Tetsuji Sanuki, Naoki Takemoto
Publication date 06-06-2023
Objectives Injection of botulinum toxin type A (BTX) into intrinsic laryngeal muscles is the current gold standard therapy for adductor spasmodic dysphonia (AdSD). However, a surgical procedure could potentially offer more stable and long-lasting voice quality to AdSD patients. Here, we report the long-term results of type 2 thyroplasty (TP2) with TITANBRIDGE® (Nobelpharma, Tokyo, Japan) compared with those of BTX injections.
Methods In total, 73 AdSD patients visited our hospital between August 2018 and February 2022. Patients were provided the option of BTX injections or TP2. They were assessed via the Voice Handicap Index (VHI)-10 before treatments and at scheduled clinical follow-ups at 2, 4, 8, and 12 weeks for BTX and at 4, 12, 26, and 52 weeks for TP2.
Results Overall, 52 patients selected the BTX injection and had a pre-injection mean VHI-10 score of 27.3 ± 8.8. Following injections, the scores significantly improved to 21.0 ± 11.1, 18.6 ± 11.5, and 19.4 ± 11.7 at 2, 4, and 8 weeks, respectively. There were no significant differences between the pre-injection scores and the 12-week scores (21.5 ± 10.7). Alternately, 32 patients opted to be treated with TP2 and had a pre-treatment mean VHI-10 score of 27.7. All patients reported an improvement in their symptoms. Additionally, the mean VHI-10 score significantly improved to 9.9 ± 7.4 at 52 weeks following treatment. There was a significant difference between the two treatment groups at 12 weeks. Some patients received both treatments.
Conclusion These preliminary results provide important insights into the value of TP2 as a potential permanent treatment for AdSD patients.
Level of EvidenceIII Laryngoscope, 2023
Jake A. Langlie, Luke J. Pasick, David E. Rosow
Publication date 06-06-2023
Serial intralesional steroid injections (SILSI) are used to prolong the surgery-free interval in subglottic stenosis patients. Through an adapted economic model, we found that SILSI is cost-effective if it prolongs the surgery-free interval of at least 1 out of 5 cases.
Objectives Repeat endoscopic dilation (ED) in the operating room for subglottic stenosis (SGS) remains an economic burden to patients. The cost-effectiveness (CE) of adjuvant serial intralesional steroid injections (SILSI) to prolong the surgery-free interval (SFI) in SGS patients requiring ED has yet to be studied.
Methods Details of the cost of SILSI and ED were received from our tertiary academic center. SFI, cost of intervention, and the effect of SILSI on prolonging SFI were collected from a systematic review by Luke et al. SGS etiologies in the review included idiopathic, iatrogenic, or autoimmune. A break-even analysis, comparing the cost of SILSI alone with the cost of repeat ED, was performed to determine if SILSI injections were cost-effective in prolonging the SFI.
Results Average extension of the SFI with SILSI was an additional 219.3 days compared to ED alone based on a systematic review of the literature. 41/55 (74.5%) cases did not require further ED once in-office SILSI management began. SILSI administered in a 4-dose series in 3-to-7-week intervals (~$7,564.00) is CE if the reported recurrence rate of SGS requiring ED (~$39,429.00) has an absolute risk reduction (ARR) of at least 19.18% with the use of SILSI. Based on the literature, SILSI prevents ~3 out of every 4 cases of SGS at sufficient follow-up from undergoing repeat ED, resulting in an ARR of ~75%.
ConclusionsSILSI is economically reasonable if it prolongs the SFI of at least one case of recurrence out of 5. SILSI, therefore, can be CE in extending the interval for surgical ED.
Level of EvidenceN/A Laryngoscope, 2023
Neel R. Sangal, Praneet Kaki, Jason Brant, Robert M. Brody
Publication date 05-06-2023
John Wilson, Alok Jaju, Nitin Wadhwani, Michael Gorelik, Douglas Johnston, Jeffrey Rastatter, Bharat Bhushan, Inbal Hazkani, Iga Fudyma, John Maddalozzo
Publication date 05-06-2023
In this largest comprehensive series to date, we review imaging, pathology, and surgical data from 56 children with first branchial cleft anomalies. We provide a novel classification system based on lesion location relative to the parotid gland. We also review the validity of the popular Work classification.
Objectives To evaluate the clinical features of first branchial cleft anomalies (BCAs) and their relationship to pre-operative imaging, pathologic data, and post-operative surveillance outcomes. Additional aims were to assess the validity of the Work classification and describe features of recurrent cysts.
Methods Records for 56 children (34 females, 22 males; age at surgery of 5.6 ± 4.4 years) collected over a 12-year period (2009–2021) were reviewed. Imaging and pathologic slides were re-reviewed in a blinded fashion by experts in those respective areas. Parents were contacted via telephone to obtain extended follow-up. An alternate classification method based on the presence (type II) or absence (type I) of parotid involvement is provided.
Results Only 55% of first BCAs could be successfully classified using Works method. First BCAs within the parotid were more likely to present with recurrent infections, involve scarred tissue planes and lymphadenopathy, and demonstrate enlarged lymphoid follicles on pathology. The overall recurrence rate was 16%, and recurrence was 5.3 times more likely when external auditory canal cartilage was not resected. Preoperative imaging was useful for predicting the extent of surgery required and the presence of scarred tissue planes.
Conclusion First BCAs within the parotid gland involve more difficult and extensive surgical resection and the potential for morbidity related to facial nerve dissection. Appropriately aggressive surgical resection, which may include the resection of involved ear cartilage, is necessary to prevent morbidity related to recurrence.
Level of Evidence4 Laryngoscope, 2023
Margaret B. Mitchell, Alan D. Workman, Vinay K. Rathi, Neil Bhattacharyya
Publication date 02-06-2023
Our study utilized the 2021 Adult National Health Interview Survey to understand the relationship between COVID-19 infection and smell and taste loss. We found the majority of Americans infected with COVID-19 reported smell and taste disturbances with a small minority reporting limited or no sensory recovery.
Objective The aim of this study was to quantify the impact of COVID-19 on olfactory and gustatory function in US adults.
Methods From the 2021 Adult National Health Interview Survey, demographic and survey-specific module data concerning COVID-19 diagnoses, testing and disease severity, and data quantifying disturbances and eventual recovery of smell and taste were extracted. Sample weights were applied to obtain nationally representative statistics. The overall rate of COVID-19 infection was determined, and those diagnosed with COVID-19 were analyzed with respect to disease severity, smell and taste disturbance, and respective recoveries.
Results In 2021, 35.8 million or 14% of the adult population (95% CI 13.5–14.7%; mean age, 43.9 years; 53.8% female) had been diagnosed with COVID-19. Among those, 60.5% (58.6–62.5%) and 58.2% (56.2–60.1%) reported accompanying losses in smell or taste, respectively; there was a significant association between overall COVID-19 symptom severity and smell (p < 0.001) and taste disturbance (p < 0.001). Following infection, 72.2% (69.9–74.3%), 24.1% (22.2–26.2%), and 3.7% (3.0–4.6%) of the patients experienced complete, partial, and no smell recovery, respectively. Recovery rates for gustatory function paralleled olfaction, with 76.8% (74.6–78.9%), 20.6% (18.7–22.7%), and 2.6 (1.9–3.4%) reporting complete, partial, and no recovery of taste, respectively. When sensory disturbance was present, severity of overall symptomatology was negatively associated with smell and taste recovery (p < 0.001 for each).
Conclusion The majority of adults infected with COVID-19 in 2021 experienced olfactory or gustatory dysfunction with a non-negligible population reporting incomplete or no near-term sensory recovery. Our results are useful for providers counseling patients and suggest that interventions lessening overall COVID-19 symptom burden may prevent prolonged sensory dysfunction.
Level of evidenceIV. Laryngoscope, 2023
Amy L. Zhang, Rebecca Z. Lin, Emma K. Landes, Amy E. Ensing, Henok Getahun, Judith E. C. Lieu
Publication date 02-06-2023
Children with hearing loss and children with obstructive sleep apnea experience higher fatigue and lower quality of life than peers without a chronic medical condition. Similar cognitive fatigue in both groups suggests that fatigue in children with hearing loss may be overlooked.
Objective To investigate the fatigue levels of children with hearing loss (HL) and obstructive sleep apnea (OSA), hypothesizing that the fatigue experienced by children with HL is under-recognized.
Study Design Cross-sectional survey.
Methods We identified children aged 2–18 with HL, OSA, sleep-disordered breathing (SDB), and controls from a pediatric otolaryngology clinic and sleep center. Children and/or parents completed the Pediatric Quality of Life Inventory Multidimensional Fatigue Scale (PedsQL MFS), Hearing Environments And Reflection on Quality of Life (HEAR-QL), and OSA-18.
Results Responses of 50 children with HL, 79 with OSA, and 18 with SDB were compared with those of 49 recruited controls (RC) and literature controls (LC). Children with HL or OSA had higher fatigue than controls in the PedsQL MFS self-reported (HL 65.4, OSA 54.7, RC 71.8, LC 80.5, p < 0.001) and parent-reported (HL 64.6, OSA 59.3, RC 75.2, LC 89.6, p < 0.001). Children with HL had Cognitive Fatigue similar to that of children with OSA (self 60.4 vs. 49.5, p = 0.170; parent 56.0 vs. 56.7, p = 0.998), though with decreased Sleep/Rest Fatigue (self 67.8 vs. 56.3, p = 0.033; parent 69.8 vs. 57.5, p = 0.001). Children with HL or OSA had lower disease-related quality of life (QOL) than controls in the HEAR-QL and OSA-18, respectively. Stratification with disease severity revealed no differences in fatigue.
Conclusion Children with HL or OSA experience higher fatigue and lower QOL than controls. Similar Cognitive Fatigue in both groups suggests under-recognized fatigue in children with HL.
Level of Evidence Level 3 Laryngoscope, 2023
Phillip Nulty, William Mason, Edward L. Peterson, Bernard Cook, Jack Rock, Jacob Eide, John R. Craig
Publication date 02-06-2023
For unilateral clear thin nasal drainage, a 0.06% ipratropium bromide nasal spray trial is a highly effective screening tool for excluding nasal cerebrospinal fluid leaks. This could help some patients avoid unnecessary invasive testing for nasal cerebrospinal fluid leaks.
Objectives Unilateral clear thin rhinorrhea (UCTR) can be concerning for a nasal cerebrospinal fluid (CSF) leak. Beta-2 transferrin electrophoresis has been the gold standard for initial non-invasive confirmatory testing for CSF rhinorrhea, but there can be issues with fluid collection and testing errors. Ipratropium bromide nasal spray (IBNS) is highly effective at reducing rhinitis-related rhinorrhea, and should presumably not resolve CSF rhinorrhea. This study assessed whether different clinical features and IBNS response helped predict presence or absence of CSF rhinorrhea.
MethodsA prospective cohort study was conducted where all patients with UCTR had nasal fluid tested for beta-2 transferrin, and were prescribed 0.06% IBNS. Patients were diagnosed with CSF rhinorrhea or other rhinologic conditions. Clinical variables like IBNS response (rhinorrhea reduction), positional worsening, salty taste, postoperative state, female gender, and body-mass index were assessed for their ability to predict CSF rhinorrhea. Sensitivity, specificity, and predictive values and odds ratios were calculated for all clinical variables.
Results Twenty patients had CSF rhinorrhea, and 53 had non-CSF etiologies. Amongst clinical variables assessed for predicting CSF absence or presence, significant associations were shown for IBNS response (OR = 844.66, p = 0.001), positional rhinorrhea worsening (OR = 8.22, p = 0.049), and body-mass index ≥30 (OR = 2.92, p = 0.048). IBNS response demonstrated 96% sensitivity and 100% specificity, and 100% positive and 91% negative predictive values for predicting CSF rhinorrhea.
Conclusions In patients with UCTR, 0.06% IBNS response is an excellent screening tool for excluding CSF rhinorrhea, and should be considered in the diagnostic workup of CSF rhinorrhea.
Level of Evidence2 Laryngoscope, 2023
Fahad Rind, Songzhu Zhao, Catherine Haring, Stephen Y Kang, Amit Agrawal, Enver Ozer, Matthew O Old, Ricardo L. Carrau, Nolan B Seim
Publication date 02-06-2023
Objectives The increase in incidence of thyroid cancer correlates with strict increases in body mass index (BMI) and obesity in the United States. Thyroid hormone dysregulation has been shown to precipitate circulatory volume, peripheral resistance, cardiac rhythm, and even cardiac muscle health. Theoretically, thyroid surgery could precipitate injury to the cardiopulmonary system.
Methods The American College of Surgery National Quality Improvement Program database was queried for thyroidectomy cases in the 2007–2020 Participant User files. Continuous and categorical associations between BMI and cardiopulmonary complications were investigated as reported in the database.
Results The query resulted 186,095 cases of thyroidectomy procedures in which the mean age was 51.3 years and sample was 79.3% female. No correlation was evident in univariate and multivariate analyses between BMI and the incidence of postoperative stroke or myocardial infarction. The incidence of complications was extremely low. However, risk of deep venous thrombosis correlated with BMI in the categorical, univariate, and multivariate (OR 1.036, CI 1.014–1.057, p < 0.01) regression analysis. Additionally, increased BMI was associated with increased risk of pulmonary embolism (PE) (OR 1.050 (1.030, 1.069), p < 0.01), re-intubation (OR 1.012 (1.002, 1.023), p = 0.02), and prolonged intubation (OR 1.031 (1.017, 1.045), p < 0.01).
Conclusion Despite the rarity of cardiopulmonary complications during thyroid surgery, patients with very high BMI carry a significant risk of deep venous thrombosis, PE, and prolonged intubation.
Level of Evidence Level 3 Laryngoscope, 2023
Jing Jin, Bei Guo, Wei Zhang, Jian‐jun Chen, Yu‐qing Deng, Rong Xiang, Lu Tan, Pei‐qiang Liu, Li Zheng, Zhe Chen, Ze‐zhang Tao, Yu Xu
Publication date 31-05-2023
In order to diagnose ECRS noninvastically and efficiently, this study attempted to verify the value of eosinophils and ECP in nasal secretions in the diagnosis of ECRS. This study find that measurement of EOS% and ECP in nasal secretions is useful for the early diagnosis of ECRS.
Objectives To investigate the value of secretions Eosinophilic cationic protein (ECP) detection in the diagnosis of endotypes of Chronic rhinosinusitis (CRS) and its correlation with clinical symptoms, so as to provide guidance for the clinical application of EOS and ECP detection in secretions.
Methods Patients nasal secretions and polyps (or middle turbinate for control) were collected and their EOS% and ECP levels were measured. Correlation analysis was performed for EOS% and ECP levels in secretions and tissues, respectively. The correlation between secretions EOS% and ECP and clinical symptom scores (symptomatic visual analog scale (VAS) scores, Lanza-kennedy scores from nasal endoscopy and Lund-Mackay scores from sinus CT) was further analyzed. Receiver operating characteristic curves were used to assess the predictive potential of EOS% and ECP in nasal secretions.
Results Eosinophilic chronic rhinosinusitis (ECRS) patients had higher concentrations of ECP in nasal secretions than healthy subjects and NECRS (non-eosinophilic CRS) (p < 0.0001;0.0001); EOS% in nasal secretions was higher in ECRS than healthy subjects (p = 0.0055), but the differences between ECRS and NECRS were not statistically significant (p = 0.0999). Correlation analysis showed that tissue EOS% was correlated with ECP concentration and EOS% in nasal secretions (R = 0.5943;0.2815). There was a correlation between EOS% in secretions with a total LM score (R = 0.3131); ECP concentration in secretions with a total LK score (R = 0.3792). To diagnose ECRS, the highest area under the curve (0.8230) was determined for ECP in secretions; the highest area under the curve (0.6635) was determined for EOS% in secretions.
Conclusion Measurement of ECP in nasal secretions is useful for non-invasive diagnosis of ECRS.
Level of Evidence Level 3 Laryngoscope, 2023
Farhoud Faraji, Abhishek Kumar, Rohith Voora, Shady I. Soliman, Daniel Cherry, P. Travis Courtney, Andrey Finegersh, Theresa Guo, Ezra Cohen, Joseph A. Califano, Loren Mell, Brent Rose, Ryan K. Orosco
Publication date 31-05-2023
Using the US Veterans Affairs database, we identified 161 patients with HPV-positive oropharyngeal carcinoma treated with TORS of which 29 (18%) were low-risk, 45 (28%) intermediate-risk, and 87 (54%) high-risk. TORS followed by adjuvant treatment revealed 5-year DSS of 100%, 90%, and 89% for low, intermediate, and high-risk patients. ENE, pT3/T4 tumor, and >5 pathologic lymph nodes were associated with poor DSS. Cumulative incidence of first recurrence was 17%, 18%, and 13% and of distant metastasis was 0%, 12%, and 8%.
Objectives Most transoral robotic surgery (TORS) literature for HPV-positive oropharyngeal squamous cell carcinoma (HPV-OPC) derives from high-volume tertiary-care centers. This study aims to describe long-term recurrence and survival outcomes among Veterans Health Administration patients.
Materials and Methods Using the US Veterans Affairs database, we identified patients with HPV-OPC treated with TORS between January 2010 and December 2016.
Patients were stratified in risk categories: low (0–1 metastatic nodes, negative margins), intermediate (close margins, 2–4 metastatic nodes, lymphovascular or perineural invasion, pT3-pT4 tumor), or high (positive margins, extranodal extension (ENE), and/or ≥5 metastatic nodes). Primary outcomes included overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS).
Results The cohort included 161 patients of which 29 (18%) were low-risk, 45 (28%) intermediate-risk, and 87 (54%) high-risk. ENE was present in 41% of node-positive cases and 24% had positive margins. Median follow-up was 5.6 years (95% CI, 3.0–9.3). The 5-year DSS for low, intermediate, and high-risk groups were: 100%, 90.0% (95% CI, 75.4–96.1%), and 88.7% (95% CI, 78.3–94.2%). Pathologic features associated with poor DSS on univariable analysis included pT3-T4 tumors (HR 3.81, 95% CI, 1.31–11; p = 0.01), ≥5 metastatic nodes (HR 3.41, 95% CI, 1.20–11; p = 0.02), and ENE (HR 3.53, 95% CI, 1.06–12; p = 0.04). Higher 5-year cumulative incidences of recurrence were observed in more advanced tumors (pT3-T4, 33% 95% CI, 14–54% versus pT1-T2, 13% 95% CI, 8–19%; p = 0.01).
