wall. Recently, novel surgical strategies for repair of posterior TM have been introduced. To our knowledge, these strategies have not been evaluated in a model of posterior TM. Thus, we sought to design an ex vivo mechanical model of posterior TM to evaluate potential repair interventions.
MethodsA model for posterior TM was created with partial thickness longitudinal incisions to the posterior aspect of ex vivo porcine trachea.
Three groups of tracheas were tested: (1) control (unmanipulated), (2) posterior TM (injury), and (3) intervention (repair). Interventions included external splinting with 0.3 and 0.5 mm bioresorbable plates, posterior tracheopexy, and injection tracheoplasty with calcium hydroxylapatite. An airtight tracheal system was created to measure tracheal wall collapse with changes in negative pressure. A bronchoscope and pressure transducer were connected to either end. Cross-sectional area of the tracheal lumen was analyzed using ImageJ software (National Institutes of Health, Bethesda, MD).
Results Average percent reduction in cross-sectional area of the tracheal lumen was compared using a two-tailed paired t-test. Significant differences were found between control and TM groups (p < 0.019). There was no significant difference between control and external splinting and posterior tracheopexy groups (p > 0.14).
Conclusion We describe an ex vivo model for posterior TM that replicates airway collapse. External splinting and tracheopexy interventions showed recovery of the injured tracheal segment. Injection tracheoplasty did not improve the TM.
Level of EvidenceN/A Laryngoscope, 2022

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Beyond Laryngeal Clefts: Interarytenoid Injection Augmentation to Predict Success of Suture Augmentation in Children

Emmanuel J. Jáuregui, Matthew F. Abts, John P. Dahl, Sanjay R. Parikh, David L. Horn, Michael Pickens, Jason S. Park, Kim DeMarre, Jennifer Hoang, Kaalan Johnson

Publication date 07-09-2022


We present our work to children with persistent pharyngeal dysphagia and use the interarytenoid injection augmentation (IAIA) procedure as a diagnostic and therapeutic tool to help determine which patients will be the most likely to respond to interarytenoid suture augmentation (IASA) or laryngeal cleft repair. This work represents the largest series in the literature on IAIA procedures, including one of the oldest patient populations, which serves to isolate the impact of this intervention and improve the ability of this data to best predict which patient will respond to IASA. This data has been incredibly useful to better inform peri-operative conversations with the families of patients undergoing these procedures.
Objective To assess the efficacy of interarytenoid injection augmentation (IAIA) and the ability of IAIA to predict response to interarytenoid suture augmentation (IASA) based on diet advancement on video fluoroscopic swallow studies (VFSS).
Methods Retrospective cohort analysis of patients with persistent pharyngeal dysphagia at a tertiary childrens hospital with VFSS pre- and post-IAIA were included between March 2011 and June 2019.
Results Median age of the 229 patients was 2.2 years (5.8 months–19 years). Interarytenoid mucosal height (IAMH) was found to be above the false vocal folds in 112 patients (53.4%) and at true vocal folds in 10 (4.9%) patients. On VFSS post-IAIA, 95 (41.5%) patients were successfully advanced in recommended diet consistency, 115 (50.2%) were stable, and 19 (8.3%) needed thicker consistency. Paired t-tests on pre- and post-operative consistency scores showed significant improvement, p-value of <0.0001, 95% confidence interval (CI; 0.50–0.85). Poisson regression found no covariates with significant association with improvement on IAIA. For IASA patients, 35/60 (58.3%) improved on post-op VFSS. Paired t-tests on pre- and post-operative consistency scores showed significant improvement, p-value of <0.0001, 95% CI (0.63–1.33). Positive predictive value for IAIA predicting response to IASA was 77% with positive likelihood ratio of 2.3. The response to IAIA versus no response to IAIA likelihood ratios were found to have a statistically significant difference (p < 0.05).
Conclusions Our study suggests IAIA yields objective improvement in swallow function on VFSS in nearly half of our patients and may be a reliable diagnostic tool to predict response to IASA in patients with persistent pharyngeal dysphagia with or without a laryngeal cleft.
Level of Evidence Level 3 Laryngoscope, 2022

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Knockdown of Cadherin 26 Prevents the Inflammatory Responses of Allergic Rhinitis

Tiancong Liu, Yang Sun, Zhaohui Guo, Weiliang Bai

Publication date 07-09-2022


Cadherin 26 (CDH26) contributes to the development of allergic rhinitis (AR), and CDH26 knockdown by LV-shCDH26 can effectively attenuate the AR-induced inflammatory response both in vivo and in vitro.
Objectives Allergic rhinitis (AR) is an inflammatory autoimmune disease with disorder of the nasal mucosa. Cadherin 26 (CDH26), an alpha integrin-binding epithelial receptor, is regulated during allergic inflammation. This study aimed to investigate whether CDH26 contributes to the severity of AR.
Study design In vivo and in vitro.
Methods We investigated the effects of CDH26 knockdown by lentivirus (LV)-mediated shRNA on ovalbumin (OVA)-induced AR mice and IL-13-stimulated human nasal epithelial cells (NECs).
ResultsCDH26 mRNA and protein expression was significantly increased in the nasal mucosa of AR patients and mice. Intranasal instillation of LV-shCDH26 alleviated allergic symptoms and decreased the histological changes of nasal mucosa in AR mice. Furthermore, the serum levels of OVA-specific IgE, IgG, pro-inflammatory factors IL-25, IL-33, and TSLP were decreased in AR mice with CDH26 knockdown. With regard to AR-induced Th2 inflammation, LV-shCDH26 intervention effectively decreased the distribution of CD4+/GATA3+ Th2 cells, and the mRNA expression of IL-4, IL-5, and IL-13 in the nasal mucosa. CDH26 knockdown down-regulated the expression of β-catenin but not for E-cadherin and ZO-1 in nasal mucosa induced by AR. In vitro, CDH26 knockdown inhibited the protein expression of TSLP, GM-CSF and eotaxin in NECs, and CDH26 overexpression remarkably promoted the production of these inflammatory factors in IL-13-induced NECs.
ConclusionsCDH26 knockdown attenuates the AR-induced inflammatory response both in vivo and in vitro.
Level of EvidenceNA Laryngoscope, 2022

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Voluntary Cough Testing as a Clinical Indicator of Airway Protection in Cervical Spinal Cord Injury

Laura Pitts, Valerie K. Hamilton, Erin A. Walaszek, Stephanie Watts, Leora R. Cherney

Publication date 05-09-2022


Voluntary cough testing (VCT) is an established predictor of aspiration in neurogenic dysphagia. However, the relation between VCT and protective laryngeal kinematics during swallowing post-traumatic cervical spinal cord injury (tCSCI) remains unknown. Our study shows that blunted volitional cough post-tCSCI reflects airway invasion and impaired laryngeal kinematics during swallowing.
Objective Voluntary cough testing (VCT) may be useful for determining aspiration risk in neurogenic dysphagia; however, has yet to be investigated in traumatic cervical spinal cord injury (tCSCI). The study explored if VCT may elucidate swallowing safety and kinematics related to airway protection in tCSCI survivors.
Methods Ten inpatients, 13–73 days post-tCSCI (7 incomplete injuries), completed VCT and a modified barium swallowing study that was analyzed via the Penetration Aspiration Scale (PAS) and norm-referenced measures of swallowing events related to airway protection. Spearman rho correlations explored relations among cough airflow, median PAS, and airway protection. Mann–Whitney U tests explored group differences based on clinical airway invasion (PAS > 2) and receiver operating characteristic statistics probed the sensitivity/specificity of VCT measures.
Results Safe (PAS > 2) and unsafe swallowers differed by cough volume acceleration (CVA) for the total sample and by inspiratory duration for incomplete injuries (p = 0.03, r > 0.7). A cut-off value of 24.8 L/s for CVA predicted airway invasion (AUC = 0.917, p = 0.03) with sensitivity = 100%/specificity = 75%. CVA correlated with delayed laryngeal vestibule closure during swallowing for both the total sample and for incomplete injuries (rs > 0.6, p < 0.05). Blunted peak flow and prolonged cough phases were associated with disordered laryngeal kinematics and prolonged bolus transit during swallowing (p < 0.05).
Conclusions Reduced CVA, blunted peak flow, and prolonged cough phases reflected PAS and disrupted mechanisms of airway protection in tCSCI survivors, demonstrating promise for VCT as a clinical assessment for post-tCSCI dysphagia.
Level of Evidence3 Laryngoscope, 2022

