Laryngoscope 2024-06-20

Derivation and Initial Validation of the Utility Function for the Hearing Utility Measure (HUM)

Peter R. Dixon, Justin Shapiro, Theodore R. McRackan, David Feeny, Sharon L. Cushing, Joseph M. Chen, George Tomlinson

Publication date 20-06-2024


The new Hearing Utility Measure was designed to improve the ability of the Health Utilities Index, Mark 3 to measure clinically important changes in hearing-related quality of life. This manuscript describes the culmination of a multi-step instrument development process: the derivation of the instruments utility scoring function. The final instrument performs well in the estimation of hearing utility and detects changes in hearing utility that are not detectable with the legacy HUI-3.
Objective The Hearing Utility Measure (HUM) is a replacement hearing attribute for the Health Utilities Index, Mark 3 (HUI-3) designed to improve the responsiveness of utility estimates to changes in hearing-related quality of life. The final development step is to derive the instruments utility scoring function.
Methods Residents of Ontario, Canada, aged ≥18 years participated in standard gamble and visual analogue scale exercises. Valuations for levels (response options) within each domain, and for each domain relative to the other domains were elicited and used to generate a hearing utility function. The function outputs hearing utility ranging from 0 = ‘unable to hear at all’ to 1 = ‘perfect hearing’ for each of the 25,920 hearing states classifiable by the HUM.
Performance was assessed relative to the criterion standard: directly elicited standard gamble utility. Distributions of HUM-derived hearing utility were compared with legacy HUI-3 derived estimates.
ResultsA total of 126 respondents participated (mean age 39.2, range 18–85 years, 53% female 67/126). The utility function performed well in the estimation of directly elicited utilities (mean difference 0.03, RMSE 0.06). Using the legacy HUI-3, estimated hearing utility was 1.0 for 118/126 respondents (93.6%) compared with just 66/126 (52.4%) using the HUM.
Conclusion The new hearing attribute is capable of measuring variations in hearing utility not captured by the legacy HUI-3, especially near the ceiling of hearing function. These findings justify its application and further work to study its measurement properties in hearing loss populations.
Level of Evidence3 Laryngoscope, 2024

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Impact of Obesity on Timing of Tracheotomy: A Multi‐institutional Retrospective Study

"Andrew Yousef, Shady I. Soliman, Isaac Solomon, Bharat A. Panuganti, David O. Francis, John Pang, Dasha Klebaner, Alicia Asturias, Ali Alattar, Samuel Wood, Morgan Terry, Paul C. Bryson, Courtney B. Tipton, Elise E. Zhao, Ashli ORourke, Chloe Santa Maria, David R. Grimm, C.K. Sung, Wilson P. Lao, Jordan M. Thompson, Brianna K. Crawley, Sarah Rosen, Anna Berezovsky, Robbi Kupfer, Theresa B. Hennesy, Matthew Clary, Ian T. Joseph, Kamron Sarhadi, Maggie Kuhn, Yassmeen Abdel‐Aty, Maeve M. Kennedy, David G. Lott, Philip A. Weissbrod"

Publication date 19-06-2024


This retrospective multi-institutional study shows differences in tracheotomy timing based on BMI. Patients with obesity had delays in tracheostomy timing compared with patients with a normal BMI.
Objective To examine the impact of increased body mass index (BMI) on (1) tracheotomy timing and (2) short-term surgical complications requiring a return to the operating room and 30-day mortality utilizing data from the Multi-Institutional Study on Tracheotomy (MIST).
MethodsA retrospective analysis of patients from the MIST database who underwent surgical or percutaneous tracheotomy between 2013 and 2016 at eight institutions was completed. Unadjusted and adjusted logistic regression analyses were used to assess the impact of obesity on tracheotomy timing and complications.
Results Among the 3369 patients who underwent tracheotomy, 41.0% were obese and 21.6% were morbidly obese. BMI was associated with higher rates of prolonged intubation prior to tracheotomy accounting for comorbidities, indication for tracheotomy, institution, and type of tracheostomy (p = 0.001). Morbidly obese patients (BMI ≥35 kg/m2) experienced a longer duration of intubation compared with patients with a normal BMI (median days intubated IQR 25%–75%: 11.0 days 7–17 days versus 9.0 days 5–14 days; p < 0.001) but did not have statistically higher rates of return to the operating room within 30 days (p = 0.12) or mortality (p = 0.90) on multivariable analysis. This same finding of prolonged intubation was not seen in overweight, nonobese patients when compared with normal BMI patients (median days intubated IQR 25%–75%: 10.0 days 6–15 days versus 10.0 days 6–15 days; p = 0.36).
ConclusionBMI was associated with increased duration of intubation prior to tracheotomy. Although morbidly obese patients had a longer duration of intubation, there were no differences in return to the operating room or mortality within 30 days.
Level of EvidenceIII Laryngoscope, 2024

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"The Transformation of Neck Unicentric Castlemans Disease to Follicular Dendritic Cell Sarcoma"

Yingying Li, Yue Shao, Xiumei Sun, Hai Huang, Xiaochen Leng, Yuliang Wang

Publication date 19-06-2024


We report a case of malignant transformation from the hyaline-vascular subtype of neck unicentric Castlemans disease(UCD) to follicular dendritic cell sarcoma. UCD is uncommon and the malignant transformation of UCD is extremely rare in the head and neck region. Regional lymph node resection including one or more adjacent regions is the preferred treatment choice. Appropriate treatment procedures for UCD and regular follow-up are essential for a good prognosis.
A patient with a large neck mass underwent appropriate imaging, routine blood tests, and serological evaluations. The medical history revealed the patient had undergone a lymphadenectomy in the same region 8 years ago, and the pathological diagnosis was the hyaline-vascular subtype of unicentric Castlemans disease (UCD). The incisional biopsy and subsequent histopathological and immunohistochemical examination revealed the diagnosis of follicular dendritic cell sarcoma, consistent with the malignant transformation of UCD. UCD is uncommon and the malignant transformation of UCD is extremely rare in the head and neck region. Regional lymph node resection of one or more adjacent regions is the preferred treatment choice. Appropriate treatment procedures for UCD and regular follow-up are essential for a good prognosis. Laryngoscope, 2024

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Safety of An Enhanced Recovery After Surgery Protocol After Head and Neck Free Tissue Transfer

Ari D. Schuman, Mohini Bindal, Grace Amadio, Anne M. Turney, David J. Hernandez, Vlad C. Sandulache, N. Eddie Liou, Ray Wang, Andrew T. Huang

Publication date 19-06-2024


With implementation of an enhanced recovery after surgery protocol after microvascular free tissue transfer, lengths of stay were cut from a median of 9 to 6 days. There was no increase in readmission rate or return to the emergency department without readmission.
Objectives Implementing enhanced recovery after surgery (ERAS) protocols and decreasing length of stay (LOS) have become a priority for major surgeries, including microvascular free tissue transfer (MVFTT) reconstruction of the head and neck. We describe an ERAS protocol with the goal to further reduce length of stay beyond national medians.
Methods Retrospective chart review between August 2016 and February 2023, including all patients who underwent MVFTT after oral cavity, skull base, salivary gland, and cutaneous ablative surgery. An ERAS protocol was implemented in March 2020.
ResultsA total of 383 patients were included. Approximately 59.8% underwent oral cavity MVFTT, 34.5% cutaneous and lateral skull base, and 5.8% maxillary and anterior skull base. A total of 209 (54.7%) patients had surgery prior to implementation of the ERAS protocol and 174 (45.3%) after. Median LOS decreased from 9 days (interquartile interval IQR 8–11) to 6 (IQR 5–7.5, p < 0.0001) following oral cavity MVFTT. For cutaneous and lateral skull base reconstruction, median LOS decreased from 6 days (IQR 5–8) to 3 (IQR 3–7, p < 0.0001). For anterior skull base and sinonasal MVFTT, median LOS decreased from 8 (IQR 7–9) to 5 days (IQR 4.5–7, p = 0.0005). Rate of discharge to skilled nursing or subacute rehabilitation facilities decreased (24% before ERAS, 9.2% after, p < 0.0001). Thirty-day readmission rate was similar before and after implementation (10.5% vs. 10.3, p = 0.954). Discharge to facility was associated with readmission (OR 2.34, 95% CI 1.12–4.89, p = 0.024).
Conclusion and Relevance Implementation of the ERAS protocol was associated with decreased LOS. There was no increase in rate of readmission.
Level of EvidenceN/A Laryngoscope, 2024

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Facility Volume and Changing Facilities for Postoperative Radiotherapy in Salivary Gland Cancer

Rushi Patel, Aman M. Patel, Lucy Revercomb, Vivienne Qie, Christopher C. Tseng, Soly Baredes, Richard Chan Woo Park

Publication date 19-06-2024


Patients treated at high-volume facilities (HVFs) for salivary gland cancer experience worse survival if changing facility for postoperative radiation therapy (PORT). Our results suggest that patients treated surgically at HVFs should be counseled to continue their PORT at the same institution.
Objectives Changing location of postoperative radiotherapy (PORT) after treatment at a high-volume facility (HVF) is associated with worse survival in various head and neck cancers. Our study investigates this relationship in salivary gland cancer (SGC).
Methods The 2004–2016 National Cancer Database was queried for all cases of adult SGC treated with surgery and PORT with or without adjuvant chemotherapy. Patients with multiple cancer diagnoses, metastatic disease, or unknown PORT facility were excluded. Reporting facilities with >95th percentile annual case volume were classified as HVFs, the remainder were classified low-volume facilities (LVFs).
ResultsA total of 7885 patients met inclusion criteria, of which 418 (5.3%) were treated at an HVF. Patients treated at an HVF had higher rates clinical nodal positivity (18.2% vs. 14.0%, p < 0.001) and clinical T3/T4 (27.3% vs. 20.7%, p = 0.001) disease. Patients at HVFs changed facility for PORT at lower rates (18.9% vs. 24.5%, p = 0.009). Patients treated at an HVF had higher 5-year overall survival (5-OS) than those treated at an LVF (79.0% vs. 72.0%, p = 0.042). Patients treated at an HVF that changed PORT facility had worse 5-OS (60.8% vs. 83.2%, p < 0.001). Radiation facility change was an independent predictor of worse survival in patients treated at an HVF (HR: 8.99 3.15–25.67, p < 0.001) but not for patients treated at a LVF (HR: 1.11 0.98–1.25, p = 0.109).
Conclusions Patients treated at an HVF changing facility for PORT for SGC experience worse survival. Our data suggest patients treated surgically at an HVF should be counseled to continue their PORT at the same institution.
Level of Evidence3 Laryngoscope, 2024

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Botulinum Toxin Injection for Retrograde Cricopharyngeal Dysfunction: A Prospective Cohort Study

Can Doruk, Evan L. Kennedy, Courtney Tipton, Yassmeen Abdel‐Aty, Michael J. Pitman

Publication date 19-06-2024


Although In-Office (IO) and Operating Room (OR) BTX injections are both equally effective in treating RCPD, postoperative swallowing problems are more severe with OR injections.
Objectives Retrograde Cricopharyngeal Dysfunction (RCPD) is treated by botulinum toxin (BTX) injection into the cricopharyngeus. This prospective study compares the effectiveness and side effects of operating room (OR) and in-office (IO) injections.
Methods Patients over 18 years of age with inability to burp, abdominal, thoracic, or cervical gurgling sounds, bloating, and excessive flatulence were diagnosed with RCPD and included in the study. Injections were performed in the OR (80U) or IO (30U) by the senior author. An RCPD questionnaire quantifying major and minor symptoms on a Likert scale, Eating Assessment Tool-10 (EAT-10), and Generalized Anxiety Score−7 (GAD-7), were completed preinjection; at 1, 2, and 3 weeks; and 3 months postoperatively. Linear mixed models were used to analyze effects of BTX injection on RCPD symptoms, the EAT-10, and the GAD-7.
Results108 (55 M/53F) patients completed the pretreatment survey, 53 (31 OR vs. 22 IO) completed the 3-week follow-up, and 36 (22 OR vs. 14 IO) completed the 3-month questionnaire. Average posttreatment RCPD scores were significantly lower in both groups at 3 weeks and 3 months (p < 0.0001), There was no difference between IO or OR (p = 0.4924). GAD-7 scores were significantly lower in both groups at week 3 (p = 0.0018) and month 3 (p = 0.0012). Postinjection EAT-10 scores were significantly higher in OR compared with IO (p = 0.0379).
ConclusionOR and IO injections are equally effective in the treatment of RCPD. Postinjection dysphagia is more severe after the OR injections which may be related to higher doses of BTX used. General anxiety levels decrease with treatment.
Level of Evidence2 Laryngoscope, 2024

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Utility of Ultrahigh‐Resolution Computed Tomography for Laryngeal Reconstructive Surgery

Norimoto Kise, Hitoshi Hirakawa, Soya Aniya, Taiyo Ooshiro, Shunsuke Kondo, Atsushi Tomoda, Yoshiki Oyakawa, Asanori Kiyuna, Mikio Suzuki

Publication date 19-06-2024


The present study reveals that the value of preoperative ultrahigh-resolution computed tomography, especially vocal fold level difference between the affected and unaffected vocal folds, in surgical decision-making afford insights for optimal phonosurgery and individualized intervention. Patients with LD >1.0 mm may benefit from type 1 thyroplasty with arytenoid adduction.
Objective Unilateral vocal fold paralysis (UVFP) presents as incomplete glottal closure and leads to breathy hoarseness. Various treatments, including laryngeal framework surgery (type 1 thyroplasty TP1 and arytenoid adduction AA), have been devised to correct this condition. Ultrahigh-resolution computed tomography (U-HRCT) allows detailed three-dimensional imaging of the larynx, which aids our understanding of vocal fold motion disorders. This study assessed whether U-HRCT is beneficial for correct diagnosis and surgical planning.
Methods The participants were 26 UVFP patients who underwent laryngeal framework surgery (TP1 and/or AA). U-HRCT was used to measure the vocal fold volume (VFV) and level difference (LD). The need to combine AA with TP1 to obtain satisfactory surgical outcomes was evaluated by U-HRCT and various voice function tests.
ResultsVFV was smaller in paralyzed folds than in unaffected folds. LD correlated strongly with voice parameters and showed high intra-rater and inter-rater reliability. The surgical outcome of the laryngeal framework surgery performed was judged to be excellent for improving voice function. Comparison of LD between the TP1 group and TP1 + AA group indicated that LD is an excellent parameter to determine the need to combine AA with TP1.
Conclusion These findings underscore the value of preoperative U-HRCT, especially LD, in surgical decision-making and afford insights for optimal phonosurgery and individualized intervention. Patients with LD >1.0 mm may benefit from thyroplasty with AA.
Level of Evidence Level 3 (case–control study) Laryngoscope, 2024

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Are There Hidden Adverse Events in Hypoglossal Nerve Stimulation: Comparing Social Media and a Federal Database

Mihai A. Bentan, Emaan Dawood, David Moffatt, Maria V. Suurna, Ryan Nord

Publication date 18-06-2024


Objective Hypoglossal nerve stimulation (HNS) can be an effective treatment for moderate to severe obstructive sleep apnea (OSA) in positive airway pressure (PAP) intolerant patients. To better understand patient experiences with HNS therapy, we explored reported events from HNS-related Facebook groups and the Manufacturer and User Facility Device Experience (MAUDE) database.
MethodsA retrospective analysis of HNS-related Facebook posts from three groups pertaining to HNS therapy, from October 1, 2022 to October 1, 2023, was performed. Posts were analyzed for patient-reported adverse events. Concurrently, the MAUDE database was reviewed for HNS-related events during the same timeframe.
Results From 737 Facebook posts, 132 (17.55%) adverse events were identified. Adverse events included pain (34.85%), stimulation discomfort (14.39%), lip weakness (6.82%) and issues related to lead tethering or tight leads around the neck (3.79%). Analysis of the MAUDE database found 428 adverse events, including pain (24.07%), lip weakness (0.44%), and lead tethering (1.64%).
Conclusion Facebook group members reported higher rates of lip weakness and lead tethering than recorded in the MAUDE database. These findings illustrate how diverse data sources, such as social media, can enhance our understanding of patient experiences and identify gaps in patient education with HNS therapy.
Level of EvidenceNA Laryngoscope, 2024

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Masseteric Atrophy Following Masseteric Nerve Transfer: Radiographic Findings of Asymmetry in the Paralyzed Face?

Derek J. Vos, Michael A. Fritz, Dane J. Genther, Patrick J. Byrne, Peter J. Ciolek

Publication date 17-06-2024


Objectives To characterize the effect of facial reanimation using masseteric nerve transfer on the masseter muscle itself, examining whether there is any demonstrable atrophy postoperatively.
Methods Electronic medical records of adult patients who underwent facial reanimation using masseteric nerve transfer at our institution over a 15-year period were reviewed. To account for the impact of postoperative radiation, randomly selected patients who underwent radical parotidectomy without nerve transfer and received postoperative radiation served as controls in a 1:1 fashion against those who underwent masseteric nerve transfer with postoperative radiation.
Results Twenty patients were identified who underwent masseteric nerve transfer and had sufficient pre- and postoperative imaging to assess masseter volume (mean age 58.2, 60% female). Of the four patients who did not receive postoperative radiation, each demonstrated masseteric atrophy on the side of their nerve transfer, with a mean reduction in masseter volume of 20.6%. The remaining 16 patients were included in the case–control analysis accounting for radiation. When compared with controls, those in the study group were found to have a statistically significant difference in atrophy (p = 0.0047) and total volume loss (p = 0.0002). The overall reduction in masseter volume in the study group was significantly higher compared with the control group, at 41.7% and 16.6%, respectively (p = 0.0001).
Conclusion Facial reanimation utilizing masseteric nerve transfer appears to result in atrophy of the denervated masseter when compared with the contralateral muscle. This volume deficit may lead to further facial asymmetry for patients undergoing comprehensive reanimation surgery.
Level of Evidence3 Laryngoscope, 2024

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Endoscopic Excision of Optic Nerve Schwannoma

Rajesh Vishwakarma, Jaya Maheshwari, Himanshu Soni

Publication date 17-06-2024


Schwannomas are typically benign tumors of the peripheral nervous system that originate from Schwann cells. There are very few cases of Optic Nerve Schwannoma.
Optic nerve schwannoma (ONS) is an exception in that it does not possess the typical Schwann cells. Instead, it is believed to possibly originate from ectopic neural crest Schwann cells and perivascular Schwann cells. There are very few cases of Optic Nerve Schwannoma reported in literature. The patient is a 68-year-old male who presented with progressive left eye loss of vision. The patients treatment encompassed Trans Nasal Endoscopic Excision of the mass with simultaneous Orbital Decompression. Laryngoscope, 134:3102–3104, 2024

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The Cochlear Implant “Seatbelt” Technique for Receiver/Stimulator Fixation

Hunter L. Elms, Amanda Del Risco, Priya V. Dukes, William T. Reed, Calhoun D. Cunningham III

Publication date 17-06-2024


Receiver/stimulator migration and extrusion are among the most commonly reported complications of cochlear implantation. Current techniques implement either a tight subperiosteal pocket or postauricular bone well. Here we describe a safe and effective technique to secure a cochlear implant receiver/stimulator with a Mersilene cervical cerclage tape “seatbelt.” Laryngoscope, 134:3374–3376, 2024

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Bronchoscopic Intervention for Tracheobronchopathia Osteochondroplastica: A Report of Two Cases

Yue Wang, Xiaoli Li, Jieli Zhang, Yunzhi Zhou

Publication date 17-06-2024


Tracheobronchopathia osteochondroplastica (TO) is a rare benign tracheal disease marked by the presence of multiple bone and/or cartilage nodules in the trachea and bronchis submucosa. Currently, there is no standardized treatment guideline for TO. This article presents two cases involving severe tracheal stenosis due to TO, which were successfully treated using bronchoscopic stent placement and rigid bronchoscopy curettage, respectively. Both cases demonstrated positive outcomes, offering new insights and references for the treatment of TO.
Tracheobronchopathia osteochondroplastica (TO) is an uncommon non-malignant tracheal ailment characterized by the existence of numerous bone and/or cartilage nodules in the submucosa of the trachea and bronchi. At present, there is a lack of standardized treatment recommendations for TO. This article presents two instances of severe tracheal stenosis caused by TO, which were effectively managed through the implementation of bronchoscopic stent placement and rigid bronchoscopy curettage, respectively. Both cases exhibited favorable outcomes, providing novel insights and references for the treatment of TO. Laryngoscope, 134:3093–3095, 2024

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An Unusual Case of an ALK‐Negative Epithelioid Fibrous Histiocytoma in the External Auditory Canal

Morgan Leff, Alexandra Quimby, Eric Morgan, Jason A. Brant

Publication date 17-06-2024


This article represents the first reported case in the external auditory canal of epithelioid fibrous histiocytoma (EFH), a rare benign cutaneous epithelioid neoplasm. Immunostaining revealed uncommon negative staining for anaplastic lymphoma kinase (ALK) expression. This case and literature review outline the diagnostic strategy for this highly unusual neoplasm.
This article represents the first reported case in the external auditory canal of epithelioid fibrous histiocytoma (EFH), a rare benign cutaneous epithelioid neoplasm. Immunostaining revealed uncommon negative staining for anaplastic lymphoma kinase (ALK) expression. This case and literature review outline the diagnostic strategy for this highly unusual neoplasm. Laryngoscope, 134:3371–3373, 2024

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Treatment of Residual Palatal Collapse in Hypoglossal Nerve Stimulation Using a Palatal Device

Samuel Tschopp, Vlado Janjic, Urs Borner, Kurt Tschopp

Publication date 17-06-2024


Suboptimal responses to hypoglossal nerve stimulation (HNS) often stem from insufficient palatal coupling and residual velar collapse. Combining palatal devices, such as Velumount®, with HNS represents a simple and cost-effective strategy to treat residual palatal collapse. Patients desiring conservative treatment for residual palatal obstruction under HNS may consider this combined approach.
Hypoglossal nerve stimulation (HNS) has increasingly become an alternative therapy for obstructive sleep apnea patients with CPAP intolerance. Stimulation of the hypoglossal nerve during sleep enhances airway patency and alleviates collapse. Suboptimal responses to HNS often stem from insufficient palatal coupling and residual velar collapse. Combining palatal devices, such as Velumount®, with HNS represents a simple and cost-effective strategy to treat residual palatal collapse. Patients desiring conservative treatment for residual palatal obstruction under HNS may consider this combined approach. Laryngoscope, 134:3412–3414, 2024

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High‐Grade Pleomorphic Sarcoma in Postauricular Keloid Scar After Surgical Excision and Radiation

Elizabeth Walker Wadsworth, Kelsey A. Duckett, Krishna G. Patel

Publication date 17-06-2024


We report the case of a patient with a large postauricular keloid treated with excision and immediate post-operative radiation who developed a high-grade pleomorphic sarcoma in the scar bed. To our knowledge, this is the first reported case of high-grade pleomorphic sarcoma arising in a radiated keloid scar bed in the head and neck. This finding demonstrates that it is important to consider risk of radiation-induced malignancy when prescribing radiotherapy for the post-excision treatment of keloids.
Keloid scars can cause significant morbidity to the patient including substantial cosmetic disfigurement, particularly in the head and neck region. Surgical excision followed by immediate postoperative radiation therapy has been shown to be more effective than single modality treatment. Radiation therapy increases risk for radiation-induced malignancy, though very few cases have been reported in the treatment of keloids. We report the case of a patient with a large postauricular keloid treated with excision and immediate post-operative radiation who developed a high-grade pleomorphic sarcoma in the scar bed. Laryngoscope, 134:3143–3145, 2024

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The Airway Pocket: Novel Advancement in Endoscopic Submucosal Placement of Posterior Cartilage Graft

Taher Valika, Christopher Mularczyk, Diane Chen, Sarah Maurrasse, Michael Gorelik

Publication date 17-06-2024


Endoscopic technology has increased our options for treatment of airway stenosis in a minimally invasive manner. This novel technique advances endoscopic posterior graft placement by creation of an airway pocket, potentially reducing risk of graft migration and improving outcomes. Laryngoscope, 134:3402–3405, 2024

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Two Simultaneous Rare Head and Neck Lipomas: Vallecular Lipoma and Giant Intermuscular Neck Lipoma

Tatiana Ferraro, Samuel A. Collazo, Benjamin D. Malkin

Publication date 17-06-2024


Our case will review a patient with class 3 obesity and severe obstructive sleep apnea, who presented with progressive dysphagia, throat clearing, and dysphonia.
He was found to have two simultaneous rare sites for head and neck lipomas: vallecular and intermuscular, anterior neck.
Lipomas are benign soft tissue neoplasms, involving the head and neck in roughly 15% of cases. We review a patient who presented with a palpable, anterior neck mass and progressive dysphagia, throat clearing, and dysphonia.
He was found to have two simultaneous rare sites for head and neck lipomas: vallecular and intermuscular, anterior neck. He elected for surgical resection of both masses resulting in significant symptom improvement. Though originally referred for evaluation of an anterior neck mass, we underscore the importance of prompt investigation with reported laryngeal symptoms. We provide considerations for preoperative evaluation and surgical approaches. Laryngoscope, 134:3177–3180, 2024

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Issue Information

Publication date 17-06-2024


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Financial Burden of Otolaryngology Conference Attendance for Medical Students

Tatiana Ferraro, Colin Villarin, Tiffany P. Hwa

Publication date 17-06-2024


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The Laryngologist Who Saved the Brooklyn Bridge

Glenn Isaacson

Publication date 17-06-2024


Andrew Heermance Smith, an early laryngologist, combined physiological observations and experiments in the Brooklyn Bridge caissons with a review of the existing engineering and medical literature to describe the Caisson Disease and to devise strategies to ameliorate its effects.
Objective To understand the role of a single laryngologist, Andrew Heermance Smith, in elucidating the mechanisms of Caisson Disease and controlling it effects on bridge workers.
Data Sources Scientific and lay publications, letters and records of the Roebling family, obituaries and internet sources.
Review Methods Historical review.
ResultsAH Smith combined physiological observations and experiments in the Brooklyn Bridge caissons with a review of the existing engineering and medical literature to describe the Caisson Disease and to devise strategies to ameliorate its effects.
Conclusion Despite an incorrect conclusion about the pathophysiology of decompression sickness, Smiths stringent standards and timely interventions allow completion of the masonry towers of the Brooklyn Bridge.
Level of EvidenceNA Laryngoscope, 134:3044–3048, 2024