Conclusions In this nationwide study, patients with HPV-OPC treated with TORS followed by adjuvant therapy at Veterans Affairs Medical Centers demonstrated favorable survival outcomes comparable to those reported in high-volume academic centers and clinical trials.
Level of Evidence4 Laryngoscope, 2023
Beau M. Idler, Koji Iijima, Sergei I. Ochkur, Elizabeth A. Jacobsen, Matthew A. Rank, Hirohito Kita, Devyani Lal
Publication date 31-05-2023
Eosinophil peroxidase is elevated in patients with eosinophilic chronic rhinosinusitis regardless of patients polyp status and correlates with IL-5. EPX could be considered as a biomarker within eosinophilic chronic rhinosinusitis patients.
Objective To evaluate eosinophil peroxidase (EPX) as a biomarker for tissue levels of eosinophilia, cytokines, and chemokines within chronic rhinosinusitis (CRS).
Methods Twenty-eight subjects undergoing sinonasal surgery were prospectively enrolled. Ethmoid tissue was analyzed with an in-house EPX immunoassay and a 48-plex cytokine-chemokine array. Clinical severity was assessed using SNOT-22 and Lund-Mackay scores.
Subjects were grouped as follows: controls, polyp status (CRS with CRSwNP and without nasal polyps CRSsNP), tissue eosinophilia (eosinophilic CRS eCRS, non-eosinophilic CRS neCRS), or combinations thereof (eCRSwNP, eCRSsNP, neCRSsNP). eCRS was defined as >10 eosinophils per high power field (HPF). Subjects without CRS or asthma were enrolled as controls.
ResultsEPX was elevated in CRSwNP compared to control (p = 0.007), in eCRS compared to neCRS (p = 0.002), and in eCRSwNP along with eCRSsNP compared to neCRSsNP (p = 0.023, p = 0.015, respectively). eCRS displayed elevated IL-5 compared to neCRS (p = 0.005). No significant differences in EPX or IL-5 were observed between eCRSwNP and eCRSsNP. IL-5 was elevated in eCRSwNP (p = 0.019) compared neCRSsNP. Area under the receiver operator characteristic curve was 0.938 (95% CI, 0.835–1.00) for EPX and tissue eosinophilia, with an optimal cut-point of 470 ng/mL being 100% specific and 81.25% sensitive for tissue eosinophilia. Linear regression revealed a strong correlation between EPX and IL-5 (R2 = 0.64, p < 0.001). Comparing EPX and IL-5, only EPX displayed significant correlation with SNOT-22 (p = 0.04) and Lund-Mackay score (p = 0.004).
ConclusionEPX is associated with tissue eosinophilia in CRS patients regardless of polyp status. EPX correlates with IL-5 and could be potentially considered a biomarker for anti-IL-5 therapies.
Level of Evidence3 Laryngoscope, 2023
David Lobo, Ramon Sancibrian, Angela Mesones, José Ramón Llata, Monica Williams, Jaime Viera‐Artiles
Publication date 31-05-2023
This study examined the feasibility of reducing work-related pain in Endoscopic Sinus and Skull Base surgeons by using a forearm support. The initial results in terms of pain and fatigue reduction and efficacy were excellent, justifying further research into this technology.
Objective The main objective of this study was to develop and evaluate the feasibility and effectiveness of a novel exoskeleton system designed to provide ergonomic assistance to surgeons while preserving or improving the quality of endoscopic sinus and skull base surgical procedures.
Methods To evaluate the functionality and ergonomic characteristics of the device, five experiments were conducted in different and increasingly realistic scenarios: silicone model of the nasal cavity, freshly frozen cadavers and finally in a real surgery. Each volunteers task was recorded and timed. The National Aeronautics and Space Administration Task Load Index (NASA-TLX) rating scale was used to estimate the surgeons workload while performing the tasks.
Results Twenty-five volunteers took part in the experiments. Volunteers perceived more comfort and less fatigue and pain when using the armrest than when not using the device (3.3, SD 1.75 vs. 5.9 SD 1.49; p = 0.02). Participants found the device intuitive, comfortable, and improving accuracy and stability with endoscope use.
ConclusionA new system that provides ergonomic assistance to surgeons was tested in simulation surgery with acceptable usability. Initial results in terms of pain and fatigue reduction and efficiency were excellent, justifying further research into this technology.
Level of EvidenceN/A Laryngoscope, 2023
Shi‐Xu Wang, Ying Li, Ji‐Qing Zhu, Mei‐Ling Wang, Wei Zhang, Cheng‐Wei Tie, Gui‐Qi Wang, Xiao‐Guang Ni
Publication date 31-05-2023
The deep convolutional neural network model can improve the diagnosis level of junior endoscopists, and also lays the foundation for the application of artificial intelligence-assisted endoscopic diagnosis of nasopharyngeal cancer.
Objective To construct and validate a deep convolutional neural network (DCNN)-based artificial intelligence (AI) system for the detection of nasopharyngeal carcinoma (NPC) using archived nasopharyngoscopic images.
Methods We retrospectively collected 14107 nasopharyngoscopic images (7108 NPCs and 6999 noncancers) to construct a DCNN model and prepared a validation dataset containing 3501 images (1744 NPCs and 1757 noncancers) from a single center between January 2009 and December 2020. The DCNN model was established using the You Only Look Once (YOLOv5) architecture. Four otolaryngologists were asked to review the images of the validation set to benchmark the DCNN model performance.
Results The DCNN model analyzed the 3501 images in 69.35 s. For the validation dataset, the precision, recall, accuracy, and F1 score of the DCNN model in the detection of NPCs on white light imaging (WLI) and narrow band imaging (NBI) were 0.845 ± 0.038, 0.942 ± 0.021, 0.920 ± 0.024, and 0.890 ± 0.045, and 0.895 ± 0.045, 0.941 ± 0.018, and 0.975 ± 0.013, 0.918 ± 0.036, respectively. The diagnostic outcome of the DCNN model on WLI and NBI images was significantly higher than that of two junior otolaryngologists (p < 0.05).
Conclusion The DCNN model showed better diagnostic outcomes for NPCs than those of junior otolaryngologists. Therefore, it could assist them in improving their diagnostic level and reducing missed diagnoses.
Level of Evidence3 Laryngoscope, 2023
Anna Miles, Alexandra Hunting
Publication date 31-05-2023
The pharyngeal squeeze manoeuvre is a quick and simple addition to an endoscopic evaluation and has potential to predict likelihood of swallow problems and clinical outcomes. It can be used as a part of a standardised endoscopic assessment and has potential to guide the management of complex patients in acute care.
Objectives Diminished pharyngeal constriction is a common biomechanical deficit associated with dysphagia and holds strong predictive value for aspiration. Pharyngeal squeeze manoeuvre (PSM) was previously validated for evaluating pharyngeal constriction on endoscopy. However, PSM is not routinely used in laryngology clinics or flexible endoscopic evaluation of swallowing (FEES) protocols worldwide. This study explored PSM in the acute care setting and its relationship with swallowing safety and efficiency, other swallowing biomechanical functions, and clinical outcomes.
Methods This prospective observational study consented 222 consecutive inpatients of mixed aetiology who were receiving FEES as part of their standard care. Established FEES protocols were performed including assessment of secretion accumulation, urge-to-clear ratings, laryngeal motor, and sensory functional tests, PSM, as well as aspiration, and residue during oral trials. Swallow frequency and cough peak flow were also collected as well as clinical outcomes at discharge.
ResultsPSM was impaired in 46% of the patients. Accumulated secretions, penetration-aspiration, and post-swallow residue were frequent and correlated with abnormal PSM (p < 0.05). PSM was reliable and agreed with pharyngeal constriction ratio on videofluoroscopy in all 15 patients who had both assessments within 72 h. Abnormal PSM correlated with vocal cord immobility, reduced peak cough flow, and reduced swallow frequency (p < 0.05). Abnormal PSM predicted restricted diet on hospital discharge with an odds ratio of 10.38.
ConclusionsPSM is a quick and simple addition to an endoscopic evaluation and has the potential to predict likelihood of impaired swallow safety and efficiency as well as clinical outcomes.
Level of Evidence Level 3 Laryngoscope, 2023
Tengyu Yang, Xinmiao Fan, Yue Fan, Wenjie Song, Xingrong Liu, Jian Wang, Xiaowei Chen
Publication date 31-05-2023
Co-occurring SNHL and CHD is a rare condition with complex etiologies. In this study, we suggest a workflow for genetic testing of patients with co-occurring SNHL and CHD. Delay in speech development was commonly reported in these children, thus long-term follow-up of hearing and language development is required.
Objectives/Hypothesis The co-occurrence of sensorineural hearing loss (SNHL) and congenital heart disease (CHD) is a rare condition with complex etiologies. The purpose of this study is to assess the etiologies, clinical features, and outcomes of cochlear implant (CI) in this patient population.
Study Design Case series and literature review.
Methods Clinical data of children who were diagnosed with SNHL and CHD and received CIs at a tertiary hospital from 2016 to 2021 were retrospectively analyzed. A literature review was performed to identify patients with SNHL and CHD.
Findings Of the 382 children who underwent cochlear implantation at our center, eight (2.1%) were diagnosed with SNHL and CHD. A literature review identified 1525 patients from 254 studies; the database therefore consisted of 1533 patients. The most common genetic etiologies of co-occurring SNHL and CHD were CHARGE syndrome (36.3%), Turner syndrome (8.4%), 22q11.2 deletion (3.0%), Noonan syndrome (2.9%), and Down syndrome (2.5%), whereas the most common non-genetic etiologies were congenital rubella syndrome (22.9%) and SNHL after early cardiac surgery (5.5%). Most of the patients presented with congenital, bilateral, severe-profound SNHL requiring early rehabilitation. Of the 126 children who received CIs at a median age of 2.5 years, half showed delayed speech development at last follow-up.
Conclusions Co-occurring SNHL and CHD is a rare condition with complex etiologies. Timely hearing intervention with long-term follow-up and proper timing of heart surgery is essential for these children.
Level of Evidence4, case series Laryngoscope, 2023
"Agnes Zhu, Thomas J. OByrne, Travis J. Haller, Eliot Martin, Eric J. Moore"
Publication date 31-05-2023
The presence of gross CNI identified during surgical intervention in HPV(+)OPSCC patients is associated with significantly worse oncologic outcomes, including overall survival, disease-specific survival, progression free survival, and distant metastasis free survival. Patients should be counseled accordingly, and aggressive adjuvant therapy should be considered.
Objectives This study examines oncologic outcomes in patients with HPV-related oropharyngeal squamous cell carcinoma (HPV(+)OPSCC) who had evidence of gross cranial nerve invasion (CNI) identified at the time of surgery.
Study Design Retrospective cohort study comparing demographics, clinical features, and outcomes of HPV(+)OPSCC patients with and without gross CNI.
Methods Patients with biopsy proven HPV(+)OPSCC involving the base of tongue, tonsil, or unknown primary site, who underwent surgery as a part of their treatment between 1/1/2006–12/31/2020 (n = 874), were included in this study. Gross CNI was identified during operative intervention (n = 36). Statistical analyses were performed using SAS version 9.4 and R version 3.6.2. P-values <0.05 were considered statistically significant.
ResultsHPV(+)OPSCC patients with gross CNI were nearly 5 times as likely to suffer death by cancer (HR = 5.41, 95% CI 2.51 to 11.67, p < 0.0001), over 4 times as likely to see disease progression (HR = 4.25, 95% CI 2.31 to 7.84, p < 0.0001), and nearly 5 times as likely to experience metastasis (HR = 4.46, 95% CI 2.20 to 9.06, p < 0.0001) when compared to patients without CNI. Patients with gross CNI had significantly lower overall survival, cancer-specific survival, progression-free survival, and distant-metastasis free survival (p < 0.0001). Patients with gross CNI were significantly more likely to present with higher clinical N stage, higher pathological N stage and extracapsular spread than patients without gross CNI.
Conclusions Our findings indicate that the presence of CNI is associated with significantly poorer oncologic outcomes in HPV(+)OPSCC patients.
Level of Evidence3 Laryngoscope, 2023
Luc G.T. Morris
Publication date 30-05-2023
Some head and neck cancers are able to avoid detection and elimination by the immune system by developing loss of the human leukocyte antigen molecules in tumor cells, which can limit the presentation of tumor antigens on the cell surface for recognition by T cells.
Objectives/Hypothesis Cancer cells evade recognition by the immune system to survive. Head and neck squamous cell carcinoma (HNSCC) is characterized by high levels of immune infiltration and mutation-associated neoantigens; therefore, immune evasion is likely to be an important mechanism in HNSCC tumorigenesis and progression. A commonly employed mechanism of immune evasion is downregulation of human leukocyte antigen (HLA) or loss of heterozygosity (LOH) in tumor cells. The objective of this study was to integrate multi-dimensional genomic and transcriptomic data from HNSCC tumors to better understand the clinical and immunologic implications of HLA LOH.
Study type/Design Cross-sectional integrated clinical and genomic analysis.
Methods Whole-exome sequencing and RNA-sequencing data from 522 tumors profiled in The Cancer Genome Atlas HNSCC cohort were analyzed and integrated with secondary analyses including immune cell deconvolution data. Associations were analyzed with categorical hypothesis testing and multivariable logistic and Cox regression.
ResultsHLA LOH was a prevalent event that was identified in 53% of HNSCC tumors; in many cases, more than one class I HLA gene was targeted for LOH. HLA LOH was more common in advanced-stage tumors. Tumors with somatic HLA LOH had tumor microenvironments defined by decreased lymphocyte and T cell infiltration.
ConclusionsHLA LOH is one of the most prevalent genetic alterations in HNSCC, and is associated with a cold immune microenvironment, suggesting that HLA LOH is a means of immune evasion. It may have value as a predictive biomarker or potential as a cancer cell-specific therapeutic target.
Level of Evidence3 Laryngoscope, 2023
Rajeev Kumar, Mohammad Ponneth Sherif, Smita Manchanda, Adarsh Barwad, Prem Sagar, Maroof Ahmad Khan, Ashu Seith Bhalla, Chirom Amit Singh, Rakesh Kumar
Publication date 30-05-2023
Depth of invasion is new parameter add in 8th AJCC staging system for Oral cavity squamous cell carcinoma in clinical T staging. Accurate assessment is paramount for both staging and prognostication. Our study showed USG tongue is reproducible and reliable method which is quick, repeatable before surgery and cost-effective.
Background“Depth of invasion” is an additional index incorporated in 8th AJCC staging system for oral cavity squamous cell carcinoma based on its prognostic significance. Pre-operative assessment by clinical palpation and imaging modalities has been used with limitations. The aim of the study is to compare different techniques including clinical palpation, ultrasound, and magnetic resonance imaging with histopathology for assessment of depth of tumor invasion.
Materials Fifty patients of carcinoma tongue (T1–T3) were enrolled. Clinical palpation, Ultrasound tongue, and Magnetic resonance imaging were used to assess depth of tumor invasion. Microscopic depth of invasion was considered as reference. Statistical analysis was done to assess the level of agreement, reliability, and internal consistency. ROC analysis was done to find the “Area Under Curve” for microscopic depth versus ultrasound, MRI, and gross histopathological “depth of invasion”.
Results Ultrasound tongue showed highest “area under curve”, Intra class correlation (ICC:0.786) with a good consistency (Cronbachs Alpha:0.880) with histological reference compared to MRI(ICC:0.689;CA:0.816). Clinical palpation showed weak agreement (Kappa:0.43) for assessing depth. To observe the concordance between ultrasound and microscopic depth, Lins Concordance Correlation Coefficient (CCC = 0.782) was calculated with 95% limits of agreement. Lins concordance correlation between ultrasound and microscopic depth showed a good agreement.
Conclusions Ultrasound tongue is a reliable imaging modality for pre-operative T staging by assessing tumor “depth of invasion” in carcinoma tongue patients with good internal consistency as per 8th AJCC staging system.
Level of Evidence Level 2 (CEBM-Level of Evidence-2.1) Laryngoscope, 2023
Charles A. Riley, David A. Gudis
Publication date 30-05-2023
James A. Curtis, Valentina Mocchetti, Anaïs Rameau
Publication date 30-05-2023
Findings from this study suggest that the Tongueometer has the potential to be a valid substitute to the IOPI when measuring orofacial muscle strength during clinical assessments of speech and swallowing, though small differences in pressure readings are present, especially when testing pressures <10 k Pa.
Objective(s)This study examined the concurrent validity of two orofacial strength manometers: (1) the Iowa Oral Performance Instrument (IOPI) – the current, gold standard orofacial manometer; and (2) the Tongueometer – a newly-available, lower cost, orofacial manometer.
Methods This study compared IOPI and Tongueometer pressure readings across three experimental conditions. Experiment 1 compared full setup (manometer + tongue bulb) pressure readings between the IOPI and Tongueometer. Experiment 2 compared IOPI tongue bulb and Tongueometer tongue bulb pressure readings, while controlling for manometer. Experiment 3 compared IOPI manometer and Tongueometer manometer pressure readings, while controlling for tongue bulb. Pressures were applied manually within a laboratory setting. Lins concordance correlation (ρc) was used to calculate level of agreement, with ρc interpreted as ‘poor’ if <0.90, ‘moderate’ if 0.90 to <0.95, ‘substantial’ if 0.95 to <0.99, and ‘excellent’ if ≥0.99.
Results539 trials were analyzed. There was a median absolute difference of 2.4 k Pa in pressure readings between the IOPI and Tongueometer full setups (manometer + tongue bulb). Correlations revealed substantial agreement between IOPI and Tongueometer full setups (experiment 1: n = 292; ρc = 0.986), tongue bulbs (experiment 2: n = 146; ρc = 0.987–0.992), and manometers (experiment 3: n = 101; ρc = 0.970).
Conclusions Differences in pressures were consistently observed between the Tongueometer and IOPI. Despite these differences, substantial agreement was present. These data suggest the Tongueometer may be a valid, lower cost alternative to the IOPI for objectively assessing orofacial strength in clinical practice.