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Benefits of Side‐Firing Optical Fibers in Endoscopic Laser Treatment of the Larynx

Elliana Kirsh DeVore, Alex J. Chiluisa, Emily V. Minch, Rositsa Mihaleva, Hoang Do, Ryan Tougas, Loris Fichera, Thomas L. Carroll

Publication date 05-09-2022


Objective To elucidate potential tissue coverage of side-firing optical fibers in office-based endoscopic laser treatment of larynx, as well as to demonstrate their enhanced ability to address challenging anatomic areas.
Method We performed a comparative study of four different fiber designs: a traditional forward-facing fiber, and three side-firing fibers that emit light at an angle of 45°, 70°, and 90°, respectively. The study was conducted in simulation, using eight three-dimensional models of the human larynx generated from microtomography x-ray scans. A computer program simulated the insertion of the endoscope into the larynx, and the Möller–Trumbore algorithm was used to simulate the application of laser light.
Results Side-firing laser fibers increased potential tissue coverage by a mean of 50.2 (standard deviation SD 25.8), 73.8 (SD 41.3), and 84.0 (SD 47.6) percent for angles of 45°, 70°, and 90°, respectively, compared to forward-facing fibers. Angled fibers provided access to areas of the larynx considered difficult to address by traditional methods, including the infraglottis, laryngeal ventricle, and right vocal fold.
Conclusion Simulation results suggest that side-firing optical fibers have the potential to enhance anatomical access during in-office endoscopic laser procedures in the larynx. Further research is needed to better understand the benefits and any potential risks or contraindications of side-firing optical fibers.
Level of EvidenceNA Laryngoscope, 2022

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Opioid Prescribing Trends After Major Pediatric Ear Surgery: A 12‐Year Analysis

Holly Cordray, John Galvin, Addison Clark, Kristan Alfonso, Kara K. Prickett

Publication date 02-09-2022


This 2010-2021 analysis showed that opioid prescribing after major pediatric ear surgeries decreased significantly as awareness of the opioid epidemic grew, even without a targeted quality improvement intervention. Changes in surgeons prescribing behaviors reduced the annual rate of opioid prescriptions by more than 80%, and quantities per prescription became consistent with evidence-based analgesic needs. Pain-related returns to the system remained minimal while opioid prescribing declined.
Objective Postoperative opioid prescriptions tend to exceed childrens analgesic needs, but awareness of the opioid epidemic may have driven changes in prescribing behaviors. This study evaluated opioid prescribing patterns after major pediatric ear surgery.
Methods This study reviewed all cases of tympanoplasty, tympanomastoidectomy, mastoidectomy, cochlear implantation, otoplasty, and aural atresia repair at a pediatric hospital during 2010–2021. Regressions were conducted to identify opioid prescribing trends over time. Potential covariates were assessed. Returns to the system were reviewed as a balancing measure.
Results Even without a targeted protocol, opioid prescribing declined significantly. After prescribing peaked in 2012–2013, significant negative trends yielded lower rates of opioid prescriptions, fewer doses per prescription, smaller patient-weight-standardized dose sizes, and less variability (all p < 0.001). In 2012, 96.1% of patients received opioid prescriptions; the rate fell to 13.5% by 2021. For patients ages, 0–6, the annual rate of opioid prescriptions dropped from a maximum of 96.3% in 2012 to 0.0% in 2021. The annual average supply of doses per prescription decreased by 68% between 2013 and 2021, reducing the total days supply to an evidence-based 3.1 ± 1.6 days. Regressions did not detect changes in returns to the system. Pain-related returns were rare (0.9%) and did not vary by opioid prescriptions (p = 0.37). Prescribing trends were closely correlated with a tonsillectomy-focused protocol that our institution implemented in 2019.
Conclusion Surgeon-driven opioid stewardship has improved with no resultant change in revisit rates. Procedure-specific quality improvement interventions may have broader off-target effects on prescribing behaviors.
Level of EvidenceIV Laryngoscope, 2022

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Predicting Early Vestibular and Motor Function in Congenital Cytomegalovirus Infection

Cleo Dhondt, Leen Maes, Sarie Martens, Saartje Vanaudenaerde, Lotte Rombaut, Marieke Sucaet, Annelies Keymeulen, Helen Van Hoecke, Els De Leenheer, Ingeborg Dhooge

Publication date 02-09-2022


This study demonstrates the detrimental impact of vestibular loss on early motor development and is the first to identify predictors for vestibular loss in a large cohort of congenital cytomegalovirus (cCMV)-infants. This could facilitate widespread implementation of (targeted) vestibular assessment in cCMV.
Objectives Congenital cytomegalovirus (cCMV) can affect vestibular function, which is an important cornerstone for early motor development. This study aims to identify risk factors for early vestibular dysfunction with severe repercussions on the motor outcome.
Methods This prospective cohort study included 169 cCMV-patients with complete vestibular assessment (lateral video Head Impulse Test and cervical Vestibular Evoked Myogenic Potentials) before the age of 18 months (mean 8.9, standard deviation 3.27 months). Motor results using the Alberta Infant Motor Scale were collected in 152 of these patients. Logistic and linear regression models were applied to identify risk factors for the vestibular and motor outcomes, respectively.
Results The odds of developing early vestibular dysfunction were 6 times higher in patients presenting with hearing loss at birth compared to those born with normal hearing (p = .002). Within the latter group, significant predictors for vestibular dysfunction were (delayed-onset) hearing impairment at the time of vestibular testing (p = .003) and the presence of periventricular cysts on magnetic resonance imaging (p = .005). Remarkably, none of the patients infected during the third trimester of pregnancy (n = 14) developed early vestibular dysfunction. On average, vestibular-impaired patients had a z-score on the Alberta Infant Motor Scale that was 1.17 points lower than patients without vestibular deficit (p < .001).
Conclusion Early vestibular loss can have a significant adverse effect on motor development. Hearing and cranial imaging findings could facilitate the widespread implementation of a (targeted) vestibular assessment approach in the cCMV-population.
Level of Evidence3 Laryngoscope, 2022

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A Novel Grading System for Supraglottic Stenosis Based on Morphology and Functional Status

"Steven Aziz, Karla ODell, Michael Johns, Josh Schindler, Al Merati, Abdullah Alanazi, Stephanie Watts, David Garber, Rebecca Nelson, Yael Bensoussan"

Publication date 02-09-2022


A novel grading system for supraglottic stenosis based on stenosis morphology and patient functional status has been created. The proposed grading system demonstrates strong inter-rater reliability and intra-rater reliability to grade case examples of supraglottic stenosis.
Objective Currently, no classification system exists to grade the severity of supraglottic stenosis. The aim of this investigation was to (1) develop a novel grading system for supraglottic stenosis that can both enhance communication between providers and relay information about patient functional status and (2) determine the reliability of the grading system.
MethodsA retrospective analysis of patients with supraglottic stenosis at three institutions from 2010–2021 was conducted. After demographic data were collected, two focus group meetings of five laryngologists were held to develop a grading system based on functional status and morphology of stenosis seen on laryngoscopy. Three laryngologists then used the grading system to rate 20 case examples of supraglottic stenosis. Quadratic-weighted kappa coefficients were calculated to assess inter-rater and intra-rater reliabilities of the novel grading system.
Results Twenty-eight patients were included. Epiglottic and arytenoid fixation were morphological features associated with worse functional outcomes such as requiring a G-tube or a tracheostomy, respectively. Inter-rater reliability was substantial to almost perfect (Kw = 0.79–0.81) and intra-rater reliability was almost perfect for all raters (0.88–1.0) when using the novel grading system.
ConclusionA grading system for supraglottic stenosis has been proposed with strong inter-rater and intra-rater reliabilities. The proposed system has the advantage of being descriptive of both patient functionality and morphology of the stenosis.
Level of Evidence Level 3—According to the Oxford Center for Evidence-Based Medicine 2011 level of evidence guidelines, this non-randomized retrospective cohort study is classified as level 3 evidence Laryngoscope, 2022