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Serum Biomarkers after Adenotonsillectomy for Pediatric OSA: A Systematic Review and Meta‐Analysis

Yichen Ding, Jin Hean Koh, Xing Yi Cheah, Brian Sheng Yep Yeo, Darien W.J. Leong, Yao Hao Teo, Benjamin Kye Jyn Tan, Anna See, Song Tar Toh

Publication date 17-06-2024


Adenotonsillectomy is the mainstay of treatment for pediatric obstructive sleep apnea. This study evaluates whether adenotonsillectomy affects the levels of pro-inflammatory, hormonal, and cardiometabolic markers in children. Adenotonsillectomy was associated with improvements in serum biomarkers.
Objective To assess whether adenotonsillectomy improves levels of inflammatory and cardiometabolic markers in children with polysomnographically diagnosed obstructive sleep apnea (OSA).
Data Sources Two authors independently searched Pub Med, Embase, and Cochrane databases up to August 16, 2022, for studies relating to pre- and post-operative levels of serum markers in pediatric patients undergoing adenotonsillectomy.
Review Methods Data were extracted from included articles into a structured proforma. Meta-analyses of the standardized mean difference (SMD) were conducted in random-effects models. We calculated the probability of benefit (POB) and number needed to treat (NNT) for outcomes that demonstrated a statistically significant effect after adenotonsillectomy. The primary outcomes were changes in serum markers including C-reactive protein (CRP), high-sensitivity CRP (hs-CRP), Insulin-like growth factor 1 (IGF-1), interleukin-10 (IL-10), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), Brain natriuretic peptide (BNP), insulin, glucose, total cholesterol, triglyceride, low-density lipoprotein (LDL), high-density lipoprotein (HDL).
Results We screened 1616 studies and included 26 studies with 1331 participants. Meta-analysis was performed on 20 of the included studies. Adenotonsillectomy was associated with a significant decrease in insulin levels (SMD = −0.322, 95% Confidence Interval (CI) = −0.583 to −0.061), CRP (SMD = −0.946, 95% CI = −1.578 to −0.314), and BNP (SMD = −1.416, 95% CI = −2.355 to −0.477) and significant increase in levels of IGF-1 (SMD = 0.691, 95% CI = 0.207 to 1.176). There were no significant changes in levels of triglyceride, total cholesterol, TNF-α, LDL, HDL, glucose, IL-10, and IL-6.
Conclusion In children with polysomnographically diagnosed OSA, adenotonsillectomy was associated with improvements in serum biomarkers, comprising lower CRP, insulin, and BNP, and higher IGF-1. Laryngoscope, 134:3030–3037, 2024

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Outcomes of Supracricoid Partial Laryngectomy Performed in the United States: A Systematic Review

Michael Saturno, Ariana L. Shaari, Jun Yun, Lauren E. Wein, Diana Shaari, Catharine Kappauf, Benjamin M. Laitman, Raymond L. Chai

Publication date 17-06-2024


This research provides the first systematic review of all published cases of supracricoid laryngectomy (SCL) performed in the United States. The findings demonstrate SCL performed in the United States is an effective surgical technique that produces excellent outcomes in qualifying patients, thus validating its viability as an organ-preserving surgical alternative.
Objective The primary objective of this study was to evaluate oncologic outcomes of all published cases of supracricoid partial laryngectomy (SCPL) performed in the United States. The secondary objective was to assess the functional outcomes associated with this procedure.
Review MethodsA systematic review of Pub Med, SCOPUS, and Embase for all English-language studies pertaining to SCPL performed in the United States was conducted until August 2021. Primary outcomes included disease-specific survival (DSS), overall survival, and local recurrence rate. Secondary outcomes included larynx preservation rate, gastrostromy tube dependency, days to gastrostomy tube removal, decannulation rate, and days to decannulation.
ResultsA total of six studies were included in the analysis. A total of 113 patients (58.5%) underwent SCPL surgery as a primary treatment method whereas 80 patients (41.5%) underwent SCPL as salvage surgery. The 5-year DSS rates were 87.8% and 100% for primary and salvage procedures, respectively. Approximately 10.3% of patients undergoing a salvage SCPL procedure experienced a local recurrence whereas only 1.85% of primary SCPL procedures resulted in local recurrence. The rates of decannulation following primary and salvage SCPL were 92.7% and 88.1%, respectively. With regard to swallowing, primary and salvage SCPL procedures demonstrated comparably low postoperative gastrostomy tube dependency rates of 3.66% and 4.76%, respectively.
ConclusionsSCPL performed in the United States is an effective surgical technique that produces excellent outcomes in qualifying patients, thus validating its viability as an organ-preserving surgical alternative. Laryngoscope, 134:3003–3011, 2024

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Onabotulinum Toxin A (BoNT‐A) for Drooling in Children: A Systematic Review and Meta‐Analysis

Haresh Oad, Alix Maltezeanu, Sabrina D. da Silva, Sam J. Daniel

Publication date 17-06-2024


BoNT-A is a clinically effective therapy that improves drooling severity in children with sialorrhea. Although there were some adverse side effects reported, they were transient and not severe. Future studies are needed to further evaluate the best techniques and to identify the ideal dosages required to achieve the optimal outcomes.
Introduction Sialorrhea, also known as drooling, hypersalivation, or ptyalism, has a significant impact on the medical and psychosocial well-being of children. Onabotulinum toxin A (BoNT-A) is the most commonly used botulinum toxin worldwide for the treatment of sialorrhea in children.
Objectives To conduct a comprehensive systematic review and meta-analysis to assess the clinical efficacy and potential adverse effects of BoNT-A as a treatment for drooling in children.
Methods Cochrane, Embase, and Medline databases were systematically searched (up to May 2023). Out of 535 identified publications, 20 were found eligible for inclusion. A systematic review and meta-analysis were performed to determine the efficacy of BoNT-A treatment in children in reducing the frequency and severity of drooling.
Results Out of the 20 studies included, a meta-analysis was conducted on the complete dataset of eight studies involving 131 patients. BoNT-A was found to significantly decrease the severity of drooling in patients with sialorrhea (standardized mean difference SMD, −2.07; 95% confidence interval CI, −2.91 to −1.23; p < 0.0001) when compared with the conditions before injections using random-effects models. Six studies out of 20 reported dysphagia as an adverse effect after injection. Other side effects included thickness of saliva and pain at the site of injection.
Conclusion BoNT-A is a clinically effective therapy that improves drooling severity in children with sialorrhea. Although there were some adverse side effects reported, they were transient and not severe. Future studies are needed to further evaluate the best techniques and to identify the ideal dosages required to achieve the optimal outcomes. Laryngoscope, 134:3012–3017, 2024

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Endoscopy‐Assisted Thyroglossal Duct Cyst Resection: A Scoping Review

Maoshan Du, Shanwen Chen, Yu Wu, Dong Wang, Jing Wu, Yi Zhao, Kaile Wu, Yehai Liu

Publication date 17-06-2024


This review aimed to summarize existing studies on endoscopy-assisted thyroglossal duct cyst (TGDC) surgery and discuss the advantages and disadvantages of this novel technique. A systematic review of the databases identified 85 patients. The areola, axillo-breast, transoral vestibular, and transoral-sublingual approaches have been reported, and the operative time varies across studies, ranging from 50 to 480 min. All patients completed the endoscopic procedure without conversion to open surgery or postoperative recurrence. Complications were noted in seven patients. Endoscopy-assisted TGDC surgery is a potential alternative for patients seeking improved cosmetic outcomes.
Objectives Thyroglossal duct cysts (TGDCs) are a common congenital mass in the cervical region. As the traditional surgical approach for TGDC removal, the Sistrunk procedure, often leaves a visible neck scar, the demand for improved cosmetic outcomes has increased. Emerging endoscopy-assisted approaches offer promise for addressing cosmetic concerns. We conducted a scoping review to evaluate the feasibility and safety of endoscopy-assisted TGDC surgery.
Data Sources Pub Med, Embase, and Cochrane databases.
Methods Electronic databases were searched from their respective inception dates to January 2023. Data on surgical approach, patient demographics, surgical procedure, and postoperative outcomes were extracted and analyzed. The quality of the studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist.
Results The literature search yielded nine articles published between 2011 and 2022. Overall, 85 patients in these studies successfully underwent endoscopy-assisted TGDC surgery using various approaches, including areolar, axillo-breast, transoral-vestibular, and transoral-sublingual. The operative time varied across the studies, ranging from 50 to 480 min. TGDC sizes ranged from 1 to 3 cm in diameter. Complications, including infection, skin bruising, and dysarthria, were reported in seven patients (8%). No cases of conversion to open surgery or postoperative recurrences were reported.
Conclusion Endoscopy-assisted surgery is a potential alternative for patients seeking TGDC resection with satisfactory aesthetic results while ensuring safety. However, existing evidence is insufficient to support the superior effectiveness of endoscopy-assisted TGDC surgery over the traditional Sistrunk procedure. Laryngoscope, 134:3038–3043, 2024

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Vascularized Tissue to Reduce Fistula After Salvage Total Laryngectomy: A Network Meta‐analysis

Andrew Williamson, Faizan Shah, Irene Benaran, Vinidh Paleri

Publication date 17-06-2024


We have performed an update of a systematic review first published in 2014 which found a rate of pharyngocutaneous fistula (PCF) after salvage laryngectomy using primary closure of 31.2% and 22.2% with flap-assisted closure, and a number needed to treat of 11. This updated review found an increase in the rate of PCF after primary closure of 37% and further reduction following flap-assisted closure to 19%, with a resultant reduction in the number needed to treat of 6.5. In addition, the PCF rates after free, pedicled, on-lay, and patch flaps were 17% (OR 0.62), 16% (OR 0.36), 15% (OR 0.38), and 16% (OR 0.39), respectively. Additional network meta-analysis found that all combinations of free and pedicled flaps using reinforcement and patch closure methods were superior to primary closure techniques.
Objective Salvage laryngectomy is more predisposed to complications than primary operations, with pharyngocutaneous fistula (PCF) being among the most challenging to manage. Vascularized flaps are increasingly employed during salvage laryngectomy, with a previous review finding a PCF incidence of 31.2% and 22.2% after primary and flap-assisted closure respectively. We aim to better define the role of vascularized flaps after salvage laryngectomy by performing an updated review comparing the rate of PCF in those undergoing primary or vascularized flap-assisted closure.
Data Sources Pubmed/Medline, CINAHL, and CENTRAL.
Review Methods An updated literature review was conducted of English language literature from 2003 to 2023. A random effects and network meta-analysis of odds ratios (OR) and pooled proportions were conducted.
Results Literature search found 31 studies, including seven from the previous review. Overall random effects pooled PCF rate was 25% (95% CI 0.21; 0.30, I2 = 72%, p = <0.01), whereas incidence in primary closure was 37% (95% CI 0.32; 0.43, I2 = 60%, p = <0.01) and 19% (95% CI 0.12; 0.20, I2 = 47%, p = <0.01) after flap closure. Pooled OR was 0.39 (95% CI 0.28; 0.55, I2 = 36%, p = 0.04) in favor of vascularized tissues. The number needed to treat was 6.5. The rate of PCF was lower after free and pedicled flaps, and on-lay and patch closure compared to primary closure techniques. Network meta-analysis found all combinations of closure techniques and vascularized tissue were superior to primary closure.
Conclusion The updated analysis has demonstrated a widening in the rates of PCF between primary and vascularized flap-assisted closure. Surgeons should strongly consider the use of free or pedicled flaps in any salvage laryngectomy procedure. Laryngoscope, 134:2991–3002, 2024

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Analgesic Efficacy of Ropivacaine Infiltration on Early Post‐Tonsillectomy Pain in Pediatrics

Ebraheem Albazee, Omar A. Abdelwahab, Ahmed Abdelaziz, Duha Magzoub, Ahmed Abu‐Zaid

Publication date 17-06-2024


This systematic review and meta-analysis demonstrated the safety and postoperative analgesic efficacy of ropivacaine versus placebo among pediatric patients undergoing tonsillectomy. There was no significant difference between both groups regarding intraoperative blood loss, time to first analgesia, and rate of postoperative bleeding.
Objective To assess the analgesic efficacy of ropivacaine infiltration in the tonsillar fossa among pediatric patients undergoing tonsillectomy.
Data Sources Pub Med, Scopus, Web of Science, and CENTRAL.
Review Methods Eligible randomized controlled trials (RCTs) were assessed for bias using Cochranes risk of bias tool (version 2). Our primary outcome was postoperative pain within 24 h, and secondary outcomes included operative time, intraoperative blood loss, time to first analgesia, bleeding, and nausea/vomiting. Data were pooled as mean difference, standardized mean difference, and risk ratio with a 95% confidence interval.
Results Our review included 11 RCTs, with a total of 712 patients. The quality of studies varied and included low risk (n = 8 RCTs), some concerns (n = 2 RCTs), and high risk (n = 1 RCT) of bias. The primary endpoint of postoperative pain across all time points was significantly reduced in the ropivacaine group compared with the placebo group. Trial sequential analysis (TSA) of the postoperative pain depicted conclusive evidence and unnecessity for further RCTs. The mean operative time was significantly reduced in the ropivacaine group compared with the placebo group. However, there was no significant difference between both groups regarding additional clinical (i.e., mean intraoperative blood loss and mean time to first analgesia) and safety (i.e., rates of bleeding and nausea/vomiting) outcomes.
Conclusion This systematic review and meta-analysis demonstrated the safety and postoperative analgesic efficacy of ropivacaine versus placebo among pediatric patients undergoing tonsillectomy. There was no significant difference between both groups regarding intraoperative blood loss, time to first analgesia, and rate of postoperative bleeding.
Level of Evidence1 Laryngoscope, 134:3018–3029, 2024

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In Reference to Gastroesophageal Reflux and Chronic Rhinosinusitis: A Mendelian Randomization Study

Antonino Maniaci, Giannicola Iannella, Carlos M. Chiesa‐Estomba, Alberto M. Saibene, Jerome R. Lechien

Publication date 17-06-2024


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In Response to Gastroesophageal Reflux and Chronic Rhinosinusitis: A Mendelian Randomization Study

Tao Guo, Hui Xie

Publication date 17-06-2024


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Pepsin Inhibitors Prevent Inflammation and Loss of Laryngeal Barrier Function in Mice with Gastroesophageal Reflux

Thiago M.A.L. Sales, Flavio M.N.O. Sidou, Humberto B. da Costa Filho, Kerolayne de Melo Nogueira, Genilson J. Dias Júnior, Marcos A. de Sousa Lima, Lara M.G. da Silva, Lucas A.D. Nicolau, Pedro M.G. Soares, Miguel Â. Nobre e Souza, Daniel Sifrim, Marcellus H.L.P. de Souza

Publication date 17-06-2024


Pepstatin and darunavir may effectively reduce gastric reflux in the larynx of experimental gastroesophageal reflux (GERD) mice by decreasing inflammation and preserving the barrier function of the laryngeal mucosa.
Objective This study aimed to evaluate the role of pepsin inhibitors in the inflammatory response and their effects on laryngeal mucosal integrity during gastroesophageal reflux (GERD) under in vivo conditions.
MethodsA surgical model of GERD was used, in which mice were treated with pepstatin (0.3 mg/kg) or darunavir (8.6 mg/kg) for 3 days. On the third day after the experimental protocol, the laryngeal samples were collected to assess the severity of inflammation (wet weight and myeloperoxidase activity) and mucosal integrity (transepithelial electrical resistance and paracellular epithelial permeability to fluorescein).
Results The surgical GERD model was reproduced. It showed features of inflammation and loss of barrier function in the laryngeal mucosa. Pepstatin and darunavir administration suppressed laryngeal inflammation and preserved laryngeal mucosal integrity.
Conclusion Pepsin inhibition by the administration of pepstatin and darunavir improved inflammation and protected the laryngeal mucosa in a mouse experimental model of GERD.
Level of EvidenceNA Laryngoscope, 134:3080–3085, 2024

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Transtracheal Pressure for Evaluation of Decannulation Readiness

Ashley Young, Katie Walsh, Jonathan Ida, Dana M. Thompson, Inbal Hazkani

Publication date 17-06-2024


Transtracheal pressure (TTP) is a novel method for evaluating decannulation readiness. Our data suggest an association between TTP and pre-decannulation microdirect laryngoscopy and bronchoscopy findings and polysomnography results. This method may be used to refine the decannulation process in children.
Background Pediatric tracheostomy decannulation protocols vary among institutions and may include toleration of Passy Muir Valve (PMV), microlaryngoscopy and bronchoscopy (MLB) findings, and polysomnography evaluation. Transtracheal pressure (TTP) is an objective measurement utilized to evaluate PMV toleration. We aimed to investigate the role of TTP in decannulation candidates and compare TTP measurements with polysomnography and MLB findings.
MethodsA retrospective cohort study of children who underwent TTP measurement during PMV trial between December 2012 and November 2022.
ResultsA total of 79 patients underwent TTP measurement and MLB evaluation; of these, 16 (20.3%) patients had a capped polysomnography. Twenty-eight (35.4%) patients had TTPs ≤10 cm H2O, and 51 (64.6%) patients had TTPs >10 cm H2O. The most common indication for tracheostomy was upper airway obstruction (n = 41, 51.9%), followed by a need for mechanical ventilation (n = 24, 30.4%). Twenty-five (31.6%) patients were decannulated. Patients with TTPs ≤10 cm H2O had a mean Apnea-Hypopnea Index of 0.17 ± 0.26/h compared with 6.93 ± 7.67/h in those with TTPs >10 cm H2O, p = 0.0365. Patients with TTPs >10 cm H2O were found to have a significantly higher occurrence of airway obstruction (96.1% vs. 46.4%, p < 0.0001) and multilevel airway obstruction (70.6% vs. 21.4%, p < 0.0001) on MLB. Neither TTP measured at time of PMV assessment nor capped polysomnography was associated with successful decannulation.
ConclusionsTTP measurements at time of PMV evaluation are associated with polysomnography and MLB findings. One-time PMV measurements were not indicative of decannulation success.
Level of Evidence4 Laryngoscope, 134:3377–3383, 2024

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"An Update on the Epidemiology and Clinicodemographic Features of Menieres Disease"

Emma De Ravin, Alexandra E. Quimby, Michael Bartellas, Sydnie Swanson, Tiffany P. Hwa, Douglas C. Bigelow, Jason A. Brant, Michael J. Ruckenstein

Publication date 17-06-2024


Objective To characterize the estimated prevalence and clinicodemographic features of Ménières disease (MD) using current diagnostic criteria.
MethodsA cross-sectional study was undertaken at our tertiary academic referral center. All patients seen in Otolaryngology clinic with ICD-10 diagnoses of MD, from January 1, 2013 to July 31, 2022 were identified. Chart review was undertaken to determine the estimated prevalence of MD meeting AAO-HNS diagnostic criteria. Clinicodemographic features were evaluated against a comparator group without MD seen in our health system.
Results Of 806 ICD-10 diagnoses of MD, we identified 480 MD cases meeting diagnostic criteria (168 definite). Mean age at presentation for MD cases was 49 years. Forty-seven percent of cases were male. A significantly higher proportion of MD cases than comparators were white (76% vs. 66%, p < 0.001). Mean time since MD symptom onset was 6.7 years, with a mean attack duration of 4.6 h; 7.5% of MD cases reported a positive family history, and 7% had bilateral disease. The odds of reporting migraine were significantly greater among MD patients than comparators (OR 1.74 1.26–2.42); the odds of having autoimmune conditions were lower (OR 0.45 0.28–0.74); and the odds of reporting allergies were no different (OR 0.96 0.74–1.25) versus comparator patients after controlling for demographic characteristics.
Conclusions Among MD diagnoses, there is a low estimated prevalence of MD meeting diagnostic criteria, and an even lower prevalence of definite MD. Compared to a comparator group of patients seen for any disorder, patients with MD are more likely to be white, male, and have a history of migraine.
Level of Evidence4 Laryngoscope, 134:3310–3315, 2024

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Timing of First Set of Pressure Equalization Tubes in Pediatric Patients With Cleft Deformities

Lindsey K. Greenlund, Autefeh Sajjadi, Meagan Nowariak, Siva Chinnadurai, Robert Tibesar, Noelle Morrell, Brianne Roby

Publication date 17-06-2024


Objectives Children with cleft palates often have comorbid eustachian tube dysfunction requiring pressure equalization tubes (PETs). PETs can relieve middle ear effusions that impede hearing. Ideal PET placement timing in this population is controversial. In this study, the audiologic exam passing rates of patients with cleft palate prior to and following PET insertion were assessed. Rates for patients receiving PETs at different ages were compared. It was hypothesized that earlier PET placement may benefit patients with additional months of improved hearing.
MethodsA retrospective chart review was performed of patients with cleft palate between November 22, 2016 and November 22, 2021 at a tertiary center. Statistical analysis compared passing/normal audiologic exams in patients receiving PETs at different ages.
ResultsA total of 348 patients had cleft palate diagnoses, received PETs, and had adequate hearing data for inclusion. Those with PETs inserted at 3 months of age or less had an increase in percent of patients passing audiologic exams following versus prior to PET insertion of 13% (1.3 times improvement). Those receiving PETs between 7- and 12-months had the largest rate of improvement (42%) (2.4 times improvement); other groups had changes in passing rates between 31% and 40%. The rate of passing audiologic exams following PET insertion was high across all groups, ranging from 66% to 81%.
Conclusion This is one of the first studies exploring the timing of PET placement in this population and showed that patients receiving PETs at 3 months of age or younger passed subsequent audiologic exams at similar rates relative to those receiving PETs later in life.
Level of Evidence3 Laryngoscope, 134:3391–3394, 2024

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Assessment of a Novel Tool for the Clinical Grading of Nasal Septal Perforation

Amar Miglani, India Rangel, Cody Smith, Stephen F. Bansberg, Devyani Lal, Michael J. Marino

Publication date 17-06-2024


We found that an endoscopic evaluation of NSP comprising five exam findings has acceptable interrater and intrarater reliability and correlates with patient-reported outcomes. NSP endoscopy may be applied to future clinical studies for characterization of NSP and assessment of treatment outcomes.
Background Nasal septal perforations (NSP) can have a heterogeneous appearance on endoscopic examination with varying degrees of crusting, inflammatory change, and associated septal deviation. The clinical applicability of these findings as contributors to patient symptoms may be enhanced by use of a standardized assessment.
Methods Video nasal endoscopy recordings were obtained from 40 patients with NSP.
Five raters with varied levels of training ranging from a senior resident to an experienced septal perforation surgeon independently reviewed the videos for the following exam findings: crusting, scarring, granulation tissue, septal deviation, and edema. Scoring for each item was reported on a 3-point (0–2) scale, and each reviewer repeated scoring at a 14-day interval. Interrater and intrarater agreement were calculated using Fleiss kappa for each item and the total scores. Additionally, endoscopy scores were correlated with patient-reported NOSE-Perf symptom scores.
Results Interrater agreement for the overall instrument was in the “fair-to-moderate” range with the following interrater agreement for each item: crusting (0.458–0.575), scarring (0.286–0.308), granulation (0.403–0.406), deviation (0.487–0.494), and edema (0.253–0.406). Intrarater agreement was generally “substantial” for individual items as well as the overall instrument (0.688). The NSP endoscopy scores were moderately correlated with NOSE-Perf scores (r = 0.44, p = 0.008).
Conclusions An endoscopic evaluation of NSP comprising five exam findings has acceptable interrater and intrarater reliability and correlates with patient-reported outcomes. NSP endoscopy may be applied to future clinical studies for characterization of NSP and assessment of treatment outcomes.
Level of Evidence3 Laryngoscope, 134:3049–3053, 2024

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Correlation of 3D Morphometric Changes, Kinematics, and Muscle Activity During Smile

Özlem Özsoy, Umut Özsoy, Yılmaz Yıldırım, Ege Alkan, Beste Yılmaz, Selin Esma Güllü

Publication date 17-06-2024


Knowing the morphological, kinematic, and electrophysiological parameters of the smile in healthy individuals may contribute to evaluating, planning, and monitoring the smile reanimation. This study aimed to determine the correlation between 3D morphometric changes, movement kinematics, and muscle activity in the facial soft tissue of healthy individuals.
Objective Knowing the morphological, kinematic, and electrophysiological parameters of the smile in healthy individuals may contribute to evaluating, planning, and monitoring the smile reanimation. This study aimed to determine the correlation between 3D morphometric changes, movement kinematics, and muscle activity in the facial soft tissue of healthy individuals.
Method In this cohort study, 20 volunteers were selected from healthy individuals with no facial disorders. During smiling, three-dimensional face scanning, facial motion capture, and surface electromyography (sEMG) were performed. The average displacement, velocity, and acceleration during facial movements were measured. The mean change in 3D surface morphometry and activation of the zygomaticus major were determined.
Results The volunteers, comprising 10 males and 10 females, had a mean age of 24 ± 10 years; for female, mean age was 23 ± 5 years and for men 26 ± 13 years. Significant correlations were found between kinematic and morphometric data (r = 0.51, p < 0.001), sEMG and morphometric (r = 0.50, p < 0.001) data, and sEMG and kinematic data (r = 0.49, p < 0.002). The maximum acceleration occurred during approximately 65% of the muscle activation time and 64% of the peak muscle activation value. Additionally, the maximum velocity was reached at around 73% of the muscle activation time and 67% of the peak muscle activation value. Furthermore, the maximum displacement values were observed at approximately 88% of the muscle activation time and 76% of the peak muscle activation value.
Conclusion The findings may provide insights into the smiles functional parameters, contribute to understanding facial muscle-related disorders, and aid in improving the diagnosis and treatment of the smile.
Level of EvidenceNA Laryngoscope, 134:3112–3119, 2024