Level of Evidence Level 2 Laryngoscope, 2023
Raj Sindwani, Satyan B. Sreenath, Pablo F. Recinos
Publication date 30-05-2023
This is the largest, single center series of intraconal orbital lesions managed purely via the endoscopic intranasal approach (EEA). This technique, performed by 2 surgeons using multiple hands, is safe and effective for accessing lesions in the medial orbit.
Background Lesions involving the intraconal space of the orbit are rare and challenging to manage. Operative techniques and outcomes for the endoscopic endonasal approach (EEA) to tumors in the medial intraconal space (MIS) remain poorly characterized.
Objective We present our experience with a wide range of isolated intraconal pathology managed via an EEA.
MethodsA retrospective review of all cases (2014–2021) performed by a single skull base team in which the EEA was employed for the management of an intraconal orbital lesion.
Results Twenty patients (13 men, 7 women) with a mean age of 59 years (range, 40–89 years) were included. All lesions were isolated to the MIS, pathology addressed included: cavernous hemangioma (6), schwannoma (4), lymphoma (4), inflammatory pseudotumor (2), chronic invasive fungal sinusitis (2), and metastatic disease (2). Either a biopsy (10/20) or a complete resection (10/20) was performed. In all cases, the MIS was accessed via an endonasal corridor between the medial and inferior rectus muscles. Retraction and safe, intra-orbital dissection of the lesion was performed using a two-surgeon, multi-handed technique. Gross total resection of benign lesions was achieved in 90% (9/10) of cases; a pathologic diagnosis was achieved in 100% (10/10) of biopsy cases. No orbital reconstruction was required. Visual acuity returned to normal in 80% (8/10) of planned resection cases and postoperative diplopia resolved by 3 months in 90%. Mean follow-up was 15 months.
Conclusion This study demonstrates that the EEA is safe and effective for accessing lesions in the MIS. This technique affords very favorable outcomes with minimal postoperative morbidity.
Level of Evidence4 Laryngoscope, 2023
Alice E. Huang, Daenis Camiré, Peter H. Hwang, Vladimir Nekhendzy
Publication date 30-05-2023
Airway status of patients with nasopharyngeal carcinoma after primary radiation treatment remains unstudied. This retrospective review of 150 post-radiation intubation events found a much higher rate of difficult and failed intubations in these patients compared to the general surgical population. The ability to predict intubation difficulty with standard preoperative airway assessment measures was poor.
Objective The aim of the study was to characterize the incidence and management of difficult tracheal intubations (DTIs) in nasopharyngeal carcinoma (NPC) after primary radiation therapy (RT).
Methods The study was a retrospective review of airway assessment and outcomes in post-RT NPC patients. Primary analysis was performed on patients who underwent post-RT procedures, who were split into non-DTI and DTI groups. Patients were classified as DTI if they (i) required >1 attempt to intubate, (ii) failed to be intubated, or (iii) experienced complications attributed to airway management. Secondary analysis was performed between patients who underwent post-RT procedures (procedure group) and those who did not (control group).
Results One-hundred and fifty patients were included, and 71.3% underwent post-RT procedures, with no differences in characteristics between the procedure and control groups. One-hundred and fifty procedures were identified, and 28.0% were categorized as DTI. There was no difference in patient characteristics or airway assessment measures between DTI and non-DTI groups. Regression analysis revealed concurrent cervical mobility restriction, and trismus increased DTI incidence by 7.1-fold (p = 0.011). Being non-White was an independent predictor of DTI. The incidence of high-grade intraoperative laryngoscopic view was lower in the non-DTI compared to the DTI group (20.4% vs. 64.3%, p < 0.0001). Failure to intubate occurred in 2.0% of cases, and 6.0% cases had perioperative complications. Based on preoperative assessment, sensitivity of predicting DTI was 54.8% and specificity was 63.9%.
ConclusionNPC patients frequently undergo post-RT procedures requiring complex airway management. Rates of DTI and failed intubation are significantly higher than those in the general surgical population, and the ability to predict DTI with standard preoperative airway measures is poor.
Level of Evidence Level 4 Laryngoscope, 2023
"Josh Wiedermann, Dontre M. Douse, Katerina J. Green, Jonathan C. Pang, Quinton Blount, Karina Yu, Mark Shrime"
Publication date 30-05-2023
This systematic review explored the current literature to understand how ENT short-term surgical trips contribute to surgical, educational, and sustainability-based outcomes in Low- and Middle-Income Countries (LMICs). 47 studies contributed to our findings that most publications focus on surgical interventions with only 55% of studies mentioning follow-up. Few publications indicate education (27.7%) or sustainability (25.5%) as a primary aim.
Objective This scoping review aims to explore the current body of literature to characterize how short-term surgical trips (STSTs) in Otolaryngology-Head and Neck Surgery (OtoHNS) contribute to surgical, educational, and sustainability-based outcomes in low- and middle-income countries (LMICs). We aim to use these data to synthesize aspects of STSTs that are successful with the hopes of shaping future global efforts.
Data Sources Data sources included Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus.
Review MethodsA comprehensive search was conducted on several databases from inception to October 14, 2021. We included primary studies exploring any surgical or educational outcomes of global short-term surgical endeavors within LMICs. Data were then extracted to evaluate the heterogenous body of literature that exists, characterizing the surgical, educational, and sustainability-based outcomes.
Results Forty-Seven studies were included in the final analysis. Most publications were focused on surgical interventions (39 of 47; 82.9%); 13 (27.7%) studies included education as the primary aim and 12 (25.5%) considered sustainability a significant aim. Of the 94 first and last authors, there were zero first authors and only one last author with an LMIC affiliation. Twenty-six studies (55%) mentioned that any patients were seen in follow-up, ranging from one day to five years.
Conclusion Our scoping review demonstrates that most STSTs have focused primarily on surgical procedures with a lack of appropriate long-term follow-up. However, the available outcome-based information presented helps identify factors that characterize a strong short-term global surgical program.
Level of EvidenceN/A Laryngoscope, 2023
Ryosuke Nakamura, Renjie Bing, Gary J. Gartling, Michael J. Garabedian, Ryan C. Branski
Publication date 29-05-2023
This work provides additional in vitro support for optimizing glucocorticoid dosing when treating patients with vocal fold pathology. Increased concentrations enhanced the fibrotic response in vocal fold fibroblasts induced by polarized macrophages.
Objective The diversity of glucocorticoid (GC) properties may underlie variability of clinical efficacy for vocal fold (VF) disease. Optimized therapeutic approaches must account for tissue complexity as well as interactions between cell types. We previously reported that reduced GC concentrations inhibited inflammation without eliciting fibrosis in mono-cultured VF fibroblasts and macrophages. These data suggested that a refined approach to GC concentration may improve outcomes. In the current study, co-culture of VF fibroblasts and macrophages was employed to investigate the effects of different concentrations of methylprednisolone on fibrotic and inflammatory response genes in VF fibroblasts to optimize management paradigms.
Study Design In vitro.
MethodsTHP-1 monocyte-derived macrophages were stimulated with interferon-γ (IFN-γ), lipopolysaccharide (LPS), or transforming growth factor-β (TGF-β) to induce inflammatory (M(IFN/LPS)) and fibrotic (M(TGF)) phenotypes. Macrophages were then co-cultured with a human VF fibroblast cell line using a 0.4 μm pore membrane with or without 0.1–3000 nM methylprednisolone. Inflammatory (CXCL10, TNF, and PTGS2) and fibrotic (ACTA2, CCN2, and COL1A1) gene expression was quantified in fibroblasts.
Results Incubating VF fibroblasts with M(IFN/LPS) macrophages increased expression of TNF and PTGS2, and this effect was inhibited by methylprednisolone. Incubation of VF fibroblasts with M(TGF) macrophages increased expression of ACTA2, CCN2, and COL1A1, and this effect was enhanced by methylprednisolone. The concentration of methylprednisolone required to downregulate inflammatory genes (TNF and PTGS2) was lower than that to upregulate fibrotic genes (ACTA2, CCN2, and COL1A1).
Conclusion Reduced concentration of methylprednisolone effectively suppressed inflammatory genes without enhancing fibrotic genes, suggesting that a refined approach to GC concentration may improve clinical outcomes.
Level of EvidenceN/A Laryngoscope, 2023
August A. Culbert, Anna‐Karoline Israel, Jamie Ku, Natalie L. Silver
Publication date 29-05-2023
Syphilis is an infectious disease caused by the spirochete Treponema pallidum. Rates have been rising in the US and globally. Known as the “Great Imitator,” syphilis can involve head and neck subsites, and often can masquerade as possible carcinoma of the head and neck. Here, we present three distinct cases of syphilis presenting as suspected head and neck malignancy involving the oropharynx, larynx and oral cavity. All cases were diagnosed on surgical pathologic examination of diseased tissues and treated. It is important for practicing otolaryngologists to understand head and neck manifestations of syphilis to facilitate proper diagnosis and treatment. Laryngoscope, 2023
Pubmed PDF WebZuzana Javorská, Karol Zeleník, Kristína Lukáčová, Renata Taimrová, Adéla Vrtková, Viktória Hránková, Jakub Lubojacký, Martin Formánek, Miroslav Tedla
Publication date 29-05-2023
Extraesophageal reflux (EER) causes mucosal inflammatory changes. In our study, mulberry changes to the posterior inferior nasal turbinate (MPINT) were more often present in patients with acidic pH drops proven by 24-h oropharyngeal pH monitoring. Therefore, the acidic pH environment might be a possible cause of MPINT formation.
Objectives Mulberry-like changes of the posterior inferior nasal turbinate (MPINT) can lead to nasal obstruction. Extraesophageal reflux (EER) characterized by lower pH causes mucosal inflammation and therefore can contribute to sinonasal pathologies. No prior studies have objectively examined the possible association between acidic pH and MPINT formation. Therefore, this study is aimed to investigate the 24-h pharyngeal pH value in patients with MPINT.
Study design Prospective case–control multi-center study.
Methods Fifty-five patients with chronic EER symptoms were included in the study. They filled in questionnaires aimed at reflux and sinonasal symptoms (RSI®, SNOT-22) and underwent video endoscopy evaluating the laryngeal findings (RFS®) and the presence or absence of the MPINT. And, 24-h oropharyngeal pH monitoring was used to detect the acidic pH environment in the pharynx.
Results Out of the 55 analyzed patients, 38 had the MPINT (group 1), and in 17 patients, the MPINT was absent (group 2). Based on the pathological RYAN Score, in 29 (52.7%) patients, severe acidic pH drops were detected. In group 1, the acidic pH drops were diagnosed significantly more often (68.4%) compared with those in group 2 (p = 0.001). Moreover, in group 1, a significantly higher median total percentage of time spent below pH 5.5 (p = 0.005), as well as a higher median number of events lasting more than 5 min (p = 0.006), and higher median total number of events with pH drops (p = 0.017) were observed.
Conclusion In this study, the MPINT was significantly more often present in patients with acidic pH events detected by 24-h oropharyngeal pH monitoring. Acidic pH in the pharynx might lead to MPINT formation.
Level of Evidence3 Laryngoscope, 2023
Chen‐Long Li, You‐Zhou Xie, Aijuan He, Ning‐Hua Liu, Chun‐Xiao Cui, Ying Chen, Yaoyao Fu, Tianyu Zhang
Publication date 27-05-2023
Hearing improvement is another basic requirement for microtia patients in addition to aesthetic needs. This quantitative framework fabrication method can reduce the learning curve, obtain satisfactory aesthetic results with few complications, and reserve a certain space for future canalplasty. Laryngoscope, 2023
Pubmed PDF WebRamya Bharathi, Gopikrishna M. Rao, Jeremiah Tracy, Jan Groblewski, Maria Koenigs
Publication date 26-05-2023
This study demonstrates that percutaneous tracheostomy techniques require more force than open tracheostomy techniques, and thus have an increased risk for trauma and tracheal injury.
Objective To understand the etiology of tracheotomy-induced tracheal stenosis by comparing the differences in techniques and mechanical force applied with open tracheotomy (OT) versus percutaneous tracheotomy (PCT) placement.
Methods This study is an unblinded, experimental, randomized controlled study in an ex-vivo animal model. Simulated tracheostomies were performed on 10 porcine tracheas, 5 via a tracheal window technique (OT) and 5 using the Ciaglia technique (PCT). The applied weight during the simulated tracheostomy and the compression of the trachea were recorded at set times during the procedure. The applied weight during tracheostomy was used to calculate the tissue force in Newtons. Tracheal compression was measured by anterior–posterior distance compression and as percent change.
Results Average forces for scalpel (OT) versus trocar (PCT) were 2.6 N and 12.5 N (p < 0.01), with the dilator (PCT) it was 22.02 N (p < 0.01). The tracheostomy placement with OT required an average force of 10.7 N versus 23.2 N (p < 0.01) with PCT. The average change in AP distance when using the scalpel versus trocar was 21%, and 44% (p < 0.01), with the dilator it was 75% (p < 0.01). The trach placement with OT versus PCT had an average AP distance change of 51% and 83% respectively (p < 0.01).
Conclusion This study demonstrated that PCT required more force and caused more tracheal lumen compression when compared to the OT technique. Based on the increased force required for PCT, we suspect there could also be an increased risk for tracheal cartilage trauma.
Level of EvidenceN/A Laryngoscope, 2023
Deniz Can Guven, Bettzy Stephen, Taha Koray Sahin, Ibrahim Yahya Cakir, Sercan Aksoy
Publication date 25-05-2023
The available evidence demonstrates that the addition of immunotherapy to chemotherapy as a first-line treatment in the of advanced NPC provided superior ORR, PFS and OS with manageable safety profile. Further research is needed to delineate the use of immunotherapy in EBV-negative NPC, radiotherapy after immunotherapy, and the performance of other immunotherapeutic agents in the treatment of advanced NPC.
Objectives Data regarding the clinical benefits of immune checkpoint inhibitors (ICIs) are limited in nasopharyngeal carcinoma (NPC). Therefore, we conducted a meta-analysis of phase-III clinical trials to evaluate the benefit of adding ICIs to chemotherapy in the first-line treatment of advanced NPC.
Methods We conducted a systematic review using Web of Science, Pub Med, and Embase for studies published until September 21, 2022. The meta-analyses were performed with the generic inverse-variance method with a random-effects model. Hazard ratios (HRs) with 95% confidence interval (CI) for progression-free survival (PFS) and overall survival (OS) were the principal summary measures. This protocol was registered in the PROSPERO database (registration number: CRD 42022361866).
Results Three eligible studies with a total of 815 patients were included. The addition of ICIs to standard chemotherapy significantly improved PFS (HR: 0.52, 95% CI: 0.43–0.63, p < 0.0001). Although the OS results were immature, ICIs significantly reduced the risk of death (HR: 0.63, 95% CI: 0.47–0.84, p = 0.0020). The benefit of ICIs was consistent regardless of initial disease presentation (recurrent or de novo), baseline EBV levels, PD-L1 expression, and ECOG performance status. No significant difference in the rates of serious adverse events (HR = 0.98, 95% CI 0.74–1.30) was found between the two groups.
Conclusion The available evidence demonstrates that adding ICIs to chemotherapy in the first-line treatment of advanced NPC provided better PFS with acceptable safety. However, a longer follow-up is required to evaluate the true OS benefit of these combinations.
Level of EvidenceNA Laryngoscope, 2023
Gary Gartling, Ryosuke Nakamura, Renjie Bing, Ryan C. Branski
Publication date 25-05-2023
Primary isolated myofiber culture is considered an optimal model to investigate pathological/treatment conditions in mature myofibers in vitro but has not been conducted in thyroarytenoid (TA) myofibers. This paper provides methodology for a feasible TA myofiber culture model.
Objectives/Hypothesis Myofiber culture has been employed to investigate muscle physiology in vitro and is well-established in the rodent hind limb. Thyroarytenoid (TA) myofiber culture has not been described, providing an opportunity to employ this method to investigate distinct TA myofiber functions. The purpose of this study was to assess the feasibility of a TA myofiber culture model.
Study Design In vitro.
MethodsTA muscles from five Sprague Dawley rats were independently isolated and digested for 90 min. A smooth-tip, wide-bored pipette dissociated TA myofibers from cartilage, and the fibers were distributed on collagen-coated dishes and incubated at 37°C, 5% CO2 for 2 h. Myofiber specificity was determined via immunolabeling for desmin and myosin heavy chain (MHC). Myofibers viability was assessed over 7 days via esterase assay. Additional myofibers were immunolabeled for satellite cell marker Pax-7. Glucocorticoid (GC) receptor (GR) was immunolabeled following GC treatment.
Results The harvest technique yielded ~120 myofibers per larynx. By day 7, ~60% of the fibers remained attached and were calcein AM-positive/ethidium homodimer-negative, indicating viability. Myofibers were positive for desmin and MHC, indicating muscle specificity. Cells surrounding myofibers were positive for Pax-7, indicating the presence of myogenic satellite cells. Myofibers also responded to GC treatment as determined by GR nuclear translocation.
ConclusionTA myofibers remained viable in culture for at least 7 days with a predictable response to exogenous stimuli. This technique provides novel investigative opportunities regarding TA structure and function.
Level of EvidenceN/A Laryngoscope, 2023
Renee E. King, Andrea Bilger, Josef Rademacher, Paul F. Lambert, Susan L. Thibeault
Publication date 25-05-2023
HPV can cause highly morbid laryngeal diseases, including benign communication impairment, and cancer. Preclinical models of these diseases are needed to develop effective treatments. This study summarizes all research studies that describe models of laryngeal HPV infection.
Objective Laryngeal human papillomavirus (HPV) infection causes recurrent respiratory papillomatosis (RRP) and accounts for up to 25% of laryngeal cancers. Lack of satisfactory preclinical models is one reason that treatments for these diseases are limited. We sought to assess the literature describing preclinical models of laryngeal papillomavirus infection.
Data Sources Pub Med, Web of Science, and Scopus were searched from the inception of database through October 2022.
Review Methods Studies searched were screened by two investigators. Eligible studies were peer-reviewed, published in English, presented original data, and described attempted models of laryngeal papillomavirus infection. Data examined included type of papillomavirus, infection model, and results including success rate, disease phenotype, and viral retention.