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Body Dysmorphic Disorder in Adult Patients With an Orofacial Cleft: An Unseen Psychological Burden

Wesley H. Stepp, Eva J. Stein, Michael W. Canfarotta, Jeyhan Wood, Eva Vandoros, Margot Stein, Renie Daniel, William W. Shockley, Joseph Madison Clark, Amelia F. Drake

Publication date 02-09-2022


Adults with orofacial clefts are at a higher risk of developing conditions associated with appearance. In this study, we examine the role that orofacial clefts have on the incidence on Body Dysmorphic Disorder in a US cohort.
Objectives Facial dysmorphic disorder (FDD), a variant of body dysmorphic disorder, occurs when individuals are preoccupied with perceived defects in their facial appearance. Cleft lip and/or palate (CL/P) requires many clinical interventions and has significant psychological impacts on a patients perception of appearance. This study identified psychological burdens related to living as an adult with CL/P and characterizes the degree of FDD symptoms in an adult craniofacial population.
Methods This was a prospective, single-center, cross-sectional case–control study using semi-structured interviews and symptom assessments at a university-based craniofacial center. Patients without CL/P undergoing non-cosmetic facial surgery were recruited as controls (n = 20). Patients with an orofacial cleft (n = 30) were recruited from medical and dental providers at the University of North Carolina. Body Dysmorphic Disorder-Yale Brown Obsessive Compulsive Scale (BBD-YBOCS) scores were collected from a control population and patients with CL/P to assess FDD severity.
Results Demographic factors such age, biological sex, and ethnicity had no significant impact on FDD symptom scores. Patient with CL/P were more likely to have significant FDD symptoms (BDD-YBOCS greater than 16) than patients without CL/P (OR 10.5, CI95 2.7–41.1), and had a mean difference in FDD symptoms scores of 10.04 (p < 0.0001; CI95 5.5–14.6). Patients with CL/P seen by a mental health provider in the past 3 months had 3-fold lower overall FDD symptom scores (OR 0.081; CI95 0.0085–0.77).
Conclusions Adults with CL/P would benefit from treatment for cleft-specific needs and psychological support as they face unique stressors related to their appearance, including an increase in FDD-associated symptoms. This study emphasizes the importance of recognizing psychological symptoms and providing ongoing multidisciplinary care to adults with CL/P.
Level of Evidence3; Individual case–control study Laryngoscope, 2022

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In Reference to PET/CT Poorly Predicts AJCC 8th Edition Pathologic Staging in HPV‐Related Oropharyngeal Cancer

Ming Li, Chi Zhang, Tianfei Yu

Publication date 01-09-2022


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In Response to PET/CT Poorly Predicts AJCC 8th Edition Pathologic Staging in HPV‐Related Oropharyngeal Cancer

Vusala Snyder, William Gooding, Shaum Sridharan

Publication date 01-09-2022


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Survival Outcomes of Patients with Mycosis Fungoides Involving the External Ear and Ear Canal

Alex J. Wilkinson, Marc‐Elie Nader, Dianna Roberts, Madeleine Duvic, Jillian R. Gunther, Bouthaina S. Dabaja, Paul W. Gidley

Publication date 31-08-2022


This manuscript reports our retrospective review of 40 patients with mycosis fungoides, and it demonstrates a comparison in outcomes of patients with ear involvement with those without ear involvement. Overall survival was shorter when the ear canals were involved.
Objectives/Hypothesis Mycosis Fungoides (MF) is the most common subtype of cutaneous T-cell lymphoma. Disease involvement of specific locations may be more significant than simply the symptoms associated with that site; it is possible that involvement of certain sites could be associated with poor prognosis. We aimed to evaluate the outcomes of patients with MF with documented involvement of the EAC and external ear.
Study Design Retrospective analysis.
Methods We retrospectively reviewed 40 patients with MF that were treated by otologists between 2012 and 2021.
Results We report the largest series of patients with MF involving the external ear and EAC. Of the 40 patients included in this study, 17 presented with Mycosis Fungoides in the otologic region (MFO). Of these 17 MFO patients, 2/17 had involvement of the external ear only, 3/17 of the EAC only, 11/17 of both the external ear and EAC, and 1/17 of the periauricular skin. Of note, 11/14 (79%) patients presenting with EAC disease died compared to11/26 (42%) of patients without involvement. In addition, eight of the 13 (62%) patients with external ear involvement died compared to 14/27 (52%) of patients without involvement. Ear canal involvement was associated with a statistically significant shorter overall survival duration in patients with MF (p = 0.03). Furthermore, disease in the EAC was found to have a hazard ratio value of 2.565 (CI 1.102–5.970).
Conclusions Involvement of the EAC by MF portends a poor prognosis. This finding highlights the need for a more in-depth otologic evaluation of patients with MF.
Level of Evidence Level 4 Laryngoscope, 2022

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Inter‐Rater Reliability of Thyroid Ultrasound Risk Criteria: A Systematic Review and Meta‐Analysis

Phillip Staibano, Jennifer Ham, Jennifer Chen, Han Zhang, Michael K. Gupta

Publication date 30-08-2022


Thyroid nodules are common and often characterized by ultrasound criteria, including ACR Thyroid Imaging and Reporting Data System and American Thyroid Association guidelines. Our meta-analysis demonstrates moderate inter-rater reliability of these ultrasound criteria, but these findings are impacted by poor study quality and a lack of standardization. Future studies of thyroid ultrasound must focus on this aspect of diagnostic validity.
Objective The most commonly employed diagnostic criteria for identifying thyroid nodules include Thyroid Imaging and Reporting Data System (TI-RADS) and American Thyroid Association (ATA) guidelines. The purpose of this systematic review and meta-analysis is to determine the inter-rater reliability of thyroid ultrasound criteria.
Methods We performed a library search of MEDLINE (Ovid), EMBASE (Ovid), and Web of Science for full-text articles published from January 2005 to June 2022. We included full-text primary research articles that used TI-RADS and/or ATA guidelines to evaluate thyroid nodules in adults. These included studies must have calculated inter-rater reliability using any validated metric. The Quality Appraisal for Reliability Studies (QAREL) was used to assess study quality. We planned for a random-effects meta-analysis, in addition to covariate and publication bias analyses. This study was performed in accordance with Preferred Reporting Items for a Systematic Review and Meta-analysis guidelines and registered prior to conduction (International prospective register of systematic reviews—PROSPERO: CRD42021275072).
Results Of the 951 articles identified via the database search, 35 met eligibility criteria. All studies were observational. The most commonly utilized criteria were ACR Thyroid Imaging and Reporting Data System (TI-RADS) and/or ATA criteria, while the majority of studies employed Κ statistics. For ACR TI-RADS, the pooled Κ was 0.51 (95% confidence interval CI: 0.42, 0.57; n = 7) while for ATA, the pooled Κ was 0.52 (95% CI: 0.37, 0.67; n = 3). Due to the small number of studies, covariate or publication bias analyses were not performed.
Conclusion Ultrasound criteria demonstrate moderate inter-rater reliability, but these findings are impacted by poor study quality and a lack of standardization. Laryngoscope, 2022

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Oral Premalignant and Malignant Lesions in Fanconi Anemia Patients

Hunter Archibald, Krystina Kalland, Alexander Kuehne, Frank Ondrey, Brianne Roby, Luke Jakubowski