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Long‐Term Outcomes and Revision Rates in Laryngeal Reinnervation

Vanessa F. Torrecillas, Matthew R. Hoffman, Breanne Schiffer, Katherine Keefe, Marshall E. Smith

Publication date 17-06-2024


This study uses a single surgeons career-long experience with ansa cervicalis-RLN laryngeal reinnervation technique to provide information on the ability to rehabilitate dysphonia related to unilateral vocal fold paralysis. Unilateral, nonselective laryngeal reinnervation can provide reliable improvement in vocal symptoms after recurrent laryngeal nerve injury. The revision rate after laryngeal reinnervation is favorable and comparable to framework surgery.
Objectives Nonselective laryngeal reinnervation is an effective procedure to improve voice quality after unilateral vocal fold paralysis. Few studies have captured long-term outcome data, and the revision rate for this operation is currently unknown. The objective of this study is to describe the long-term outcomes and revision rates of unilateral, nonselective reinnervation in pediatric and adult patients.
Methods Patients who underwent laryngeal reinnervation from 2000 to 2022 with a single surgeon were identified for inclusion. Patients who underwent bilateral, super selective, deinnervation and reinnervation, and/or concurrent arytenoid adduction procedures were excluded. Outcome measures included maximum phonation time MPT, voice handicap index score VHI, patient-reported percent normal voice, revision procedures, and complications. Data were compiled and analyzed using paired t-tests, repeated measures analysis of covariance, and binary logistic regression analysis.
Results One hundred thirty-two patients underwent unilateral, nonselective ansa-recurrent laryngeal nerve RLN laryngeal reinnervation. Reinnervation significantly improved MPT and patient-reported percentage of normal voice and significantly decreased VHI. Eleven patients underwent revision procedures, corresponding to a revision rate of 8.3%. Additional procedures included medialization laryngoplasty n = 3, medialization laryngoplasty with arytenoid adduction n = 3 and injection augmentation greater than 1 year after reinnervation n = 5. The only factor associated with the need for additional surgery was time lapse from nerve injury to reinnervation. The overall complication rate was 6.8%; no patient required reintubation or tracheostomy.
Conclusion Unilateral, nonselective laryngeal reinnervation can provide reliable improvement in vocal symptoms after recurrent laryngeal nerve injury. The revision rate after laryngeal reinnervation is favorable and comparable to framework surgery.
Level of Evidence4 Laryngoscope, 134:3187–3192, 2024

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Improved Recovery after Vestibular Schwannoma Excision with Intratympanic Gentamicin Prehabilitation

Mathieu Trudel, Emma J. Stapleton, Andrea M. Wadeson, William Spiller, Hannah J. North, Calvin Heal, Joseph Sebastian, Simon R. Freeman, Scott A. Rutherford, Helen Entwistle, Charlotte L. Hammerbeck‐Ward, Omar Pathmanaban, Andrew T. King, Simon K.W. Lloyd

Publication date 17-06-2024


Objective Translabyrinthine excision of a vestibular schwannoma is associated with acute vestibular failure. Preoperative intratympanic gentamicin (ITG) injections can improve objective balance function after surgery but its clinical benefits remain to be established.
Methods Adult patients undergoing translabyrinthine removal of a vestibular schwannoma between January 2014 and February 2018 underwent preoperative vestibular function testing. Patients were divided in to 3 groups, those with vestibular function (VF) who received ITG injections, those with VF but did not receive ITG and those with no VF. Groups were compared according to degree of vertigo, length of stay, time to unassisted mobilization, and postoperative anti-emetic consumption.
Results Forty six patients had ITG injections (Group 1), 7 had residual VF but refused treatment (Group 2), 21 had no VF (Group 3). Group 1 had a significant improvement in vertigo over time whereas groups 2 and 3 did not. There was a statistically significant 70% decrease in time to independent mobilization between Group 1 and other groups and a 19% decrease in length of stay in Group 1 compared to other groups although this did not reach statistical significance. Two patients had injection-related complications. Group 1 used less anti-emetics than other groups but this was not statistically significant.
Conclusion Preoperative intratympanic gentamicin injection with vestibular rehabilitation exercises is associated with less postoperative vertigo and earlier postoperative mobilization. There was reduced duration of hospitalization and decreased consumption of anti-emetic but not significantly so possibly because of low numbers of patients in the no treatment group.
Level of Evidence2 Laryngoscope, 134:3316–3322, 2024

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Trends in Management and Cost Burden of Facial Fractures: A 14‐Year Analysis

Rachel E. Weitzman, Tejas Subramanian, Karena Zhao, Andre Shomorony, Anthony P. Sclafani

Publication date 17-06-2024


This study represents one of the largest reviews of clinical characteristics, management, and costs associated with facial fractures at a major metropolitan level 1 trauma center.
Objective To discuss patient demographics and management and better understand the economic impact associated with the treatment of facial fractures at a major metropolitan level 1 trauma center.
Study Design Retrospective chart review.
Methods We identified 5088 facial fractures in 2479 patients who presented from 2008 to 2022. Patient demographics, mechanism of injury, associated injuries, treatment information, and hospital charges were collected and analyzed to determine factors associated with surgical management and increased cost burden.
Results Our 14-year experience identified 1628 males and 851 females with a mean age of 45.7 years. Orbital fractures were most common (41.2%), followed by maxilla fractures (20.8%). The most common mechanism was fall (43.0%). Surgical management was recommended for 41% of patients. The odds of surgical management was significantly lower in female patients, patients age 65 and older, and patients who presented after the onset of the COVID-19 pandemic. The odds of surgical management was significantly higher for patients who had a mandible fracture or greater than 1 fracture. The average cost of management was highest for naso-orbito-ethmoidal fractures ($37,997.74 ± 52,850.88), followed by Le Fort and frontal fractures ($29.814.41 ± 42,155.73 and $27,613.44 ± 39.178.53, respectively). The highest contributor to the total average cost of management was intensive care unit-related costs for every fracture type, except for mandible fractures for which the highest contributor was operating room (OR)-related costs.
Conclusions This study represents one of the largest comprehensive databases of facial fractures and one of the first to provide a descriptive cost analysis of facial trauma management.
Level of Evidence4 Laryngoscope, 134:3120–3126, 2024

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Partial Ossicular Reconstruction With a Novel Ball Joint Prosthesis: The mCLIP ARC Partial Prosthesis

Nicholas Bevis, Thomas Effertz, Marc Hüser, Dirk Beutner

Publication date 17-06-2024


Patients underwent tympanoplasty with ossicular reconstruction using the mCLIP ARC partial prosthesis. This titanium prosthesis is equipped with a clip mechanism for coupling at the stapes and a ball joint connecting headplate and shaft. The mCLIP ARC partial prosthesis, a new middle ear prosthesis with a balanced ball joint, shows promising audiological results and is a safe and effective choice for patients with chronic ear disease.
Objective Middle ear surgery involves reconstruction of the ossicular chain, predominately using rigid implants. New middle ear prostheses strive to mimic the physiologic micromovements of the ossicular chain and prevent dislocation, protrusion, and preloading of the annular ligament due to pressure fluctuations.
Methods Thirty-five patients were included in a monocentric, prospective observational study. Patients received tympanoplasty with ossicular reconstruction using the mCLIP ARC partial prosthesis. This titanium prosthesis is equipped with a clip mechanism for coupling at the stapes and a ball joint connecting headplate and shaft. At short-term (ST) and mid-term (MT) follow-up, pure-tone audiometry was performed and the pure tone average of 0.5, 1, 2, and 3 k Hz (PTA4) was calculated. The audiological outcome was compared with retrospective data of the Dresden titanium clip prosthesis.
Results The new prosthesis shows favorable clinical results. Pure-tone audiometry showed satisfactory results in ST and MT follow-up, with the PTA4 air-bone gap (ABG) decreasing from 24.5 (±11) dB to 17.4 (±7.9) dB at the ST follow-up at 27 days to 15.6 (±10.3) dB at MT follow-up at 196 days (n = 32). A PTA4-ABG value of less than 20 dB was achieved by 63% of patients at ST follow-up and by 77% at MT follow-up. There was no significant difference in PTA4 ABG compared to the Dresden titanium clip prosthesis during ST follow-up (p = 0.18).
Conclusion The mCLIP ARC partial prosthesis, a new middle ear prosthesis with a balanced ball joint, shows promising audiological results and is a safe and effective choice for patients with chronic ear disease.
Level of Evidence3 Laryngoscope, 134:3323–3328, 2024

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Recovery of Recurrent Laryngeal Nerve Function With Neoadjuvant Treatment: Neural Characterization

Marika D. Russell, Amr H. Abdelhamid Ahmed, Zipei Feng, David C. Shonka Jr, Amanda S. Karcioglu, Ayaka J. Iwata, Natalia Kyriazidis, Sameer H. Siddiqui, Tejas S. Athni, Jong C. Park, Lori J. Wirth, Mark E. Zafereo, Gregory W. Randolph

Publication date 17-06-2024


Objectives Neoadjuvant targeted therapy has emerged as a promising treatment strategy for locally aggressive thyroid cancer. Its impact on tumor and adjacent tissues remains a nascent area of study. Here we report on a series of six subjects with locally advanced thyroid cancer and recurrent laryngeal nerve (RLN) paralysis who experienced recovery of RLN function with neoadjuvant treatment and describe the morphologic and electrophysiologic characteristics of these recovered nerves.
Methods This is a multicenter retrospective review.
Descriptive analysis was conducted to examine the following parameters for recovered nerves: (1) nerve morphology, characterized as Type A (involving epineurium only) versus Type B (extending beyond epineurium); (2) proximal stimulability (normal vs. abnormal vs. absent); and (3) surgical management (resection vs. preservation).
Results Six subjects with unilateral VFP were identified. Median time to return of VF mobility was 3 months (range 2–13.5). All nerves (100%) were noted to have Type A morphology at surgery. Proximal stimulability was normal in four subjects (66.7%), abnormal in one (16.7%), and absent in one (16.7%). Nerves that had improvement of function through neoadjuvant therapy were able to be surgically preserved in five subjects (83.3%).
Conclusions This represents the first characterization of RLNs that have recovered function with neoadjuvant treatment of locally advanced thyroid cancer. Although much remains unknown, our findings indicate carcinomatous neural invasion is a reversible process and recovered nerves may demonstrate normal morphology and electrophysiologic activity.
Level of Evidence4 Laryngoscope, 134:3415–3419, 2024

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Real‐World Adverse Events After Type 2 Biologic use in Chronic Rhinosinusitis with Nasal Polyps

Marisa Dorling, Juan C. Hernaiz‐Leonardo, Athenea Pascual, Arif Janjua, Andrew Thamboo, Amin Javer

Publication date 17-06-2024


In a real-world study of chronic rhinosinusitis with nasal polyps (CRSwNP) patients, we investigated and compared adverse events associated with type 2 biologics. Dupilumab had a significantly higher adverse event rate (45%) compared with mepolizumab (20%) (p < 0.01). For dupilumab, arthralgia and rash were the most common adverse events, whereas for mepolizumab, headache and fatigue predominated. Notably, 8% of dupilumab and 6% of mepolizumab patients discontinued therapy due to adverse events, differing from clinical trial data.
Objective To investigate the frequency and nature of adverse events related to type 2 biologic use in patients with chronic rhinosinusitis with nasal polyps (CRSwNP), including dupilumab and mepolizumab.
Methods This is a single-institution retrospective study of real-world patient data. Patients were included if they have a diagnosis of CRSwNP, have undergone at least one endoscopic sinus surgery, and have taken at least two doses of dupilumab or mepolizumab between January 1, 2016, and July 1, 2023. Data collected include clinicodemographic information and past medical/surgical history. The primary outcomes are the incidence and types of adverse events. Adjusted odds ratio was calculated to compare the biologics using logistic regression. Risk factors for developing adverse events were investigated.
Results Eighty-seven patients on dupilumab and 51 patients on mepolizumab were included. Thirty-nine (45%) and 10 (20%) patients respectively encountered adverse events, which differed from phase 3 trial data. The adjusted odds ratio for adverse event rates between these two treatment groups was 3.8 (95% CI, 1.5–10.5). The most common adverse events for dupilumab were arthralgia (16%), rash (14%), and conjunctivitis or xerophthalmia (10%). The main adverse events for mepolizumab were headache (6%) and fatigue (6%). Seven dupilumab and three mepolizumab patients discontinued therapy due to adverse events. The average duration of treatment was 22.5 (range: 1–77) months for mepolizumab and 15.9 (range: 1–35) months for dupilumab.
Conclusion Dupilumab and mepolizumab have distinct adverse event profiles. This study contributes to informing clinicians decisions regarding the use of type 2 biologics in CRSwNP patients.
Level of Evidence3 Laryngoscope, 134:3054–3059, 2024

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The Clinical Behavior and Recurrence Patterns of Oral Cavity Cancer in Oral Lichen Planus Patients

Eyal Yosefof, Noga Kurman, Nofar Edri, Eli Rosenfeld, Gideon Bachar, Thomas Shpitzer, Moshe Yehuda, Aviram Mizrachi, Esmat Najjar

Publication date 17-06-2024


OLP patients are significantly more likely to present with second primary tumors. Their survival rates are similar to non-OLP patients. These patients should be closely monitored after treatment for the possibility of further primary tumors, with a low threshold of suspension and biopsy of any suspicious lesion that appears on follow-up.
Objectives Oral lichen planus (OLP) is a chronic inflammatory disorder involving epithelia with squamous differentiation. Although described as a potential malignant precursor, the characteristics of malignancies arising among these patients are not widely described. Our goal was to describe the patterns of disease recurrence of patients with oral cavity squamous cell carcinoma (OSCC) arising on the background of OLP.
MethodsA retrospective analysis of all surgically treated patients with OSCC at a university-affiliated tertiary care center between 2000 and 2020.
Results Two hundred seventy-nine patients with OSCC treated surgically were included. Forty (14.3%) had OLP. The mean age of patients with OLP was 70.9 years compared with 64.3 years for non-OLP patients (p = 0.03). OLP patients had a significantly higher rate of disease recurrence, persistence, or multiple primary disease (70% vs. 33.9%, p < 0.001). The mean number of sequential oncologic events for each patient with recurrence was also significantly higher among OLP patients (1.86 vs. 1.36, p = 0.03), a difference explained by a higher rate of multiple primary presentations (0.71 vs. 0.28, p = 0.008). A significant difference in disease-free survival (DFS) was demonstrated between the groups as patients with OLP had a lower 5-year DFS (34.7% vs. 61.3%, log-rank p value <0.001). On multivariate analysis, OLP was significantly associated with multiple primary events (p < 0.001, Odds ratio = 7.42, 95% confidence interval 2.9–19).
ConclusionsOSCC patients with OLP background demand close clinical follow-up, as multiple primary disease is significantly more common and the DFS is significantly lower among these patients. A thorough clinical evaluation for all oral cavity subsites is mandatory.
Level of Evidence3 Laryngoscope, 134:3146–3151, 2024

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Microalbuminuria and Functional Iron Deficiency are Risk Factors for Hearing Loss in Adolescents

Sang‐Yoon Han, Young Ho Kim

Publication date 17-06-2024


Microalbuminuria and functional iron deficiency were independently associated with the hearing loss. Since microalbuminuria can be easily detected by dipstick test and urine analysis, hearing evaluations for individuals with microalbuminuria might be helpful to identify hearing impairments earlier in adolescents.
Objectives Renal impairment and some systemic diseases are associated with hearing loss (HL) in adults. However, studies of these relationship in adolescents are rare. The objective of this study was to determine the association between HL and renal or systemic disease in adolescents.
Methods Subjects were extracted from the 5th Korea National Health and Nutrition Examination Survey from 2011 to 2012. We included adolescents aged 10–19 years old with normal tympanic membrane and those who underwent a physical and laboratory examination and pure tone audiometry. HL, high-frequency hearing loss (HFHL), albuminuria, impaired glomerular filtration rate, hypertension, diabetes, and obesity were evaluated based on the data.
Results Individuals with microalbuminruia (MIA) exhibited higher prevalence of HL (p = 0.003) and HFHL (p = 0.012) than those without MIA. The prevalence of HL and HFHL appeared to increase according to the severity of albuminuria. Additionally, individuals with HL or HFHL showed lower transferrin saturation (TSAT) than individuals without HL (p = 0.002) or HFHL (p = 0.001). And, HFHL was associated with lower ferritin levels (p = 0.017). HL and HFHL were related to MIA (p = 0.004 and p = 0.022, respectively) and TSAT (p = 0.005 and p = 0.011, respectively) after controlling other factors.
ConclusionMIA and TSAT level were independently associated with the HL and HFHL. Since MIA can be easily detected by dipstick test and urine analysis, hearing evaluations for individuals with MIA might be helpful to identify hearing impairments earlier in adolescents.
Level of Evidence3 (individual cross-sectional study) Laryngoscope, 134:3329–3334, 2024

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Effect of Complex Decongestive Therapy on Quality of Life and Physical Parameters in Head and Neck Lymphedema

Songul Keskin Kavak, Arzubetül Duran, Sibel Ünsal Delialioğlu, Lale Aktekin

Publication date 17-06-2024


We have demonstrated in our study that neck disability, cervical ROM, quality of life, and facial and neck lymphedema size (tissue size) have a positive effect on the results.
Objective To assess the effect of complex decongestive therapy treatment (CDT) on quality of life, neck disability, cervical range of motion, and facial and neck lymphedema size using specific anatomical landmark points.
Methods This prospective study was conducted in a tertiary cancer center in Turkey. Thirty patients included in the study were treated with CDT for 21 days. The patients were evaluated before and after CDT with MD Anderson Cancer Center Head and Neck Lymphedema (MDACC HNC) staging system, The Neck Disability Index, European Organization for Research and Treatment of Cancer Quality of Life 30 (EORTC-QLOC30), Facial Composite score and Neck Circumferences, cervical range of motion.
Results Median follow-up was 7.2 months. After treatment of 30 patients significant cognitive function, emotional function, and social function (p < 0.001). After CDT treatment, the quality of life sub-parameters of EORTC QLQ-C30 showed significant improvement (p < 0.001). The facial composite score and neck circumferences indices showed significant improvement (p < 0.001). A decrease of 2% or more in the facial composite score and neck circumferences was observed in all patients participating in the study.
Conclusion There have been few studies on the effectiveness of CDT on the EORTC QLQ-C30, facial composite score, and neck circumferences in head and neck lymphedema. In patients with head and neck lymphedema following head and neck cancer, our study demonstrated the positive effects of complex decongestive therapy (CDT) on neck disability, range of motion, quality of life, and facial and neck lymphedema tissue size.
Level of Evidence4 Laryngoscope, 134:3152–3157, 2024

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Presentation, Management, and Outcomes of Pathologic Scars Within a Pediatric Otolaryngology Practice

Alessandra Zaccardelli, Jennifer L. Harb, Evangelos Papathanasiou, Andrew R. Scott

Publication date 17-06-2024


This study aims to review the spectrum of scarring that may present to an urban, pediatric otolaryngology practice and determine if associations exist between race, scar location, treatment modality, and outcomes following interventions for scarring.
Objectives This study aims to review the spectrum of scarring that may present to an urban, pediatric otolaryngology practice and determine if associations exist between race, scar location, treatment modality, and outcomes following interventions for scarring.
Methods Retrospective cohort study among 115 pediatric patients with 138 unique keloids or hypertrophic scars (HTS), and 141 children presenting for tonsillectomy at Tufts Medical Center. Age at presentation and sex assigned at birth were collected for both populations. For those presenting for pathologic scars, income quintile, self-identified race/ethnicity, anatomical location, treatment number and type, and clinical outcome were also analyzed. Multivariate analyses calculated adjusted odds ratios (aORs) and 95% confidence intervals to assess associations between scar subsite, intervention type, and persistence after treatment.
Results Compared to individuals presenting for tonsillectomy, a disproportionate percentage of patients presenting for scarring identified as Black (26.6% vs. 13.5%) or Asian (17.4% vs. 7.1%, p = 0.016) or were male (61.7% vs. 49.7%, p = 0.053). Individuals identifying as Black or Asian were more likely to present with ear lobe and neck scars, respectively (50.0% vs. 45.5%, p = <0.001). Ear scars were significantly more likely to receive excision at initial treatment (aOR = 5.86 1.43–23.96) compared to other subsites, and were more likely to require >1 treatment (aOR = 5.91 1.53–22.75).
Conclusion Among pediatric patients presenting with keloids or HTS, children who identified as Black or Asian were more likely to present with ear and neck scars, respectively. Ear scars were frequently treated with excision and appear more likely to require adjuvant treatments and multiple interventions.
Level of Evidence3 Laryngoscope, 134:3127–3135, 2024

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Impact of Early Research Productivity on Future Academic Output Among Head and Neck Fellows

Nadia L. Samaha, Kaelyn Gwynne, Andy M. Habib, Jackson Randolph, Amanda R. Walsh, David A. Boyd, Jessica H. Maxwell

Publication date 17-06-2024


This study aims to assess whether pre-fellowship research productivity is associated with future research productivity and career placement of head and neck (H&N) surgery fellowship graduates from 2014 to 2022. Overall, we found that research productivity has been on the rise among recent H&N surgery fellowship graduates. Graduates with more pre-fellowship publications and more first-authorship designations tend to have higher research output during the later stages of their training and a greater likelihood of academic career placement.
Objective To examine the impact of pre-fellowship publications on future research productivity and career placement among head and neck (H&N) surgery fellowship graduates.
MethodsH&N surgery fellowship graduates between 2014 and 2022 were identified from publicly available data. Timing of fellowship graduation, number of publications during each stage of education and training, and number of first authorship publications were analyzed for association with scholarly productivity and academic career placement.
Results In our analysis of 409 H&N fellowship graduates, there was a strong positive correlation between the year of fellowship graduation and the average number of publications in residency (R2 = 0.82) and fellowship (R2 = 0.79). Graduates producing more than the average of 2.37 publications prior to residency had a significantly higher average number of publications during residency and fellowship compared to those who published below average (p < 0.001). A higher number of publications prior to and during residency were both independently associated with a higher likelihood of academic career placement (p = 0.015 and p = 0.002, respectively). More first-author publications prior to residency were associated with a higher number of publications during residency and fellowship (p = 0.015). In sub-analyses, gender did not impact the average number of publications during residency and fellowship. Similarly, the COVID-19 pandemic did not significantly impact the average number of publications during the fellowship when comparing the classes of 2020–2022 to 2017–2019.
Conclusion Research productivity among H&N fellowship graduates has increased in recent years. Research productivity in medical school and residency is associated with scholarly output in later stages of training and academic career placement.
Level of EvidenceNA Laryngoscope, 134:3165–3169, 2024

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Gram‐negative Bacteria are Associated With Sensorineural Hearing Loss in Chronic Otitis Media

Jintao Lou, Wuhui He, Bozhen Cui, Fan Wu, Wei Liu, Jingman Deng, Yan Huang, Zhigang Zhang, Yu Si

Publication date 17-06-2024


This study aimed to assess the risk and severity of sensorineural hearing loss (SNHL) in patients with different etiologic pathogen infections in chronic otitis media (COM). The analysis of 137 COM cases revealed that bacterial infections were an independent risk factor for SNHL. Additionally, higher levels of circulating monocytes were associated with more severe hearing loss. These findings suggest that bacterial infections, especially gram-negative bacteria are related to the SNHL in COM, and increased circulating monocytes are potentially associated with SNHL.
Object Chronic otitis media (COM) is an inflammatory disease that commonly presents with otorrhea and hearing loss. Bacteria-induced inflammation can cause inner ear damage, leading to sensorineural hearing loss (SNHL). This study aimed to compare the prevalence and severity of SNHL in patients with gram-negative versus gram-positive cultures and examine associations between the concentrations of circulating monocytes and neutrophils with bacteria species and SNHL.
Methods This was a retrospective study. Cholesteatoma or chronic suppurative otitis media patients with otorrhea were enrolled. Middle ear secretions were collected using sterile swabs under an otoscope, and sent for bacterial detection within 30 min. Pure tone audiometry and circulating leukocyte counts were recorded and analyzed in patients infected with different pathogens. Logistic regression analysis was used to identify the risk factors associated with SNHL.
ResultsA total of 137 patients were enrolled, including 45 patients infected with gram-negative bacteria, 41 with gram-positive bacteria, 20 with polymicrobial infection, and 31 with no bacterial growth. Logistic regression analysis showed that bacterial culture positive infections (OR = 7.265, 95% CI 2.219–23.786, p = 0.001) were an independent risk factor for SNHL. Patients with gram-negative bacteria had higher risks of SNHL (p < 0.0001) and more severe hearing loss (p = 0.005) than those with gram-positive bacteria. COM patients infected with gram-negative bacteria showed an increase in circulating monocytes, which correlated with the occurrence of SNHL (p = 0.0343).
Conclusion Gram-negative bacteria are associated with elevated circulating monocyte counts and have a higher risk of severe SNHL.
Level of Evidence4 Laryngoscope, 134:3335–3341, 2024

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Quality of Life of Oligometastatic and Polymetastatic Head and Neck Squamous Cell Carcinoma Patients

Diako Berzenji, Maarten C. Dorr, Aniel Sewnaik, Hetty Mast, Marinella P.J. Offerman, Robert J. Baatenburg de Jong, Jose A. Hardillo