Results After screening 440 citations and 138 full-text studies, 77 studies published between 1923 and 2022 were included. Models used low-risk HPV or RRP (n = 51 studies), high-risk HPV or laryngeal cancer (n = 16), both low- and high-risk HPV (n = 1), and animal papillomaviruses (n = 9). For RRP, 2D and 3D cell culture models and xenografts retained disease phenotypes and HPV DNA in the short term. Two laryngeal cancer cell lines were consistently HPV-positive in multiple studies. Animal laryngeal infections with animal papillomaviruses resulted in disease and long-term retention of viral DNA.
Conclusions Laryngeal papillomavirus infection models have been researched for 100 years and primarily involve low-risk HPV. Most models lose viral DNA after a short duration. Future work is needed to model persistent and recurrent diseases, consistent with RRP and HPV-positive laryngeal cancer.
Level of EvidenceN/A Laryngoscope, 2023
Vijay Patel, Marta Kulich, Amit Kochhar, Gabriel Gomez
Publication date 23-05-2023
Described herein is an innovative, minimally-invasive technique to harvest temporoparietal fascia flap used in implant-based ear reconstruction for children with microtia. This technique utilizes a never previously described application of intra-operative Indocyanine Green Angiography to optimize flap viability and minimizing the risk of facial nerve injury. Laryngoscope, 2023
Pubmed PDF WebTed Mau, Milan R. Amin, Peter C. Belafsky, Simon R. Best, Aaron D. Friedman, Adam M. Klein, David G. Lott, Randal C. Paniello, Seth M. Pransky, Nabil F. Saba, Tamara Howard, Michael Dallas, Aditya Patel, Matthew P. Morrow, Jeffrey M. Skolnik
Publication date 19-05-2023
The aim of this study was to evaluate the safety, immunogenicity, and efficacy of INO-3107, a DNA immunotherapy designed to elicit targeted T-cell responses against human papillomavirus (HPV) types 6 and 11, in adult patients with recurrent respiratory papillomatosis (RRP). Among an initial cohort of 21 patients, 15 had ≥1 TEAE; most commonly injection site or procedural pain. INO-3107 induced durable cellular responses against HPV-6 and HPV-11, and 16 patients had fewer surgical interventions in the year following INO-3107 administration.
Objective To evaluate the safety, immunogenicity, and efficacy of INO-3107, a DNA immunotherapy designed to elicit targeted T-cell responses against human papillomavirus (HPV) types 6 and 11, in adult patients with recurrent respiratory papillomatosis (RRP; NCT04398433).
Methods Eligible patients required ≥2 surgical interventions for RRP in the year preceding dosing. INO-3107 was administered by intramuscular (IM) injection followed by electroporation (EP) on weeks 0, 3, 6, and 9. Patients underwent surgical debulking within 14 days prior to first dose, with office laryngoscopy and staging at screening and weeks 6, 11, 26, and 52. Primary endpoint was safety and tolerability, as assessed by treatment-emergent adverse events (TEAEs). Secondary endpoints included frequency of surgical interventions post-INO-3107 and cellular immune responses.
Results An initial cohort of 21 patients was enrolled between October 2020 and August 2021. Fifteen (71.4%) patients had ≥1 TEAE; 11 (52.4%) were Grade 1, and 3 (14.3%) were Grade 3 (none treatment related). The most frequently reported TEAE was injection site or procedural pain (n = 8; 38.1%). Sixteen (76.2%) patients had fewer surgical interventions in the year following INO-3107 administration, with a median decrease of 3 interventions versus the preceding year. The RRP severity score, modified by Pransky, showed improvement from baseline to week 52. INO-3107 induced durable cellular responses against HPV-6 and HPV-11, with an increase in activated CD4 and CD8 T cells and CD8 cells with lytic potential.
Conclusion The data suggest that INO-3107 administered by IM/EP is tolerable and immunogenic and provides clinical benefit to adults with RRP.
Level of Evidence3 Laryngoscope, 2023
Noah J. Thornton, Glenn Isaacson
Publication date 19-05-2023
Removal of retained Armstrong beveled grommet fluoroplastic tympanostomy tubes at 2.5 years rather than 2 years reduces the number of required surgeries by nearly half with an acceptable incidence of persistent perforations and a low rate of subsequent re-intubations.
Objectives In 2001, we instituted a protocol for the removal of retained tympanostomy tubes, delaying elective removal until 2.5 years after placement. It was hoped that this would decrease the number of surgeries without increasing the rate of permanent tympanic perforations compared to removal at 2 years.
Methods Protocol: Fluoroplastic Armstrong beveled grommet tympanostomy tubes were placed by a single surgeon supervising the residents. The children were seen at 6-month intervals after placement. Children with a retained tympanostomy tube(s) at 2 years were seen again at 2.5 years, and the retained tubes were removed under general anesthesia with patch application. All were evaluated 4 weeks after surgery by otoscopy, otomicroscopy, behavioral audiometry, and tympanometry.
Study: A computerized collection of patient letters and operative reports was queried to identify children treated according to the protocol between 2001 and 2022. Those with examinations at 2 years ± 1 month and 2.5 years ± 1 month and complete follow-up were included.
Results Of the 3552 children with tympanostomy tubes, 497 (14%) underwent tube removal. One-hundred and forty seven children fit the strict inclusion criteria. Among those with retained tubes at 2 years, 67/147 (46%) had lost any remaining tube or tubes at 2.5 years and did not need surgery, 80/147 (54%) required unilateral or bilateral tube removal, 9/147 (6%) had a persistent perforation at 1-year follow-up, and 4/147 children (3%) required tympanic re-intubation after either spontaneous extrusion or removal and patching at 2.5 years.
Conclusions Delaying tympanostomy tube removal until 2.5 years can cut the need for surgery in half with, an acceptable (6%) incidence of persistent perforations.
Level of Evidence Four case series—historical control Laryngoscope, 2023
Leo L.T. Meller, Milind Vasudev, Anh‐Tram Bui, Jenny Wang, Edward C. Kuan, Tjoson Tjoa, Yarah M. Haidar
Publication date 18-05-2023
The present bibliometric analysis identified eight core journals in otolaryngology literature, which were: Laryngoscope, Otolaryngology—Head and Neck Surgery, Otology & Neurotology, JAMA Otolaryngology—Head & Neck Surgery, Head & Neck, European Archives of Oto-Rhino-Laryngology, International Journal of Pediatric Otorhinolaryngology, Annals of Otology, Rhinology & Laryngology. These eight core journals should be incorporated into the daily reading routine of otolaryngology clinicians and researchers.
Objectives As research in otolaryngology continues to expand rapidly, it is important to identify core journals to keep clinicians updated with the latest advances. This study is the first to characterize core journals in otolaryngology.
Methods Using h-index and impact factor (IF), the top 15 NLM-indexed otolaryngology journals were selected for analysis. The references from all articles published in these journals in one randomized quarter were compiled into a citation rank list, with the most cited journal ranked the highest. Citation zonal distribution analysis was conducted to identify the zonal distribution of otolaryngology journals.
ResultsA total of 3150 journals containing 26876 articles were cited in otolaryngology literature in April–June 2019. Laryngoscope was the most cited journal containing 1762 citations. IF is significantly associated with the h-index for the top 10 otolaryngology journals (p = 0.032). Three core journal zones were identified, with Zone 1 containing 8 journals, Zone 2 containing 36 journals, and Zone 3 containing 189 journals. A linear relationship between the log journal rank for Zones 1–3 and a cumulative number of citations was found (R2 = 0.9948).
Conclusion Eight core journals for otolaryngology were identified: Laryngoscope, Otolaryngology—Head and Neck Surgery, Otology & Neurotology, JAMA Otolaryngology—Head & Neck Surgery, Head & Neck, European Archives of Oto-Rhino-Laryngology, International Journal of Pediatric Otorhinolaryngology, Annals of Otology, Rhinology & Laryngology. In the face of rapidly evolving research and a multitude of journals, the high citation density within these core journals highlights their utility in updating busy clinicians.
Level of EvidenceNA Laryngoscope, 2023
Isam Alobid, Alfonso Santamaría‐Gadea, Franklin Mariño‐Sánchez
Publication date 18-05-2023
Endoscopic Racket-on-Donut technique is a combination of a modified greater palatine artery and inverted edges flaps. Endoscopic Racket-on-Donut technique is very useful for anterior NSP repair. Laryngoscope, 2023
Pubmed PDF WebCM Lawlor, Sukgi S. Choi
Publication date 18-05-2023
Robert R. Lorenz
Publication date 17-05-2023
Consecutive case series of first 28 patients undergoing “Maddern” procedure for subglottic stenosis. Technique modifications, complications, and results over 7 years of data collection.
IntroductionA novel technique to treat subglottic stenosis, the “Maddern Procedure”, has been gaining acceptance in academic centers. This study describes the technique in detail, as well as its evolution over the first 28 patients performed at an academic center.
MethodsA prospective case-series, with descriptive technique modifications cataloged throughout the 6 years needed to accumulate the patient cohort with a minimum of 2 years of follow-up (11/2015–11/2021). Main outcomes examined included changes to surgical indications, complications, and post-operative outcomes as measured by validated measures of voice and breathing.
Results Complete resection of subglottic scaring was performed, at first transcervically (2 pts), then transorally (26 pts). Successful performance of the procedure occurred in all patients without complications, with either successful decannulation of previously existing tracheotomies, or removal of perioperative tracheotomies. Buccal grafts (8/26) replaced skin graft as the graft of choice. Although high subglottic disease was first thought to be a contraindication, superior results became evident in cases of high stenosis rather than disease that included the upper trachea, with 4/26 patients requiring subsequent tracheal resection or tracheal dilation. Of the 22 remaining patients, 19/22 had successful arresting of restenosis, with 2/22 undergoing subsequent cricotracheal resection, and 1/22 pts requiring subglottic dilation. Overall, 19/26 Maddern pts (73%) had objectively favorable outcomes, with 24/26 (92%) reporting that they would have undergone the procedure again.
Conclusion Full-thickness mucosal resection and relining of the subglottis is a developing technique that is a safe, yet technically challenging procedure which addresses the recurrent nature of the disease.
Level of Evidence Level 4 (Case-series) Laryngoscope, 2023
Sarek A. Shen, Andy S. Ding, Jared Zhao, Stefanie Seo, Kenneth Ng, Jonathan Walsh
Publication date 17-05-2023
Endoluminal functional imaging probes (EndoFLIP) can provide accurate and repeatable measurements of the diameter, length, and compliance of a stenotic pediatric airway model.
Objectives Accurate and reproducible measurements of the pediatric airway are critical for diagnostic evaluation and management of subglottic and tracheal stenosis. The endoluminal functional lumen imaging probe (EndoFLIP) is a catheter-based imaging probe which utilizes impedance planimetry to calculate luminal parameters, including cross-sectional area and compliance. Herein, we demonstrate the feasibility of this system for multidimensional evaluation of the pediatric airway.
Methods3D-printed pediatric laryngotracheal models were created based on computed tomography scans, then artificially deformed to simulate both circumferential and posterior subglottic stenosis. Two observers made six measurements of the minimum cross-sectional area (MCSA) and length of stenosis of each model with EndoFLIP. Agreement between observer measurements and model dimensions was evaluated using Lins concordance correlation coefficient; inter-observer reliability was assessed using intraclass correlation.
Results Four models were created: two without pathology (MCSA: 132.4, 44.3 mm2) and two with subglottic stenosis (MCSA: 28.7, 59.7 mm2, stenotic length 27.8, 24.4 mm). Observer measurements of MCSA and length of stenosis demonstrated high concordance with the models (r = 0.99, 0.95, p < 0.001) with a mean error of 4.5% and 18.2% respectively. There was a low coefficient of variation (0.6%–2.8%) for measurements, indicating high precision. Interrater reliability was high for both MCSA and stenotic length (ICC: 0.99, 0.98).
Conclusions The EndoFLIP system allows for accurate and reproducible measurements of cross-sectional area and stenotic length in pediatric airway models. This method may provide further advantages in the evaluation of airway distensibility, as well as measurements of asymmetric airway pathology.
Level of EvidenceN/A Laryngoscope, 2023
Jarrad H. Van Stan, James Burns, Tiffiny Hron, Steven Zeitels, Bharat A. Panuganti, Phillip R. Purnell, Daryush D. Mehta, Robert E. Hillman, Hamzeh Ghasemzadeh
Publication date 17-05-2023
Training the Daily Phonotrauma Index (DPI) using only controls and patients with mild phonotrauma improved the DPIs sensitivity while still maintaining its overall accuracy. Neck-surface acceleration magnitude skew was predictive of phonotraumatic vocal hyperfunction regardless of phonotrauma severity, indicating the feature may be associated with etiological phonotraumatic vocal behavior. H1 − H2 variability was more strongly predictive of moderate and severe phonotrauma, suggesting this measure may be associated with voicing in the presence of lesions. Future work could further validate the DPI as a useful screening tool and evaluate whether additional measures of vocal dose and physiology can improve the models performance and/or interpretation.
Objective The aim of this study was to gain quantitative insights into the role of daily voice use associated with mild phonotrauma via the Daily Phonotrauma Index (DPI), a measure derived from neck-surface acceleration magnitude (NSAM) and difference between the first two harmonic magnitudes (H1 − H2).
Methods An ambulatory voice monitor recorded weeklong voice use for 151 female patients with phonotraumatic vocal hyperfunction (PVH) and 181 female vocally healthy controls. Three laryngologists rated phonotrauma severity from each patients laryngoscopy. Mixed generalized linear models evaluated the accuracy, sensitivity, and specificity of the original DPI trained on all patients versus a mild DPI version trained on only patients rated with mild phonotrauma. Individual contribution of NSAM and H1 − H2 to each DPI model was also evaluated.
Results Reliability across the laryngologists phonotrauma ratings was moderate (Fleiss κ = 0.41). There were 70, 69, and 12 patients with mild, moderate, and severe phonotrauma, respectively. The mild DPI, compared to the original DPI, correctly classified more patients with mild phonotrauma (Cohens d = 0.9) and less controls (d = −0.9) and did not change in overall accuracy. H1 − H2 contributed less to mild phonotrauma classification than NSAM for mild DPI.
Conclusions Compared with the original DPI, the mild DPI exhibited higher sensitivity to mild phonotrauma and lower specificity to controls, but the same overall classification accuracy. These results support the mild DPI as a promising detector of early phonotrauma and that NSAM may be associated with early phonotrauma, and H1 − H2 may be a biomarker associated with vocal fold vibration in the presence of lesions.
Level of Evidence Level 4, case–control study Laryngoscope, 2023
Julia Nguyen, Rushi Patel, Jean Anderson Eloy, Soly Baredes, Richard Chan Woo Park
Publication date 17-05-2023
Introduction To assess the association between time to surgery (TTS) and survival in sinonasal squamous cell carcinoma patients (SSCC).
Methods We queried the 2004–2016 National Cancer Database for all cases of adult SSCC undergoing primary surgical treatment. Patients with missing TTS information were excluded. We conducted a multivariate analysis of patient demographic and clinicopathological characteristics effect on overall survival (OS) using a Cox proportional hazards model enhanced with cubic spline non-linear approximation. Bootstrapping methods were utilized to detect the aggregate risk of TTS delay on patient OS.
ResultsA total of 2,881 patients met the inclusion criteria. The majority of patients were male (63.5%), White (86.3%), and over the age of 60 (58.4%). Parametric cubic spline approximation Cox hazard model detected a non-linear association between patient OS and TTS below 30 days with the lowest risk occurring at 18 days and steadily increasing subsequently. To analyze the aggregate risk and identify the optimal TTS cut-off after 30 days of surgical delay, the cohort sample was bootstrapped and dichotomized. The largest increase in aggregated risk was identified at 59 days (Hazards Ratio HR = 1.006 0.839–1.084, p = 0.003). 60 days were used as the optimal TTS cut-off for analyzing the survival rate using the Cox proportional hazard model. Undergoing surgery within 60 days translated to a 14.6% decreased chance of death (HR: 0.854 0.83–0.96).
Conclusions Increasing TTS is associated with worse overall survival in patients with SSCC. Our study suggests that surgery should be done within 60 days to achieve optimal survival results.
Level of Evidence4 Laryngoscope, 2023
Jacob C. Harris, Rosemary C. Patel, Ryan L. Ruiz
Publication date 17-05-2023
Customized and custom tracheostomies are useful for medically complex children with unique ventilatory needs. Customization most commonly includes altered tube lengths, internal inflation lines, custom cuffs and shaft curvatures. There are obvious and immediate benefits to tracheostomy tubes specifically designed for the individual patient, but cost and institutional resources must be considered in each instance to ensure a net benefit to the patient.
Objectives To describe the use of customized and custom tracheostomies at our institution, and to identify trends in patient presentation and tracheostomy design.
MethodsA retrospective review was conducted for patients at our institution for whom a customized or custom tracheostomy tube was ordered between January 2011 and July 2021. Customized tracheostomy tubes allow for a small selection of alterations to trach design, such as cuff length and flange type. Custom tracheostomies have a unique design created by tracheostomy tube engineers in collaboration with the clinical provider, and are built specifically for a single patient.
ResultsA total of 235 patients were included, of whom 220 (93%) received customized tracheostomies and 15 custom (7%). The most common indications for customized tracheostomy were tracheal or stomal breakdown on a standard tracheostomy (n = 73, 33%) and ventilation difficulties (n = 61, 27%). The most frequent customization was shaft length (n = 126, 57%). The most common indication for custom tracheostomies was a persistent air leak on a standard or customized trach (n = 9) and the most frequent designs were custom cuffs (n = 8), flanges (n = 4), and anteriorly curved shafts (n = 4). Patients treated with a customized tracheostomy had a 5-year overall survival of 75.3%, compared to 51.4% for custom.
Conclusion These are the first cohorts of pediatric patients with customized and custom tracheostomies to be described. Modifications to tracheostomies, in particular shaft length and cuff design, can address common complications of extended tracheostomy, and may help improve ventilation in the most challenging cases.
Level of Evidence4 Laryngoscope, 2023
Rebecca Howell, Christopher Johnson, Jacqui Allen, Mekibib Altaye, Milan Amin, Semirra Bayan, Peter Belafsky, Brian Cervenka, Brad Desilva, Gregory R. Dion, Dale Ekbom, Aaron Friedman, Mark Fritz, John Paul Giliberto, Elizabeth Guardiani, Jan Kasperbauer, Brandon Kim, Brittany N. Krekeler, Maggie Kuhn, Paul Kwak, Yue Ma, Lyndsay L. Madden, Laura Matrka, Ross Mayerhoff, Mallory McKeon, Cyrus Piraka, Clark A. Rosen, Meredith Tabangin, Shaun A. Wahab, Keith Wilson, Carter Wright, VyVy N. Young, Gregory Postma, Prospective OUtcomes of Cricopharyngeal Hypertonicity (POUCH) Collaborative
Publication date 16-05-2023
Objective To compare improvement in patient-reported outcomes (PROM) in persons undergoing endoscopic and open surgical management of Zenker diverticula (ZD).