Publication date 30-08-2022


Objective There is a lack of data supporting cancer surveillance in pediatric Fanconi Anemia patients. We sought to describe the rates of upper aerodigestive lesions and malignancy in this population to augment current management guidelines.
MethodsA retrospective cohort study of patients with Fanconi Anemia from a quaternary referral center between 2007–2021 was completed for head and neck cancer risk.
Results One hundred and five FA patients were reviewed. Average age at presentation was 11.3 years old and 90.5% of patients underwent hematopoietic stem cell transplant (HSCT). A total of 8.6% of patients had leukoplakia or erythroplakia and 3.8% developed malignancy. The standardized incidence ratio of head and neck malignancy was 483.8. Patients presented with leukoplakia and malignancy at an average age of 14.6 and 25.1 years old, respectively. Malignancies were aggressive and marked by recurrence. There were no premalignant or malignant lesions found on flexible laryngoscopy. This series represents the largest longitudinal series of pediatric FA head and neck lesions.
Conclusions Fanconi Anemia patients should begin screening for head and neck cancer at age 10 or after HSCT.
Level of Evidence Level 4 Laryngoscope, 2022

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Longitudinal Analysis of Swallowing Displacement Kinematics After Oropharyngeal Cancer Treatment

Joseph Kidane, Joey Laus, Arushi Gulati, Grant E. Gochman, Sarah L. Schneider, Jason W. Chan, Sue S. Yom, Patrick Ha, W. John Boscardin, William R. Ryan, Yue Ma

Publication date 29-08-2022


We aimed to longitudinally assess quantitative swallowing displacement kinematic measurements and correlate them with functional swallowing outcomes. Quantitative swallowing kinematic measures can effectively track changes in swallowing physiology. Increased posterior pharyngeal wall thickness and restricted hyolaryngeal movement were seen in patients with oropharyngeal squamous cell carcinoma after treatment and correlated with change in swallowing outcome, emphasizing the need for serial videofluoroscopic swallow studies monitoring and targeted intervention.
Background/Objective Quantitative swallowing displacement kinematics evolve in patients treated for oropharyngeal squamous cell carcinoma (OPSCC). We aimed to longitudinally assess these measurements and correlate them with functional swallowing outcomes.
MethodA retrospective review was conducted on patients with OPSCC treated with definitive (chemo)radiation (CRT) or surgery with adjuvant (chemo)radiation (S-CRT) who completed at least two videofluoroscopic swallow studies (VFSS). Longitudinal analysis was accomplished via mixed-effects logistic regression for the Functional Oral Intake Scale (FOIS), and Penetration Aspiration Scale (PAS), and mixed-effects linear regression for kinematic measures. Spearmans correlation was conducted between changes in FOIS/PAS and kinematic measures.
Results Ninety-seven patients (76 males; mean age 61) completed 245 VFSS studies. A total of 94% had human papillomavirus (HPV)/p16 positive OPSCC and 74% were T0–T2. Sixty-four patients underwent CRT while 33 patients underwent S-CRT. After treatment, posterior pharyngeal wall at hold (PPWhold) increased 3.2 standard deviation (SD) between 0 and 6 months (p < 0.001), then decreased 2.2 SD between 6 and 12 months (p < 0.001) and did not return to baseline. Hyoid-to-larynx (HL) (p = 0.046) and maximal hyoid displacement (Hmax) + HL (p = 0.042) increased between 6 and 12 months. Hmax (p = 0.020) and Hmax + HL (p < 0.001) decreased between 12–24 months beyond baseline values. The decrease in HL and increase in PPWhold (p < 0.05) correlated with an increase in PAS. From baseline, increased pharyngeal constriction ratio correlated with decreased FOIS and PPWhold (p < 0.05).
Conclusions Quantitative swallowing kinematic measures can effectively track changes in swallowing physiology. Increased PPWhold and restricted hyolaryngeal movement were seen in patients with OPSCC after treatment and correlated with a change in swallowing outcome, emphasizing the need for serial VFSS monitoring and targeted intervention.
Level of Evidence3 Laryngoscope, 2022

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Long‐Term Binaural Hearing Improvements for Cochlear Implant Users with Asymmetric Hearing Loss

Nicholas J. Thompson, Kevin D. Brown, Emily Buss, Meredith A. Rooth, Margaret E. Richter, Margaret T. Dillon

Publication date 29-08-2022


Cochlear implant (CI) recipients with unilateral hearing loss reached early asymptote for binaural hearing abilities, and CI recipients with asymmetric hearing loss continued to improve out to 5-years post-activation for spatial release from masking when the masker was presented toward the better hearing ear. There was a significant correlation with improvement and age at implantation and contralateral hearing thresholds which may influence these differences.
Objective To assess long-term binaural hearing abilities for cochlear implant (CI) users with unilateral hearing loss (UHL) or asymmetric hearing loss (AHL).
MethodsA prospective, longitudinal, repeated measures study was completed at a tertiary referral center evaluating adults with UHL or AHL undergoing cochlear implantation. Binaural hearing abilities were assessed with masked speech recognition tasks using Az Bio sentences in a 10-talker masker. Performance was evaluated as the ability to benefit from spatial release from masking (SRM). SRM was calculated as the difference in scores when the masker was presented toward the CI-ear (SRMci) or the contralateral ear (SRMcontra) relative to the co-located condition (0°). Assessments were completed pre-operatively and at annual intervals out to 5 years post-activation.
Results Twenty UHL and 19 AHL participants were included in the study. Linear Mixed Models showed significant main effects of interval and group for SRMcontra. There was a significant interaction between interval and group, with UHL participants reaching asymptotic performance early and AHL participants demonstrating continued growth in binaural abilities to 5 years post-activation. The improvement in SRM showed a significant positive correlation with contralateral unaided hearing thresholds (p = 0.050) as well as age at implantation (p = 0.031).
ConclusionsCI recipients with UHL and AHL showed improved SRM with long-term device use. The time course of improvement varied by cohort, with the UHL cohort reaching asymptotic performance early and the AHL cohort continuing to improve beyond 1 year. Differences between cohorts could be driven by differences in age at implantation as well as contralateral unaided hearing thresholds.
Level of Evidence Level III Laryngoscope, 2022

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Using Item‐Response Theory to Improve Interpretation of the Trans Woman Voice Questionnaire

Nina W. Zhao, James M. Mason, Alexander M. Blum, Eric K. Kim, VyVy N. Young, Clark A. Rosen, Sarah L. Schneider

Publication date 29-08-2022


The objective of this study was to use item-response theory to evaluate the relationship between Trans Woman Voice Questionnaire (TWVQ) items and persons on a common scale and identify improvements to increase the meaningfulness of TWVQ scores. Analysis resulted in a new interval scoring system that retained high reliability and supported a unidimensional construct with regions can be interpreted as minimal, low, moderate, and high voice-related life impact for trans women, respectively. Empiric data from Rasch analysis provides updated TWVQ scoring that advances the clinical and research utility of the instrument and lays the foundation for future improvements in clinical care and outcomes assessment.
Objective The Trans Woman Voice Questionnaire (TWVQ) is commonly used to quantify self-perceptions of voice for trans women seeking gender-affirming voice care, but the interpretation of TWVQ scores remains challenging. The objective of this study was to use item-response theory (IRT) to evaluate the relationship between TWVQ items and persons on a common scale and identify improvements to increase the meaningfulness of TWVQ scores.
MethodsA retrospective review of TWVQ scores from trans women patients between 2018–2020 was performed. Rasch-family models were used to generate item-person maps positioning respondent location and item difficulty estimates on a logit scale, which was then converted into a scaled score using linear transformations.
ResultsTWVQ responses from 86 patients were analyzed. Initial item-person maps demonstrated that the middle response categories (“sometimes” and “often”) performed inconsistently across items (poor threshold banding); interpretability improved when these ratings were scored as one category. The models were rerun using revised scoring, which retained high reliability (0.93) and supported a unidimensional construct. Updated item-person maps revealed four scaled score zones (≤54, >54 to ≤101, >101 to ≤140, and >140) that each corresponded to an increasing pattern of item thresholds (probability of selecting one response category vs. others). These ranges can be interpreted as minimal, low, moderate, and high, respectively.
Conclusions Empiric data from Rasch analysis supports new interval scoring for the TWVQ that advances the clinical and research utility of the instrument and lays the foundation for future improvements in clinical care and outcomes assessment.
Level of EvidenceNA Laryngoscope, 2022