Publication date 17-06-2024


Our head and neck cancer study emphasizes distinguishing distant metastasis patterns. Oligometastasis, characterized by limited spread, has relatively better quality of life and survival than polymetastatic patients. These results underscore the need for tailored interventions, highlighting the unique challenges faced by different metastatic groups.
Objective Evidence suggests that distant metastasis in head and neck squamous cell carcinoma is a spectrum of disease. Previous studies show that oligometastasis has favorable survival compared with polymetastasis. The quality of life of patients with oligometastasis remains unknown. To further solidify the position of oligometastasis as a separate entity, we hypothesized that oligometastatic patients experience better quality of life than polymetastatic patients.
Methods Patients with distant metastasis were stratified into three groups: oligometastasis (≤3 metastatic foci in ≤2 anatomic sites), explosive metastasis (≥4 metastatic foci at one anatomic site), and explosive-disseminating metastasis (spread to ≥3 anatomic sites). Quality of life was assessed every 2 months post distant metastasis diagnosis.
Results Between January 1, 2016, and December 31, 2021, a total of 161 patients with distant metastasis were identified, with a total of 397 measurements. In this group, 57 (35.4%) patients had oligometastasis, 35 (21.7%) patients had explosive metastasis, and 69 (42.9%) patients had explosive-disseminating metastasis. Their median post-distant metastasis survivals were 8.5 months, 3.2 months, and 3.2 months respectively (p < 0.001). A significantly better overall quality of life was observed in the oligometastasis group compared with the polymetastatic groups (+0.75 out of 7, p < 0.05). Furthermore, oligometastatic patients performed better in the subdomains of “physical functioning,” “fatigue,” and “pain.”Conclusion Results from this study underscore that subgroups exist regarding quality of life and survival within distant metastasis, with polymetastatic patients performing worse than oligometastatic patients. This highlights the significance of tailored interventions that consider the unique challenges faced by each metastatic group of patients.
Level of Evidence3, retrospective cohort study Laryngoscope, 134:3170–3176, 2024

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Multidisciplinary Advanced Surgical Planning for Slide Tracheoplasty Using 3D‐Printed Models

Clare M. Richardson, Scott Walton, Jason S. Park, Juliana Bonilla‐Velez, Randall A. Bly, John P. Dahl, Sanjay R. Parikh, Seth Friedman, Kaalan E. Johnson

Publication date 17-06-2024


A 3D-printed model of a congenital airway stenosis was designed and successfully used by surgeons of all training levels. Use of the model in surgical planning sessions increased surgeon confidence and impacted the final surgical plan for repair.
Objective The objective of this study was to develop and assess multidisciplinary advanced surgical planning (ASP) sessions using three dimensional (3D) printed models for cervicothoracic slide tracheoplasty (CST). We hypothesized that these sessions would improve surgeon confidence, streamline intraoperative planning, and highlight the utility of 3D modeling.
Methods3D-printed patient-specific trachea models were used in pre-operative ASP sessions consisting of a multidisciplinary case discussion and hands-on slide tracheoplasty simulation. Participants completed a survey rating realism, utility, impact on the final surgical plan, and pre- and post-session confidence. Statistical analysis was performed via Wilcoxon and Kruskal-Wallis tests.
Results Forty-eight surveys were collected across nine sessions and 27 different physicians. On a 5-point Likert scale, models were rated as “very realistic”, “very useful” (both median of 4, IQR 3–4 and 4–5, respectively). Overall confidence increased by 1.4 points (+/− 0.7, p < 0.0001), with the largest change seen in those with minimal prior slide tracheoplasty experience (p = 0.005). Participants felt that the sessions “strongly” impacted their surgical plan or anticipated performance (median 4, IQR 4–5), regardless of training level or experience.
Conclusion3D-printed patient-specific models were successfully implemented in ASP sessions for CST. Models were deemed very realistic and very useful by surgeons across multiple specialties and training levels. Surgical planning sessions also strongly impacted the final surgical plan and increased surgeon confidence for CST.
Level of Evidence4 Laryngoscope, 134:3395–3401, 2024

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Morphology, Not Only Volume: A Study on Empty Nose Syndrome and Inferior Turbinates

Chia‐Hsiang Fu, Chien‐Cheng Chen, Chi‐Che Huang, Po‐Hung Chang, Yi‐Wei Chen, Ya‐Cheng Tang, Ta‐Jen Lee

Publication date 17-06-2024


Empty Nose Syndrome (ENS) is a clinically significant but underdiagnosed condition linked to severe rhinologic and psychiatric symptoms. In a study of 54 ENS patients, the relationship between remnant inferior turbinate volume (ITV) and morphological phenotypes was investigated, revealing a positive correlation between ITV and symptom severity in specific phenotypes. These findings underscore the importance of investigating the role of ITV in ENS and suggest that the effectiveness of surgical reconstruction may be tied more to restoring nasal morphology than volume alone.
Objectives Empty nose syndrome (ENS) is an underdiagnosed but burdensome clinical condition. Studies that have addressed the impact of remnant inferior turbinate volume (ITV) on ENS are scarce. We aimed to evaluate the impact of ITV and phenotyping on the severity and presentation of ENS.
Methods All the enrolled patients underwent the following subjective assessments: the ENS 6-Item Questionnaire (ENS6Q), Sino-Nasal Outcome Test-25 (SNOT-25), Beck Depression Inventory-II (BDI-II) and Beck Anxiety Inventory (BAI). The ITV was obtained from finely cut (1-mm-thick slices) sino-nasal computed tomography scan images and analyzed using ImageJ. The correlation between ITV, subjective measurements, and morphology of inferior turbinates was evaluated. ENS was categorized as torpedo type (balanced tissue volume) or pistol type (posterior dominance) based on the morphology.
Results Overall, 54 patients met the inclusion criteria. The ITV was positively correlated with the ENS6Q score and domain of ENS symptoms in SNOT-25. Neither BDI-II nor BAI scores had a significant correlation with ITV. Based on their morphological classification, the torpedo type exhibited diverse manifestations in the SNOT-25 analysis in response to changes in ITV, while the pistol type demonstrated an elevated rhinologic symptom burden and ENS-specific symptoms as their ITV increased. Nasal resistance did not correlate with the ITV in either type of ENS.
Conclusions Symptoms were paradoxically worse in ENS patients with greater remnant ITV, and distinct morphological phenotypes in the nasal cavities may result in different presentations. Further investigation into the correlation between remnant inferior turbinates and nerve function is warranted.
Level of Evidence3 Laryngoscope, 134:3060–3066, 2024

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Validated Symptom Outcomes Following Septal Perforation Repair: Application of the NOSE‐Perf Scale

Cullen M. Taylor, Stephen F. Bansberg, Michael J. Marino

Publication date 17-06-2024


One-hundred and seventeen patients underwent bilateral mucosal flap repair with autologous interposition graft with high closure rate. Application of the Nasal Obstruction Symptom Evaluation (NOSE)-Perf scale, a psychometrically validated instrument specific to nasal septal perforations, demonstrated significant quality of life improvement following repair.
Objective The Nasal Obstruction Symptom Evaluation (NOSE)-Perf scale was developed and validated to measure symptoms associated with nasal septal perforations. This study reports the application of the NOSE-Perf scale to evaluate symptom change following septal perforation repair.
Methods Patients with NOSE-Perf evaluations ≥6 months following attempted perforation closure from July 2018 to December 2021 utilizing bilateral nasal mucosal flaps with an interposition graft were eligible for study inclusion. Change in NOSE-Perf scores were noted. Patient demographics, perforation size, and concurrent functional procedures were analyzed for impact on symptom outcomes.
Results One-hundred and seventeen patients met the study criteria. Seventy-nine (67.5%) of the patients were female and the mean (range) age at surgery was 47.3 (14–78) years. Repair failure was noted in 7 (6.0%) patients. Mean (SD) preoperative NOSE-Perf score was 25.3 (95% CI, 23.5–27.1) and postoperative score was 7.9 (95% CI, 6.5–9.3). Minimal clinically important difference (MCID) was estimated and greater than 91% of patients had improvement above this threshold. Patient age, perforation size, or concurrent functional procedures did not impact outcomes. Postoperative scores at short (2–4 months), intermediate (5–8 months), and long-term (≥9 months) time periods showed significant improvement (all p < 0.001) compared to preoperative NOSE-Perf scores.
Conclusion Significant reduction in nasal symptoms as measured by the NOSE-Perf scale is noted following bilateral mucosal flap repair. Although the nose does not completely normalize following repair, clinically important improvement was noted in at least 91% of patients. The NOSE-Perf scale is positioned to play a role in the standardization of septal perforation evaluation and outcomes assessment.
Level of Evidence4 Laryngoscope, 134:3067–3072, 2024

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"Association Between Vestibular Aqueduct Morphology and Menieres Disease"

Yan Huang, Ruowei Tang, Ning Xu, Heyu Ding, Wei Pu, Jing Xie, Zhenghan Yang, Yuhe Liu, Shusheng Gong, Zhenchang Wang, Pengfei Zhao

Publication date 17-06-2024


Our results showed that the morphological characteristics of the vestibular aqueduct, including a narrowed lumen and shortened length, may be related to Menieres disease (MD), as well as the degree of endolymphatic hydrops. These findings may be beneficial for investigating the pathogenesis of MD from an anatomical perspective.
Objective To investigate the relationship between vestibular aqueduct (VA) morphology and Menieres disease (MD) using ultrahigh-resolution computed tomography (U-HRCT).
Methods Retrospective data were collected from 34 patients (40 ears) diagnosed with MD in our hospital who underwent temporal bone U-HRCT with isotropic 0.05-mm resolution, magnetic resonance with gadolinium-enhanced, and pure-tone audiometry; 34 age- and sex-matched controls (68 ears) who underwent U-HRCT were also included. VA patency was qualitatively classified as locally not shown (grade 1), locally faintly shown (grade 2), or clearly shown throughout (grade 3). The width of the outer orifice and VA length and angle were quantitatively measured. Differences in VA morphology between the MD and control groups were analyzed. The correlations between VA morphology and the degrees of hearing loss and endolymphatic hydrops (EH) were also analyzed.
ResultsVA was classified as grades 1–3 in 11, 17, and 12 ears in the MD group and 5, 26, and 37 ears in the control group, respectively. The patency differed significantly between the groups (p < 0.01). The width of the outer orifice and length of VA were significantly smaller in the MD group than those in the control group (p < 0.05). Both VA patency and length were correlated with the degree of EH in the cochlea and the vestibule (p < 0.05). No difference was found between VA morphology and the degree of hearing loss (p > 0.05).
Conclusion The morphological characteristics of VA were found to be associated with the occurrence of MD and the degree of EH.
Level of Evidence4 Laryngoscope, 134:3349–3354, 2024

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Characterizing Long‐Term Swallowing and Voice Outcomes Following Anterior Transcervical Approach

Ahmed Toure, Audrey Abend, Rachel S. Lipsky, David I. Kutler

Publication date 17-06-2024


Objectives(1) Assess the frequency and severity of long-term swallowing and voice complaints, follow-up care, risk factors for the development of long-term swallowing and voice complications in patients who underwent anterior transcervical approach (ACA). (2) Determine incidence of long-term swallowing and voice complications requiring follow-up otolaryngologic care and assess the frequency of otolaryngologic follow-up for postoperative swallowing and voice complaints.
Methods Retrospective cohort study of patients between January 2017 and March 2020 who underwent ACA. Demographic information, data from preoperative evaluation, operative records, and data from postoperative visits were collected. Patients were contacted to complete the Eating Assessment Tool and the “Impairment” subset of the Voice Symptoms Scale.
ResultsA total of 48 patients (10.6%) followed up with a head and neck surgeon for swallowing complaints and 31 patients (6.8%) for voice complaints. Otolaryngology follow-up for swallowing complaints among patients with at least 3 and 12 months of follow-up was 16.4% and 17.8%, respectively. Otolaryngology follow-up for voice complaints among patients with at least 3 and 12 months of follow-up was 11.7% and 11.9%, respectively. Swallowing function was abnormal in 40.7% at least 3 months after surgery and in 41.8% 12 months after. Voice function was abnormal in 55.7% of respondents at least 3 months after surgery and in 54.5% of respondents 12 months after.
ConclusionsACA is associated with otolaryngologic complications that include dysphagia and dysphonia. This study demonstrates that long-term swallowing and voice dysfunction appear to persist longer than what is noted by patient utilization of follow-up otolaryngologic care.
Level of Evidence4 Laryngoscope, 134:3201–3205, 2024

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Efficacy of Adjuvant Sublingual Immunotherapy After Septomeatoplasty

Bing‐Han Hsieh, Yu‐Chun Kuo, Su‐Boon Yong, Hui‐Chi Tien, Chun‐chieh Hsu, Che‐Lun Hsu, Yung‐An Tsou, Chia‐Der Lin, Chih‐Jaan Tai, Jiu‐Yao Wang, Liang‐Chun Shih

Publication date 17-06-2024


Sublingual immunotherapy(SLIT) may serve as an ideal adjuvant therapy after septomeatoplasty in patients with allergic rhinitis (AR), providing beneficial effects within a short timeframe. SLIT may prevent recurrence of AR symptoms, especially sneezing.
Background The efficacy of adjuvant sublingual immunotherapy (SLIT) in correcting structural problems in patients with allergic rhinitis (AR) caused by mite who have undergone septomeatoplasty (SMP) has not been studied.
Methods This non-randomized controlled study recruited patients with AR (caused by mite) and concurrent septal deviation and inferior turbinate hypertrophy, at a tertiary hospital in Taiwan. SMP was performed on all patients as a surgical intervention.
The patients were then divided into two groups: the control group, which underwent surgery only, and the experimental group, which received SLIT as an adjuvant treatment. Demographic data and rhinitis control assessment test (RCAT) results were analyzed.
ResultsA total of 96 patients were enrolled in the study (SMP + SLIT group, n = 52; SMP only group, n = 44). No significant differences were observed in any of the variables between the two groups before and one month after surgery. However, during evaluations at the third and sixth month, the SMP + SLIT group showed significant improvement in the total RCAT scores compared to the SMP only group (28.6 ± 1.56 vs. 24.5 ± 3.66, p < 0.001; 27.1 ± 2.87 vs. 19.9 ± 5.56, p < 0.001). In addition, significantly better control of all RCAT sub-categories was observed in the SMP + SLIT group at the third and sixth month evaluations.
ConclusionsSLIT may serve as an ideal adjuvant therapy after SMP in patients with AR.
Level of Evidence3 Laryngoscope, 134:3073–3079, 2024

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Improving HPV‐Related Oropharyngeal Cancer Knowledge and HPV Vaccination Rates via Virtual Workshops

Lauran K. Evans, Shaghauyegh S. Azar, Haidee Chen, Miryam Saad, Sneha Subhash, Brooke M. Su‐Velez, Maie A. St. John

Publication date 17-06-2024


In the current epidemic of HPV+ oropharyngeal cancer, interactive and easily distributed virtual workshops can improve HPV vaccination rates by improving awareness of HPV-driven head and neck disease among primary care and dental trainees. Interprofessional collaboration and knowledge transfer involving otolaryngologists can enhance educational efforts among trainees in other fields, to improve HPV knowledge, attitudes, and vaccination rates.
Objective To validate the efficacy of a virtual, interdisciplinary workshop in improving HPV knowledge, and vaccination practices among primary care and dental trainees.
MethodsA virtual platform was utilized to hold HPV educational workshops with primary care and dental trainees. Online surveys were distributed before and after the 1-h interactive workshop, led by otolaryngology residents. Surveys included the workshops impact on (a) improving knowledge of HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) and (b) affecting change in HPV vaccination practices. The vaccination rates of trainees were recorded prior to and after workshop attendance.
Results After the workshop, participants demonstrated significantly improved scores related to knowledge of HPV in the head and neck (p = 0.003) and showed an increased comfort level with counseling on HPV vaccination (p = 0.002). Respondents were also more aware that the HPV vaccine is approved to prevent OPSCC (61% vs. 95%, p < 0.05). Ninety-seven percent of respondents stated that the workshop changed their HPV vaccination practices, and 95% of those not fully vaccinated stated they would now be more likely to receive the vaccine themselves. There was a significant increase in the average number of HPV vaccines administered at the studied trainee clinic, from 16.83 vaccines/month to 37.6 vaccines/month (percent increase = 123%) in 5 months following the workshop (p = 0.002).
Conclusion The present interactive virtual workshop demonstrates efficacy in improving HPV-related knowledge and vaccination practices among trainees. The virtual nature of the course facilitates knowledge transfer and can be used to foster multi-institutional partnerships regarding medical education and vaccination efforts.
Level of Evidence4 Laryngoscope, 134:3096–3101, 2024

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Comparison of Angiolytic Effects Between the 445‐nm Blue Laser and 532‐nm Pulsed KTP Laser

Duy Duong Nguyen, Jing‐Yin Pang, Daniel Novakovic

Publication date 17-06-2024


This study compared the selective absorption of the 445-nm Blue laser (BL) and the 532-nm pulsed potassium-titanyl-phosphate (KTP) laser by blood vessels. Results showed that, at long pulse width, BL appeared to perform better than KTP at high or low energy, but they were the same for medium energy. At medium pulse width, both performed similarly from high to medium energy but at lower energy, KTP appeared to perform better than BL.
Objective This study aimed to compare the selective absorption of the 445-nm Blue laser (BL) and the 532-nm pulsed potassium-titanyl-phosphate (KTP) laser by blood vessels.
Methods Thirty-six chicken eggs at day 14 of incubation were dissected to expose the chick chorioallantoic membrane (CAM). Third-order vessels of the CAM were identified and irradiated using BL and KTP lasers using various settings at a laser-to-vessel distance of 3 mm using 0.4 mm fiber size. In total, 494 vessels segments were irradiated. Mean (standard deviation) number of irradiations for each setting was 26.0 (4.6), range from 15 to 39. Outcome measures included ablation rate (AR) and rupture rate (RR).
Results The two lasers were compared for AR and RR at long and medium pulse width (PW) associated with different power levels. At long PW (above 100 ms), BL showed significantly higher AR than KTP at high energy (600 mJ/pulse) and low energy (400 mJ/pulse); they did not show different AR and RR at medium energy levels (500 mJ/pulse). Using medium PW settings plus high and medium energy levels, BL and KTP showed relatively high AR and did not significantly differ in performance. However, at medium PW plus low energy (400–450 mJ/pulse), KTP showed significantly higher AR compared to BL.
Conclusion At long PW, BL appeared to show higher AR than KTP at high or low energy levels, but they showed equivalent performance at medium energy. At medium PW, both performed similarly from high to medium energy, but KTP appeared to perform better than BL at lower energy settings.
Level of EvidenceNA Laryngoscope, 134:3220–3225, 2024

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Adjuvant Human Papillomavirus Vaccination in Recurrent Respiratory Papilloma Patients Older than 45

Ryan Ivancic, Taylor Freeman, Brad de Silva, Arick Forrest, Brandon Kim, Laura Matrka

Publication date 17-06-2024


Adjuvant Gardasil use in recurrent respiratory papillomatosis patients older than 45 years significantly reduces the intersurgical interval. Current CDC recommendations include only patients ages 9 to 45, but this study provides evidence that RRP patients outside this age range may benefit from adjuvant HPV vaccination.
Objectives The primary objective was to examine the intersurgical interval (ISI) of recurrent respiratory papillomatosis (RRP) in patients older than 45 years before and after a Gardasil vaccination series.
Methods We conducted a retrospective chart review of adult patients >45 years of age diagnosed with RRP from 2012 to 2022. Patients were excluded if they did not receive at least two doses of the Gardasil vaccine series or if they underwent two or fewer surgeries during the study period.
Results Thirteen patients met the inclusion criteria, 11 males and two females. The age at initial diagnosis ranged from 46 to 80 years, with a mean of 59 years. There was a significant increase in the average ISI, from 126 ± 87 days pre-vaccination compared to 494 ± 588 days post-vaccination (p < 0.01). The average number of surgeries per patient was 6.8 ± 2.4 over an average follow-up of 49.7 ± 30.3 months.
Conclusion Adjuvant Gardasil use in RRP patients older than 45 years significantly increases the ISI. Current CDC recommendations include only patients ages 9 to 45, but this study provides evidence that RRP patients outside this age range may benefit from adjuvant HPV vaccination.
Level of Evidence4 Laryngoscope, 134:3226–3229, 2024

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Depth of Invasion Assessment in Laryngeal Glottic Carcinoma: A Preoperative Imaging Approach for Prognostication

Marta Filauro, Simone Caprioli, Paola Lovino Camerino, Claudio Sampieri, Cristina Conforti, Andrea Iandelli, Pietro Benzi, Giulia Gabella, Elisa bellini, Francesco Mora, Giuseppe Cittadini, Giorgio Peretti, Filippo Marchi

Publication date 17-06-2024


Depth of invasion has proven to be an important prognosticator in several head and neck cancers but there is a lack of evidence for laryngeal carcinoma. This study demonstrates that depth of invasion is significantly associated with other pathological risk factors and the presence of nodal metastasis. The feasibility of reliably measuring the depth of invasion preoperatively using imaging is also explored.
Objective The prognostic value of depth of invasion (DOI) in oral squamous cell cancer carcinoma and cutaneous melanoma is well established, while there is a lack of reports investigating the role of DOI in laryngeal cancer. This study aims to explore the association of glottic cancer DOI with other established pathological risk factors and nodal metastasis and evaluate the feasibility of measuring DOI preoperatively using tomographic imaging.
Methods The medical records of glottic cancer patients treated between 2015 and 2020 in a single tertiary referral center were screened retrospectively. Pathologically measured DOI (pDOI) value was also reviewed and registered. Preoperative computer tomography (CT) was used to obtain the radiological DOI (rDOI) measured by two dedicated radiologists. Their inter-rated agreement was assessed and the correlation between pDOI and rDOI was calculated. pDOI association with the main pathology report features was assessed with univariable analysis. Cox univariable and multivariable models were used to explore the role of pDOI on survival.
Results Ninety-one patients had pDOI data available, of which 59 also had rDOI data. A strong concordance between the two radiologists was found (concordance correlation coefficient = 0.96); rDOI and pDOI were highly and significantly correlated (R = 0.85; p < 0.001). pDOI was significantly higher in patients with perineural invasion (PNI; p < 0.001), lymphovascular invasion (LVI; p < 0.001), and nodal metastasis (p < 0.001). pDOI was associated with disease-free survival at univariable analysis (p = 0.04) while it did not show a significant impact (p = 0.10) at multivariable analysis.
Conclusion Glottic carcinoma DOI correlates with PNI, LVI, and nodal metastasis and it can be reliably assessed in a preoperative setting using CT imaging.
Level of Evidence3 Laryngoscope, 134:3230–3237, 2024

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"Systemic Bevacizumab for Recurrent Respiratory Papillomatosis: A Single Institutions Experience"

Raymond J. So, Christopher Rayle, Henry H. Joo, Emily Y. Huang, Tanguy Y. Seiwert, Eric H. Raabe, Simon R. Best

Publication date 17-06-2024


Adjuvant agents to limit disease recurrence and thereby decrease surgical frequency are critically needed in the management for recurrent respiratory papillomatosis (RRP). In this study, we show that systemic bevacizumab is effective in reducing the number of surgeries needed for RRP while exhibiting a relatively safe complication profile. Papillomas in the larynx and trachea are most responsive to systemic bevacizumab, while pulmonary RRP is most likely to exhibit a partial-to-stable response.
Objectives Medical therapies to limit disease recurrence are critically needed for recurrent respiratory papillomatosis (RRP). Systemic bevacizumab is emerging as an exciting adjuvant therapy toward this end, but uptake has been poor due to the lack of experience and awareness of best prescribing practices. The objective of this study was to describe a single tertiary care academic medical centers experience using systemic bevacizumab for the treatment of RRP.
MethodsA retrospective review was performed to identify patients with RRP on systemic bevacizumab. Demographic and clinical characteristics, findings on imaging reports, and disease response at all anatomic subsites involved in papilloma were documented.
Results Of the 17 RRP patients on systemic bevacizumab, 9 (52.9%) were male, and 12 (70.6%) were diagnosed with juvenile-onset RRP. The total lifetime number of surgeries was high, with more than half (n = 9; 52.9%) undergoing more than 50 surgeries. Following induction of systemic bevacizumab, a significant reduction in patients with laryngeal (n = 15; 94.1% vs. n = 7; 41.2%, p < 0.001) and tracheal (n = 11; 64.7% vs. n = 5; 29.4%, p = 0.04) RRP was noted. Surgical frequency was significantly lower following systemic bevacizumab (2.5 vs. 0.5 surgeries per year; p < 0.001). The most common complications were new-onset hypertension (n = 4; 23.5%) and proteinuria (n = 5; 29.4%).
Conclusion Systemic bevacizumab is effective in reducing the number of surgeries needed for RRP while exhibiting a relatively safe complication profile. Papillomas in the larynx and trachea are most responsive to systemic bevacizumab, while pulmonary RRP is most likely to exhibit a partial-to-stable response.
Level of Evidence4 Laryngoscope, 134:3253–3259, 2024

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Analyzing Vocal Fold Frequency Dynamics Using High‐Speed 3D Laser Video Endoscopy

Rita R. Patel, Michael Döllinger, Bernhard Jakubaß, Hanna Pinhack, Ute Katz, Marion Semmler

Publication date 17-06-2024


The study provides new data on absolute measurements of vocal fold surface dynamics using a clinical 3D laser endoscope coupled with high-speed videoendoscopy. We report changes in the lateral and vertical vibratory motion along the anterior, middle, and posterior sections of the vocal folds as a function of vocal frequency changes. Overall, the superior surface vertical motion of the vocal fold is greater compared to the lateral motion, highlighting the importance of assessing the vertical motion of the superior surface to understand dynamic voice production.
Objective To examine changes in lateral and vertical vibratory motion along the anterior, middle, and posterior sections of the vocal folds, as a function of vocal frequency variations.
Methods Absolute measurements of vocal fold surface dynamics from high-speed videoendoscopy with custom laser endoscope were made on 23 vocally healthy adults during sustained /i:/ production at 10%, 20%, and 80% of pitch range. The 3D parameters of amplitude (mm), maximum velocity opening/closing (mm/s), and mean velocity opening/closing (mm/s) were computed for the lateral and vertical vibratory motion along the anterior, middle, and posterior sections of the vocal folds. Linear mixed model analysis was conducted to evaluate the differences in (a) vocal frequency levels (high vs. normal vs. low pitch), (b) axis level (vertical vs. lateral), (c) position level (anterior vs. middle vs. posterior), and (d) gender differences (male vs. female).
Results Overall, the superior surface vertical motion of the vocal fold is greater compared with the lateral motion, especially in males. Along the superior surface, the mean and maximum closing velocities are greater posteriorly for low pitch. The location (anterior, middle, and posterior) along the superior surface is relevant only for vocal fold closing rather than opening, as the dynamics are different along the various locations.
Conclusions The study highlights the significance of assessing the vertical motion of the superior surface of the vocal fold to understand the complex dynamics of voice production.
Level of EvidenceNA Laryngoscope, 134:3267–3276, 2024

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Impact of Hypoglossal Nerve Stimulation on Consumer Sleep Technology Metrics and Patient Symptoms

Yi Cai, Yixuan James Zheng, Chloe M. Cheng, Kingman P. Strohl, Ashley E. Mason, Jolie L. Chang

Publication date 17-06-2024


In OSA patients well-established on hypoglossal nerve stimulator therapy, a 1-week therapy withdrawal period led to worsened sleep symptom scores. In this pilot study of seven participants, changes in OSA-related sleep symptoms correlated with select sleep-related metrics, as measured by a wearable consumer sleep technology.
Objectives Obstructive sleep apnea (OSA) is usually assessed at discrete and infrequent timepoints. Wearable consumer sleep technologies (CST) may allow for more granular and longitudinal assessments of OSA therapy responses and OSA-related symptoms.
Methods In this case series, we enrolled hypoglossal nerve stimulator (HGNS) patients who had an effective treatment response for an 8-week study using a wearable CST. Participants started with “HGNS-on,” were randomized to turn off HGNS therapy during either week 4 or 5 (“HGNS-off”), followed by a return to therapy, “HGNS-resume.” Participants completed validated symptom questionnaires assessing sleepiness, insomnia symptoms, functional status, and overall sleep health (Satisfaction, Alertness, Timing, Efficiency, and Duration, SATED) each week. CST metrics and survey scores were compared between HGNS treatment phases. Associations between CST metrics and survey scores were assessed.
Results Seven participants with a total of 304 nights of CST data showed no statistically significant changes in total sleep time (TST), wake time after sleep onset, or sleep efficiency (SE) across the study periods. During HGNS-off, survey scores indicated significantly worsened OSA-related symptom scores. Two participants had significantly higher heart rate variability (HRV) during HGNS-off (by 3.3 and 6.3 ms) when compared to HGNS active therapy periods. Amongst CST metrics, SATED scores correlated with TST (r = 0.434, p < 0.0001), HRV (r = −0.486, p < 0.0001), and SE (r = 0.320, = 0.0014). In addition, FOSQ-10 scores correlated with average HR during sleep (r = −0.489, p < 0.001).
ConclusionA 1-week HGNS therapy withdrawal period impacted OSA-related sleep symptoms. Sleep-related metrics measured by a wearable CST correlated with symptom scores indicating potential value in the use of CSTs for longitudinal sleep-tracking in OSA patients.
Level of Evidence4 Laryngoscope, 134:3406–3411, 2024

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Assessing Facial Palsy: Does Feedback Improve Assessment Using the eFACE and Sunnybrook Facial Grading System?