Methodology Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgery for ZD. Patient survey, radiography reports, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were abstracted from a REDCap database, which summarized means, medians, percentages, and frequencies of. Outcome based on operative intervention (endoscopic vs. open) was compared using t-test, Wilcoxon rank sum test or chi-square test, as appropriate.
Results One hundred and forty-seven persons were prospectively followed. The mean age (SD) of the cohort was 68.7 (11.0). Overall, 66% of patients reported 100% improvement in EAT-10; 81% of patients had greater than 75% improvement; and 88% had greater than 50% improvement. Endoscopic was used for n = 109 patients, and open surgical intervention was used for n = 38. The median interquartile range, IQR EAT-10 percent improvement for endoscopic treatment was 93.3% 72, 100, and open was 100% 92.3, 100 (p = 0.05). The incidence of intraoperative complications was 3.7% for endoscopic and 7.9% for open surgical management. The median IQR in follow-up was 86 and 97.5 days, respectively.
Conclusion Both endoscopic and open surgical management of ZD provide significant improvement in patient-reported outcomes. The data suggest that open diverticulectomy may provide a modest advantage in symptomatic improvement compared to endoscopic management. The data suggest that the postoperative complication rate is higher in the open surgical group.
Level of Evidence Level 3 Laryngoscope, 2023
Min Wang, Senmiao Zhu, Bingyan Shen, Yenan Fang, Qiqi Xie, Qin Dai, Ziwen Chen, Xinyu Li, Wencan Wu
Publication date 16-05-2023
The study presents a large prospective observational study of endoscopic unilateral optic nerve decompression in fibrous dysplasia patients presenting with optic neuropathy. Follow-up was at least 6 months. NSS-guided ETOCD appeared to be safe and effective for visual recovery in patients with CON due to CFD, and early surgical intervention was critical for long-term recovery. Unbalanced compression of the optic canal by the blunt bony process may be a major cause of visual impairment.
Objective To investigate the feasibility of endoscopic transnasal optic canal decompression (ETOCD) guided by a navigation surgical system (NSS) for vision recovery in patients with compressive optic neuropathy (CON) caused by craniofacial fibrous dysplasia (CFD), and to explore the underlying cause of visual impairment.
Methods All patients underwent unilateral NSS-guided ETOCD and were followed up periodically for at least six months. Paired sample t-test and Pearson correlation analyses were used to compare continuous variables of the visual outcomes at the final review. A histopathological test of abnormal bone specimens was performed postoperatively.
Results Thirty-four patients were finally included, and all surgeries were uneventful. The best corrected visual acuity (BCVA) (logMAR units) decreased from 1.29 ± 0.80 preoperatively to 0.97 ± 0.78 at the last follow-up (p = 0.0012), improving in 28 patients (82.35%). The absolute value of mean defect (MD) significantly decreased (p < 0.001). Color vision was impaired in 17 patients preoperatively and improved in 6 patients. BCVA at the last follow-up was significantly correlated with preoperative BCVA, onset time, preoperative retinal nerve fibril layer thickness, and MD (all p < 0.05). Among 34 patients, 26 had a blunt bony process near the anterior foot of the optic chiasm. Of the total patients, 73.53% patients experienced bony fiber recurrence 6 months or earlier after surgery without visual loss.
ConclusionNSS-guided ETOCD appeared to be safe and effective for visual recovery in patients with CON due to CFD, and early surgical intervention was critical for long-term recovery. Unbalanced compression of the optic canal by the blunt bony process may be a major cause of visual impairment.
Level of Evidence4 Laryngoscope, 2023
Julian S. De La Chapa, Katherine Webb, Cameron Stadlin, Adithya Reddy, Stephen F. Schoeff, Robert Reed, Logan F. McColl, Robert H. Thiele, James J. Daniero
Publication date 16-05-2023
Compared to men, women are intubated with larger-than-preferred endotracheal tubes relative to their height. Both men and women patients in our study were intubated for longer than preferred based on intensivist surveys thereby increasing the risk of Laryngeal Tracheal Stenosis.
Objectives The complex management of intubation-related laryngeal injury makes prevention vital. The purpose of this study is to assess endotracheal tube (ETT) practices and preferences among intensivists at our institution.
Methods Chart review of intubated patients and intensivist survey were simultaneously performed in January 2016 and August 2022. A height-to-ETT size ratio (H:ETT) was calculated for each patient in the 2022 cohort. Intubated patients were followed until tracheostomy, extubation, or death occurred. Surveys assessed intensivist preferences for ETT size and management of intubated patients.
Results300 ICU patients were included. The mean ETT size for males decreased from 7.73 ± 0.30 in 2016 to 7.57 ± 0.25 in 2022 (p < 0.001). The average H:ETT of men was higher than females (p = 0.004), indicating that females in this population were intubated with larger ETTs relative to their height compared to males. Whereas the majority (66.7%) of intensivists endorse 7.0 ETTs as the standard for women, the majority (70%) of women at our institution are intubated with a 7.5 ETT or larger. Of intubated patients in the ICU, 23 (19.5%) were intubated for 11 days or longer.
Conclusions Compared to men, women are intubated with larger-than-preferred ETTs relative to height. Additionally, patients in our study were intubated for longer than preferred based on intensivist surveys, putting this population at higher risk for acute laryngeal injury (AlgI)-related laryngotracheal stenosis (LTS). Further studies should seek to identify similar trends and barriers to reducing ALgI-related LTS.
Level of Evidence3 Laryngoscope, 2023
Douglas M. Hildrew, Philip L. Perez, Leila J. Mady, Jinhong Li, Marci L. Nilsen, Barry E. Hirsch
Publication date 13-05-2023
This is a longitudinal review of hearing results and tumor control following Cyber Knife stereotactic radiation treatment of vestibular schwannoma. Criteria for predicting hearing preservation is provided.
Objectives(1) To determine tumor control rates for treating growing vestibular schwannoma (VS) with Cyber Knife stereotactic radiosurgery (CK SRS); (2) to determine hearing outcomes after CK SRS; (3) to propose a set of variables that could be used to predict hearing outcomes for patients receiving CK SRS for VS.
Study Design Retrospective case series review.
Methods127 patients who received CK SRS for radiographically documented growing VS were reviewed. Tumors were monitored for post-procedure growth radiographically with linear measurements and three-dimensional segmental volumetric analysis (3D-SVA). Hearing outcomes were reviewed for 109 patients. Cox proportional hazard modeling was used to identify variables correlated with hearing outcomes.
Results Tumor control rate was 94.5% for treating VS with CK SRS. Hearing outcomes were categorized using the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) classification system. As of their last available audiogram, 33.3% of patients with pre-treatment class A and 26.9% of patients with class B retained their hearing in that class. 15.3% of patients starting with class A or B with extended follow-up (>60 months), maintained hearing within this same grouping. Our final model proposed to predict hearing outcomes included age, fundal cap distance (FCD), tumor volume, and maximum radiation dose to the cochlea; however, FCD was the only statistically statistical variable.
ConclusionCK SRS is an effective treatment for control of VS. Hearing preservation by class was achieved in a third of patients. Finally, FCD was found to be protective against hearing loss.
Level of Evidence4 Laryngoscope, 2023
"Courtney B Tipton, Rameen Walters, Rachana Gudipudi, Drasti Smyre, Shaun Nguyen, Ashli K ORourke"
Publication date 11-05-2023
Superior laryngeal nerve blocks were found to be an effective treatment option for patients with chronic cough when compared to placebo injections. There were no major side effects associated with the in-office injections.
Objectives Chronic cough is a common and debilitating problem. The objective of this study is to assess the efficacy and safety of superior laryngeal nerve (SLN) block for neurogenic cough through a placebo-controlled, prospective trial.
Methods Patients were recruited in an outpatient tertiary care center. Inclusion criteria included a history consistent with neurogenic cough and age ≥ 18. Exclusion criteria included patients with untreated other etiologies of chronic cough (i.e., uncontrolled reflux) and current neuromodulating medication use. Patients were randomized into the treatment (1–2 mL of a 1:1 triamcinolone 40 mg: 1% lidocaine with 1:200,000 epinephrines) or placebo (saline) group and received two unilateral injections at approximately 2-week intervals. Outcomes were measured primarily by the Leicester Cough Questionnaire (LCQ) and a patient symptom log including a visual analog scale of cough severity.
Results17 patients completed the study, including 10 in the treatment group and seven in the placebo group. Eight (80%) patients in the treatment group reported improvement with at least one of the injections, whereas only 1 (14.3%) patient reported improvement in the placebo group (p < 0.0001). Average total LCQ scores increased in the treatment group from 10.09 to 13.15 (p = 0.03), with the most change occurring in the social domain. There was no statistically significant change in LCQ scores for the placebo group. There were no serious adverse events.
Conclusion An SLN block is a safe and efficacious procedure for the treatment of neurogenic cough. Further studies are needed to optimize treatment protocol and assess long-term follow-up of patient outcomes.
Level of Evidence2 Laryngoscope, 2023
Jenny Kim, Stephen R. Chorney, Yann‐Fuu Kou, Helene Dabbous, Romaine F. Johnson
Publication date 11-05-2023
"Alexandra DOto, Hayley Baker, Ted Mau, Lesley F. Childs, Kathleen M. Tibbetts"
Publication date 11-05-2023
Idiopathic subglottic stenosis (iSGS) most commonly affects women aged 30–60 years old, but a small group of patients develop the condition later in life. This study compares a group of patients who developed iSGS at ≥65 years old to younger patients with the condition. We found that patients ≥65 years have higher rates of type 2 diabetes mellitus and tobacco use but did not require surgery more frequently than younger patients.
Objective To compare characteristics of patients ≥65 years presenting with idiopathic subglottic stenosis (iSGS) to patients diagnosed at <65 years. We hypothesize that the groups have similar comorbidities and disease courses.
Data Sources Medical records of patients treated for iSGS at a tertiary care institution from January 2005–September 2022.
Review Methods Patient demographics, time from symptom onset to diagnosis, medical history and comorbidities, and treatment modalities/intervals were recorded and analyzed. Characteristics of patients ≥65 and <65 years at presentation were compared using Chi-square analysis for non-numeric values and the Mann–Whitney U-test for numeric values.
Results One hundred seven patients with iSGS were identified and 16 (15%) were aged ≥65 years (mean age 72.6, 15 female) at presentation. These patients were compared to 91 patients aged <65 years (mean age = 47.6, 90 female). Patients ≥65 years had higher rates of type 2 diabetes mellitus (T2DM) (p = 0.004) and tobacco use (p = 0.004). There were no significant differences in body mass index, gastroesophageal reflux disease, hormone replacement therapy, time from symptom onset to presentation, or length of operative treatment intervals.
Conclusion Patients ≥65 years with iSGS have higher rates of tobacco use, suggesting that alterations in wound healing may play a role in the development of iSGS in this age group. Although rates of T2DM were higher in the elderly group, clinical significance may be limited given the overall higher rate of diabetes mellitus in the elderly population.
Level of Evidence4 Laryngoscope, 2023
Adaobi Ahanotu, Elliana Kirsh DeVore, Thomas L. Carroll, Maria Edelen, Mary Morcos, Elizabeth Willard, Nina W. Zhao, Peter Belafsky, Jennifer J. Shin
Publication date 11-05-2023
Patient-centered measures are important in the evaluation and management of dysphagia. Item response theory (IRT) may improve the efficiency of questionnaire administration by identifying items which convey the most information. We found that dysphagia could be validly measured with three proposed 5-item subsets, leading to more efficient and targeted information intake.
Objectives To assess: (1) the Eating Assessment Tool (EAT-10) with item response theory (IRT) to determine which individual items provide the most information, (2) the extent to which dysphagia is measured with subsets of items while maintaining precise score estimates, and (3) if 5-item scales have the differing discriminatory ability, as compared to the parent 10-item instrument.
Methods Prospectively collected data from 2,339 patients who completed the EAT-10 questionnaire during evaluation at a tertiary care otolaryngology clinic were utilized. IRT analyses provided discrimination and location parameters associated with individual questions. Residual item correlations were also assessed for redundant information. Based on these results, three 5-item subsets were further evaluated using item information function curves. Areas under receiver-operator characteristic curves (ROC-AUC) were also calculated to evaluate the discriminatory ability for dysphagia-related clinical diagnoses.
Results Item discrimination parameter estimates ranged from 1.71 to 5.46, with higher values indicating more information. Residual item correlations were determined within item pairs, and location parameters were calculated. Based on these data, in combination with clinical utility, three 5-item subsets were proposed and assessed. ROC-AUC analyses demonstrated no significant difference between the EAT-5-Alpha subset and the original 10-item instrument for discriminating dysphagia as a primary diagnosis (0.88, 0.88). The EAT-5-Clinical subset outperformed the original 10 instruments in ROC-AUC for aspiration. The EAT-5-Range subset was significantly associated with problems with thin liquids.
ConclusionsIRT analyses distinguished three proposed 5-item subsets of the EAT-10 instrument, supporting shorter survey options, while still reflecting the impact of dysphagia without significant loss of discrimination.
Level of Evidence3 (Diagnostic testing with consistently applied reference standards, partial blinding). Laryngoscope, 2023
Raymond J. So, Ashley Davis, Lee M. Akst, Alexander T. Hillel, Simon R. Best
Publication date 10-05-2023
Effective vocal care requires consistent patient follow-up, but factors associated with loss to follow-up in transgender voice patients have never before been investigated. Delivery of vocal care through telemedicine improves follow-up rates. Conversely, transgender patients who receive several gender-affirming treatments simultaneously are more likely to be lost to follow-up.
Objectives Optimal vocal care for transgender patients necessitates regular follow-up. Factors associated with loss of follow-up in voice patients have never been investigated. In this study, we report a case series of transgender patients seeking vocal care at our institution and compare those who were and were not lost to follow-up.
Methods Charts of transgender patients diagnosed with gender dysphoria who sought vocal care at our institution from January 2018 through May 2022 were reviewed. A chronological timeline of each patients care at our vocal clinic was recorded. Loss of follow-up was defined as instances in which patients were not yet satisfied with their vocal outcomes and expressed interest in scheduling a subsequent visit but had not yet done so. Logistic regressions were performed to identify factors associated with loss of follow-up.
Results Of 73 patients identified, 59 (80.8%) were assigned male at birth, and 72 (98.6%) were non-Hispanic White. Loss of follow-up occurred in 35 (47.9%) patients. Patients who received vocal surgery were significantly less likely to be lost to follow-up (OR: 0.16 (0.03, 0.79); p = 0.03). The availability of telemedicine options for vocal care was protective against loss of follow-up (OR: 0.09 (0.02, 0.44); p = 0.003). Patients who received other non-voice gender-affirming treatments concomitant to their vocal care were more likely to be lost to follow-up (OR: 4.44 (1.35, 14.59); p = 0.01).
Conclusion Loss of follow-up in transgender patients receiving vocal care is common. Providing telemedicine options and encouraging patients to complete vocal care prior to or after receiving other non-voice gender-affirming treatments may help increase rates of follow-up.
Level of Evidence4 Laryngoscope, 2023
Fang Wang, Maria Buchberger, Katja Böck, Markus Wirth
Publication date 10-05-2023
The work describes a case of palatal myoclonus with distressing tinnitus in a 9-year-old boy and its successful treatment with injections of botulinum toxin. This case report discusses common questions about myoclonic-induced clicking tinnitus and provides answers. Laryngoscope, 2023
Pubmed PDF WebJosef Madrigal, Edward K. Tie, Arjun Verma, Peyman Benharash, David A. Rapkin, Maie A. St. John
Publication date 10-05-2023
Depression is increasingly prevalent in patients with head and neck cancer. In the present study, comorbid depression was not associated with in-hospital mortality or perioperative complication though did increase rates of non-routine discharge and readmission. Such findings highlight the need for further work assessing screening and therapeutic interventions targeted at this at-risk population.
Objective Depression remains prevalent in patients undergoing head and neck cancer (HNCA) operations. The present study aimed to assess the impact of depression on perioperative and readmission outcomes following HNCA resection.
Methods All elective hospitalizations involving HNCA resection were identified from the 2010–2019 Nationwide Readmissions Database. Patients were stratified by history of depression. To perform risk-adjustment in assessing perioperative and readmission outcomes, 3:1 nearest neighbor matching was performed. A subpopulation analysis was also conducted to assess interval development of depression in the postoperative period.
Results Of an estimated 133,018 patients undergoing HNCA operations, 8.9% (n = 11,855) had comorbid depression. Over the decade-long study period, the prevalence of depression in this population increased (7.8% in 2010 vs. 10.0% in 2019, NPTrend<0.001). Among 24,938 propensity matched patients, those with depression had similar incidence of in-hospital mortality (0.4 vs. 0.7%, p = 0.14) as well as perioperative medical (22.0 vs. 21.9%, p = 0.93) and surgical (10.2 vs. 10.3, p = 0.84) complications, though had higher rates of non-home discharge (16.9 vs. 13.5%, p < 0.001) and 30-day readmission (13.6 vs. 11.8%, p = 0.030). Predictors of depression in the postoperative period included primary coverage by Medicare or Medicaid as well as comorbid anxiety or drug use disorder.
Conclusion The prevalence of depression in HNCA patients continues to increase. Although depression was not associated with increased in-hospital mortality and complications, it did impact rates of rehospitalization as well as non-routine discharge. Screening and therapeutic interventions addressing such postoperative events may serve to improve long-term clinical and financial outcomes in this at-risk population.
Level of Evidence3—Retrospective cohort study Laryngoscope, 2023
"Alexander N. Duffy, Rahul Alapati, Chandala Chitguppi, Glen DSouza, Sean M. Parsel, Elina M. Toskala, Marc R. Rosen, Gurston G. Nyquist, Mindy R. Rabinowitz"
Publication date 09-05-2023
Comorbid obstructive sleep apnea (OSA) is seen in a large percentage of patients with chronic rhinosinusitis (CRS), and these patients face high risk in the perioperative setting. Surgeons do not routinely screen patients for OSA prior to pursuing endoscopic sinus surgery, nor are validated OSA screening tools often used. This study investigates the sleep subdomain of the widely employed SNOT-22 questionnaire as a potential screening tool for OSA when validated questionnaires are not available.