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Risk Factors for Recurrence of Peritonsillar Abscess

Kayoko Mizuno, Masato Takeuchi, Yo Kishimoto, Koichi Omori, Koji Kawakami

Publication date 27-08-2022


Objectives This study aimed to investigate the risk factors associated with peritonsillar abscess (PTA) recurrence in adult patients.
Methods This retrospective cohort study used a nationwide insurance claims database in Japan. Adult patients (aged ≥ 20 years) who received intravenous antibiotics or surgical therapy within 5 days of their first PTA diagnosis were included.
Multivariable Cox proportional modeling was used to investigate the risk factors for PTA recurrence using the variables: age, sex, comorbidities, tobacco use, history of recurrent tonsillitis, duration of intravenous antibiotics, and surgical therapy for PTA.
Results This study included 12,012 patients (8784 men, 73.1%). Of them, 1358 (11.3%) experienced PTA recurrence. An age ≥40 years and treatment with intravenous antibiotics for 3 days or more were associated with a lower risk of PTA recurrence (aged ≥ 40 years: adjusted hazard ratio HR: 0.69; 95% confidence interval CI: 0.62–0.78, treated with intravenous antibiotics for 3 days or more: adjusted HR: 0.85; 95% CI: 0.76–0.96). Patients with a history of recurrent tonsillitis were associated with a higher risk of recurrence (adjusted HR: 1.79; 95% CI: 1.47–2.19).
ConclusionA median age of 20–39 years, a history of recurrent tonsillitis, and less than 3 days of intravenous antibiotic therapy may be risk factors for PTA recurrence among adult patients. Further studies exploring more detailed clinical data are necessary to confirm the risk factors for PTA recurrence.
Level of Evidence3 Laryngoscope, 2022

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Prognostic Value of 18F‐Fluoro‐Deoxyglucose‐Positron Emission Tomography Volumetric Parameters in Human Papillomavirus‐Related Oropharyngeal Squamous Cell Carcinoma

Anthony Noor, Manish Mair, Lachlan Cook, Harrison Bolt, Sanith Cheriyan, Charmaine M. Woods, James Hopkins, Eng H. Ooi

Publication date 26-08-2022


Background This study evaluates and compares the prognostic significance of 18F-fluoro-deoxyglucose-positron emission tomography (18F-FDG PET) volumetric parameters in human papillomavirus-related oropharyngeal squamous cell carcinoma (OPSCC).
MethodsA retrospective review of all patients treated for OPSCC with curative intent between 2012 and 2018 was performed. Volumetric parameters analyzed included the maximum standardized uptake value (SUVmax), SUVpeak, metabolic tumor volume (MTV), and total lesion glycolysis (TLG) in both the primary tumor and nodal metastases. Prognostic significance was determined using Cox proportional hazards models for disease-free survival (DFS) and overall survival (OS).
Results Primary tumor MTV and TLG significantly correlated with both DFS and OS however the commonly reported SUVmax was not found to be predictive. Nodal measures of SUVmax, MTV, and TLG were not significant predictors of survival outcomes.
ConclusionA higher burden of metabolically active primary tumor as measured on volumetric 18F-FDG PET parameters is associated with poorer DFS and OS. This improved prognostication may be used to counsel patients and select those appropriate for treatment de-escalation in the future.
Level of Evidence Level 3 Laryngoscope, 2022

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Compensation Rates for Pediatric Otolaryngology Procedures Under the Medicare Physician Fee Schedule in 2021

Ashley L. Miller, Vinay K. Rathi, Michael J. Rutter

Publication date 26-08-2022


Compensation rates (total and intraservice) vary widely for procedures performed by pediatric otolaryngologists. Additional investigation is necessary to examine validity of assumptions underlying Centers for Medicare & Medicaid Services valuations and empirically inform more equitable compensation across procedures.
Introduction The Medicare Physician Fee Schedule (PFS) is the basis for physician reimbursement by public and private payers. The PFS values physician services according to the estimated time and intensity required to perform them; intensity reflects the summation of technical skill, cognitive load, and risk-related stress. The fee schedule uses relative value units (RVUs) as a metric that permits comparison across procedures. Recent debate has focused on whether the methods by which the Centers for Medicare & Medicaid Services (CMS) estimate procedural intensity are valid. We therefore sought to investigate current CMS estimates of intensity (RVUs/min) for surgical procedures performed by pediatric otolaryngologists.
Methods We performed a retrospective, cross-sectional analysis of fiscal year 2021 PFS valuations for pediatric otolaryngology key indicator procedures specified by the Accreditation Council for Graduate Medical Education. We additionally examined general otolaryngology procedures, including adenotonsillectomy and tympanostomy tube insertion. We utilized the 2021 Medicare PFS conversion factor of $34.89/RVU to convert intensity (wRVUs/min) to a compensation rate ($/min).
Primary outcomes were: (1) total compensation rate and (2) intraservice (i.e., incision-to-closure) compensation rate for each studied procedure.
Results Our study sample included 167 unique procedures. The mean (standard deviation) total compensation rate for all included procedures was $1.35/min ($0.29/min) and the mean intraservice rate was $1.71/min ($0.89/min). Intraservice compensation rates ranged from $-1.50/min (drainage of throat abscess) to $4.75/min (pediatric tracheostomy).
Discussion Total and intraservice compensation rates under the Medicare PFS vary widely for surgical procedures performed by pediatric otolaryngologists. Further investigation is necessary to examine the validity of assumptions underlying these procedural intensity valuations.
Level of EvidenceNA Laryngoscope, 2022

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Novel Outcome Analysis Tool for Hypoglossal Nerve Stimulator Sensor Lead Function and Comparison by Incision Type (2 Versus 3)

Mohamad Z. Saltagi, Kayla Powell, Abdul K. Saltagi, Stephanie Stahl, Shalini Manchanda, Noah P. Parker

Publication date 26-08-2022


This study demonstrates a method of sensor electrode outcome measurement that is reproducible for surgeons and sleep medicine specialists looking to evaluate intraoperative sensor function during hypoglossal nerve stimulator (HNS). The 2-incision technique for HNS placement demonstrates no reduction in quality, and even may provide some improvement in intraoperative sensory waveforms, supporting the transition to the 2-incision procedure among surgeons.
Objective No reported outcome measures have been established to evaluate sensor lead function in the hypoglossal nerve stimulator (HNS). This study describes the development of novel functional outcome measures for intraoperative sensor electrode function and compares 2-incision and 3-incision outcomes for HNS.
MethodsA retrospective cohort study of 100 consecutive patients who underwent HNS between June 2019 and September 2021. Demographic information, intraoperative findings, and immediate postoperative outcomes were recorded.
Structured parameters were developed to compare intraoperative waveforms with six outcome measures utilized: waveform syncing, waveform amplitude, sensory current leakage, shark-fin morphology, cardiac artifact, and overall impression. Two sleep surgeons and two sleep medicine specialists compared all waveforms in a blinded fashion and assigned scores on the Likert Scale.
Results The cohort included 50 three-incision and 50 two-incision patients. Age, gender, average body mass index, comorbidity profiles, and sleep endoscopy findings did not significantly differ between the two groups. No major complications occurred. The interclass-correlation-coefficient was greater than 0.7 for all comparisons (good to very good interrater reliability). There was no difference in waveform amplitude, cardiac artifact, sensory current leakage, or shark-fin morphology between the two groups. Waveform syncing and overall impression were statistically better in the 2-incision cohort.
Conclusions This study is the first to define a structured method of HNS sensor electrode outcome measurement and showed consistent measures by surgeons and sleep medicine specialists. This article supports the transition to the 2-incision technique among surgeons for placement of the sensor lead. Consideration should be given to utilizing this novel tool in the clinical/research setting and validating these measures moving forward.
Level of Evidence Level 3 Laryngoscope, 2022

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Incidence and Prevalence of Cough in a Rural Health System: A 20‐Year Study