Tessa E. Bruins, Romy F. Lammens, Martinus M. van Veen, Katalin Tamási, Pieter U. Dijkstra, Paul M.N. Werker, Dieuwke C. Broekstra

Publication date 17-06-2024


Several assessment instruments for grading facial function are available, of which the eFACE and the Sunnybrook Facial Grading System (Sunnybrook) are commonly used. Currently, it is unknown how much training users should receive before being able to adequately assess facial palsy using these two instruments. In this study it was found that the eFACE was easier to learn than the Sunnybrook.
Objective(s)To explore learning effects when applying the clinician-graded electronic facial function scale (eFACE) and the Sunnybrook Facial Grading System (Sunnybrook).
Methods Surgeons, facial rehabilitation therapists, and medical students were randomly allocated to the eFACE (n = 7) or Sunnybrook (n = 6) and graded 60 videos (Massachusetts Eye and Ear Infirmary open-source standard set); 10 persons with normal facial function and 50 patients with a wide variation of facial palsy severity. Participants received an introduction and individual feedback after each set of 10 videos. Scores were compared to the reference score provided with the set. Multilevel analysis was performed to analyze learning effect.
ResultsA learning effect was only found for the eFACE, with significant difference scores in set 1 and 2 compared to set 6, and no significant difference scores in the following sets. The difference score was associated with the reference score (severity of facial palsy) for eFACE (β = −0.19; SE = 0.04; p < 0.001) and Sunnybrook (β = −0.15; SE = 0.04; p < 0.001). Age of participants was also associated with the difference score in the eFACE group (β = 0.18; SE = 0.03; p < 0.001). No differences in scores were found between groups of participants.
Conclusion The eFACE showed a learning effect of feedback while the Sunnybrook did not.
Level of EvidenceNA Laryngoscope, 134:3105–3111, 2024

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"Cluster Analysis to Identify Clinical Subtypes of Ménières Disease"

John Phillips, Louisa Murdin, Mizanur Khondoker, Kelly Grant, Lee Shepstone, Erika Sims, Peter Rea, Jonny Harcourt

Publication date 17-06-2024


This article outlines the process undertaken to identify clinical subtypes of Ménières disease. Two distinct clinical subtypes of Menieres disease were identified.
Objective To identify distinct clinical subtypes of Ménières disease by analyzing data acquired from a UK registry of patients who have been diagnosed with Ménières disease.
Study Design Observational study.
Methods Patients with Ménières disease were identified at secondary/tertiary care clinics. Cluster analysis was performed by grouping participants sharing similar characteristics and risk factors into groups based on a defined measure of similarity.
ResultsA total of 411 participants were recruited into this study.
Two main clusters were identified: participants diagnosed with ear infections (OR = 0.30, p < 0.014, 95% CI: 0.11–0.78) were more likely to be allocated in Cluster 1 (C1). Participants reporting tinnitus in both ears (OR = 11.89, p < 0.001, 95% CI: 4.08–34.64), low pitched tinnitus (OR = 21.09, p < 0.001, 95% CI: 7.47–59.54), and those reporting stress as a trigger for vertigo attacks (OR = 14.94, p < 0.001, 95% CI: 4.54–49.10) were significantly more likely to be in Cluster 2 (C2). Also, participants diagnosed with Benign Paroxysmal Positional Vertigo (OR = 13.14, <0.001, 95% CI: 4.35–39.74), autoimmune disease (OR = 5.97, p < 0.007, 95% CI: 1.62–22.03), depression (OR = 4.72, p < 0.056, 95% CI: 0.96–23.24), migraines (OR = 3.13, p < 0.008, 95% CI: 1.34–7.26), drug allergy (OR = 3.25, p < 0.029, 95% CI: 1.13–9.34), and hay fever (OR = 3.12, p < 0.009, 95% CI: 1.33–7.34) were significantly more likely to be clustered in C2.
Conclusions This study supports the hypothesis that Ménières disease is a heterogeneous condition with subgroups that may be identifiable by clinical features. Two main clusters were identified with differing putative etiological factors.
Level of Evidence3 Laryngoscope, 134:3286–3292, 2024

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Relevant Research of Inflammatory Cytokines Spectrum in Peripheral Blood of Sudden Hearing Loss

Xinyuan Tan, Jing Pan, Jieqing Cai, Shanshan Jiang, Fan Shu, Muqing Xu, Hua Peng, Jie Tang, Hongzheng Zhang

Publication date 17-06-2024


This study used appropriate statistical methods to screen for inflammatory cytokines associated with the pathogenesis of SHL, to analyze their network correlation, and to analyze the relationship between clinical features of SHL and inflammatory cytokines. We found that inflammatory microenvironment composed of multiple cytokines, including IL-1β, is a risk factor for the development of SHL.
Objective To investigate whether there is a correlation between the inflammatory state and the pathogenesis and clinical features of sudden hearing loss (SHL) by studying the expression of inflammation-related cytokines in the peripheral blood of patients with SHL.
Methods In this work, we analyzed the cytokine profiles of 48 analytes in 38 patients with SHL compared to 38 healthy donors using a multiplex immunoassay. This study used appropriate statistical methods to screen for inflammatory cytokines associated with the pathogenesis of SHL, to analyze their network correlation, and to analyze the relationship between clinical features of SHL and inflammatory cytokines.
Results Several cytokines, including CTACK, Eotaxin, HGF, INF-α2, IFN-β, IL-1β, IL-1ra, IL-2Rα, IL-4, IL-7, IL-8, IL-9, IL-10, IL-12(p40), IL-13, MIG, β-NGF, SCF, and TNF-α, exhibited significantly higher levels in the peripheral blood of the SHL group compared to the control group. An inflammatory network composed of multiple cytokines, including IL-1β, is a risk factor for the development of SHL.
Conclusion This study identified several inflammatory cytokines with elevated expression, which may be linked with the onset of SHL. The results of this study also provide a basis for the theoretical hypothesis of inflammation in SHL.
Level of Evidence3 Laryngoscope, 134:3293–3301, 2024

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Evaluating Quality, Credibility, and Readability of Online Over‐the‐Counter Hearing Aid Information

Veranca Shah, Christian X. Lava, Amir A. Hakimi, Michael Hoa

Publication date 17-06-2024


Objective With over-the-counter hearing aids being recently approved by the United States Food and Drug Administration, the accuracy and usefulness of online information has not yet been examined. This study evaluates the quality, credibility, readability, and accessibility of online over-the-counter hearing aids education materials.
Methods Google was queried using the search term “over-the-counter hearing aids”. The top 50 results were categorized into healthcare versus non-healthcare authored resources. The Flesch Reading Ease Score (FRES) and Flesch–Kincaid Grade Level (FKGL) tests were utilized to assess readability, whereas the Currency, Relevance, Authority, Accuracy, and Purpose (CRAAP) test and DISCERN instruments were used to assess quality and credibility. The number of clicks taken to access relevant information on each website was used to assess accessibility.
Results There was no significant difference in FRES or FKGL readability scores between healthcare and non-healthcare authored websites (p = 0.5548, p = 0.5981, respectively), but both readability scores were higher than that of the recommended reading level for patient education materials. There was no significant difference in CRAAP and DISCERN scores between both groups (p = 0.5746, p = 0.1699, respectively). The number of clicks did not significantly differ between healthcare and non-healthcare authored resources (p = 0.4932).
Conclusion This study highlights poor readability and accessibility of virtual healthcare information regarding OTC hearing aids. Although credibility in articles authored by healthcare and non-healthcare professionals was adequate, readability was greatly compromised due to the written information exceeding the recommended United States reading level. Accessibility posed a similar issue, as many sites required multiple clicks to access product information.
Level of EvidenceNA Laryngoscope, 134:3302–3309, 2024

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Economic Burden of Induced Laryngeal Obstruction in Adolescents and Children

Robert Brinton Fujiki, Tadeas Lunga, David O. Francis, Susan L. Thibeault

Publication date 17-06-2024


This study examined the financial burden associated with the diagnosis and treatment of induced laryngeal obstruction (ILO) in pediatric patients. The costs of ILO were significant, averaging $6486.93 prior to diagnosis. Pharmaceutical, procedure/office visit, and indirect costs significantly decreased following diagnosis. The source of these costs differed according to socioeconomic status.
Purpose Diagnosing pediatric induced laryngeal obstruction (ILO) requires equipment typically available in specialist settings, and patients often see multiple providers before a diagnosis is determined. This study examined the financial burden associated with the diagnosis and treatment of ILO in pediatric patients with reference to socioeconomic disadvantage.
Methods Adolescents and children (<18 years of age) diagnosed with ILO were identified through the University of Madison Voice and Swallow Outcomes Database. Procedures, office visits, and prescribed medications were collected from the electronic medical record. Expenditures were calculated for two time periods (1) pre-diagnosis (first dyspnea-related visit to diagnosis), and (2) the first year following diagnosis. The Area Deprivation Index (ADI) was used to estimate patient socioeconomic status to determine if costs differed with neighborhood-level disadvantage.
ResultsA total of 113 patients met inclusion criteria (13.9 years, 79% female). Total pre-diagnosis costs of ILO averaged $6486.93 (SD = $6604.14, median = $3845.66) and post-diagnosis costs averaged $2067.69 (SD = $2322.78; median = $1384.12). Patients underwent a mean of 3.01 (SD = 1.9; median = 2) procedures and 5.8 (SD = 4.7; median = 5) office visits prior to diagnosis. Pharmaceutical, procedure/office visit, and indirect costs significantly decreased following diagnosis. Patients living in neighborhoods with greater socioeconomic disadvantage underwent fewer procedures and were prescribed more medication than those from more affluent areas. However, total expenditures did not differ based on ADI.
Conclusions Pediatric ILO is associated with considerable financial costs. The source of these costs, however, differed according to socioeconomic advantage. Future work should determine how ILO diagnosis and management can be more efficient and equitable across all patients. Laryngoscope, 134:3384–3390, 2024

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Application of Platysma Myocutaneous Flap in Surgical Repair after T2‐3 Glottic Carcinoma Resection

Wenying Zhu, Haifeng Liang, Faya Liang, Renhui Chen, Shibei Zheng, Wenting Liang, Zhong Guan, Qian Cai

Publication date 17-06-2024


In this study, the repair effects of the platysma myocutaneous flap (PMF) and ribbon myocutaneous flap (RMF) on postoperative voice quality of patients were compared to provide a reference for selecting a repair method conducive to improving postoperative voice quality. We found that the PMF group was superior to the RMF group for voice quality assessed by voice acoustics, aerodynamics, and subjective perceptual evaluation. The PMF can provide more tissue (including ribbon muscle under the flap) for padding; therefore, supraglottic compression rarely occurs, and the reconstructed glottic closure is improved after PMF repair. Moreover, the cortical adipose tissue of the PMF can function as the Reinkes space of the vocal cord, and thus, the cortex can produce good vibration during pronunciation, with PFVWs generated in some patients, thereby achieving good voice quality after surgery.
Objective Numerous methods and materials are available for vertical partial laryngectomy. In this study, the reparative effects of the platysma myocutaneous flap (PMF) and ribbon myocutaneous flap (RMF) on the postoperative voice quality of patients were compared to provide a reference for selecting a method conducive to improving postoperative voice quality.
MethodsA retrospective analysis was performed on patients with unilateral T2-3 glottic carcinoma. Following vertical partial laryngectomy, the defect was repaired with a PMF or simple RMF. Twelve months after surgery, voice quality was assessed according to voice acoustics, aerodynamics, and subjective perceptual evaluation, and glottic morphology was recorded using a laryngeal stroboscopy.
ResultsA total of 70 patients were identified, including 54 in the PMF group and 16 in the RMF group. The PMF group was superior to the RMF group in terms of voice quality assessed by voice acoustics, aerodynamics, and subjective perceptual evaluation. In the PMF group, 72.2% of patients performed phonation with their vocal cords, and approximately 27.8% of patients were affected by supraglottic compression. In the RMF group, 81.3% of patients were affected by supraglottic compression. No significant difference was found in the 5-year survival rate between the two groups.
Conclusion For defect repair following vertical partial laryngectomy, a PMF can allow better postoperative voice quality to be achieved than an RMF because a PMF can provide more tissue (including strap muscle under the flap) for padding, which enables the glottic portion corresponding to the vocal cord to close well.
Level of Evidence3 Laryngoscope, 134:3181–3186, 2024

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The Impact of Four Smoking Metrics on Survival After Diagnosis with HPV+ Oropharyngeal Cancer

Sarah G. Wilkins, Rema Shah, Conrad W. Safranek, Hemali P. Shah, Saral Mehra

Publication date 17-06-2024


Tobacco use is traditionally understood to be a negative prognostic factor in HPV+ oropharyngeal cancer. Herein, we show that tobacco use plays a reduced role in outcomes for our institutional cohort. This finding could suggests that the risk from smoking may vary with other cohort-specific factors or that smoking may be declining in importance as rates of tobacco use decrease.
Objective While tobacco use is understood to negatively impact HPV+ oropharyngeal squamous cell carcinoma (OPSCC) outcomes, debate remains as to how this impact differs between cohorts. Multiple smoking metrics have been identified as having the greatest prognostic significance, and some recent works have found smoking to have no significant impact. Herein, we show through an analysis of four common smoking metrics that while smoking impacts overall survival (OS), it has a limited impact on recurrence-free survival (RFS) in our cohort.
Methods We conducted a retrospective review of patients treated for HPV+ OPSCC in our health system from 2012 to 2019. Patients with metastatic disease or concurrent second primaries were excluded.
Four metrics of tobacco use were assessed: current/former/never smokers, ever/never smokers, and smokers with >10 or >20 pack-year (PY) smoking histories. Our main outcomes were 3-year RFS and OS.
Results Three hundred and sixty-seven patients met inclusion criteria. 37.3% of patients (137/367) were never-smokers; 13.8% of patients (51/367) were currently smoking at diagnosis and 48.8% of patients (179/367) were former smokers. No tobacco-use metric significantly impacted 3-year RFS. On univariate analysis, all smoking metrics yielded inferior OS. On multivariate analysis, current and ever smoking status significantly impacted 3-year OS.
Conclusion The impact of tobacco use on HPV+ OPSCC outcomes is not universal, but may instead be modulated by other cohort-specific factors. The impact of smoking may decrease as rates of tobacco use decline.
Level of Evidence3 (Cohort and case–control studies) Laryngoscope, 134:3158–3164, 2024

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Noninvasive Treatment of Venous Pulsatile Tinnitus with an Internal Jugular Vein Compression Collar

Benjamin Succop JR, Nicholas J. Thompson, Matthew M. Dedmon, Aaron Gelinne, Anne Selleck, Samuel Reed, MAJ Brian D. Sindelar

Publication date 17-06-2024


20 participants with venous pulsatile tinnitus achieved a median 50% reduction in symptom intensity when wearing an FDA approved internal jugular vein compression collar. These collars provided a novel symptomatic treatment for this population of patients.
Objective The study was conducted to evaluate the safety and efficacy of mild internal jugular (IJV) compression via an FDA approved compression collar for symptomatic treatment of venous pulsatile tinnitus.
Methods This is a prospective study that recruited 20 adult patients with venous pulsatile tinnitus. Participants completed the Tinnitus Handicap Inventory (THI), were fitted with the collar, and rated symptom intensity on a 10-point tinnitus intensity scale before and during collar use. Once weekly for 4 weeks, they answered a survey quantifying days used, average tinnitus intensity before and after wearing the collar each day of use, and any safety concerns. Lastly, they completed an exit interview. The primary outcome was symptomatic relief, with secondary outcomes of safety, effect of treatment setting, effect of time, and quality of life assessed via nonparametric testing.
Results18 participants completed the study, and 276 paired daily before use/during use intensity scores were submitted. The median symptom intensity without the collar was 6 (IQR 4, 7), whereas with the collar it was 3 (IQR 2, 5), for a median symptomatic relief of 50%. The collar had a significant effect in reducing symptom intensity (p < 0.0001) and burden of illness via the THI (p < 0.0001). There was no effect of setting, frequency, or time on symptomatic relief with the collar. There were no adverse safety events reported aside from minor discomfort upon initial application.
Conclusions Venous compression collars offer acute symptom relief for patients with venous pulsatile tinnitus. Further study is needed to assess safety and efficacy of longitudinal use.
Level of Evidence4 Laryngoscope, 134:3342–3348, 2024

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Gaze Patterns of Normal and Microtia Ears Pre‐ and Post‐Reconstruction

Steven Losorelli, Julia K. Chang, Kay W. Chang, Sam P. Most, Mai Thy Truong

Publication date 17-06-2024


We investigated normal and microtia ears as attentional gaze landmarks of the face. The ear received the most visual attention in the lateral view of the face. In close-up view of the ear, the concha received the greatest attention in comparison to all other auricular subunits for both normal and post-reconstruction microtia ears.
Objectives To understand attentional preferences for normal and microtia ears.
Methods Eye-tracking technology was used to characterize gaze preferences. A total of 71 participants viewed images of 5 patients with unilateral microtia. Profile images of patient faces and isolated ears including normal, microtia, and post-reconstruction microtia ears were shown. Total time of fixation in predefined areas of interest (AOI) was measured. Inferential statistics were used to assess significance of fixation differences between AOIs within and between facial or auricular features.
Results The ear received most visual attention in lateral view of the face (1.91 s, 1.66–2.16 s) mean, 95% CI, followed by features of the “central triangle”—the eyes (1.26 s, 1.06–1.46), nose (0.48 s, 0.38–0.58), and mouth (0.15 s, 0.15–0.20). In frontal view, microtia ears received less attention following surgical reconstruction (0.74 s vs. 0.4 s, p < 0.001). The concha was the most attended feature for both normal (2.97 s, 2.7–3.23) and reconstructed microtia ears (1.87 s, 1.61–2.13). Scars on reconstructed ears altered the typical visual scanpath.
Conclusion The ear is an attentional gaze landmark of the face. Attention to microtia ears, both pre- and post-reconstruction, differs from gaze patterns of normal ears. The concha was the most attended to subunit of the ear. Attentional gaze may provide an unbiased method to determine what is important in reconstructive surgery.
Level of EvidenceNA Laryngoscope, 134:3136–3142, 2024

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High‐Resolution Profiling of Human Vocal Fold Cellular Landscapes With Single‐Nuclei RNA Sequencing

Benjamin M. Laitman, Daniel Charytonowicz, Ashley J. Zhu, Katie Lynch, Eleni A. Varelas, Madeline Burton, Christina Andreou, Pragati Kore, Diana N. Kirke, Ya‐Wen Chen, Kristin G. Beaumont, Robert Sebra, Eric M. Genden, Mark S. Courey

Publication date 17-06-2024


This study evaluated the cellular heterogeneity of normal human vocal folds by utilizing single-nuclei RNA-sequencing. RNA sequencing revealed 18 global cell clusters. While many were of epithelial origin, expected cell types, such as fibroblasts, immune cells, muscle cells, and endothelial cells were present. Subcluster analysis defined unique epithelial, immune and fibroblast subpopulations.
Introduction The function of the vocal folds (VFs) is determined by the phenotype, abundance, and distribution of differentiated cells within specific microenvironments. Identifying this histologic framework is crucial in understanding laryngeal disease. A paucity of studies investigating VF cellular heterogeneity has been undertaken. Here, we examined the cellular landscape of human VFs by utilizing single-nuclei RNA-sequencing.
Methods Normal true VF tissue was excised from five patients undergoing pitch elevation surgery. Tissue was snap frozen in liquid nitrogen and subjected to cellular digestion and nuclear extraction. Nuclei were processed for single-nucleus sequencing using the 10X Genomics Chromium platform. Sequencing reads were assembled using cellranger and analyzed with the scanpy package in python.
ResultsRNA sequencing revealed 18 global cell clusters. While many were of epithelial origin, expected cell types, such as fibroblasts, immune cells, muscle cells, and endothelial cells were present. Subcluster analysis defined unique epithelial, immune, and fibroblast subpopulations.
Conclusion This study evaluated the cellular heterogeneity of normal human VFs by utilizing single-nuclei RNA-sequencing. With further confirmation through additional spatial sequencing and microscopic imaging, a novel cellular map of the VFs may provide insight into new cellular targets for VF disease.
Level of EvidenceNA Laryngoscope, 134:3193–3200, 2024

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Environmental Impact of a Direct Laryngoscopy: Opportunities for Pollution Mitigation

Grace I. Filley, Darpan Kayastha, Wesley Hayes, Saral Mehra, Jodi D. Sherman, Matthew J. Eckelman

Publication date 17-06-2024


We applied the environmental engineering method of life cycle assessment (the gold standard for modeling emissions of products and processes) to a common non-sterile surgical procedure—direct laryngoscopy. We aimed to estimate environmental impacts and identify simple opportunities for performance improvement. Solutions identified can be generalized to many different types of clean-contaminated surgery which, collectively, could reduce healthcares contribution to planetary disruption.
Objective To quantify the environmental impact of standard direct laryngoscopy surgery and model the environmental benefit of three feasible alternative scenarios that meet safe decontamination reprocessing requirements.
Study Design This is a life cycle assessment (LCA) modeling study.
Setting Yale-New Haven Hospital (YNHH), a 1541-bed tertiary medical center in New Haven, Connecticut, USA.
Methods We performed cradle-to-grave LCA of DLS at Yale New Haven Hospital in 2022, including global warming potential (GWP), water consumption, and fine particulate matter formation.
Three alternative scenarios were modeled: disinfecting surgical tools using high-level disinfection rather than steam sterilization, substituting non-sterile for sterile gloves and gowns; and reducing surgical towel and drape sizes by 30%.
Results Changes in disinfection practices would decrease procedure GWP by 11% in each environmental impact category. Substituting non-sterile gowns and gloves reduced GWP by 15%, with nominal changes to water consumption. Linen size reduction resulted in 28% less procedure-related water consumption. Together, a nearly 30% reduction across all environmental impact categories could be achieved.
Conclusions Not exceeding minimum Center for Disease Control (CDC) decontamination standards for reusable devices and optimizing non-sterile consumable materials could dramatically reduce healthcare-associated emissions without compromising safety, thereby minimizing the negative consequences of hospital operations to environmental and human health. Findings extend to other non-sterile surgical procedures.
Level of EvidenceNA Laryngoscope, 134:3206–3214, 2024

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A Benchtop Round Window Model for Studying Magnetic Nanoparticle Transport to the Inner Ear

Mukund M. Goyal, Sarek A. Shen, Mohamed Lehar, Angela Martinez, Hakim Hiel, Canhui Wang, Yulin Liu, Chao Wang, Daniel Q. Sun