Objectives Approximately 20% of patients with chronic rhinosinusitis (CRS) have comorbid obstructive sleep apnea (OSA). Patients with undiagnosed OSA are at high risk for perioperative complications. The Sinonasal Outcomes Test (SNOT-22) Questionnaire is commonly administered to CRS patients, whereas OSA screening tools are less routinely employed. This study compared SNOT-22 sleep subdomain (Sleep-SNOT) scores among non-OSA CRS versus OSA-CRS patients undergoing ESS, and assessed sensitivity, specificity, and diagnostic accuracy of the Sleep-SNOT for OSA screening.
Methods Retrospective review of patients that underwent endoscopic sinus surgery (ESS) for CRS from 2012 to 2021. Patients either carried a reported OSA diagnosis and completed the SNOT-22, or had undocumented OSA status and completed both STOP-BANG and SNOT-22. Demographics, questionnaire scores, and OSA status were collected. A receiver operating characteristic (ROC) curve assessed cutoff scores, sensitivity, and specificity of the Sleep-SNOT for OSA screening.
Results Of 600 patients reviewed, 109 were included. 41% had comorbid OSA. OSA patients had a higher BMI (32.1 ± 7.7 vs. 28.35 ± 6.7 kg/m2; p = 0.02), Sleep-SNOT (21.96 ± 12.1 vs. 16.8 ± 11.2; p = 0.021) and STOP-BANG (3.1 ± 1.44 vs. 2.06 ± 1.27; p = 0.038) scores. A Sleep-SNOT score of 17.5 had a sensitivity of 68.9%, specificity of 55.7%, and diagnostic accuracy of 63% for OSA detection (p = 0.022).
Conclusions Sleep-SNOT scores are greater for CRS-OSA patients. The Sleep-SNOT ROC curve demonstrates a high sensitivity, specificity, and accuracy for OSA screening in CRS patients. A Sleep-SNOT score of ≥17.5 should prompt further OSA evaluation. The Sleep-SNOT may be considered as a surrogate OSA screening tool when other validated tools are not employed.
Level of Evidence Retrospective chart review, Level 3 Laryngoscope, 2023
Lekha V. Yesantharao, Varun Vohra, Michael Cheng, Eleanor M. Simonsick, Yuri Agrawal, Sascha Lac, Nicholas R. Rowan
Publication date 09-05-2023
Objective This study aims to characterize the association between impairments in olfaction and balance, both of which are mediated in part by the cerebellum, and how this relates to prospective incidence of falls in a cohort of aging adults.
Methods The Health ABC study was queried to identify 296 participants with data on both olfaction (measured using the 12-item Brief Smell Identification Test) and balance-related function (measured using the Romberg test). The relationship between olfaction and balance was investigated using multivariable logistic regression. Predictors of performance on a standing balance assessment and predictors of falls were studied.
Results Of 296 participants, 52.7% had isolated olfactory dysfunction, 7.4% had isolated balance dysfunction, and 5.7% had dual dysfunction. Severe olfactory dysfunction was associated with increased odds of balance dysfunction when compared to those without olfactory dysfunction, even when adjusting for age, gender, race, education, BMI, smoking, diabetes, depression, and dementia (OR = 4.1, 95% CI 1.5, 13.7, p = 0.011). Dual sensory dysfunction was associated with worse performance on a standing balance assessment (β = −22.8, 95% CI −35.6, −10.1, p = 0.0005) and increased falls (β = 1.5, 95% CI 1.0, 2.3, p = 0.037).
Conclusion This study highlights a unique relationship between olfaction and balance, and how dual dysfunction is associated with increased falls. With substantial implications of falls on morbidity and mortality in older adults, this novel relationship between olfaction and balance emphasizes a potentially shared mechanism between olfactory dysfunction and increased fall risk in older adults; however, further study is required to explore the novel relationship of olfaction with balance and future falls.
Level of Evidence Level III Laryngoscope, 2023
Suhaima Tunio, Agnieszka Dzioba, Rita Dhami, Sameer Elsayed, Julie E. Strychowsky
Publication date 09-05-2023
In this pre-post intervention quality improvement study, we hoped to optimize compliance with antimicrobial stewardship guidelines with the implementation of auto-substitutions into electronic health records. This study included 196 pre-intervention procedures and 188 post-intervention procedures. Compliance with antimicrobial stewardship guidelines improved from 38.8% to 59.0% (p < 0.001).
Background Appropriate administration of perioperative antibiotics can prevent antimicrobial resistance, adverse drug events, surgical site infections, and increased costs to the health care system for many surgeries in Otolaryngology—Head and Neck Surgery (OHNS).
Objective The objective of the study is to achieve 90% compliance with evidence-based perioperative antibiotic prophylaxis guidelines among elective surgical procedures in OHNS.
Methods The pre-intervention group consisted of patients undergoing elective surgical procedures in the 13 months prior to the interventions (September 2019–2020) whereas the post-intervention group comprised patients undergoing elective procedures during the 8 months following the implementation (October 2020–May 2021). The 4 Es of knowledge translation and the Donabedian framework were used to frame the study. Components of the intervention included educational grand rounds and automatic substitutions in electronic health records. In June 2021, a survey of staff and residents assessed the self-reported perception of following evidence-based guidelines.
Results Compliance with antimicrobial prophylaxis guidelines were evaluated based on agent and dose. The overall compliance improved from 38.8% pre-intervention to 59.0% post-intervention (p < 0.001). Agent compliance did not improve from pre- to post-intervention, that is, 60.7% to 62.8%, respectively, (p = 0.68), whereas dose compliance improved from 39.6% to 89.2% (p < 0.001). Approximately 78.5% of survey respondents felt that they strongly agreed or agreed with always following evidence-based antimicrobial prophylaxis guidelines.
Conclusion Compliance with antimicrobial prophylaxis guidelines improved, primarily due to increased dosing compliance. Future interventions will target agent compliance and selected procedures with lower compliance rates.
Level of Evidence Level 3 Evidence Laryngoscope, 2023
John R. Craig, Matthew Kim, Daniel B. Spielman, Jonathan Overdevest, Tamer Ghanem, David A. Gudis
Publication date 09-05-2023
This case highlights the successful use of a large nasoseptal flap to repair a large maxillary sinus floor defect. Surgeons can therefore rely on this flap for repairing maxillary sinus floor defects of most sizes and locations. Laryngoscope, 2023
Pubmed PDF WebDavid Zimmer, Gilman Plitt, Brandon Prendes, Jamie Ku, Natalie Silver, Eric Lamarre, Emrullah Yilmaz, Jessica Geiger, Christian Nasr, Lea El Hage, Mario Skugor, Shauna Cambpell, Shlomo Koyfman, Jacob Miller, Neil Woody, Katherine Heiden, Nikhil Joshi, Tarik Elsheikh, Hong Li, Joseph Scharpf
Publication date 09-05-2023
Tall Cell Variant (TCV) is an aggressive subtype of Papillary Thyroid Cancer (PTC) with higher rates of recurrence and mortality when compared to classical PTC. We have shown, however, that patients with TCV who achieve an excellent overall response to therapy at any point during follow-up have significantly improved outcomes when compared to patients with indeterminate, biochemical incomplete, and structural incomplete overall responses. With this knowledge, physicians can more effectively counsel patients on expected outcomes, as well as potentially guide treatment and surveillance in this high-risk cohort.
Objectives Tall cell variant (TCV) papillary thyroid cancer (PTC) is a subtype of PTC associated with aggressive tumor behavior, advanced stage, and higher rates of recurrence and mortality. The present study aimed to test an established dynamic risk stratification tool in the TCV population, with the goal of better predicting the postoperative course of these patients.
Study Design Retrospective chart review.
MethodsA total of 94 patients with TCV who underwent total thyroidectomy with radioactive iodine ablation were retrospectively reviewed from 1998 through 2020. Biochemical, structural, and overall response to treatment was determined for each patient, based on postoperative thyroglobulin levels and imaging findings. Primary outcomes were locoregional and distant recurrence, presence of disease at final follow-up, need for additional intervention, and disease-specific mortality.
Results Patients with TCV who were stratified as having an excellent overall response to treatment had lower rates of locoregional recurrence than indeterminate, biochemical incomplete, and structural incomplete responses (2.0%, 33.3%, 55.0%, and 85.7% at 5 years respectively, p < 0.001). The same was true for distant recurrence as well (2.0%, 9.0%, 35.1%, and 42.9%, p < 0.001). An excellent response was also associated with lower rates of presence of disease at final follow-up, need for additional intervention, and disease-specific mortality.
Conclusions Although TCV is an aggressive subtype associated with worse clinical outcomes than classical PTC, patients with an excellent overall response to treatment have significantly improved outcomes when compared to indeterminate, biochemical incomplete, and structural incomplete responses.
Level of Evidence Level 3 Laryngoscope, 2023
Samir W. Hassanin, Rijul S. Kshirsagar, Jacob G. Eide, Jeremy Chang, Jonathan Liang, James N. Palmer, Nithin D. Adappa
Publication date 09-05-2023
Image-guided surgery (IGS) devices have become widely used for anatomic localization during functional endoscopic sinus surgery (FESS). However, there are no studies that analyze the post-market complications associated with IGS device use during FESS. This study queried the US Food and Drug Administrations Manufacturer and User Facility Device Experience database for event reports associated with neurological stereotaxic devices utilized in IGS between the dates of January 1, 2016 and December 31, 2020. Of the medical device reports between 2016 and 2020, less than 3% resulted in adverse events.
Objective Image-guided surgery (IGS) devices have become widely used for anatomic localization during functional endoscopic sinus surgery (FESS). However, there are no studies that analyze the post-market complications associated with IGS device use during FESS. The objective of this study was to better characterize post-market complications associated with the use of IGS devices during sinus surgery.
Methods The US Food and Drug Administrations Manufacturer and User Facility Device Experience database was queried for event reports associated with neurological stereotaxic devices utilized in IGS between the dates of January 1, 2016 and December 31, 2020. Medical device reports that were analyzed for this study pertained strictly to FESS.
Results There were 1873 reports involving IGS devices for FESS included in this study. Fifty-five reports involved adverse events to patients (2.9%) and 1818 (97.1%) involved device malfunctions. Of the adverse events to patients, the most common included cerebrospinal fluid leakage (45.6%), tissue damage (12.7%), and nervous system injury (3.6%). The most commonly reported device malfunction was imprecision (21.1%).
ConclusionIGS devices are widely utilized in FESS. Of the medical device reports between 2016 and 2020, less than 3% resulted in adverse events. Further studies of the infrequent post-market complications of IGS devices used in FESS can help guide surgeons on the risks of their clinical use.
Level of Evidence4—Retrospective database survey without controls Laryngoscope, 133:1310–1314, 2023
Cullen M. Taylor, Michael J. Marino, Stephen F. Bansberg
Publication date 09-05-2023
The NOSE-Perf scale is a patient-reported outcome measure specific to nasal septal patients. NOSE-Perf data are presented for a large heterogenous group of patients.
Objective To objectively identify and quantitate presenting nasal symptoms in patients with a septal perforation using the validated NOSE-Perf scale.
Study Design Case series retrospective review.
Methods The medical records from August 2018 through January 2022 of patients at a tertiary care academic center with a septal perforation, and who completed the NOSE-Perf questionnaire, were reviewed. Perforation symptoms were identified and quantified using the 12-item NOSE-Perf scale (score range 0–48). NOSE-Perf findings were correlated to patient demographics, perforation etiology, and perforation length. NOSE-Perf scores of patients who pursued treatment were compared with those who did not.
ResultsNOSE-Perf data were collected from 202 patients. Nasal crusting was noted in 94.1% of patients and was the most severe symptom reported (mean 2.9 of 4.0). Nasal congestion, difficulty breathing, and nasal obstruction followed in prevalence and severity. The mean total NOSE-Perf score was 23.7. Linear regression analysis demonstrated a weakly negative association of NOSE-Perf score with patient age and weakly positive association with increasing perforation length. NOSE-Perf scores were significantly higher in women and in patients pursuing treatment.
Conclusion This is the first study to use the validated NOSE-Perf scale to objectively characterize and establish baseline septal perforation symptomatology. The NOSE-Perf scale can play a role in the standardization of perforation evaluation and treatment outcomes assessment. Laryngoscope, 133:1315–1320, 2023
"Emily E. Karp, Linda X. Yin, Thomas Jamie OByrne, Lauren Y. Lu, David M. Routman, Scott C. Lester, Michelle A. Neben Wittich, Daniel J. Ma, Katharine A. Price, Ashish V. Chintakuntlawar, Kendall K. Tasche, Daniel L. Price, Eric J. Moore, Kathryn M. Van Abel"
Publication date 09-05-2023
Delays in care related to evaluations by multiple providers and misdiagnosis prolonged time to diagnosis in HPV(−)OPSCC. Improved patient and provider education is necessary to expedite the diagnosis of HPV(−)OPSCC.
Objective Failure to recognize symptoms of non-human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV(−)OPSCC) at presentation can delay diagnosis and treatment. We aim to identify patient factors and provider practice patterns that delay presentation and care in HPV(−)OPSCC.
Methods Retrospective review at a tertiary care center. Patients with HPV(−)OPSCC receiving treatment from 2006 to 2016. Patients were excluded if their date of symptom onset or diagnosis was unknown after thorough review of the electronic medical record or their tissue was not tested for HPV or p16. Clinical data, workup, and care timelines were abstracted. Univariate and multivariable linear regressions were performed to determine associations between patient and provider factors and delays in care.
Results Of 70 included patients, 52 (74%) were male and mean age was 60.5 (SD = 9.0). Median time to diagnosis was 69 days (IQR = 32–127 days), with a median latency of 30 days (IQR = 12–61 days) from symptom onset to first presentation and 19.5 days (IQR = 4–46 days) from the first presentation to diagnosis. Most patients visited at least 2 providers (n = 52, 74%) before diagnosis. Evaluation by 3 or more providers prior to diagnosis was associated with significant delays in diagnosis of nearly a year (357.7 days, p < 0.001) and being treated or prescribed analgesia prior to diagnosis was significantly associated with delays in diagnosis (p = 0.004) on univariate regression analysis.
Conclusions Delays in care related to evaluations by multiple providers and misdiagnosis prolonged time to diagnosis in HPV(−)OPSCC. Improved patient and provider education is necessary to expedite the diagnosis of HPV(−)OPSCC.
Level of Evidence4 Laryngoscope, 133:1394–1401, 2023
Mehdi S. Lemdani, Hannaan S. Choudhry, Aman M. Patel, Maham Ahmad, Rushi Patel, Prayag Patel, Jean Anderson Eloy
Publication date 09-05-2023
Objectives Hypoalbuminemia has been used as a proxy for poor nutrition, and has been associated with poor postoperative outcomes in varying surgical procedures. This study investigates the association between albumin status and complications following transcervical Zenker diverticulectomy.
Study Design Retrospective database review.
Methods The National Surgical Quality Improvement Program database was queried for patients who underwent transcervical Zenker diverticulectomy between 2005 and 2018. Univariate and multivariable analyses were conducted to determine associations between albumin status and postoperative complications.
Results318 patients undergoing transcervical Zenker diverticulectomy with available albumin values were queried. The mean serum albumin was 3.90 g/dL (SD = 0.56). Univariate analysis showed that hypoalbuminemia was associated with increased age (77.68 vs. 70.03 years) and female gender (54.4% vs. 45.6%), as well as sepsis (p = 0.045), reintubation (p = 0.040), urinary tract infection (p = 0.017), any medical complication (p < 0.001), any life-threatening complication (p = 0.017), and mortality (p = 0.012). Multivariable analyses found no associations between hypoalbuminemia and mortality (OR 33.136, 95% CI N/A, p = 1.000), any medical complication (OR 1.154, 95% CI 0.326–4.079, p = 0.824), any life-threatening complication (OR 0.604, 95% CI 0.079–4.586, p = 0.604), and length of stay (p = 0.249).
Conclusions This study suggests no association between hypoalbuminemia and postoperative complications in transcervical Zenker diverticulectomy. Hypoalbuminemia and malnutrition may not be a contraindication for surgery correcting Zenker diverticulectomy.
Level of Evidence4 Laryngoscope, 133:1402–1408, 2023
Jorge Rodrigues, João V. Pinto, Pedro L. Alexandre, Bernardo Sousa‐Pinto, Ana M. Pereira, Kristof Raemdonck, Ricardo P. Vaz
Publication date 09-05-2023
Participants with allergic rhinitis (AR) had higher scores of anxiety and depression than the control group. A lack of disease control and a moderate/severe presentation of AR were related to higher scores of anxiety and depression.
Objectives Allergic rhinitis (AR) has been associated with anxiety and depression. A possible influence of frequency and intensity of the AR symptoms has remained unclear. Therefore, we evaluated the association between AR, as well as its control, seasonality and severity, and the presence of anxiety and depression.
Methods Participants were selected from a preexistent national database and consecutively contacted by phone. AR was classified according to Allergic Rhinitis and its Impact on Asthma. Presence of anxiety and depression was identified by Hospital Anxiety and Depression Scale (HADS), Beck Anxiety Inventory (BAI), and Beck Depression Inventory-II (BDI-II). We built linear regression models assessing the association between any of the assessed anxiety or depression scores and the occurrence, degree of control, seasonality or severity of AR.
Results We analyzed 115 participants with AR and 38 participants with no respiratory symptoms. Patients with AR presented higher scores of anxiety (HADS: 3.1; 95% confidence interval CI = 1.9; 4.3; p < 0.001) and depression (HADS: 3.8; 95% CI = 2.5; 5.0; p < 0.001). Poorer AR control was positively associated with higher prevalence and scores of anxiety (HADS: 3.0; 95% CI = 1.5; 4.5; p < 0.001) and depression (HADS: 1.8; 95% CI = 0.2; 3.4; p = 0.031). Similar results were obtained with BAI and BDI-II scales. A moderate/severe presentation of AR were also related with higher scores of anxiety (HADS: 1.7; 95% CI = 0.1; 3.2; p = 0.040) and depression (HADS: 1.7; 95% CI = 0.1; 3.3; p = 0.037).