Kenneth W. Altman, Amanda J. Young, Mudit Gupta, Priscilla F. A. Pichardo, Melissa A. Troup, Jackie Blank

Publication date 25-08-2022


This is a population based case series of 302,284 unique patients diagnosed with cough at our health system over 20 years. Stratifying by sex, age at first cough encounter, number of cough encounters, smoking status, and insurance status sheds important insight into care of the cough patient.
Objective Understanding the cough population is critical to addressing clinical needs and gaps in best practice. We sought to characterize and stratify cough patients with the hypothesis that there are opportunities to improve access to care in our health system and characterize the population.
Methods Following institutional review board exempt status, a retrospective electronic record review was performed on all patients coded with ICD-9 786.2 or ICD-10 is R05 from January 1, 2001 through December 31, 2020 at our health system. Inclusion criteria were one or more visits for cough. The subgroup with more than one visit in each of 2 years was classified as multiple encounters. Patients were characterized by sex, age at first cough encounter, number of cough encounters, smoking status, and insurance status. Results were stratified by year, calculating frequencies, and percentages.
Results There were 302,284 unique patients diagnosed with cough, among 1,764,387 patients seen in our health system, representing an average incidence of 3.0% (2.7%–3.7%) and prevalence of 4.9% (3.1%–5.6%). New single encounter cough patients totaled 179,963, and new multiple encounter cough patients totaled 122,321. Of the 39,828,073 total encounters, there were 469,802 for new or existing cough (1.17%–1.73% annually). The age at initial presentation demonstrated 36.5% seen <10 years old, with an even distribution over the remaining decades of life. The majority were seen for cough once, but 23.8% of group two patients had two or more visits for cough in a year.
Conclusion We demonstrate a lower-than-expected incidence and prevalence of cough in our health population, suggesting challenges with access to care when compared to 10% prevalence and 3% of encounters previously documented in the literature. The study also provides a platform to explore the importance of pediatric cough, as well as population health and the longitudinal journey of cough patients in underserved areas.
Level of Evidence3 Laryngoscope, 2022

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Intranasal Corticosteroid Treatment on Recovery of Long‐Term Olfactory Dysfunction Due to COVID‐19

Masoumeh Hosseinpoor, Mona Kabiri, Mohsen Rajati Haghi, Toktam Ghadam Soltani, Alireza Rezaei, Atiyeh Faghfouri, Zahra Poustchian Gholkhatmi, Mehdi Bakhshaee

Publication date 25-08-2022


Olfactory dysfunction is a recognized manifestation in patients infected with COVID-19. This investigation is aimed to assess the effect of mometasone furoate intranasal spray on the improvement of smell dysfunction in post-COVID-19 patients.
Background and Aims Olfactory dysfunction is a recognized manifestation in patients infected with Coronavirus Disease 2019 (COVID-19). This investigation aimed to assess the effect of mometasone furoate intranasal spray on the improvement of smell dysfunction in post-COVID-19 patients.
Materials and Methods This randomized placebo-controlled trial included 80 non-hospitalized adult patients who had persistent anosmia or severe microsmia for more than 4 weeks due to COVID-19 infection. The participants were randomly allocated to the intervention or placebo group to receive mometasone furoate nasal spray or sodium chloride intranasal spray during 4 weeks of follow-up, respectively. The patients olfactory dysfunction was assessed in terms of visual analog scale (VAS), and smell test score according to the modified version of the University of Pennsylvania smell identification test for the Iranian population.
ResultsA total of 70 participants completed the follow-up period and were analyzed in this study. By comparing the olfactory scores including smell test and VAS scores, no significant differences were found between case and control groups at baseline, 2, and 4 weeks intervals. However, the change of both olfactory scores at pre to post-treatment intervals and 2–4 weeks was significantly higher in the mometasone group relative to the placebo group. At post-treatment, the frequency of anosmia was 22.9% reduced in the case group compared to the control group.
Conclusion Overall, there was no significant difference in olfactory dysfunction between the two groups during follow-up. However, based on the significant between-group difference in terms of olfactory scores changes, it seems that the nasal corticosteroids may be a positive effect on the recovery process of patients who received more than 2 weeks.
Level of EvidenceII Laryngoscope, 2022

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Longitudinal Speech Recognition Changes After Cochlear Implant: Systematic Review and Meta‐analysis

Cheng Ma, Jacob Fried, Shaun A. Nguyen, Kara C. Schvartz‐Leyzac, Elizabeth L. Camposeo, Ted A. Meyer, Judy R. Dubno, Theodore R. McRackan

Publication date 25-08-2022


This systematic review and meta-analysis are on the longitudinal changes in speech recognition of postlingually hearing-impaired adults receiving cochlear implants.
Objectives To examine patterns of change and plateau in speech recognition scores in postlingually hearing impaired adult cochlear implant recipients. The study also examines variations in change patterns for different speech materials and testing conditions.
Study Design Used systematic review with meta-analysis.
Methods Articles in English reporting speech recognition scores of adults with postlingual hearing loss at pre-implantation and at least two post-implantation time points were included. Statistically significant changes were determined by meta-analysis and the 95% confidence interval.
ResultsA total of 22 articles representing 1954 patients were included. Meta-analysis of mean difference demonstrated significant improvements in speech recognition score for words in quiet (37.4%; 95% confidence interval 34.7%, 40.7%), sentences in quiet (49.4%; 95% confidence interval 44.9%, 53.9%), and sentences in noise (30.8%; 95% confidence interval 25.2%, 36.4%) from pre-op to 3 months. Scores continued to increase from 3 to 12 months but did not reach significance. Similarly, significant improvements from pre-op to 3 months were observed for consonant nucleus consonant (CNC) words in quiet (37.1%; 95% confidence interval 33.8%, 40.4%), hearing in noise test (HINT) sentences in quiet (46.5%; 95% confidence interval 37.0%, 56.0%), Az Bio sentences in quiet (45.9%; 95% confidence interval 44.2%, 47.5%), and Az Bio sentences in noise (26.4%; 95% confidence interval 18.6%, 34.2%). HINT sentences in noise demonstrated improvement from pre-op to 3 months (35.1%; 95% confidence interval 30.0%, 40.3%) and from 3 to 12 months (15.5%; 95% confidence interval 7.2%, 23.8%).
Conclusions Mean speech recognition scores demonstrate significant improvement within the first 3 months, with no further statistically significant improvement after 3 months. However, large individual variation should be expected and future research is needed to explain the sources of these individual differences. Laryngoscope, 2022

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Geographic Distribution of Otolaryngology Training Programs and Potential Opportunities for Strategic Program Growth

Drew H. Smith, Hannah F. Case, Humzah A. Quereshy, Jeffrey C. Mecham, Sarah N. Bowe, Matthew L. Carlson, Joehassin Cordero

Publication date 23-08-2022


The geographic distribution of United States otolaryngology residents was characterized based on geographical population density (per 100,000) to determine current status and identify potential opportunities for otolaryngology residency program expansion. Metropolitan areas over 1 million inhabitants without a residency program are also identified. Growth is warranted to provide sufficient care.
Objective To characterize the geographic distribution of US otolaryngology residents based on geographical population density to determine current status and identify potential opportunities for otolaryngology residency program expansion.
Methods The locoregional population of otolaryngology residency programs was analyzed (as defined by the US Census) and the number of resident trainees per 100,000 people in each region was calculated. Otolaryngology residency program location was determined by mailing address, and program size was determined by AAMC public data.
Results The average metropolitan city in the United States contained 2.07 otolaryngology trainees per 100,000 people. Cities with low trainee numbers per population included Phoenix, AZ (0.20 trainees per 100,000 people); Las Vegas, NV (0.26 per 100,000); Dallas, TX (0.26 per 100,000), Atlanta, GA (0.33 per 100,000); and Miami, FL (0.34 per 100,000). Comparing otolaryngology to other surgical subspecialties demonstrated similar distributions. Metropolitan centers with a population over 1 million without full academic representation in otolaryngology were also identified and included Charlotte, NC; Orlando, FL; Austin, TX; Providence, RI; Jacksonville, FL; Raleigh, NC; and Grand Rapids, MI.
Conclusion Strategic residency training program expansion should be considered in cities that exhibit a low trainee to population ratio. Although many factors ultimately determine program expansion or development of new training programs, this study provides substantiated population data describing where expansion could be prioritized.
Level of EvidenceNA Laryngoscope, 2022