Publication date 17-06-2024


We designed a benchtop model for investigating transport mechanics of magnetic nanoparticles across the round window membrane. Delivery of these particles increases by 40% with application of an external magnetic field gradient, and the mechanism of transport across the membrane appears to be mediated by active cellular processes.
Introduction The round window membrane (RWM) presents a significant barrier to the local application of therapeutics to the inner ear. We demonstrate a benchtop preclinical RWM model and evaluate superparamagnetic iron oxide nanoparticles (SPIONs) as vehicles for magnetically assisted drug delivery.
Methods Guinea pig RWM explants were inset into a 3D-printed dual chamber benchtop device. Custom-synthesized 7-nm iron core nanoparticles were modified with different polyethylene glycol chains to yield two sizes of SPIONs (NP-PEG600 and NP-PEG3000) and applied to the benchtop model with and without a magnetic field. Histologic analysis of the RWM was performed using transmission electron microscopy (TEM) and confocal microscopy.
Results Over a 4-h period, 19.5 ± 1.9% of NP-PEG3000 and 14.6 ± 1.9% of NP-PEG600 were transported across the guinea pig RWM. The overall transport increased by 1.45× to 28.4 ± 5.8% and 21.0 ± 2.0%, respectively, when a magnetic field was applied. Paraformaldehyde fixation of the RWM decreased transport significantly (NP-PEG3000: 7.6 ± 1.5%; NP-PEG600: 7.0 ± 1.6%). Confocal and electron microscopy analysis demonstrated nanoparticle localization throughout all cellular layers and layer-specific transport characteristics within RWM.
Conclusion The guinea pig RWM explant benchtop model allows for targeted and practical investigations of transmembrane transport in the development of nanoparticle drug delivery vehicles. The presence of a magnetic field increases SPION delivery by 45%–50% in a nanoparticle size- and cellular layer-dependent manner.
Level of EvidenceNA Laryngoscope, 134:3355–3362, 2024

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Perceptions and Understanding of Transgender Patient Care: A Survey of Practicing Laryngologists

Megan Swonke, Jeremy Barr, Ella Brissett, Adriana Ordonez, Tariq Syed, Apurva Thekdi

Publication date 17-06-2024


Transgender individuals face significant health disparities. Laryngologists play a key role in gender-affirmation care. This is the first survey to assess educational experience and state of transgender care among practicing US-based laryngologists. We attempt to spotlight the degree by which practicing laryngologists are familiar, competent, and comfortable with transgender care.
Objectives Transgender individuals face significant health disparities including deficiencies in physician education, knowledge, and comfort with transgender health care. As the prevalence of the transgender population increases more individuals may seek gender-affirming surgery. Herein, we present a survey study which presents data on (1) the current practice patterns, (2) the familiarity with, (3) the perception of, and (4) the future educational goals of transgender health care among laryngologists in the United States.
MethodsA cross-sectional survey study of practicing laryngologists in the United States.
ResultsA total of 53 laryngologists participated in the study, with 50 (94.3%) coming from an academic practice. Survey response rate was 32.3% (54/167). The number of patients cared for and surgeries performed were significantly associated with self-perceived overall competence (p < 0.001 and p < 0.001), surgical competence (p = 0.013 and p < 0.001), and comfort counseling patients on gender-affirming surgeries (p < 0.001 and p < 0.001). Most obtained training through real-world experience (n = 46, 86.8%), whereas only 11 (20.7%) had formal training in residency or fellowship. Although 37 (70%) of participants felt competent caring for transgender patients, 38 (72%) want to learn more about transgender care, and 49 (93%) support incorporating transgender care into otolaryngology residency/fellowship curricula.
Conclusion There is a need for an increased awareness of transgender healthcare issues to address disparities experienced by this diverse population. Many laryngologists report wanting to learn more about this developing part of our field and support incorporating transgender care into training. We attempt to spotlight the degree by which practicing laryngologists are familiar, competent, and comfortable with transgender care.
Level of Evidence5 Laryngoscope, 134:3215–3219, 2024

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Patient Sex Mediates the Influence of Patient Age on Superior Canal Dehiscence Repair Outcome

Hong‐Ho Yang, Isaac Yang, Quinton S. Gopen

Publication date 17-06-2024


In this cohort study of 402 SCD repairs, older age predicted poorer symptomatic response among females but not did not predict symptomatic response among males. Older age predicted more severe high-frequency hearing loss following surgery regardless of sex.
Objective To investigate the independent and interactive effects of patient age and sex on superior canal dehiscence (SCD) repair outcomes.
Methods This was a cohort study of consecutive SCD repairs via the middle fossa approach at an institution between 2011 and 2022. We constructed multivariable regression models assessing surgical outcomes with age and sex as the primary predictors. Models controlled for surgery duration, follow-up duration, and relevant surgical and medical history. Subsequently, we repeated each model with the incorporation of an interaction term between patient age and sex.
Results Among 402 repairs, average age was 50 years, and 63% of cases were females. There was a significant interaction between patient age and sex with respect to symptom resolution score (SRS) (adj. β 0.80, 95% C.
I. 0.04–1.56). Older age was associated with lower SRS among females (−0.84, −1.29 to −0.39 point per year) but not significantly associated with SRS among males (0.04, −0.65 to 0.56 point per year). Furthermore, older age independently predicted a greater magnitude of increase in air conduction at 8000 Hz following surgery regardless of sex (adj. β 2.1, 0.2–4.0 dB per 10-year increase).
Conclusions This is the first study on the interactive effect between patient age and sex with respect to SCD repair outcomes. Older age predicted poorer symptomatic response among female patients but did not predict symptomatic response among male patients. Furthermore, older age predicted more severe high-frequency hearing loss following SCD repairs among both female and male patients.
Level of Evidence3 Laryngoscope, 134:3363–3370, 2024

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Quantification and Functional Studies of Neutrophilic Cells Identifies Distinct Papilloma Phenotypes

Ke Bai, Paul E. Clavijo, Yvette Robbins, Scott M. Norberg, Clint T. Allen

Publication date 17-06-2024


This work characterizes patterns of neutrophilic cell accumulation in respiratory papillomas from adult patients with RRP. Ex vivo functional assays demonstrate that papilloma infiltrating neutrophilic cells are immunosuppressive. This provides the scientific rationale for attempting to inhibit neutrophilic cell infiltration or function with the aim of improving local immunity within papillomas.
Objectives To characterize the distribution of immune cell subsets within laryngeal papillomas and to study the function of potentially immunosuppressive neutrophilic and regulatory T cells (Tregs).
Methods Fresh clinical papilloma specimens were collected at the time of surgery and studied with multiparameter flow cytometry. Papilloma infiltrating neutrophilic cells and Tregs were sorted and studied functionally with ex vivo T cell suppression assays.
Results Flow cytometric analysis of fresh laryngeal papillomas samples from 18 adult patients with recurrent respiratory papillomatosis revealed patterns in immune constituency between patients. Clearly divergent phenotypes based primarily on the degree of neutrophilic and T cell infiltration were identified. Relative neutrophilic cell enrichment and T cell depletion were observed in 50% of samples and neutrophilic cell depletion and T cell enrichment were observed in the others. Greater papilloma neutrophilic cell enrichment was positively associated with the number of clinically indicated interventions required in the 12 months prior to sample collection, linking papilloma neutrophil inflammation to disease severity. Functional assays revealed the ability of both papilloma infiltrating neutrophilic and Tregs to suppress T cell function at roughly equal magnitudes, but substantially increased infiltration of neutrophilic cells compared to Tregs across samples.
Conclusion Neutrophilic cells are an important contributor to immunosuppression within the respiratory papilloma microenvironment. Given these data and the association between greater neutrophilic cell infiltration and lack of clinical response to therapeutic vaccination, additional study of strategies aimed at limiting neutrophilic cell infiltration or function within papillomas is warranted.
Level of Evidence4 Laryngoscope, 134:3238–3244, 2024

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Similarity Network Analysis of the Adaptive Immune Response in the Proximal Airway

Evan Clark, Edward Ryan R Talatala, Wenda Ye, Ruth J Davis, Samuel L Collins, Alexander T Hillel, Marisol Ramirez‐Solano, Quanhu Sheng, Celestine N Wanjalla, Simon A Mallal, Alexander Gelbard

Publication date 17-06-2024


Dominant T cell clones are present throughout the airway mucosa and are not unique to subglottic stenosis scar tissue. When investigating the non-dominant clones, there are several conserved antigen targets observed in distinct iSGS patients.
Objectives Recent immunologic study of the adaptive immune repertoire in the subglottic airway demonstrated high-frequency T cell clones that do not overlap between individuals. However, the anatomic distribution and antigenic target of the T cell repertoire in the proximal airway mucosa remain unresolved.
Methods Single-cell RNA sequencing of matched scar and unaffected mucosa from idiopathic subglottic stenosis patients (iSGS, n = 32) was performed and compared with airway mucosa from healthy controls (n = 10). T cell receptor (TCR) sequences were interrogated via similarity network analysis to explore antigenic targets using the published algorithm: Grouping of Lymphocyte Interactions by Paratope Hotspots (GLIPH2).
Results The mucosal T cell repertoire in healthy control airways consisted of highly expressed T cell clones conserved across anatomic subsites (trachea, bronchi, bronchioles, and lung). In iSGS, high-frequency clones were equally represented in both scar and adjacent non-scar tissue. Significant differences in repertoire structure between iSGS scar and unaffected mucosa was observed, driven by unique low-frequency clones. GLIPH2 results suggest low-frequency clones share targets between multiple iSGS patients.
Conclusion Healthy airway mucosa has a highly conserved T cell repertoire across multiple anatomic subsites. Similarly, iSGS patients have highly expressed T cell clones present in both scar and unaffected mucosa. iSGS airway scar possesses an abundance of less highly expanded clones with predicted antigen targets shared between patients. Interrogation of these shared motifs suggests abundant adaptive immunity to viral targets in iSGS airway scar. These results provide insight into disease pathogenesis and illuminate new treatment strategies in iSGS.
Level of EvidenceNA Laryngoscope, 134:3245–3252, 2024

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Comparison of Patient Characteristics and Olfactory Sensitivity for Trigger Odorants in Parosmia and Phantosmia

Rumi Sekine, Anna Kristina Hernandez, Clara Overbeck, Marlise K. Hofer, Eri Mori, Antje Hähner, Thomas Hummel

Publication date 17-06-2024


This study aimed to determine the characteristics of patients with parosmia and phantosmia and whether individuals with parosmia exhibit increased sensitivity to odorants that have been previously reported as triggers, compared to those with quantitative olfactory dysfunction only. Parosmia and phantosmia patients have distinct characteristics and this may provide clinicians with a better understanding of possible olfactory outcomes in these patients. The higher olfactory sensitivity of all groups to trigger odors compared to PEA raises interesting points about parosmia triggers and odors in the context of warning for danger, in relation to the pathophysiology of parosmia that may be worth exploring in future studies.
Objectives This study aimed to determine the characteristics of patients with qualitative olfactory dysfunction (qualOD) and whether individuals with parosmia exhibit increased olfactory sensitivity to previously reported odorous triggers of parosmia.
Methods This study included individuals aged ≥18 years, divided into quantitative OD only, parosmia, and phantosmia groups.
Data collected included: clinical-demographic data, “Sniffin’ Sticks” scores, questionnaires (depression scale, importance of olfaction), and information about parosmia and phantosmia. A proportion of patients underwent trigger odor threshold testing for 2-Furfurylthiol FFT found in coffee and 2,6-nonadienal Nonadienal found in cucumber.
Results Those with parosmia were typically younger women, with shorter OD duration due to post-viral OD (PVOD), hyposmic/normosmic, and experienced parosmia more severely. Parosmia was 3.5 times more likely in PVOD. Those with phantosmia were older, with longer OD duration due to idiopathic OD, hyposmic/anosmic, and experienced phantosmia less severely. There were no significant differences between FFT and Nonadienal threshold scores in patients with parosmia, phantosmia, or only quantitative OD, but all groups had significantly increased olfactory sensitivity for trigger odors compared to phenyl ethyl alcohol (PEA).
Conclusion Parosmia and phantosmia patients have distinct characteristics. This may provide clinicians with a better understanding of possible olfactory outcomes in these patients. The higher olfactory sensitivity of all groups to trigger odors compared to PEA raises interesting points about parosmia triggers and odors in the context of warning for danger, in relation to the pathophysiology of parosmia that may be worth exploring in future studies.
Level of Evidence3 Laryngoscope, 134:3277–3285, 2024

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Impact of Procedural Variation in Endoscopic Dilation for Idiopathic Subglottic Stenosis

Pooja Santapuram, William S. Tierney, Li‐Ching Huang, Sheau‐Chiann Chen, Lynn D. Berry, David O. Francis, Alexander Gelbard

Publication date 17-06-2024


Divergence in operative techniques for endoscopic dilation (ED) of idiopathic subglottic stenosis (iSGS) has been anecdotally recognized but not formally characterized. Our study identified that both outcome and procedural technique vary among centers employing ED to treat iSGS. A transient delay in recurrence was observed among centers that routinely prescribed adjuvant medical therapy to iSGS patients after endoscopic dilation.
ObjectivesA small number of Idiopathic subglottic stenosis (iSGS) patients are treated at institutions across the country. Divergence in operative techniques for endoscopic dilation (ED) of iSGS has been anecdotally recognized but not formally characterized. Additionally, the relationship between procedural variation and clinical outcome has not been studied.
Methods Secondary analysis of the NoAAC iSGS1000 cohort investigated variation in procedural techniques and treatment outcomes in patients treated with ED across high-enrolling treatment centers (enrolled >10 patients in PR-02 trial).
Results Thirteen NoAAC centers each enrolled >10 patients treated with ED for a total of 281 subjects. There was significant variation in procedural details and rate of recurrence among institutions. Hierarchal cluster analysis revealed significant heterogeneity among institutions and clusters in all procedural variables. However, analysis demonstrated a transient delay in disease recurrence in cluster 2 which disappeared with longer longitudinal follow-up. Patient-reported outcome and peak expiratory flow data supported the potential benefit of the technical variation in Cluster 2. Distinct to cluster 2, however, was routine use of adjuvant triple medical therapy (proton pump inhibitor (PPI), antibacterial agent, and steroid inhaler).
Conclusions Both outcome and procedural technique vary among centers employing ED to treat iSGS. A transient delay in recurrence was observed among centers that routinely prescribed adjuvant medical therapy (antibiotic, inhaled corticosteroid, and PPI) to iSGS patients after endoscopic dilation, which was further supported by patient-reported data and peak expiratory flow data. Prospective studies are needed to understand the effects of adjuvant medical therapy on recurrence after endoscopic dilation.
Level of Evidence4 Laryngoscope, 134:3260–3266, 2024

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Gastroesophageal Reflux and Chronic Rhinosinusitis: A Mendelian Randomization Study

Tao Guo, Hui Xie

Publication date 17-06-2024


Multivariable Mendelian randomization combined with mediation analysis was used to explore the causal relationship between gastroesophageal reflux and chronic rhinosinusitis.
Objective Chronic rhinosinusitis (CRS) is associated with gastroesophageal reflux (GERD). However, the causal relationship is controversial. We conducted a two-sample Mendelian Randomization (MR) analysis to explore this potential association.
Methods Based on genome-wide association studies (GWAS), a univariable MR was performed to explore the causal relationship of GERD with CRS. Instrumental variables (IVs) pertinent to anti-GERD treatment were employed as a means of validation. The primary MR outcome was established using an inverse variance weighted (IVW) method, supplemented by multiple sensitivity analyses. Subsequently, a multivariable MR was conducted to account for potential confounding variables, thereby ascertaining a direct effect of GERD on CRS. Finally, a network MR analysis was carried out to elucidate the mediating role of asthma in the relationship between GERD and CRS.
Results The univariable MR demonstrated an association between GERD and an elevated risk of CRS (IVW OR = 1.30, 95% CI = 1.18–1.45, p = 4.19 × 10−7). Omeprazole usage was associated with a reduction in CRS risk (IVW OR = 0.64, 95% CI = 0.42–0.98, p = 0.039). The causal relationship between GERD and CRS remained after adjusting for potential confounders, such as smoking characteristics, body mass index, asthma, allergic rhinitis, in the multivariable MR analysis. Besides, the proportion of the causal effect of GERD on CRS mediated by asthma was 19.65% (95% CI = 2.69%–36.62%).
ConclusionGERD was independently associated with an increased risk of CRS. The mediating role of asthma between GERD and CRS also reveals that GERD is one of the mechanisms underlying unified airway disease.
Level of Evidence3 Laryngoscope, 134:3086–3092, 2024

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Is p16 Testing Sufficient as a Surrogate for HPV‐Related Squamous Cell Carcinoma?

Krishna K. Bommakanti, Maie A. St. John

Publication date 17-06-2024


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Established Adult Tracheostomy Tube Exchange: How Often is Enough?

Patrick Spiller, Karuna Dewan, Karen M. Kost, Cherie‐Ann Nathan

Publication date 17-06-2024


Currently, there is no clinical consensus on how often adults with long-term tracheostomies should have their tubes exchanged. For high-functioning patients who are able to provide diligent tracheostomy care tubes can be exchanged every 6 months. Patients who have a difficult time with tracheostomy care should have them exchanged every 1–3 months.

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Practice Patterns in Asymmetric Sensorineural Hearing Loss: Survey Data

Elliot Schiff, Sara A. Friedman, Kareem Al‐Mulki, Juan Lin, Howard S. Moskowitz

Publication date 15-06-2024


This research highlights a lack of consensus among otolaryngologists in their management of patients who present with asymmetric sensorineural hearing loss (ASNHL). There is wide disparity among practitioners as to which diagnostic criteria comprise this clinical entity, and how to proceed in counseling patients. As such, this study contributes to the body of evidence calling for clinical practice guidelines for providers to use when evaluating patients with ASNHL.
Objective Although screening protocols for patients who present with asymmetric sensorineural hearing loss (ASNHL) exist, there are no clear guidelines to direct practitioners. In particular, various thresholds have been proposed for the degree of hearing loss that should prompt MRI studies, but the topic remains understudied. This project aims to compare protocols followed by practitioners to guide their imaging practices.
Study Design Web-based survey.
Setting Otolaryngology faculty at academic medical centers.
MethodsA list of 530 otolaryngologists (276 otology/neurotology specialists, 254 general otolaryngologists) was compiled.
A survey consisting of three parts: demographics, general practice patterns, and simulated patient cases was distributed.
ResultsA total of 468 surveys were successfully distributed, resulting in 88 (18.8%) responses. The majority of respondents (63.8%) self-reported their definition of ASNHL as “>30 dB hearing asymmetry at one frequency OR >20 dB hearing asymmetry at two continuous frequencies OR >10 dB hearing asymmetry at three contiguous frequencies.” Overall, general otolaryngologists were more likely to observe asymmetric findings with serial audiogram alone, whereas otology/neurotology specialists were more likely to obtain imaging.
Conclusion There is significant variability between providers with regard to managing patients with ASNHL and evidence-based guidelines would be useful in guiding imaging practices.
Level of EvidenceN/A Laryngoscope, 2024

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Endoscopic Distance and its Impact on Quantified Age‐related Vocal Fold Atrophy Measures

Mohamed A. Aboueisha, Cara Sauder, Zaroug Jaleel, Yasmine Fatahallah, Kelson Adcock, Hamzah Al‐awadi, Aria Jafari, Neel K. Bhatt

Publication date 15-06-2024


The BI and NGGA were impacted by the endoscope position. A greater difference between the two endoscopic distances was observed for examinations that exhibited a greater bowing severity. The findings call for heightened awareness for measurement discrepancies due to varying endoscopic distances.
Introduction The bowing index (BI) and normalized glottal gap area (NGGA) are used to quantify vocal fold morphology in ARVA; however, the influence of the distance between the flexible laryngoscope lens and the target area is not known. The goal is to test whether the endoscopic distance impacts vocal fold morphology measurements in patients with ARVA during flexible video laryngostroboscopy (VLS).
Method Patients with ARVA who underwent VLS were included. Images were classified into near (close to the petiole of the epiglottis) and far (below nasopharynx, with tongue base and entire epiglottis visible) conditions. BI was calculated using a mobile application, and NGGA was measured using ImageJ.
Results This study included 23 patients; the mean age was 77 ± 7 years. Mean BI measured at the near distance was higher than far distances with a mean difference of 1.94 (95% CI: 0.92–2.96, p = 0.001). NGGA showed difference with changed distance −0.24 (95% CI: −0.48 to 0.01, p < 0.05).
When stratifying patients into two groups based on median BI measurement, there was a statistically significant difference between near and far conditions, with increased BI in the near condition for patients above the median (p < 0.05), but no difference between the near and far condition for patients with BI below the median.
Conclusion The BI and NGGA were impacted by the endoscopic distance during flexible VLS. BI was significantly higher in the near condition compared with the far condition. The difference in BI between the near and far conditions was more pronounced when the vocal fold bowing was greater. These findings call for heightened awareness of measurement discrepancies secondary to the endoscopic distance during flexible laryngostroboscopy.
Level of Evidence Level 2 Laryngoscope, 2024

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Opioid Prescription Trends Among Sleep Surgeons in the United States

Jasmeet Saroya, Amritpal Singh, Jolie L. Chang, Megan L. Durr

Publication date 15-06-2024


The study analyzed opioid prescription trends among US sleep surgeons from 2013 to 2021, finding no significant change in the number of prescriptions but a notable decrease in opioid cost per beneficiary. Surgeons who graduated before 2000 prescribed more opioids than those graduating after 2000. Overall, opioid prescriptions in this specialty remained stable, contrasting with the trend of decreasing prescriptions in other otolaryngology subspecialties.
Objective This study aimed to describe trends in opioid prescriptions among US sleep surgeons between 2013 and 2021 via a retrospective analysis conducted using publicly available data.
Methods Utilizing the CMS part D database, we analyzed data from 82 sleep surgeons, focusing on metrics including number of opioid beneficiaries and claims, opioid cost, and opioid day supply per beneficiary. We employed statistical methods including ANOVA, t-tests, Fishers exact test with Monte Carlo Simulation, and regression models.
Results There were no significant changes in the number of opioid claims (p = 0.782) or beneficiaries per provider (p = 0.590) nor was there a decrease in opioid day supply per beneficiary (p = 0.489) over time. Surgeons who graduated residency before 2000 prescribed significantly more opioids over the course of the study period compared to those graduating after 2000 with higher opioid day supply per beneficiary (13.34 vs. 7.42, p < 0.001), higher opioid beneficiaries per provider (21.62 vs. 19.36, p = 0.028), and higher opioid claims per provider (30.30 vs. 21.78, p < 0.001). A significant annual decrease in opioid cost per beneficiary (ANOVA, p = 0.006) was noted.
Conclusions This study illuminates a significant impact of provider years in practice on opioid prescribing trends, alongside a decreasing trend in opioid cost per beneficiary. Despite the evolving paradigm emphasizing opioid reduction and evidence of decreasing opioid prescriptions in other otolaryngology subspecialties, our findings depict that opioid prescriptions among sleep surgeons remained stable from 2013 to 2021.
Level of EvidenceIII Laryngoscope, 2024

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Radiology–Pathology Concordance and Prognostication of Nodal Features in pN+ Oral Cavity Cancer

"Marie Duguet‐Armand, Jie Su, Brian OSullivan, John de Almeida, Ali Hosni, Ilan Weinreb, Bayardo Perez‐Ordonez, Stephen Smith, Ian Witterick, Christopher Yao, David Goldstein, Andrew Hope, Ezra Hahn, John Waldron, Jolie Ringash, Anna Spreafico, Eugene Yu, Shao Hui Huang"

Publication date 14-06-2024


Image-identified nodal features, despite modest sensitivity, have high specificity for pathologic findings. The prognostic value of adverse pathological nodal features is retained in radiologic assessment, and reduced OS is observed for imaging-identified N+, LN size >3 cm, >2 vs. ≤2 nodes, and iENE+.
Background and Purpose The aims of our study are to evaluate the diagnostic performance and prognostic value of radiological lymph node (LN) characteristics in pN+ oral cavity squamous carcinoma (OSCC).
Materials and MethodspN+ OSCC treated between 2012 and 2020 were included.
Preoperative imaging was reviewed by a single radiologist blinded to pathologic findings for the following nodal features: imaging-positive LN (iN+), laterality and total number, and image-identified extranodal extension (iENE). The sensitivity of iN+ for pN+ was calculated. The diagnostic performance of other nodal features was evaluated in the iN+ subgroup. The association of radiologic nodal features with overall survival (OS) was evaluated. Inter-rater kappa for radiologic nodal features was assessed in 100 randomly selected cases.
Results Of 406 pN+ OSCC, 288 were iN+. The sensitivity of iN+ for pN+ was 71% overall, and improved to 89% for pN+ LN >1.5 cm. Within iN+, sensitivity/specificity for LN size (>3 cm), total LN number (>4), and ENE were 0.44/0.95, 0.57/0.84, and 0.27/0.96, respectively. Sensitivity of iENE was higher in the subset, with major (>2 mm) versus minor (≤2 mm) pENE (43% vs. 13%, p = 0.001). Reduced OS was observed in iN+ versus iN– (p = 0.006), iENE+ versus iENE– (p = 0.004), LN size >3 versus ≤3 cm (p < 0.001), and higher LN number (p < 0.001). Inter-rater kappa for iN+, laterality, total LN number, and presence of iENE were 0.71, 0.57, 0.78, and 0.69, respectively.
Conclusion Our study shows that despite modest sensitivity of most radiological nodal features, the specificity of image-identified nodal features is high and their prognostic values are retained in pN+ OSCC.
Level of Evidence Level 3 (retrospective review comparing cases and controls) Laryngoscope, 2024

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Development of a Novel Airway‐Exchange Broncholaryngoscope

"Roger W. Boles, Wihan Kim, Karla ODell"

Publication date 14-06-2024


We have developed a novel airway-exchange broncholaryngoscope. This device combines the bronchoscope and AEC into a single tool for airway-exchange procedures and allows placement of AECs under visual guidance. Successful early findings using airway models suggest that the AEBLScope could make airway-exchange procedures safer for patients by decreasing procedural time and reducing the morbidity and mortality that can occur from blind placement of AECs.
Objective The purpose of this project was to develop a novel airway-exchange broncholaryngoscope (AEBLScope) to improve the efficiency and accuracy of airway-exchange procedures.
Methods The AEBLScope was designed to combine a bronchoscope and airway-exchange catheter (AEC) into a single device and to reduce the blind placement of AECs. The prototype was constructed by modifying an existing distal-chip bronchoscope. A custom AEC was procured to fit concentrically over the flexible portion of the scope. The catheter was connected to the scope handpiece by a customized push–pull locking attachment. The AEBLScope was used to perform airway-exchange procedures with both tracheostomy and endotracheal tubes using two different airway models. Experimental procedures were recorded with still photography to evaluate the exchange of tubes and placement of AECs.
Results In two airway models using the AEBLScope, both tracheostomy and endotracheal tubes were successfully exchanged on first-pass attempt, and AECs were accurately placed under visual guidance.
Conclusion The AEBLScope combines a bronchoscope and AEC into a single tool. Based on these first results, this novel scope has the potential to perform airway-exchange procedures more safely compared with standard procedures by increasing the accuracy of placement, decreasing procedural time, and reducing the morbidity and mortality that can occur from blind placement of AECs.
Level of EvidenceN/A Laryngoscope, 2024

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How Does Lacking a Home Program Impact Otolaryngology Applicants?