Conclusion The presence of AR, a poorer control, and a moderate/severe presentation of the disease were significantly associated with higher scores of anxiety and depression. Thus, it is important to alert to this association to allow a quick diagnosis of AR-associated pathologies. Laryngoscope, 133:1321–1327, 2023
Claudia Gutierrez, Andrew Zaninovich, Rebecca Vozzo, James Daniero
Publication date 09-05-2023
This case presents the first use of an ultrasonic pin placement system for resorbable rigid fixation of a thyroid cartilage fracture. The patient incurred a right paramedian laryngeal cartilage fracture following a high velocity injury to his left anterior neck from a lacrosse ball. A tracheostomy was avoided and post-operatively he had complete return to his vocal baseline.
Objective To present the first use of an ultrasonic pin resorbable plate fixation system for rigid fixation of a laryngeal fracture.
Methods Presentation of a 20-year-old male with a high velocity injury to his neck, via a lacrosse ball, resulting in a displaced laryngeal cartilage fracture.
Results Intraoperatively, a Poly-D, L-Lactic Acid (PDLLA) polymer plate was contoured in-situ, bridging the fracture, and secured with ultrasonically placed resorbable pins. He was extubated on post-op day one and had return to vocal baseline one-month post-op.
Conclusion Ultrasonic pin placement systems for resorbable rigid fixation of a thyroid cartilage fracture optimizes recovery of respiratory and phonatory functions. Laryngoscope, 133:1470–1472, 2023
Kumaran Arivoli, Andrew Benvenuto, Emily Stucken
Publication date 09-05-2023
Extremely rare cases of Wernicke encephalopathy (WE) can involve sensorineural hearing loss (SNHL). Here, we present a 46-year-old female with SNHL and clinical and radiologic suspicion for WE. After initiating thiamine therapy, the patient experienced robust improvement. Laryngoscope, 133:1492–1494, 2023
Pubmed PDF WebRyan Rimmer, Mathew Geltzeiler
Publication date 09-05-2023
This article showcases a technique to further expand the endoscopic endonasal approach to the skull base by traversing the orbit for further lateral exposure. Laryngoscope, 133:1336–1338, 2023
Pubmed PDF WebLuigi La Via, Antonino Maniaci, Gianluca Albanese, Ignazio La Mantia, Filippo Sanfilippo
Publication date 09-05-2023
Paul E. Hammerschlag, Daniel H. Coelho, Darius Kohan
Publication date 09-05-2023
Norman R. Friedman, Thanh Nguyen
Publication date 09-05-2023
Ozkan Onal, Merih Onal
Publication date 09-05-2023
Dejin Gao, Tun Liu, Bingqing Wang
Publication date 09-05-2023
Jeffrey M. Bumpous, J. Samuel Bumgardner
Publication date 09-05-2023
Publication date 09-05-2023
Publication date 09-05-2023
Ciersten A. Burks, Elisabeth E. Hansen, Jowan Watson, Regan W. Bergmark
Publication date 09-05-2023
Se Hwan Hwang, Sun Won Kim, Do Hyun Kim
Publication date 09-05-2023
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, 133:1281–1287, 2023
Kata Illés, Fanni Adél Meznerics, Fanni Dembrovszky, Péter Fehérvári, András Bánvölgyi, Dezső Csupor, Péter Hegyi, Tamás Horváth
Publication date 09-05-2023
Our study aims to evaluate the effectiveness of mastoid obliteration compared to the canal wall up (CWU) technique in cholesteatoma surgery based on the systematic review of the literature and the meta-analysis of the data. Our analyses based on 1847 operations data showed mastoid obliteration could decrease residual and recurrent disease rates (OR = 0.45, CI:0.26;0.80, p = 0.0014). However, randomized controlled trials are needed to confirm our results.
Objective Our study aims to evaluate the effectiveness of mastoid obliteration compared to the canal wall up (CWU) technique in cholesteatoma surgery based on the systematic review of the literature and the meta-analysis of the data.
Methods The systematic search was performed in four major databases (MEDLINE, Web of Science, Embase, and CENTRAL) on October 14, 2021. Studies comparing the CWU technique and mastoid obliteration were included. The exclusion criteria were less than 12 months follow-up, congenital cholesteatoma, indefinite description of the surgical method, and animal studies. The protocol was registered on Prospero (registration number: CRD42021282485). The risk of bias was evaluated with the ROBINS-I tool. Residual and recurrent disease proportions as primary outcomes, quality of life, ear discharge, infection rates, hearing results, and operation time as secondary outcomes were analyzed. In the quantitative synthesis, the random effect model was used, and heterogeneity was identified.
ResultsA total of 11 articles with 2077 operations data were found eligible. All the identified studies were retrospective cohorts. The odds of pooled residual and recurrent disease proportion were significantly lower in the obliteration group compared to CWU (OR = 0.45, CI:0.28;0.80, p = 0.014). However, when separated, the proportion of ears with recurrent (OR = 0.41, CI:0.11;1.57, p = 0.140) or residual (OR = 0.59, CI:0.23, 1.50, p = 0.207) disease did not show a significant difference, even though the odds were quite similar. The qualitative synthesis identified no significant difference in the secondary outcomes, but obliteration elongated the operation time.
Conclusion Mastoid obliteration significantly decreased the proportion of residual and recurrent cholesteatoma in pooled analyses compared to the CWU technique with low-quality of data.
Level of EvidenceNA Laryngoscope, 133:1297–1305, 2023
Mickey Kondo, Kartik Vasan, Nicholas Emmanuel Jufas, Nirmal P. Patel
Publication date 09-05-2023
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, 133:1288–1296, 2023
Zaid Al‐Qurayshi, Christopher B. Sullivan, Mohamed A. Shama, Nitin A. Pagedar, Emad Kandil
Publication date 09-05-2023
In states that adopted Medicaid expansion under the Affordable Care Act, the ratio of patients with Medicaid insurance to uninsured patients increased significantly.
Objective Under the Affordable Care Act (ACA), Medicaid expansion became effective in states that have adopted it. We aim to examine its impact on head and neck cancers.
MethodsA retrospective study that utilizes the Surveillance, Epidemiology, and End Results database, 2010–2016. Study population included patients with head and neck squamous cell carcinoma (HNSCC), differentiated thyroid carcinoma, and head and neck cutaneous melanoma. The objective is to examine disease-specific survival before and after Medicaid expansion.
Results In states that adopted Medicaid expansion, the ratio of Medicaid: uninsured patients increased from 3:1 to 9:1 (p < 0.001). In states that did not adopt Medicaid expansion, the ratio increased from 1:1 to 2:1 (p < 0.001), making the increase in Medicaid coverage in states that adopted the expansion significantly higher (p < 0.001). Patients diagnosed with HNSCC before the expansion had worse survival (hazard ratio HR: 1.24, 95% confidence interval: 1.11, 1.39, p < 0.001) in states that adopted Medicaid expansion.
Conclusions Early data indicate that implementation of ACA improved disease-specific survival of patients with HNSCC.
Level of Evidence3 Laryngoscope, 133:1409–1414, 2023
Richard Tjahjono, Hana Salati, Kiao Inthavong, Narinder Singh
Publication date 09-05-2023
This study examines the role of nasal mucosal temperature in the perception of nasal patency using in vivo and computational fluid dynamics measurements. We found that lower nasal mucosal temperature and higher heat flux anteriorly correlate with a perception of improved unilateral nasal patency in healthy individuals.
Objectives Recent evidence suggests that detection of nasal mucosal temperature, rather than direct airflow detection, is the primary determinant of subjective nasal patency. This study examines the role of nasal mucosal temperature in the perception of nasal patency using in vivo and computational fluid dynamics (CFD) measurements.
Methods Healthy adult participants completed Nasal Obstruction Symptom Evaluation (NOSE) and Visual Analogue Scale (VAS) questionnaires. A temperature probe measured nasal mucosal temperature at the vestibule, inferior turbinate, middle turbinate, and nasopharynx bilaterally. Participants underwent a CT scan, used to create a 3D nasal anatomy model to perform CFD analysis of nasal mucosal and inspired air temperature and heat flux along with mucosal surface area where heat flux >50 W/m2 (SAHF50).
Results Eleven participants with a median age of 27 (IQR 24; 48) were recruited. Probe-measured temperature values correlated strongly with CFD-derived values (r = 0.87, p < 0.05). Correlations were seen anteriorly in the vestibule and inferior turbinate regions between nasal mucosal temperature and unilateral VAS (r = 0.42–0.46; p < 0.05), between SAHF50 and unilateral VAS (r = −0.31 to −0.36; p < 0.05) and between nasal mucosal temperature and SAHF50 (r = −0.37 to −0.41; p < 0.05). Subjects with high patency (VAS ≤10) had increased heat flux anteriorly compared with lower patency subjects (VAS >10; p < 0.05).
Conclusion Lower nasal mucosal temperature and higher heat flux within the anterior nasal cavity correlates with a perception of improved unilateral nasal patency in healthy individuals.
Level of Evidence4 Laryngoscope, 133:1328–1335, 2023
Madeline Nottoli, Carina Tedesco, Lana Boladian, Khodayar Goshtasbi, Sunil Verma
Publication date 09-05-2023
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 EvidenceNA Laryngoscope, 133:1356–1360, 2023
Yu Han Chen, Andre Shomorony, Madeleine A. Drusin, Aaron N. Pearlman
Publication date 09-05-2023
Among our cohort, foreign body was identified and retrieved in approximately 50% of patients presenting with foreign body sensation in the aerodigestive tract. In patients with a history of foreign body ingestion or aspiration, CT is the most appropriate screening tool for locating foreign bodies and guiding further management. FFL may be inadequate for ruling out a foreign body in the aerodigestive tract, given its low sensitivity and NPV.
Objective To evaluate test characteristics of various diagnostic modalities in the workup of foreign body (FB) sensation in the aerodigestive tract.
Methods Database containing all inpatient otolaryngology consultations between 2008 and 2020 was used. Cases of FB sensation were identified by documented encounter diagnosis or hospital problem of FB or globus sensation. Variables including basic patient demographics, clinical presentations, diagnostic imaging modalities, procedures, and outpatient follow-up were collected.
Results One hundred and six patients were included in the study. A FB was visualized in 55 patients (52%) and removed in 52 patients (49%); 3 patients had a FB that was visualized initially but not found in the operating room. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were found to be 41%, 50%, 58%, and 33%, respectively, for X-ray (XR); 91%, 61%, 70%, and 87%, respectively, for computed tomography (CT). Sensitivity and NPV were 25% and 57%, respectively, for flexible fiberoptic laryngoscopy (FFL). Seventy-one of 106 patients (67%) underwent invasive interventions during their workup for FBs. Ten out of 11 (91%) chicken bones were found in the digestive tract compared to 7 out of 19 (37%) fishbones (p = 0.0046).
Conclusion In patients with history of FB ingestion, CT may be more beneficial than XR as a screening tool for locating foreign bodies and guiding further management. FFL alone is inadequate for ruling out a FB in the aerodigestive tract given FBs high likelihood of being in the esophagus or buried in soft tissue or mucosa.
Level of Evidence3 Laryngoscope, 133:1361–1366, 2023
John Wilson, Michael Gorelik, Jessica Gulliver, Alok Jaju, Bharat Bhushan, Jeffrey Rastatter, Douglas Johnston, John Maddalozzo
Publication date 09-05-2023
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, 133:1495–1500, 2023
Jalen Benson, Candace Stewart, Margaret A. Kenna, A. Eliot Shearer
Publication date 09-05-2023
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, 133:1501–1506, 2023
Nicholas J. Thompson, Kevin D. Brown, Emily Buss, Meredith A. Rooth, Margaret E. Richter, Margaret T. Dillon
Publication date 09-05-2023
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 Evidence3 Laryngoscope, 133:1480–1485, 2023
Laura Pitts, Valerie K. Hamilton, Erin A. Walaszek, Stephanie Watts, Leora R. Cherney
Publication date 09-05-2023
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, 133:1434–1441, 2023
"Steven Aziz, Karla ODell, Michael Johns, Josh Schindler, Al Merati, Abdullah Alanazi, Stephanie Watts, David Garber, Rebecca Nelson, Yael Bensoussan"
Publication date 09-05-2023
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 Evidence3—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, 133:1442–1447, 2023
Grant E. Gochman, Christopher D. Dwyer, VyVy N. Young, Clark A. Rosen
Publication date 09-05-2023
Background Despite many available patient-reported outcome measures (PROMs) for laryngeal movement disorders, there is a lack of patient input regarding which PROM most accurately and conveniently captures aspects related to their vocal disease. This study aimed to assess patients preferences among a selection of voice-related PROMs (Voice Handicap Index-10 VHI-10, OMNI-Vocal Effort Scale OMNI-VES, Communicative Participation Item Bank-General Short Form CPIB-10, and Visual Analog Scales VAS) within the laryngeal movement disorder population and investigate associations between selected instruments.
Methods Prior to botulinum toxin A injection, patients with laryngeal dystonia and/or essential tremor of the vocal tract were administered the VHI-10, OMNI-VES, CPIB-10, and three novel VAS questions in a randomized order. Patients rank ordered the four PROMs based on the PROMs reflection of their voice problems. Pearsons correlation coefficients evaluated pairwise associations among PROM scores. Fishers exact test compared the preferred PROM rankings.
Results Seventy patients (53 female, mean age = 60.7 years) participated. The VHI-10 and CPIB-10 were most preferred at 33.9% and 27.4% respectively. The OMNI-VES and VAS scales were less favored (19.4%, each). When analyzed by age ≥60 years, the CPIB-10 was most favored (33.3%), but for age <60 years, VHI-10 was most preferred (42.3%). There was a strong correlation between scores of all administered PROMs (strongest correlation between OMNI-VES and VAS, r = 0.8, p < 0.001; the weakest correlation between OMNI-VES and VHI-10, r = 0.6, p < 0.001).
Conclusions With an increasing trend in PROMs usage and a strong correlation between all evaluated outcome instruments, insight regarding patients PROM preferences is an area for further consideration.
Level of EvidenceNA Laryngoscope, 133:1448–1454, 2023
Rebecca J. Howell, Dale Ekbom, Jan Kasperbauer, Meredith Tabangin, Mekibib Altaye, Shaun Wahab, Peter Belafsky, Jacqui Allen, Milan Amin, Semirra Bayan, Brian Cervenka, Brad deSilva, Greg Dion, Aaron Friedman, Mark Fritz, John Paul Giliberto, Elizabeth Guardiani, Jeffrey Harmon, Sid Khosla, Brandon Kim, Maggie Kuhn, Paul Kwak, Yue Ma, Lyndsay Madden, Laura Matrka, Ross Mayerhoff, Cyrus Piraka, Clark Rosen, Keith Wilson, Carter Wright, Vyvy Young, Sonia Yuen, Greg Postma
Publication date 09-05-2023
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 Evidence4 Laryngoscope, 133:1349–1355, 2023
Peter A. Benedict, Adam Kravietz, Jackie Yang, Efstratios Achlatis, Carina Doyle, Aaron M. Johnson, Gregory R. Dion, Milan R. Amin
Publication date 09-05-2023
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, 133:1455–1461, 2023
Hans C. Baertsch, Neel K. Bhatt, John P. Giliberto, Connor Dixon, Albert L. Merati, Cara Sauder
Publication date 09-05-2023
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, 133:1462–1469, 2023
Serhat Inan, Goknil Gultekin, Ismail Yilmaz, Adnan Fuat Buyuklu
Publication date 09-05-2023
This study was a retrospective examination of 119 consecutive adult participants who underwent septorhinoplasty with (SRPwCB) or without concomitant concha bullosa resection (SRPO). The NOSE and SNOT-22 scales were assessed preoperatively and at the 3-month follow-up evaluation. SRPwCB patients had higher nasal obstruction and sinonasal symptom scores and greater improvement after surgery than SRPO patients. Therefore, evaluating the middle turbinate before functional SRP may be an important for surgical treatment of sinonasal symptoms.
Objective To evaluate the impact of functional septorhinoplasty (SRP) with and without concha bullosa resection (CBR) on sinonasal symptoms and nasal obstruction severity using the Nasal Obstruction Symptom Evaluation (NOSE) and Sino-Nasal Outcome Test-22 (SNOT-22) scale.
Methods Consecutive adult participants who underwent SRP were retrospectively analyzed.
Patients were divided into two groups: Group 1 (SRPwCB) underwent SRP with CBR (bulbous or extensive type MTs), and Group 2 (SRPO) underwent SRP only (normal or lamellar-type MTs). The NOSE and SNOT-22 scales were assessed preoperatively and at the 3-month follow-up evaluation. Patient demographics, self-reported outcomes, nasoseptal angle (NSA), and Lund-Mackay scores (LMS) were analyzed.
Results There were 119 participants (SRPwCB n = 57; SPRO n = 62). There were no statistically significant differences in age, sex, allergy, smoking, LMS, and NSA according to the presence of MTCB. Compared to SRPO, SRPwCB patients had significantly higher preoperative NOSE and SNOT-22 scores, whereas their postoperative NOSE and SNOT-22 scores were similar. SRPwCB patients also had significantly more postnasal discharge, ear fullness, facial pain/pressure, poor sleep, night waking, daytime fatigue, sense of taste/smell, and blockage symptoms before surgery compared with SRPO patients.
ConclusionSRPwCB patients had higher nasal obstruction and sinonasal symptom scores and greater improvement after surgery than SRPO patients. Therefore, evaluating the middle turbinate before functional SRP may be an important for surgical treatment of sinonasal symptoms.
Level of Evidence3 Laryngoscope, 133:1375–1381, 2023
Hong‐Yun Wu, Xiao‐Feng Shan, Zhi‐Gang Cai, Jing Zhang, Pei‐Jun Li, Lei Zhang, Yue Yang
Publication date 09-05-2023
Objective Determine the safety and effectiveness of a nasogastric tube removal plan designed to shorten nasogastric tube indwelling time after oral cancer surgery plus free flap reconstruction.