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Predicting Pathologic Lymph Node Positivity in cN0 Pharynx and Larynx Cancers

Eric M. Anderson, Michael Luu, Diana J. Lu, Eric M. Chung, Christopher Gay, Kevin S. Scher, Alain C. Mita, Jon Mallen‐St. Clair, Allen S. Ho, Zachary S. Zumsteg

Publication date 23-08-2022


Background Elective neck dissection is a standard of care for pharynx and most larynx cancer patients undergoing surgery, based largely on historical series. It is unclear if this is necessary for all patients in the modern era.
Methods Patients with cN0 oropharynx, larynx, and hypopharynx cancers diagnosed from 2010–2015 undergoing primary surgery were identified in the National Cancer Data Base.
Results Inclusion criteria were met by 4117 cN0 patients. The presence of lymphovascular invasion (LVI) was the strongest independent predictor of pN+ (odds ratio OR = 4.19, 95% confidence interval CI 3.56–4.93, p < 0.001). Histologic grade strongly predicted pN+ (OR 2.58, 95% CI 1.88–3.59, p < 0.001). A nomogram predicted less than 10% of cN0 patients had pN+ risk <15%.
ConclusionLVI and grade are the strongest predictors of pN+ among patients with cN0 pharynx and larynx cancer. Even in the modern era, pN+ rates warrant neck dissection for cN0 patients.
Level of Evidence3 Laryngoscope, 2022

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Retrograde Cricopharyngeus Dysfunction: The Jefferson Experience

Sana H. Siddiqui, Emily S. Sagalow, Michele A. Fiorella, Nikhita Jain, Joseph R. Spiegel

Publication date 23-08-2022


Retrograde cricopharyngeus dysfunction is a new diagnosis describing patients with the inability to belch. Botulinum toxin injection has provided relief to these patients and led to increased awareness through social media.
Objectives To describe our centers experience with the identification and treatment of retrograde cricopharyngeus dysfunction (R-CPD), a syndrome involving the inability to belch previously described by only one institution. Additionally, because all patients initially learned of their condition and sought treatment as a result of social media posts, we queried their source and comfort with this form of medical referral.
Methods Retrospective chart review of patients who underwent botulism toxin injection into the cricopharyngeus muscle for treatment of R-CPD from 2019 to 2022. Demographic data, most common symptoms at presentation, and response to treatment and complications were documented. Post-treatment questionnaires were reviewed.
ResultsA total of 85 patients were identified. Mean age at surgery was 27 years. There were 54 (63.5%) females and 31 (36.5%) males. The inability to burp (98.8%), bloating (92.9%), gurgling noises (31.8%), and excessive flatulence (21.2%) were the most common symptoms. The minimum units of botox utilized were 25, whereas the maximum was 100. The majority of patients (88.2%) had a successful response at initial follow-up visit. The most common complication was mild dysphagia (30.6%), which was transient for all patients. Most patients learned of our practice through social media, with only one patient being referred by a medical provider.
Conclusions The majority of patients in our cohort were young and female. The inability to burp and bloating were the most common presenting symptoms. Social media was the primary source of referral. Our institution favors 80–100 units for an effective response. Laryngoscope, 2022

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Risk Factors for Fear of Recurrence in Head and Neck Cancer Patients

Julia Riggauer, Daniela Blaser, Olgun Elicin, Brigitta Gahl, Roland Giger, Simon Andreas Mueller

Publication date 22-08-2022


Objective Fear of recurrence (FoR) affects the quality of life of head and neck cancer survivors. Identification of factors predisposing to FoR may help to recognize and treat patients at risk.
Materials and Methods For this exploratory study, 101 disease-free head and neck cancer survivors completed a cross-sectional survey in 2017 that included the FoR questionnaire at a random point in time during their follow-up. Additionally, the patients were asked to choose their favorite among four follow-up schedules with or without systematic imaging and varying frequency of visits.
Results Elevated FoR was present in 36.6% of patients. Females and patients ≤65 years showed significantly higher FoR overall scores than males (score difference 3.40; CI 0.49–6.32; p = 0.022) and patients >65 years (score difference 4.25; CI 1.58–6.92; p = 0.002). A history of cancer recurrence or second primary malignancy increased the relative risk (RR) for elevated FoR (RR 1.7; CI 1.01–2.86; p = 0.046). Tumor stage and treatment modality were not significantly associated with elevated FoR or FoR overall score. Higher FoR overall scores were recorded in patients who favored intensive follow-up plans (mean overall FoR score 18 vs. 15; SD 7.7; p = 0.076) and systematic imaging in follow-up (17 vs. 13, SD 7.1; p = 0.034).
Conclusion Fear of recurrence in head and neck cancer patients is associated with female sex, younger age, and history of a past recurrence or second primary malignancy. Due to its high prevalence, it should be addressed in clinical practice and future research.
Level of EvidenceN/A Laryngoscope, 2022

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Long‐term Outcomes of Vocal Fold Paralysis Following Patent Ductus Arteriosus Ligation in Neonates

Quinn Orb, Gabriel Dunya, Reema Padia, Jerald King, John Holbrook, Harlan Muntz, Marshall E. Smith

Publication date 20-08-2022


Premature infants undergoing patent ductus arteriosus ligation are at risk for vocal fold paralysis leading to long term voice and swallowing complications. In this study, we review risk factors for vocal fold paralysis and offer insight into long term outcomes and further treatment needs in this unique patient population.
Introduction In patients undergoing patent ductus arteriosus (PDA) ligation there is a significant risk of left vocal fold paralysis (LVFP) particularly in premature neonates who are small for gestational age. The objective of this study is to determine the incidence of LVFP in infants following PDA ligation and report on long-term outcomes in patients with LVFP.
Methods We performed a prospective study of patients undergoing PDA ligation in the newborn intensive care unit (NICU) between April 2004 and May 2014. Following PDA ligation, flexible laryngoscopy was performed to assess vocal fold mobility. Patients were then followed longitudinally to determine long-term outcomes.
ResultsA total of 163 infants underwent PDA ligation. Thirty-six patients (22%) developed LVFP following the procedure. Twenty-five percent of neonates <1500 g experienced LVFP versus 5% of patients >1500 g (p = 0.033). Patients with LVFP were more likely to require a feeding tube (64% vs. 19.6%; p < 0.05) and spent more time in the NICU (135 days vs. 106 days; p < 0.05). Twenty-four patients received long-term follow-up. Six (25%) had complete resolution of LVFP, 10 (42%) were compensated, and 8 (33%) demonstrated persistent LVFP with no improvement.
Conclusions The incidence of LVFP after PDA ligation is high especially in extremely low birth weight children. The majority of patients recovered well with time, but further surgical intervention was required in uncompensated cases. Long-term follow-up of these patients is needed to ensure improvement. Laryngoscope, 2022

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Novel Machine Learning Model to Predict Interval of Oral Cancer Recurrence for Surveillance Stratification

Alexandra T. Bourdillon, Hemali P. Shah, Oded Cohen, Michael A. Hajek, Saral Mehra