Leona J. Tu, William J. Benjamin, Nicholas R. Lenze, Angela P. Mihalic, Robbi A. Kupfer, Sonya Malekzadeh

Publication date 14-06-2024


This study evaluated the impact of no home otolaryngology residency program on interview and match outcomes from 2019 to 2023. Applicants with no home programs consistently received fewer interview offers and had lower match rates and odds of matching compared to applicants with home programs.
Objectives To compare otolaryngology interview and match outcomes between applicants with and without home residency programs.
Methods Otolaryngology applicants from US allopathic medical schools during the 2019–2023 cycles who responded to the Texas Seeking Transparency in Application to Residency (STAR) survey were identified. Students were stratified based upon whether their medical school had an affiliated otolaryngology residency program. The primary outcomes were number of interviews and match rate. Wilcoxon-rank sum and χ2 testing was used to assess associations between home program status and interview and match outcomes.
Results Of the 633 fourth-year medical students applying to otolaryngology during the 2019–2023 application cycles, 89 had no home program (NHP) and 544 had a home program (HP). Applicants with NHP completed significantly more away rotations than applicants with a HP (2.2 vs. 1.5; p < 0.01). There was no difference in mean number of applications submitted between applicants with NHP and applicants with a HP. However, applicants with a HP received a significantly greater number of interviews (14.7 vs. 11.8; p < 0.01), attended more interviews (12.4 vs. 11.3; p = 0.02), attended a lower percentage of their offered interviews (84.4% vs. 95.8%), and had a higher match rate (81.8% vs. 70.8%; p = 0.02) than applicants with NHP. Applicants with NHP interviewed at (1.9 vs. 1.3; p < 0.01) and matched at (33.7% vs. 23.9%; p = 0.048) significantly more away rotation institutions than applicants with a HP.
Conclusion Applicants with NHP received fewer interviews and had lower match rates. Away rotations may be especially important for applicants with NHP.
Level of EvidenceNA Laryngoscope, 2024

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Outcomes of Concurrent Balloon Eustachian Tuboplasty and Tympanostomy Tube Placement in Children

Jatin Ahluwalia, Seilesh Babu, Michael Haupert, Prasad Thottam

Publication date 14-06-2024


Objectives Balloon dilation eustachian tuboplasty (BDET) has been proven to be a safe treatment option for children with eustachian tube dysfunction (ETD). This study aims to analyze the long-term outcomes of children who underwent concurrent BDET and tympanostomy tube (TT) placement. We hypothesize that patients who underwent simultaneous therapy have experienced a low overall rate of middle ear pathology and have consistent hearing quality at subsequent office visits.
Methods Retrospective chart review of 19 pediatric patients (36 ears) who previously underwent concurrent BDET and TT placement. Patient charts within the extended postoperative period were reviewed. Specific data points included need for reoperation, rates of middle ear pathology, audiological outcomes, and number of previous TT placements.
Results Pediatric patients who underwent concurrent BDET and TT placement had long-term success in 34/36 ears (94.4%). All postoperative tympanograms and audiograms (100%) were normal when performed within 12 months after the procedure. Notably, 34/36 ears (94.4%) had history of tube placement in the past. Patients had an average of three sets of tympanostomy tubes prior to undergoing concurrent BDET and TT.
Conclusion Concurrent BDET and TT placement may be an effective treatment option for pediatric patients with persistent eustachian tube dysfunction. Specifically, BDET may be a useful adjunct tool in pediatric patients with refractory ETD despite having multiple sets of tympanostomy tubes. This study aims to strengthen the argument of performing multimodal therapy in pediatric patients with recurrent middle ear disease.
Level of Evidence4 Laryngoscope, 2024

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AI Detection of Glottic Neoplasm Using Voice Signals, Demographics, and Structured Medical Records

Chi‐Te Wang, Tsai‐Min Chen, Nien‐Ting Lee, Shih‐Hau Fang

Publication date 12-06-2024


Objective This study investigated whether artificial intelligence (AI) models combining voice signals, demographics, and structured medical records can detect glottic neoplasm from benign voice disorders.
Methods We used a primary dataset containing 2–3 s of vowel “ah”, demographics, and 26 items of structured medical records (e.g., symptoms, comorbidity, smoking and alcohol consumption, vocal demand) from 60 patients with pathology-proved glottic neoplasm (i.e., squamous cell carcinoma, carcinoma in situ, and dysplasia) and 1940 patients with benign voice disorders. The validation dataset comprised data from 23 patients with glottic neoplasm and 1331 patients with benign disorders. The AI model combined convolutional neural networks, gated recurrent units, and attention layers. We used 10-fold cross-validation (training–validation–testing: 8–1–1) and preserved the percentage between neoplasm and benign disorders in each fold.
Results Results from the AI model using voice signals reached an area under the ROC curve (AUC) value of 0.631, and additional demographics increased this to 0.807. The highest AUC of 0.878 was achieved when combining voice, demographics, and medical records (sensitivity: 0.783, specificity: 0.816, accuracy: 0.815). External validation yielded an AUC value of 0.785 (voice plus demographics; sensitivity: 0.739, specificity: 0.745, accuracy: 0.745). Subanalysis showed that AI had higher sensitivity but lower specificity than human assessment (p < 0.01). The accuracy of AI detection with additional medical records was comparable with human assessment (82% vs. 83%, p = 0.78).
Conclusions Voice signal alone was insufficient for AI differentiation between glottic neoplasm and benign voice disorders, but additional demographics and medical records notably improved AI performance and approximated the prediction accuracy of humans.
Level of EvidenceNA Laryngoscope, 2024

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Transient Receptor Potential Ankyrin 1 Channel Alters Transforming Growth Factor Beta 1/Smad Signaling in Rat Vocal Fold Fibroblasts

Hiroki Matsushita, Shigeyuki Mukudai, Keiko Hashimoto, Mami Kaneko, Yoichiro Sugiyama, Ryan C. Branski, Shigeru Hirano

Publication date 11-06-2024


The current study explored the relationship between TRPA1 and TGF-β/Smad signaling in rat vocal fold fibroblasts. Our results indicate that the activation of TRPA1 has potential antifibrotic effects by modulating TGF-β1/Smad signaling. This discovery may contribute to the development of new clinical approaches for treating vocal fold fibrosis.
Objectives Vocal fold scar remains a therapeutic challenge. Vocal fold fibroblasts (VFFs) secrete extracellular matrix (ECM), and transforming growth factor-beta 1 (TGF-β1)-mediated fibroblast to myofibroblast differentiation is central to the development of fibrosis. The transient receptor potential (TRP) channel superfamily is a group of nonselective cation channels, and activation of TRP ankyrin 1 (TRPA1) channel has been shown to have antifibrotic effects through TGF-β1/Smad signaling in various organs. This study aimed to elucidate expression of TRPA1 and the impact of TRPA1 activation on TGF-β1/Smad signaling in VFFs.
Methods Vocal folds were dissected from 10-week-old, male Sprague-Dawley rats and primary VFFs were established. TRPA1 was examined in VFFs and lamina propria via immunostaining. VFFs were treated with allyl isothiocyanate (AITC, TRP channel agonist, 10−5 M) ± TGF-β1 (10 ng/ml) ± A-967079 (selective TRPA1 channel antagonist, 5.0 × 10−7 M) for 4 or 24 h. Trpa1, Smad3, Smad7, Col1a1, Acta2, and Has1 mRNA expression were quantified via qPCR.
ResultsTRPA1 was expressed in cultured VFFs and the lamina propria. TGF-β1 administration significantly increased Trpa1 compared to control. AITC alone did not alter Smad3, Smad7, Acta2, or ECM related genes. However, the combination of AITC and TGF-β1 significantly increased Smad3 and decreased Smad7 and Acta2 compared to TGF-β1 alone; A-967079 significantly reduced this response.
ConclusionsVFFs expressed TRPA1, and the activation of TRPA1 regulated TGF-β1/Smad signaling in VFFs. These findings provide preliminary insights into potential anti-fibrotic mechanisms of TRPA1 activation through TGF-β1/Smad signaling in VFFs.
Level of EvidenceNA Laryngoscope, 2024

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Use of the 445‐nm Blue Laser for Management of Early Glottic Carcinoma: Preliminary 1‐Year Results

David E. Rosow, Eytan Keidar, Luke J. Pasick, Nicolas J. Casellas, Mursalin M. Anis

Publication date 11-06-2024


The KTP laser has been well-studied for its use in the photoangiolytic treatment of glottic cancer. Since the KTP laser ceased to be produced worldwide in 2018, the only photoangiolytic laser being produced for microlaryngeal surgery has been the 445-nm blue laser. However, there have been no studies comparing the efficacy of the blue laser to KTP in treatment of glottic cancer, and this study seeks to rectify this.
Objective To analyze oncological efficacy and voice outcomes of the 445-nm blue laser (BL) in the treatment of early glottic carcinoma and compare results with the 532-nm potassium-titanyl-phosphate (KTP) laser.
Study Design Single institution, retrospective chart review.
Methods All patients who underwent microlaryngoscopic KTP or BL laser excision of early glottic carcinoma from 2018 to the present day with at least 1-year follow-up were included. Primary and recurrent disease, including radiation and surgical failures, were included. Demographic data, voice outcomes and oncologic outcomes were compared between the two laser groups.
Results Forty-nine patients met the inclusion criteria for the BL group and 88 for the KTP group, with average follow-up of 635 and 1236 days, respectively. Oncologic outcomes were not significantly different, with disease-specific survival rates of 95.9% for BL and 100% for KTP (p = 0.13), organ preservation rates of 98.0% for BL and 95.6% for KTP (p = 0.39), and local control rates of 93.9% for BL and 92.1% for KTP (p = 0.81). Both BL and KTP groups showed significant improvement in CAPE-V (p = 0.04, 0.006 respectively) and VHI-10 scores (p = 0.003, <0.00001) following surgery.
Conclusions Photoangiolytic removal of early glottic carcinoma with BL appears to be equally safe and effective as with KTP laser at minimum one-year follow-up, and with excellent voice outcomes. Additional study will be warranted over time to assess long-term outcomes in BL patients.
Level of Evidence3 Laryngoscope, 2024

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Dependability of Electrode to Modiolus Distance in Patients Specific Electrode Selection: A Cadaveric Model Study

Vidhu Sharma, Nidhin Das K, Anupriya Jangra, Sarbesh Tiwari, Pushpinder Khera, Kapil Soni, Shilpi G. Dixit, Ashish K. Nayyar, Amit Goyal

Publication date 11-06-2024


An article describing the variability of electrode to modiolus distance among various window of insertion in cochlear implantation, its association with various cochlear parameters and its significance in the selection of patient specific electrode.
Objective This study aims to discern the disparities in the electrode-to-modiolus distance (EMD) between cochleostomy and round window approaches when performed sequentially in the same temporal bone. Additionally, the study seeks to identify the cochlear metrics that contribute to these differences.
MethodologyA cross-sectional study was conducted, involving the sequential insertion of a 12-electrode array through both round window and cochleostomy approaches in cadaveric temporal bones. Postimplantation high-resolution CT scans were employed to calculate various parameters.
ResultsA total of 12 temporal bones were included in the imaging analysis, revealing a mean cochlear duct length of 32.892 mm. The EMD demonstrated a gradual increase from electrode 1 (C1) in the apex (1.9 ± 0.07 mm; n = 24) to electrode 12 (C12) in the basal turn (4.6 ± 0.24 mm; n = 12; p < 0.01). Significantly higher EMD values were observed in the cochleostomy group. Correlation analysis indicated a strong positive correlation between EMD and cochlear perimeter (CP) (rs = 0.64; n = 12; p = 0.03) and a strong negative correlation with the depth of insertion (DOI) in both the middle and basal turns (rs = − 0.78; n = 20; p < 0.01). Additionally, EMD showed a strong negative correlation with the DOI-CP ratio (rs = −0.81; n = 12; p < 0.01).
Conclusion The cochleostomy group exhibited a significantly higher EMD compared with the round window group. The strong negative correlation between EMD and DOI-CP ratio suggests that in larger cochleae with shallower insertions, EMD is greater than in smaller cochleae with deeper insertions.
Level of EvidenceN/A Laryngoscope, 2024

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In Response to Barbed Stayed Bridge Pharyngoplasty (BSBP)

Giuseppe Magliulo, Giannicola Iannella, Manuele Casale, Claudio Vicini, Annalisa Pace

Publication date 10-06-2024


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In Reference to Barbed Stayed Bridge Pharyngoplasty (BSBP)

Antonino Maniaci, Salvatore Ronsivalle, Mario Lentini, Jerome R. Lechien

Publication date 10-06-2024


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Pediatric Cholesteatoma Follow‐Up: Residual and Recurrence in 239 Cases with Over 5‐Year Hindsight

François Simon, Françoise Remangeon, Natalie Loundon, Nicolas Leboulanger, Vincent Couloigner, Noel Garabédian, Françoise Denoyelle

Publication date 10-06-2024


Pediatric cholesteatoma should be considered as a chronic disease with at least 10 years clinical follow-up and 5 years MRI follow-up after the last procedure. Congenital cholesteatoma have less residuals than acquired but similar risk of retraction pockets and recurrent disease.
Introduction Pediatric cholesteatoma is an aggressive disease which requires long-term evaluation to assess management strategies. The objective was to determine optimal follow-up duration in pediatric cholesteatoma to detect residual and recurrent diseases.
Methods This cohort study was set in a tertiary referral center. All consecutive patients with a minimum 5-year follow-up were included. Medical history, initial extension, surgical procedures, and follow-up were collected. The main outcome measure were Kaplan–Meier survival curves of residual and recurrence cumulative incidence.
Results Totally 239 ears with the first tympanoplasty between 2008 and 2014 were studied including 25% congenital. At first surgery (S1), mean age was 8.4 years and mean follow-up time 7.9 years. Mastoidectomy was performed in 69% and stapes was absent in 38% of cases. Notably, 83% (199 ears) had a second procedure (S2) of which 186 were planned. After S1, maximum cumulated incidence of residual was 45% 95%CI, 38%; 52% at 74 months, with probability of residual of 39% at 3 years. After S2 (n = 199), maximum cumulated residual incidence was 21% 95%CI, 12%; 32% at 62 months and 16% at 3 years. Concerning recurrence, maximum cumulated incidence after S1 (n = 239) was reached at 98 months with 21% 95%CI, 12%; 32%, 13% at 3 years and 16% at 5 years. Congenital disease had significantly less residuals after S1 (p = 0.02), but similar recurrence rate (p = 0.66) compared with acquired.
Conclusions and Relevance We recommend MRI follow-up of at least 5 years after the last surgery for residual disease and clinical follow-up of at least 10 years to detect recurrence.
Level of Evidence4 Laryngoscope, 2024

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Quality of Life in Symptomatic Septal Perforation

Berta Alegre Edo, María Jesús Rojas‐Lechuga, Mireia Quer‐Castells, Nesly González‐Sánchez, Mauricio Lopez‐Chacon, Claire Hopkins, Isam Alobid

Publication date 08-06-2024


This study examines the influence of septal perforation (SP) on quality of life (QoL) compared to the general population and patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) using the Sino-Nasal Outcome Test 22 (SNOT-22). A total of 392 patients were included divided into controls, CRSwNP, and SP groups, revealing significantly higher SNOT-22 scores in the CRSwNP and SP groups compared to controls, with no significant difference between CRSwNP and SP. Patients with SP reported notably worse QoL in the sleep, function, and psychological domains compared to CRSwNP.
Objective The aim of this study is to investigate the impact of septal perforation (SP) on quality of life (QoL). SP is compared to the general population and patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) using the Sino-Nasal Outcome Test 22 (SNOT-22).
Methods Prospective single-center study in a referral Rhinology Unit from January 2014 to March 2023.
ResultsA total of 392 patients were included in three groups: controls (n = 141), CRSwNP (n = 118), and SP (n = 133). The mean score of the SNOT-22 was significantly higher in the CRSwNP group (42.4, SD = 24.4) and SP (46.5, SD = 22) compared to the control group (6.2, SD = 8.4). Scores by either items or domains were significantly higher in the CRSwNP and SP groups compared to the control group. There were no significant differences in the mean SNOT-22 between the CRSwNP and SP groups (p = 0.26; 95% CI −1.68–9.99). Domain-specific analysis of overall SNOT-22 scores revealed that patients with SP experienced higher levels of disturbances in sleep, function, and psychological domains (p ≤ 0.001).
ConclusionSP produces a negative impact on QoL similar to CRSwNP. Moreover, sleep, psychological, and function domains are significantly worse in SP. Etiology and area of SP influence nasal and emotion domain, though more studies on SP using SNOT-22 and specific questionnaires are needed.
Level of Evidence Level III Laryngoscope, 2024

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Computer Vision Foundation Models in Endoscopy: Proof of Concept in Oropharyngeal Cancer

Alberto Paderno, Anita Rau, Nikita Bedi, Paolo Bossi, Giuseppe Mercante, Cesare Piazza, Floyd Christopher Holsinger

Publication date 08-06-2024


A computational study using endoscopic frames with a focus on the application of a trained self-supervised vision transformer model for tissue classification. This study supports the feasibility of employing vision foundation models in the endoscopic evaluation of mucosal lesions.
Objectives To evaluate the performance of vision transformer-derived image embeddings for distinguishing between normal and neoplastic tissues in the oropharynx and to investigate the potential of computer vision (CV) foundation models in medical imaging.
Methods Computational study using endoscopic frames with a focus on the application of a self-supervised vision transformer model (DINOv2) for tissue classification. High-definition endoscopic images were used to extract image patches that were then normalized and processed using the DINOv2 model to obtain embeddings. These embeddings served as input for a standard support vector machine (SVM) to classify the tissues as neoplastic or normal. The models discriminative performance was validated using an 80–20 train-validation split.
Results From 38 endoscopic NBI videos, 327 image patches were analyzed. The classification results in the validation cohort demonstrated high accuracy (92%) and precision (89%), with a perfect recall (100%) and an F1-score of 94%. The receiver operating characteristic (ROC) curve yielded an area under the curve (AUC) of 0.96.
Conclusion The use of large vision model-derived embeddings effectively differentiated between neoplastic and normal oropharyngeal tissues. This study supports the feasibility of employing CV foundation models like DINOv2 in the endoscopic evaluation of mucosal lesions, potentially augmenting diagnostic precision in Otorhinolaryngology.
Level of Evidence4 Laryngoscope, 2024

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Ewing Sarcoma of the Larynx with Thyroid Cartilage Destruction: A Case Report

Gergely Lerant, Balint Torok, Erika Toth, Tamas Pinter, Maria Godeny

Publication date 07-06-2024


Ewing sarcoma of the larynx is extremely rare; only a few number of cases have been reported. In this report, we describe a case of extraskeletal Ewing sarcoma of the larynx with thyroid cartilage destruction.
Ewing sarcoma of the larynx is extremely rare, only a few number of cases have been reported. In this report, we describe a case of extraskeletal Ewing sarcoma of the larynx with thyroid cartilage destruction. Laryngoscope, 2024

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The Impact of Race and the Affordable Care Act on Thyroid Carcinoma Outcomes: A National Cancer Database Study

Margaret Nurimba, Megha Sheth, Mark Swanson, Tamara Chambers

Publication date 06-06-2024


This cross-sectional study of differentiated thyroid carcinoma patients in the National Cancer Database demonstrates significant racial differences in disease presentation, treatment, and survival outcomes. The Affordable Care Act Medicaid was associated with improved survival outcomes.
Objective To assess the impact of race and the Affordable Care Act (ACA) of 2010 on disease presentation and overall survival for patients with well-differentiated thyroid carcinoma.
Study Design Cross-sectional study of patients (n = 51,078) who underwent partial or total thyroidectomy with or without postoperative radioactive iodine (RAI) for well-differentiated thyroid carcinoma between 2004 and 2018 in the National Cancer Database (NCDB).
Methods Cumulative survival (CS) was assessed with Cox proportional hazard regression analyses.
Results There were significant disparities in disease presentation at the time of diagnosis, with Black, Asian/Pacific Islander (API), and Hispanic patients were more likely to have metastatic disease (p < 0.001) and higher TNM stage (p < 0.001) at the time of diagnosis compared to White patients. Black patients had significantly increased risk of death (HR 1.147, 95%CI 1.021–1.289) but API patients had improved CS (HR 0.730, 95% CI 0.608–0.877) compared to White patients. Passage of the ACA was associated with lower risk of mortality, regardless of whether patients lived in states that did not expand Medicaid (HR 0.866, 95% CI 0.823–0.910) or whether they lived in expansion states (HR 0.818, 95% CI 0.758–0.884).
Conclusion Racial disparities significantly impact thyroid carcinoma diagnosis and treatment in the United States but have improved over time. Both expansion and non-expansion states had improved survival outcomes over time, and suggesting analysis of the ACAs long-term impact and ability to address health inequities is still warranted.
Level of Evidence Level 3 Laryngoscope, 2024

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Clinical Effect Analysis of Fire‐needle Acupuncture at Neiyingxiang Treating Persistent Allergic Rhinitis

Jianwei Ai, Suying Guo, Yaqin Wang, Yuezhi Kang, Man Wang, Jingyi Zhao, Shaoting Huang, Junge Wang

Publication date 06-06-2024


Fire-needle acupuncture at Neiyingxiang (ExHN 9) is effective for improving nasal allergy symptoms and quality of life in patients with moderate and severe persistent AR, and the duration of its effects is long.
Objectives We conducted the first trial to evaluate the effect that fire-needle acupuncture at Neiyingxiang (ExHN 9) in patients with moderate to severe persistent AR.
Methods This was a randomized, single-center, sham, and placebo-controlled rial. Patients were kept blinded to their group assignment. All participants were equally assigned to the fire-needle acupuncture (FA) treatment group, sham fire-needle acupuncture (SFA) group, or loratadine group. The trial was designed with an acupuncture intervention once a week for 4 weeks and follow-up 4 weeks. The Total Nasal Symptom Scores (TNSS), Total Non-Nasal Symptom Scores (TNNSS), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), Allergic Rhinitis Control Test (ARCT), and total nasal resistance of 150 Pa were evaluated as outcome measures.
ResultsA total of 180 participants were enrolled, and 175 participants completed the trials. At 2 and 4 weeks, the TNSS, TNNSS, and RQLQ scores of the FA and loratadine groups were significantly lower than those of the SFA group. At 8 weeks, the scores of loratadine group increased compared with the FA group (Cohens d >0.80, p < 0.01). The ACRT score of the FA treatment group rose gradually. After treatment, the total nasal resistance of the FA group was significantly decreased and was lower than that of the other two groups (Cohens d >0.80, p < 0.01).
Conclusion Fire-needle acupuncture at Neiyingxiang (ExHN 9) is effective for improving nasal allergy symptoms and quality of life in patients with moderate and severe persistent AR, and the duration of its effects is long.
Level of Evidence2 Laryngoscope, 2024

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Endoscopic‐Assisted Cochlear Implantation via a “Microfacial Recess”

Taseer F. Din, Faisal Abdulkader, Kay W. Chang

Publication date 05-06-2024


This is the first report to illustrate performance of an endoscopic trans-canal bony cochleostomy with insertion of the cochlear implant performed via a novel “microfacial recess.”Syndromic patients can have severely anomalous anatomy significantly challenging conventional cochlear implant (CI) surgery. This case report describes a 20-year-old with brachio-oto-renal syndrome with a severely anomalous facial nerve completely covering the round window and preventing a traditional posterior tympanotomy CI. This is the first report to illustrate the performance of an endoscopic trans-canal bony cochleostomy with insertion of the CI performed via a “microfacial recess.” We describe the performance of an endoscopic trans-canal bony cochleostomy and a modification of the conventional wide posterior tympanotomy usually performed into a 1 mm “microfacial recess,” which allowed a full insertion to take place. Laryngoscope, 2024

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Diagnosis and Management of Riga–Fede Disease: A Case Series

Catherine G. Nguyen, Emily E. Wikner, Thomas Q. Gallagher, Laurie A. Birsch, David H. Darrow

Publication date 05-06-2024


In this case series, we present four unique cases of Riga–Fede disease (RFD), a rare disorder characterized by mucosal trauma as a result of repetitive tongue protrusion against the incisors, leading to the development of a large oral mass/ulceration. Due to the rapid development and growth of these lesions mimicking malignancy, it is important for the general and pediatric otolaryngologist to correctly diagnose and treat this benign disorder. This series highlights the variable clinical presentations, along with comorbidities of RFD, as well as the importance of interdisciplinary care between the pediatric otolaryngologist and pediatric dentist in its management.
In this case series, we present four unique cases of Riga–Fede disease (RFD), a rare disorder characterized by mucosal trauma as a result of repetitive tongue protrusion against the incisors, leading to the development of a large oral mass/ulceration. Due to the rapid development and growth of these lesions mimicking malignancy, it is important for the general and pediatric otolaryngologist to correctly diagnose and treat this benign disorder. This series highlights the variable clinical presentations, along with comorbidities of RFD, as well as the importance of interdisciplinary care between the pediatric otolaryngologist and pediatric dentist in its management. Laryngoscope, 2024