Materials and MethodsA parallel randomized clinical trial was conducted from May 2021 to December 2021 at Peking University School of Stomatology. Volunteers (n = 128) were separated into four groups: non-tracheostomy control and intervention groups and tracheostomy control and intervention groups. Control patients received the conventional nasogastric tube removal plan. Non-tracheotomy intervention patients were asked to swallow 5 ml of water on the first postoperative day. If there was no coughing, they were allowed progressively increasing amounts of water for the following 2 days. The nasogastric tube was removed only after ensuring level I/II performance on the Watian water swallowing test, no “wet voice” after drinking water, no marked decrease in blood oxygen saturation after drinking, and satisfactory daily oral nutritional intake. Tracheotomy intervention patients received the same protocol plus an additional Watian water swallowing test after tracheal tube removal.
Results Nasogastric tube removal time was earlier in the intervention subgroups than in control subgroups: 5.0 ± 2.3 days versus 7.8 ± 3.9 days (p = 0.001) in non-tracheostomy patients and 9.8 ± 1.1 days versus 16.2 ± 13.0 days (p = 0.049) in tracheostomy patients. Incidence of wound complications and daily food intake were comparable between the groups. The incidence of pneumonia was lower in the tracheostomy intervention group than in the tracheostomy control group (12.5% vs. 3.1%, p = 0.162). Pharyngeal pain score was lower in tracheotomy intervention patients than in tracheotomy control patients (p = 0.029). Postoperative hospital stay was shorter in tracheotomy intervention patients than in tracheotomy control patients (p = 0.005).
Conclusions On the basis of ensuring safety and effectiveness, patients undergone free flap reconstruction for oral cancer could be offered oral intake early after surgery, which will not increase the incidence of wound complications and pneumonia or adversely affecting the oral intake of the patients; it can also help minimize pharyngeal pain and shorten postoperative hospital stay of patients with a tracheotomy.
Level of Evidence2 Laryngoscope, 133:1382–1387, 2023
Farshid Taghizadeh, Scott H. Troob, Mark K. Wax
Publication date 09-05-2023
A retrospective study of the use of fluorescent angiography in free flap reconstruction of the head and neck shows that although the use of this technology in every free tissue transfer is not justifiable, it can guide the clinical course in challenging scenarios.
Objectives Highlight the use of fluorescent angiography in free flap reconstruction of the head and neck. Qualify how fluorescent angiography can be selectively added to management paradigms for head and neck free flap reconstruction.
Methods Retrospective chart review of 993 free flaps completed from the time the SPY Elite® system first became available at our institution between September 2013, until August 2020. Cases that used the SPY Elite® system were grouped into three broad categories: evaluation during initial flap harvest while still attached to the donor site, evaluation after anastomosis in the head and neck area, and evaluation post-operatively for questionable flap viability.
Results The SPY Elite® system was used in 64 cases. Forty flaps were evaluated intraoperatively during initial harvest and before anastomosis to the head and neck area. Of these, 20 had signs of poor perfusion of the entire skin paddle, 12 had large myogenous or skin flaps with questionable perfusion of the distal aspect, and 8 were evaluated for other reasons. In this group the use of SPY Elite® changed the management of the patient in 20 cases (50%). Ten flaps were evaluated intraoperatively after anastomosis to the head and neck to ascertain adequate flow to the entire flap. In this group management was changed in two (20%). Fourteen flaps were evaluated 3–5 days post operatively due to suspected failure of a component. In five cases (36%), the use of SPY Elite® determined management with either trimming or discarding the flap.
Conclusion Assessment of flap perfusion via fluorescent angiography during initial flap harvest or when flap compromise is suspected post-operatively can guide decision making in free flap reconstruction of the head and neck and can be added to existing planning and management paradigms.
Level of Evidence4 Laryngoscope, 133:1388–1393, 2023
Evan R. Edwards, Inbal Hazkani, Eli Stein, Jami L. Josefson, Jill H. Samis, Jennifer L. Miller, Jeffrey Rastatter
Publication date 09-05-2023
Using CDC growth charts to control for expected growth in childhood, this study identified greater-than-expected weight gain in children in the first two years following thyroidectomy—especially in Hispanic and younger patients.
Objective To evaluate weight gain in children post-thyroidectomy and identify predictors.
Methods Charts from patients at a tertiary health care facility who underwent total thyroidectomy from 2014 to 2020 were reviewed for Body Mass Index z-scores (BMIz) at the time of thyroidectomy and at 1 and 2-year post-operation intervals. Patient demographic information, comorbidities, pre- and postoperative thyroid stimulating hormone, and postoperative free T4 levels were also extracted. Patients with other known endocrine abnormalities, chronic kidney disease, or without sufficient follow-up were excluded.
ResultsA total of 56 patients (ages 3–17 years old) met the inclusion criteria (n = 17 Graves disease; n = 39 presumed cancer). Over the first year, average BMIz significantly increased in patients with Graves disease (∆BMIz = 0.45 ± 0.77, p = 0.03), Hispanic ethnicity (∆BMIz = 0.43 ± 0.68, p = 0.004), Medicaid/no insurance coverage (∆BMIz = 0.33 ± 0.74, p = 0.038), age <13 years at thyroidectomy (∆BMIz = 0.35 ± 0.68, p = 0.016), and persistent postoperative hypothyroidism (∆BMIz = 0.41 ± 0.41, p = 0.012). These changes remained significant after the second year. Age at thyroidectomy correlated negatively with ∆BMIz only after the first year (r = −0.40, p = 0.002). Regression analysis, controlling for Graves status, persistent postoperative hypothyroidism, and insurance coverage, identified age at thyroidectomy as a significant predictor of ∆BMIz after the first year (b = −0.06, p = 0.004) and Hispanic ethnicity as a significant predictor after the second year (b = 0.60, p = 0.003).
ConclusionA small increase in BMIz post-thyroidectomy was observed across several patient subgroups. Younger age at thyroidectomy and Hispanic ethnicity were associated with increased BMIz in the first 2 years post-thyroidectomy.
Level of Evidence Level 4 - Historically controlled cohort Laryngoscope, 133:1518–1523, 2023
Kittichai Mongkolkul, Mohammad Bilal Alsavaf, Eman H. Salem, Kyle K. VanKoevering, Kathleen Kelly, Douglas A. Hardesty, Daniel M. Prevedello, Ricardo L. Carrau
Publication date 09-05-2023
New minimally endoscopic multiport approach to infratemporal fossa. Step-by-step cadaveric dissection.
Objective To demonstrate anatomic relationships pertinent to the endoscopic multiport approach to the infratemporal fossa (ITF). Discuss advantages and limitations of each individual approach.
Study Design Cadaveric study.
Methods Endoscopic and endoscopic-assisted endonasal transpterygoid, sublabial transmaxillary, endoscopic transorbital, and endoscopic transoral approaches to accessing the ITF were completed in five silicone-injected fresh cadaveric specimens (10 sides) with the assistance of 0, 30, and 450 rods-lens endoscopes. Image guidance was used to confirm and document the anatomical relationships encountered in each approach.
Results The endonasal endoscopic transpterygoid approach provides better visualization and more direct exposure to median structures. Endoscopic-assisted sublabial transmaxillary approach enhances the field of exposure, angle of attack, and ease of instrumentation to the lateral part of the ITF. Endoscopic-assisted transorbital approach via the inferior orbital fissure provided cephalic and anterior access. Endoscopic-assisted transoral approach complements the access to lesions extending inferior to the hard palate or far lateral to the mandibular condyle.
ConclusionsA combination of minimal access infratemporal approaches can provide adequate exposure of the entire ITF while avoiding some of the morbidity associated with open approaches.
Level of EvidenceNA Laryngoscope, 133:1367–1374, 2023
Michele Fiorella, Maria Armache, Elizabeth Scott, Julianna Rodin, Maurits Boon, Colin Huntley
Publication date 09-05-2023
Objective Continuous Positive Airway Pressure (CPAP) is the typical first treatment for Obstructive Sleep Apnea (OSA); however, patient adherence is often suboptimal. Expansion Sphincter Pharyngoplasty (ESP) is an alternative treatment option for patients with OSA who demonstrate signs of palatal and lateral pharyngeal collapse. The aim of this study is to compare therapeutic outcomes, using the mean disease alleviation concept, for patients who underwent ESP to patients undergoing CPAP therapy.
Data Sources Single-institution retrospective cohort study.
Methods All patients who underwent ESP from 2018 to 2021 or were prescribed CPAP from December to June 2021 at our institution were assessed for inclusion. ESP patients who had pre- and post-operative sleep studies available and CPAP patients who followed up at our institutions sleep clinic were included for analysis. Charts were reviewed for demographic information and sleep study results, and treatment outcomes were measured by calculating mean disease alleviation.
Results There were 77 patients in the ESP group and 107 patients in the CPAP group. AHI reduction was greater in the CPAP group (p = 0.016); however, mean disease alleviation was similar between groups (p = 0.076). One-way ANCOVA demonstrated similar MDA between groups when controlling for patient age, BMI, gender, and pre-operative AHI (F 1,177 = 2,931.6, p = 0.104).
ConclusionCPAP therapy provided superior reduction in AHI compared to ESP; however, overall treatment efficacy as measured by mean disease alleviation was similar for both groups.
Level of Evidence3 Laryngoscope, 133:1513–1517, 2023
Rong‐San Jiang, Karen Yan, Yi‐Fang Chiang, Pei‐Jung Chiang
Publication date 09-05-2023
Chinese herbal medicine has been implemented as a form of treatment for olfactory dysfunction. Our results show that adding a tailored Guizhi decoction to OT conferred a limited benefit to the olfactory function of patients experiencing traumatic anosmia.
Objective Chinese herbal medicine (CHM) has been implemented as a form of treatment for olfactory dysfunction. In this study, we aimed to use a tailored Guizhi decoction for the treatment of traumatic olfactory dysfunction.
Methods Patients who had lost olfactory function after experiencing head trauma and whose olfactory function was anosmic were selected. The eligible patients were randomly assigned to two groups. In the CHM group, a tailored Guizhi decoction was prescribed, with patients also undergoing olfactory training (OT). In the OT group, patients performed OT only. The olfactory function of each patient was evaluated by both the phenyl ethyl alcohol (PEA) odor detection threshold test and the traditional Chinese version of the University of Pennsylvania Smell Identification Test (TC-UPSIT), at both 3 and 6 months after the completion of treatment.
ResultsA total of 38 patients in the CHM group and 40 in the OT group completed the study. The TC-UPSIT scores of patients slightly rose after treatment in both the CHM and OT groups. Nevertheless, there were no significant differences in TC-UPSIT scores before and after treatment in both groups. However, the PEA thresholds improved significantly in both CHM and OT groups (p = 0.005 and 0.016, respectively). Of note, there were no significant differences in threshold or identification scores between the CHM and OT groups.
Conclusion Our results show that adding a tailored Guizhi decoction to OT conferred a limited benefit to the olfactory function of patients experiencing traumatic anosmia.
Level of Evidence2 Laryngoscope, 133:1473–1479, 2023
Yoshiki Watanabe, Shinzo Tanaka, Koki Hasebe, Yasuyuki Hiratsuka, Takao Yoshida, Junko Kusano, Shusei Hori, Kana Okamura, Chisato Tanaka, Shiori Fujikawa, Yuka Osada, Manabu Minoyama
Publication date 09-05-2023
Objective End-flexible-rigidscopic transoral surgery (E-TOS) is a new and minimally invasive transoral surgery for resection of Tis-selected T3 pharyngolaryngeal cancers. We evaluated long-term oncological outcomes and whether postoperative voice and swallowing function were preserved following E-TOS.
Methods In this retrospective single-center study, 154 patients treated with E-TOS using a curved retractor, flexible-tip rigid endoscope, and thin curved instruments were included. Their survival rate, larynx preservation rate, and disease control rate were estimated using the Kaplan–Meier method. Postoperative voice function was evaluated using both objective and subjective tests. Postoperative swallowing function was assessed using the Hyodo score and the functional outcome swallowing scale.
Results The 3-year and 5-year overall survival, disease-specific survival, disease-free survival, laryngectomy-free survival, local control, and loco-regional control rates post E-TOS were 89.8% and 82.2%, 95.6% and 92.3%, 78.5% and 70.3%, 87.2% and 80.9%, 93.9% and 92.5%, and 87.2% and 85.7%, respectively. Both objective and subjective postoperative voice and swallowing function tests were within normal limits in more than 90% of the patients.
ConclusionE-TOS is an effective, safe, low-cost, and minimally invasive transoral surgery for Tis-selected T3 pharyngolaryngeal cancer; it also preserves postoperative voice, larynx, and swallowing function.
Level of Evidence4 Laryngoscope, 133:1415–1424, 2023
Elena Russo, Andrea Costantino, Maria Vittoria Veneroni, Bianca Maria Festa, Raul Pellini, Flaminia Campo, Gerardo Petruzzi, Giuseppe Spriano, Giuseppe Mercante, Armando De Virgilio
Publication date 09-05-2023
The aim of this systematic review and meta-analysis was to determine the oncological outcomes of salvage transoral laser microsurgery (TLM) in the treatment of patients suffering from recurrent laryngeal cancer. We demonstrated that TLM is a valuable treatment option for the management of locally recurrent laryngeal carcinoma if performed by experienced surgeons and following rigorous patients selection criteria. Further studies should be conducted to define stage-based clinical guidelines.
Objective To determine the oncological outcomes of salvage transoral laser microsurgery (TLM) in the treatment of patients suffering from recurrent laryngeal cancer.
Methods Pub Med/MEDLINE, Cochrane Library, and Scopus databases were searched. English language, original studies investigating oncological outcomes of TLM in adult patients with recurrent laryngeal cancer were included. Data were pooled using a distribution-free approach for estimating summary local control (LC), disease-specific survival (DSS), and overall survival (OS) curves with random effects.
Results Two hundred and thirty-five patients underwent salvage TLM after primary (chemo)radiotherapy. The mean follow-up time was 60.8 months (95% CI: 32.7–88.9). Estimated pooled LC rates (95% CI) at 1, 3 and 5 years were 74.2% (61.7–89.4), 53.9% (38.5–75.3), and 39.1% (25.2–60.8). Estimated pooled DSS rates (95% CI) at 1, 3 and 5 years were 88.4% (82.0–95.3), 67.8% (50.9–90.3), and 58.9% (42.7–81.1). Two hundred and seventy-one patients underwent TLM after primary laser treatment. The mean follow-up time was 70.9 months (95% CI: 36.9–104.9). Estimated pooled LC rates (95% CI) at 1, 3 and 5 years were 72.2% (64.7–80.6), 53.2% (42.2–66.9), and 40.4% (29.6–55.2). Estimated pooled DSS rates (95% CI) at 1, 3 and 5 years were 92.1% (85.5–99.1), 77.0% (64.4–92.0), and 67.1% (51.6–87.3).
ConclusionsTLM is a valuable treatment option for the management of locally recurrent laryngeal carcinoma if performed by experienced surgeons and following rigorous patients selection criteria. Further studies should be conducted to define stage-based clinical guidelines.
Level of EvidenceNA Laryngoscope, 133:1425–1433, 2023
Yichen Xu, Hanyao Huang, Min Wu, Yuting Tian, Qianbing Wan, Bing Shi, Tao Hu, Sebastian Spintzyk
Publication date 09-05-2023
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, 133:1507–1512, 2023
Pubmed PDF WebJoseph 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 09-05-2023
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, 133:1339–1348, 2023
Alex J. Wilkinson, Marc‐Elie Nader, Dianna Roberts, Madeleine Duvic, Jillian R. Gunther, Bouthaina S. Dabaja, Paul W. Gidley
Publication date 09-05-2023
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 Evidence4 Laryngoscope, 133:1486–1491, 2023
Claire M. Lawlor, Sukgi S. Choi
Publication date 09-05-2023
Pranati Pillutla, Kirsten Meenan, Dinesh K. Chhetri
Publication date 09-05-2023
Vocal cord paralysis can cause a hoarse voice and has many treatment options, including reinnervation of the vocal cords. Some patients have been shown to get the most benefit from reinnervation surgery. This article reviews available evidence for reinnervation surgery in adults.
Pubmed PDF WebDerek D. Kao, Yann Fuu‐Kou, Cynthia S. Wang, David Lehenbauer, Sara Zak, Dan Benscoter, David LS Morales, Alessandro Alarcon, Michael J Rutter
Publication date 09-05-2023
We present the characteristics and outcomes of a series of pediatric patients who underwent surgical treatment for bronchial anomalies. Complete bronchial rings were the most common anomaly treated, followed by absent rings and trauma. Surgical treatment can be successful but mortality rates are higher in patients with complete rings, possibly due to higher rates of pulmonary and cardiac comorbidities.
Objectives Bronchial anomalies are rare but challenging conditions to treat in children, encompassing a variety of structural abnormalities that could compromise airway patency. This includes complete rings, absent cartilage, traumatic avulsions, bronchoesophageal fistulas, and cartilaginous sleeves. The objective of this study is to describe the characteristics and outcomes of a series of pediatric cases of bronchial anomalies that were treated by slide tracheobronchoplasty.
Methods This is a single-institution retrospective case series of pediatric patients with bronchial anomalies who underwent surgical treatment between February 2004 and April 2020. Data extracted from electronic medical records included patient demographics, comorbidities, and surgical outcomes.
Results There were a total of 29 patients included in the study, of which 14 had complete bronchial rings, 8 had absent bronchial rings, 4 had traumatic bronchial avulsions, 2 had bronchoesophageal fistulas, and one had a cartilaginous sleeve. Median follow-up time was 13 months (with a range of 0.5–213 months). The overall mortality rate was 17.2% (5 patients), all of whom had complete bronchial rings. Patients with complete bronchial rings also had a higher rate of not only cardiac (85.7%) and pulmonary comorbidities (85.7%) but also secondary airway lesions (78.6%).
Conclusion This is the largest series to date describing surgical treatment for bronchial anomalies. Complete bronchial rings were the most common anomaly treated, followed by absent rings and trauma. Surgical treatment can be successful but mortality rates are higher in patients with complete bronchial rings, possibly due to higher rates of pulmonary and cardiac comorbidities.
Level of Evidence4 Laryngoscope, 2023
David Myssiorek, Stephen C Scharf
Publication date 04-05-2023
Nuclear medical imaging is indicated in most, but not all, patients with suspected paragangliomas of the head and neck. Advances in technology and somatostatin receptor analogs have improved the selectivity and sensitivity of this imaging.
Pubmed PDF Web