Publication date 20-08-2022


We developed a machine learning model using a feature selection data input that was able to reliably predict oral cancer recurrence within 1-year intervals. Precise modeling of timing of recurrence can help personalize surveillance protocols to enhance early detection and reduce extraneous healthcare costs.
Objective(s)We aimed to develop a machine learning (ML) model to accurately predict the timing of oral squamous cell carcinoma (OSCC) recurrence across four 1-year intervals.
Methods Patients with surgically treated OSCC between 2012–2018 were retrospectively identified from the Yale-New Haven Health system tumor registry. Patients with known recurrence or minimum follow-up of 24 months from surgery were included.
Patients were classified into one of five levels: four 1-year intervals and one level for no recurrence (within 4 years of surgery). Three sets of data inputs (comprehensive, feature selection, nomogram) were combined with 4 ML architectures (logistic regression, decision tree (DT), support vector machine (SVM), artificial neural network classifiers) yielding 12 models in total. Models were primarily evaluated using mean absolute error (MAE), lower values indicating better prediction of 1-year interval recurrence. Secondary outcomes included accuracy, weighted precision, and weighted recall.
Results389 patients met inclusion criteria: 102 (26.2%) recurred within 48 months of surgery. Median follow-up time was 25 months (IQR: 15–37.5) for patients with recurrence and 44 months (IQR: 32–57) for patients without recurrence. MAE of 0.654% and 80.8% accuracy were achieved on a 15-variable feature selection input by 2 ML models: DT and SVM classifiers.
Conclusions To our knowledge, this is the first study to leverage multiclass ML models to predict time to OSCC recurrence. We developed a model using feature selection data input that reliably predicted recurrence within 1-year intervals. Precise modeling of recurrence timing has the potential to personalize surveillance protocols in the future to enhance early detection and reduce extraneous healthcare costs.
Level of EvidenceIII Laryngoscope, 2022

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Superficial Parotidectomy for Juvenile Recurrent Parotitis

John Wilson, Michael Gorelik, Jessica Gulliver, Alok Jaju, Bharat Bhushan, Jeffrey Rastatter, Douglas Johnston, John Maddalozzo

Publication date 18-08-2022


This case series reviews 20 children undergoing superficial parotidectomy for recalcitrant juvenile recurrent parotitis over a 10-year period. All but one patient experienced complete cessation of symptoms. We discuss their long-term outcomes, preoperative imaging, and pathologic findings.
Objectives To investigate long-term outcomes, imaging, and pathologic findings in pediatric patients who underwent superficial parotidectomy for recalcitrant juvenile recurrent parotitis (JRP).
Methods Records for 20 children (23 parotidectomies; 9 females, 11 males; age at surgery of 8.6 ± 3.7 years) collected over a 10-year period (2012–2021) were reviewed. Parents were contacted via telephone to obtain extended follow-up. A simplified scoring system was used to assess imaging findings and an additional pathologic review was conducted to further clarify the underlying disease process.
Results All but one patient experienced resolution of their recurrent symptoms after superficial parotidectomy. Three of the patients studied required surgery on the contralateral side, and this could be predicted based on their imaging at the time of the initial surgery. Pathologic findings included ductal fibrosis, metaplasia, and dilatation as well as parenchymal atrophy and fatty deposition. There were no major surgical complications, however, the incidence of Freys syndrome in this sample was 43.5% of surgical sites.
Conclusion For patients with frequent recalcitrant symptoms or significant quality of life impairment related to JRP, superficial parotidectomy represents a potential treatment option with the noted reduction in symptom burden following surgery. Further longitudinal studies are needed.
Level of Evidence4 Laryngoscope, 2022

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Otolaryngologic Manifestations of Trisomy 13 and Trisomy 18 in Pediatric Patients

Jalen Benson, Candace Stewart, Margaret A. Kenna, A. Eliot Shearer

Publication date 18-08-2022


The survival rate of patients with trisomy 13 and trisomy 18 has increased dramatically over the past two decades. We reviewed all patients diagnosed with trisomy 13 and trisomy 18 and evaluated by the Otolaryngology service at our institution. We identified the most common diagnoses and procedures performed by our specialty.
Objective The survival rate of patients with trisomy 13 and trisomy 18 has increased dramatically over the past two decades. We sought to comprehensively describe the otolaryngologic clinical characteristics and procedures required for these patients at our institution.
Methods We performed algorithmic identification of patients with a diagnosis of trisomy 13 and trisomy 18 for whom the otolaryngology service provided inpatient or outpatient care at our institution between the dates of February 1997 and March 2021.
Results Of the 47 patients studied, 18 patients had a diagnosis of trisomy 13, and 29 had a diagnosis of trisomy 18. Complete trisomy was present in 44% (8/18) of trisomy 13 patients and 55% (16/29) of trisomy 18 patients. 81% of patients were living at the time of the study. About 94% (44/47) of patients required consultation with another specialty in addition to Otolaryngology. Overall, the most common diagnoses among this cohort were gastroesophageal reflux disease (47%), dysphagia (40%), otitis media (38%), and obstructive sleep apnea (34%). Nearly three-quarters (74%) of patients studied required an otolaryngologic procedure. The most common surgical procedure was tonsillectomy and/or adenoidectomy. Patients with trisomy 18 were significantly more likely to have external auditory canal stenosis and obstructive sleep apnea whereas patients with trisomy 13 were more likely to have cleft lip and palate.
Conclusions Patients with a diagnosis of trisomy 13 or 18 often require multidisciplinary management and the range of required care spans the breadth of otolaryngology.
Level of Evidence4 Laryngoscope, 2022

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Developing a Social Media Ontology Across Otolaryngology and its Subspecialties

Candace A. Flagg, John P. Marinelli, Matthew L. Carlson, Eric J. Kezirian, Gregory R. Dion, Kathryn M. Van Abel, Garret Choby, Grant S. Hamilton, Sarah N. Bowe

Publication date 17-08-2022


Social media use within the otolaryngology community has increased substantially. As social media use continues to play a larger role in the dissemination of otolaryngology-related information, the importance of standardization of language surrounding key ideas is critical to avoid redundancy in posts that lower readership across all key stakeholders. The current work proposes a standardized ontology for our field that is meant to serve as a foundation from which the otolaryngology community can build its common language on social media.
Objective To determine how social media is used in the dissemination of new information within otolaryngology, and to emphasize the importance of standardizing Twitter hashtag use.
Methods Based on the 2019 SCImago journal rankings, the Twitter posts from the accounts of the top three journals covering each otolaryngology subspecialty were reviewed from August 1, 2020 to May 1, 2021. Twitter posts from the primary otolaryngology-related academic societies were also reviewed during this timeframe. A list of hashtags was generated based on a combination of the most common otolaryngologic procedures and most commonly used hashtags in the social media space. This list was then crowd-sourced with 10 fellowship-trained otolaryngologists for each subspecialty.
Results Hashtag use among key stakeholders in the otolaryngology social media space varies considerably. For instance, #HNSCC, #Head And Neck Squamous Cell Carcinoma, #Head And Neck Cancer, #Head And Neck Cancers, #Oropharyngeal Cancer, #Oropharynx Cancer, #Oral Cancer, and #OPSCC were all commonly used hashtags to identify posts discussing oropharyngeal squamous cell carcinoma. #Head And Neck Cancer and #HNSCC were most popular and used in a total of 85 and 65 tweets, respectively. #Head And Neck Cancer was found alone in 32 out of 85 tweets (38%), whereas #HNSCC was found alone in 27 out of 65 tweets (42%). A standardized hashtag ontology covering all subspecialties within otolaryngology is proposed herein.
Conclusions Adoption of a standardized social media ontology within otolaryngology will improve information dissemination across all key stakeholders. Laryngoscope, 2022

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Interference With Implanted Upper Airway Stimulation Device by Phones With Magnet Technology

Andrea Plawecki, Nitika Tripathi, Maria Tovar Torres, Kathleen Yaremchuk

Publication date 17-08-2022


Recent studies have raised concern regarding electromagnetic interference from new cellular phones that incorporate novel magnetic technology with the function of implanted medical devices. This case series evaluates the effect of these cellular devices on the implanted hypoglossal nerve stimulator. This case series tested the function of hypoglossal nerve stimulator device in the presence of the i Phones 12 and 13 and found interference with the implant function in all three patients. Patients implants can now be informed about the potential for cellular phones with magnetic technology to cause interference with their devices.
Newer i Phone models with Mag Safe magnetic technology can cause electromagnetic interference with the Inspire upper airway stimulator device (a surgical implant for the treatment of obstructive sleep apnea). Laryngoscope, 2022

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