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Seven Days of Voice Rest Post‐phonosurgery Is Not Better than 3\u2009days: A Prospective Randomized Short‐term Outcome Study

Liat Voloch, Michal Icht, Boaz M. Ben‐David, Narin Nard Carmel Neiderman, Guy Levenberg, Yael Manor, Dina Shpunt, Yael Oestreicher‐Kedem

Publication date 04-06-2024


This randomized trial indicates that opting complete voice rest (VR) of 7 days over 3 days post-phonosurgery does not improve the objective voice quality parameters measured. A shorter VR protocol of 3 days reduces the patients burden of keeping silent and facilitates earlier initiation of voice therapy which could optimize long-term recovery.
Objective The aim of the study is to compare the short-term effect of 7 versus 3 days of voice rest (VR) on objective vocal (acoustic) parameters following phonosurgery.
MethodsA prospective randomized study conducted at a tertiary referral medical center. Patients with vocal fold nodules, polyps, or cysts and scheduled for phonosurgery were recruited from the Voice Clinic. They were randomized into groups of 7- or 3-day postoperative VR periods and their voices were recorded preoperatively and at 4-week postoperatively. A mixed linear model statistical analysis (MLMSA) was used to compare pre- and postoperative jitter, shimmer, harmonic-to-noise ratio, and maximum phonation time between the two groups.
Results Sixty-five patients were recruited, but only 34 fully complied with the study protocol, and their data were included in the final analysis (19 males, 20 females; mean age: 40.6 years; 17 patients in the 7-day VR group and 16 in the 3-day VR group). The groups were comparable in age, sex, and type of vocal lesion distribution. The preoperative MLMSA showed no significant group differences in the tested vocal parameters. Both groups exhibited significant (p < 0.05) and comparable improvement in all vocal parameters at postoperative week 4.
ConclusionsA VR duration of 7 days showed no greater benefit on the examined vocal parameters than the 3-day protocol 4-week postoperatively. Our results suggest that a 3-day VR regimen can be followed by patients who undergo phonosurgery without compromising the vocal results. Larger-scale and longer-duration studies are needed to confirm our findings.
Level of Evidence2 Laryngoscope, 2024

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The Association Between Medicaid Expansion and Disparities in Vestibular Schwannoma Incidence

Alexander S. Homer, Viknesh S. Kasthuri, Benjamin J. Homer, Rishubh Jain, Emily K. Gall, Kathryn Y. Noonan

Publication date 04-06-2024


Objectives The effect of Medicaid expansion as a part of the Affordable Care Act on vestibular schwannoma (VS) incidence overall and in marginalized populations has not yet been elucidated. The goal of this study was to determine if Medicaid expansion was associated with increases in VS incidence overall, as well as in patients of non-white race or in counties of low socioeconomic status (SES).
Methods We performed a difference-in-difference (DiD) analysis from January 1st 2010–December 31st 2017 utilizing the Surveillance, Epidemiology, and End Results (SEER) database. Our DiD method compared the change in VS rate between counties that did and did not expand Medicaid among patients of white and non-white race, in low and high SES counties, before and after expansion.
Results The study included 17,312 cases across 1020 counties. Medicaid expansion was associated with a 15% increase (incidence rate ratio 95% CI: 11%, 19) in VS incidence. White populations saw a 10% increase (CI: 1.06, 1.19), Black populations saw a 20% increase (CI: 1.10, 1.29), and patients of other races saw a 44% increase in incidence associated with expansion (CI: 1.21, 1.70). Low SES counties saw an increase in incidence 1.12 times higher than that of high SES counties (CI:1.04, 1.20).
Conclusion Medicaid expansion was associated with increases in VS incidence across populations. Furthermore, this increase was more evident in disadvantaged populations, such as patients of non-white race and those from low SES counties. These findings emphasize the impact of Medicaid expansion on healthcare utilization for VS diagnosis.
Level of Evidence Step/Level 3—Retrospective Cohort Study Laryngoscope, 2024

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Incidentally Discovered 99mTc‐MDP Uptake on Bone Scan in Otosclerosis

Karl Berendt, Ho Jen, Richard Liu, Dean Jeffery

Publication date 04-06-2024


Otosclerosis is a poorly understood clinical entity causing progressive conductive hearing loss. Here we present the first known evidence of otosclerosis demonstrating 99m Tc-MDP uptake on bone scan. This presents an opportunity to explore the role of nuclear medicine imaging in early detection, staging, and even informing treatment and prognosis of this condition.
Otosclerosis is a poorly understood clinical entity causing progressive conductive hearing loss. Here we present the first known evidence of otosclerosis demonstrating 99m Tc-MDP uptake on bone scan. This presents an opportunity to explore the role of nuclear medicine imaging in early detection, staging, and even informing treatment and prognosis of this condition. Laryngoscope, 2024

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Quality of Life Outcomes for Parotid Malignancies

Anthony Tang, Jinhong Li, Nicole Scheff, Jonas T. Johnson, Kevin J. Contrera, Marci L. Nilsen

Publication date 04-06-2024


This study describes patient-reported outcome measures and associated factors in patients who underwent surgery for malignant parotid tumors. Adjuvant radiotherapy and chemoradiotherapy were both independently associated with impaired swallowing and neck mobility, as well as worse physical and social-emotional quality of life.
Background This study describes patient-reported outcome measures (PROMs) and associated factors in patients who underwent surgery for malignant parotid tumors (MPT).
Methods This is a retrospective study of all surgically treated MPT patients in a multidisciplinary head and neck cancer (HNC) survivorship clinic (2017–2023). PROMs included University of Washington Quality of Life Questionnaire (UW-QOL), Eating Assessment Tool (EAT-10), Patient Health Questionnaire (PHQ-8), Generalized Anxiety Disorder (GAD-7), Neck Disability Index (NDI), and Insomnia Severity Index. Multivariable regression analysis was used to investigate clinical predictors associated with PROMs.
Results In 62 MPT patients, the prevalence of clinically relevant dysphagia symptoms (EAT-10), elevated symptoms of depression (PHQ-8), moderate/severe symptoms of anxiety (GAD-7), moderate/severe neck pain with activities of daily living (NDI), and moderate/severe symptoms of insomnia at last follow-up was 32.3%, 15.5%, 7.1%, 17.7%, and 7.2%, respectively. Nonparametric one-sided test revealed that patients treated with adjuvant CRT had significantly worse physical QOL, social-emotional QOL, and swallowing scores than patients treated with surgery alone (p = 0.01, p = 0.02, p = 0.03, respectively); that patients treated with surgery and adjuvant RT had significantly worse physical QOL and social-emotional QOL than patients treated with surgery alone (p < 0.01, p = 0.01, respectively) and that patients treated with surgery and adjuvant CRT had significantly worse swallowing and neck pain than patients treated with surgery and adjuvant RT (p = 0.03, p = 0.05, respectively).
Conclusions In patients with surgically treated MPT, adjuvant CRT and RT were associated with worse PROMs.
Level of Evidence4 Laryngoscope, 2024

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In Response to Real‐World Adverse Events After Type 2 Biologic use in Chronic Rhinosinusitis with Nasal Polyps

Marisa Dorling, Juan Carlos Hernaiz‐Leonardo, Athenea Pascual, Arif Janjua, Andrew Thamboo, Amin R. Javer

Publication date 04-06-2024


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In Reference to Real‐World Adverse Events After Type 2 Biologic use in Chronic Rhinosinusitis with Nasal Polyps

Elena Cantone, Paolo Pezzella, Mario Brandon Russo

Publication date 04-06-2024


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New Model and Public Online Prediction Platform for Risk Stratification of Vocal Cord Leukoplakia

Zufei Li, Jinghui Lu, Baiwen Zhang, Joshua Si, Hong Zhang, Zhen Zhong, Shuai He, Wenli Cai, Tiancheng Li

Publication date 03-06-2024


The current diagnosis and treatment of vocal cord leukoplakia is relatively chaotic, lacking effective high-risk assessment methods. This study established and validated a model for vocal cord leukoplakia risk stratification, it not only has high accuracy, but also has been developed into a public prediction platform, which can be used and tested by everyone, and has strong practicality. This study may provide significant assistance to otolaryngologists in the treatment of vocal cord leukoplakia.
Objective To extract texture features from vocal cord leukoplakia (VCL) images and establish a VCL risk stratification prediction model using machine learning (ML) techniques.
MethodsA total of 462 patients with pathologically confirmed VCL were retrospectively collected and divided into low-risk and high-risk groups. We use a 5-fold cross validation method to ensure the generalization ability of the model built using the included dataset and avoid overfitting. Totally 504 texture features were extracted from each laryngoscope image. After feature selection, 10 ML classifiers were utilized to construct the model. The SHapley Additive ex Planations (SHAP) was employed for feature analysis. To evaluate the model, accuracy, sensitivity, specificity, and the area under the receiver operating characteristic (ROC) curve (AUC) were utilized. In addition, the model was transformed into an online application for public use and further tested in an independent dataset with 52 cases of VCL.
ResultsA total of 12 features were finally selected, random forest (RF) achieved the best model performance, the mean accuracy, sensitivity, specificity, and AUC of the 5-fold cross validation were 92.2 ± 4.1%, 95.6 ± 4.0%, 85.8 ± 5.8%, and 90.7 ± 4.9%, respectively. The result is much higher than the clinicians (AUC between 63.1% and 75.2%). The SHAP algorithm ranks the importance of 12 texture features to the model. The test results of the additional independent datasets were 92.3%, 95.7%, 90.0%, and 93.3%, respectively.
Conclusion The proposed VCL risk stratification prediction model, which has been developed into a public online prediction platform, may be applied in practical clinical work.
Level of Evidence3 Laryngoscope, 2024

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"Association of Alzheimers Disease With Peripheral Vestibular Disorder: A Case–Control Study"

Shih‐Han Hung, Sudha Xirasagar, Yen‐Fu Cheng, Herng‐Ching Lin, Chin‐Shyan Chen

Publication date 03-06-2024


Objectives Vestibular disorders can impact cognitive domains, including spatial orientation and memory, which are also affected in Alzheimers disease. This study aimed to examine the association between Alzheimers disease and a prior diagnosis of peripheral vestibular disorders in the elderly Taiwanese population.
Methods The case–control study sample was retrieved from Taiwans Longitudinal Health Insurance Database 2010. We included 3138 cases with Alzheimers disease and 9414 propensity-matched controls. We conducted multivariable logistic regression modeling to investigate the association between Alzheimers disease and a prior diagnosis of peripheral vestibular disorders after accounting for sociodemographic characteristics and medical comorbidities including diabetes, coronary heart disease, hypertension, hyperlipidemia, and hearing loss.
Results The results revealed a statistically significant difference in the prevalence of prior peripheral vestibular disorders between patients with Alzheimers disease and controls; 20.6% among patients with Alzheimers disease and 11.4% among controls (p < 0.001). Multivariable logistic regression analysis found that patients with Alzheimers disease were twice as likely as controls to have had a prior diagnosis of peripheral vestibular disorders, adjusted odds ratio 2.040 (95% confidence interval: 1.829–2.274).
Conclusions The findings suggest the possibility of shared or related pathophysiological pathways in Alzheimers disease and vestibular dysfunction disorders.
Level of Evidence3 Laryngoscope, 2024

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Association Between COPD and Hearing Loss

Hyo Geun Choi, Mi Jung Kwon, Ji Hee Kim, Joo‐Hee Kim, Yoonjoong Kim, So Young Kim

Publication date 03-06-2024


The goal of the present study was to estimate the risk of hearing impairment in patients with COPD using huge nationwide population. The propensity score was calculated, and overlap-weighted multinomial logistic regression was used to calculate the odds ratios of COPD for hearing impairment.
Objective The goal of the present study was to estimate the risk of hearing impairment in patients with COPD using huge nationwide population.
MethodsA retrospective case–control study was performed using the National Health Insurance Database in South Korea from 2002 through 2019. Totally 614,370 COPD patients and matched 2,170,504 control participants were selected at a 1:4 ratio. Hearing impairment was defined based on the registered data in the Ministry of Health and Welfare of Korea with six levels of severity of hearing impairment. The propensity score was calculated, and overlap-weighted multinomial logistic regression was used to calculate the odds ratios of COPD for hearing impairment.
ResultsA total of 2.67% of COPD patients and 1.9% of control participants had hearing impairment. The COPD patients indicated 1.10–1.21 times higher odds for hearing impairment according to the severity of hearing impairment than the control group. In accordance with age and sex, the younger age group (<65 years old) and female group demonstrated higher odds for hearing impairment related to the presence of COPD. The high odds for hearing impairment in patients with COPD was consistent in all other subgroups, except for the underweight group.
ConclusionsCOPD was associated with an increased risk of hearing impairment in the general population in Korea.
Level of Evidence3 Laryngoscope, 2024

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Nodal Metastases in Stage 3 Head and Neck Melanoma: Patterns of Metastases and Patterns of Failure

Sharon Tzelnick, John R. de Almeida, Christopher M.K.L. Yao, Seth Kibel, Nathan Kuehne, Rajan Grewal, Marcus O Butler, Sam Saibil, Anna Spreafico, Alexandra Easson, David P Goldstein

Publication date 03-06-2024


Objective Stage 3 patients with clinically positive nodal metastasis are treated with therapeutic neck dissection and adjuvant systemic therapy. The aim of our study was to examined the predictability of pre-operative CT as a nodal drainage assessment tool.
Methods Retrospective review of all patients with clinically positive head and neck cutaneous melanoma between 2010 and 2019. Clinical disease was diagnosed as radiological suspicious, biopsy-proven node. A pre-operative CT evaluation for nodal metastasis was compared to pathology report.
ResultsA total of 53 patients were included. Forty patients (75.5%) were males with a mean age of 59 (SD 15.52). The majority of patients (26.4%) had an unknown primary site. The most common sites for primary were the cheek in eight patients (15.1%) followed by forehead (9.4%) and lateral neck (9.4%). Preoperative CT predicted nodal disease in 84.6% of cases. The primary region that mainly failed from the previously described clinical prediction was the upper anterior neck with 83.3% parotid involvement. A total of 10 patients (18.9%) were diagnosis with non-clinical nodes on pathology with a median non-clinical node of 1 (range 1–2). Of them, 9 (90%) were in the same clinical levels detected by CT. Pre-operative CT was associated with a neck level accuracy of 98.1%.
Conclusion Stage 3 head and neck melanoma with clinically positive nodal metastasis that are eligible for an adjuvant systemic treatment, may benefit from a highly selective neck dissection according to their pre-operative imaging studies. This should be further evaluated in a large-scale clinical trial.
Level of Evidence3 Laryngoscope, 2024

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Transoral Excision of a Hypopharyngeal Liposarcoma

Achilles Kanaris, Jeffrey Larson, Farres Obeidin, Kevin Zhan, James Burns

Publication date 01-06-2024


Transoral extrusion of a mucosal-covered soft tissue mass found to be hypopharyngeal liposarcoma.
Liposarcomas are the most common soft tissue sarcoma in adults, whereas liposarcomas of the head and neck, particularly the hypopharynx, are incredibly rare - with approximately 50 cases reported in the literature. We present a case of an otherwise healthy and asymptomatic 42-year-old male who presented dramatically after vomiting up a large soft tissue mass. The lesion was surgically removed via transoral approach with blue laser, and diagnosis of well-differentiated liposarcoma was made via MDM2 gene amplification by FISH. Oral extrusion is a rare feature of this disease. This is the first documented case of an orally extruded liposarcoma to present in an otherwise asymptomatic and healthy patient, demonstrating how this entity may be indolent until initial presentation. Laryngoscope, 2024

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Negative Pressure Wound Therapy with Instillation and Dwell Time for Pharyngocutaneous Fistula

Kou Fujisawa, Shimpei Miyamoto, Yuki Saito, Mutsumi Okazaki

Publication date 01-06-2024


Pharyngocutaneous fistula is a critical complication of head and neck cancer reconstruction and it is often difficult to manage. We herein report two cases of pharyngocutaneous fistulas that developed after oropharyngeal reconstruction and were successfully treated with negative pressure wound therapy with instillation and dwell time (NPWTi-d), an advanced form of traditional NPWT. NPWTi-d may be a useful nonsurgical treatment for pharyngocutaneous fistula.
Pharyngocutaneous fistula is a critical complication of head and neck cancer reconstruction and it is often difficult to manage. We herein report two cases of pharyngocutaneous fistulas that developed after oropharyngeal reconstruction and were successfully treated with negative pressure wound therapy with instillation and dwell time (NPWTi-d), an advanced form of traditional NPWT. NPWTi-d may be a useful nonsurgical treatment for pharyngocutaneous fistula. Laryngoscope, 2024

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Post‐Tonsillectomy Bleeding and Analgesic Use Before and After the FDA Boxed Warning Against Codeine

Chloe Cottone, Arunima Vijay, Anjalika Chalamgari, Michele M. Carr

Publication date 01-06-2024


Objective The aim of this study was to investigate the trends in post-tonsillectomy analgesic utility and incidence of post-tonsillectomy hemorrhage before and after the 2013 FDA Boxed Warning against codeine use after pediatric tonsillectomy.
MethodsA retrospective study was conducted using Tri NetX. A search for patients up to 18 years from 2008 to 2022 within the US Collaborative Network identified 15,648,542 subjects. CPT and ICD-10 codes were used to identify children who experienced post-tonsillectomy hemorrhage within 14 days of a tonsillectomy. Analgesics given within 14 days of tonsillectomy were tabulated annually from 2008 to 2022, including codeine, ibuprofen, acetaminophen, oxycodone, ketorolac, and hydrocodone. Bleeding percentage and analgesic utility were grouped into events before and after 2013.
Results Mean age at tonsillectomy was 5.6 years (SD = 3.0). Before 2013, the median percentage of children who experienced postoperative bleeding was 1.8% with 0.73% returning to the OR for bleeding control. After 2013, the median percentage of children who experienced postoperative bleeding was 2.4% (p = 0.029), and 0.99% returned to the OR (p = 0.008). Use of post-tonsillectomy codeine fell from 10.4% to 0.5% (p = 0.003) whereas ibuprofen rose from 2.0% to 63.9% (p = <0.001), acetaminophen from 42.8% to 77.2% (p = <0.001), ketorolac from 1.2% to 9.2% (p = <0.001), and oxycodone from 2.0% to 30.9% (p = <0.001). No change was detected in use of hydrocodone.
Conclusion Analgesics used post-tonsillectomy in children have changed since the FDA Boxed Warning against codeine. There has been a small but statistically significant increase in post-tonsillectomy bleeding.
Level of EvidenceIV Laryngoscope, 2024

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Genetically Predicted Sleep Traits and Sensorineural Hearing Loss: A Mendelian Randomization Study

Yan Gao, Yuanzheng Qiu, Shanhong Lu

Publication date 31-05-2024


Mendelian randomization analysis provided evidence to support that morning chronotype and daytime sleepiness were causal contributors to the burden of sensorineural hearing loss (SNHL). Optimal sleep might facilitate the prevention and development of SNHL.
Objective Observational studies suggest a potential association between sleep characteristics, sensorineural hearing loss (SNHL), and sudden SNHL (SSNHL), but causal evidence is scarce. We sought to clarify this issue using two-sample Mendelian randomization analysis.
Methods The inverse-variance weighted (IVW) method was performed as primary analysis to assess bidirectional causal associations between sleep traits (chronotype, sleep duration, insomnia, daytime sleepiness, and snoring) and SNHL/SSNHL using publicly available Genome-Wide Association Studies summary data from two large consortia (UK Biobank and Finn Gen). Sensitivity analyses, including Mendelian randomization (MR)-Egger, Mendelian randomization pleiotropy residual sum and outlier, weight median, Cochrans Q test, leave-one-out analysis, and potential pleiotropy analysis, were conducted to ensure robustness.
ResultsIVW analysis found suggestive associations of morning chronotype (odds ratio OR = 1.08, 95% confidence interval CI = 1.01–1.16, p = 0.031) and daytime sleepiness (OR = 1.88, 95% CI = 1.24–2.87, p = 0.003) with SNHL onset. Additionally, morning chronotype was nominally associated with SSNHL onset using IVW method (OR = 1.37, 95% CI = 1.10–1.71, p = 0.006). However, there was no evidence for the causal effect of SNHL and SSNHL on different sleep traits (all p > 0.05). Sensitivity analysis showed that the results were stable.
Conclusion Within the MR limitations, morning chronotype and daytime sleepiness were underlying causal contributors to the burden of SNHL, indicating that optimal sleep might facilitate the prevention and development of SNHL.
Level of Evidence3 Laryngoscope, 2024

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As‐Needed Pilocarpine for Radiation‐Induced Xerostomia in Head and Neck Cancers

Natcha Watanapokasin, Worawat Rawangban, Napadon Tangjaturonrasme

Publication date 30-05-2024


Our study evaluates the effectiveness of as-needed pilocarpine in managing radiation-induced xerostomia in head and neck cancer patients, revealing its superiority in symptom relief with fewer side effects and lower treatment costs compared to fixed-dose regimens. These findings advocate for a shift toward patient-centered, flexible dosing strategies in clinical settings, potentially improving patient care and adherence.
Objectives This study aimed to evaluate the efficacy of as-needed pilocarpine for the management of radiation-induced xerostomia. Additionally, the study sought to assess the side effects associated with an as-needed regimen.
MethodsA randomized, double-blinded, placebo-controlled crossover study was conducted on patients who had undergone radiation therapy for head and neck cancers and developed xerostomia. Participants took pilocarpine or placebo as needed for symptom relief at 2 weeks per treatment, which included a one-week washout period. The primary outcome measure was the severity of dry mouth symptoms, quantified using the Xerostomia Inventory (XI). The primary outcome was the change in the XI score.
Results Among the 20 participants who completed the crossover study, there was a significant reduction in XI scores during the treatment phase with pilocarpine compared to the scores during the placebo phase. The mean difference in XI scores was −18.05 (95% CI: −17.17, −6.13, p < 0.001), with a−49.77 ± 3.22% change (p < 0.001). Only one participant withdrew due to pilocarpine side effects.
Conclusion As-needed pilocarpine administration is effective in relieving symptoms of radiation-induced xerostomia, with fewer side effects and reduced treatment costs compared to fixed-dose regimens. This study guides the potential shift toward flexible dosing strategies in clinical practice, promoting enhanced patient-centered, tailored care and adherence.
Level of Evidence Level 2. According to the Oxford Center for Evidence-Based Medicine 2011 level of evidence guidelines Laryngoscope, 2024

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Natural History of Untreated Idiopathic Sudden Sensorineural Hearing Loss

Yu‐Lan M. Ying, Christopher C. Tseng, Jennifer Shin, Steven Rauch

Publication date 29-05-2024


Although corticosteroids and other treatments for idiopathic sudden sensorineural hearing loss (ISSNHL) have been described, understanding its prognosis without intervention provides valuable information for patient management. The objective of this study is to provide a comprehensive, quantitative statistical analysis of the natural history of untreated ISSNHL. In the absence of future studies collecting prospective natural history data from untreated or placebo treated ISSNHL patients, the data presented here provides the best available historical control data for reconsideration of results in past ISSNHL studies, as well as a roadmap for design and interpretation of future ISSNHL treatment clinical trials.
Objective Although corticosteroids and other treatments for idiopathic sudden sensorineural hearing loss (ISSNHL) have been described, understanding its prognosis without intervention provides valuable information for patient management. The objective of this study is to provide a comprehensive, quantitative statistical analysis of the natural history of untreated idiopathic sudden sensorineural hearing loss (ISSNHL).
Study Type and DesignA systematic review and meta-analyses.
Methods Two independent searches of Pub Med, Scopus, Web of Science, and Cochrane Library databases up to June 30, 2022, were performed. Adults with idiopathic sudden sensorineural hearing loss who received placebo or were untreated and had audiometric outcome measures in all study types were reviewed. These data indicative of the natural history of ISSNHL were analyzed, as were study characteristics related to risk of bias. Heterogeneity as assessed via I2 and random effects analyses were performed.
Results Six studies meeting the inclusion criteria yielded 319 untreated patients whose natural history could be assessed. Heterogeneity among studies was moderate, with a variety of reported outcomes. A hearing improvement of at least 30 dB HL was observed in 36% (95% CI 0.28–0.44) of untreated patients, and of at least 10 dB HL was observed in 70% (95% CI 0.57–0.82) of untreated patients at 3 months. The mean hearing gain among untreated patients was 24.0 dB HL (95% CI 2.65–45.37) at 2–3 months.
Conclusions The observed natural history of ISSNHL suggests that patients can regain some hearing without active treatment. In the absence of future studies collecting prospective natural history data from untreated or placebo-treated ISSNHL patients, the data presented here provide the best available historical control data for reconsideration of results in past ISSNHL studies, as well as a roadmap for design and interpretation of future ISSNHL treatment clinical trials. Furthermore, knowing there is a statistically significant mean hearing gain of 24.0 dB HL in the untreated/placebo group provides an ethical basis for future placebo study of ISSNHL. The current status on ISSNHL management calls for a multi-institutional, randomized, double-blind placebo-controlled trial with validated outcome measures to provide science-based treatment guidance. Laryngoscope, 2024

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Lipids and Statin Medication With Sensorineural Hearing Loss: A Mendelian Randomization Study

Haoyang Wu, Wenting Deng, Yuelian Luo, Yaodong Xu, Hao Xiong

Publication date 28-05-2024


(1) This study is the pioneering effort employing Mendelian Randomization (MR) analysis to elucidate the relationship between lipids, statins, and sensorineural hearing loss (SNHL). (2) Our findings establish a causal link between elevated triglyceride levels and an increased risk of SNHL. (3) Although statins have demonstrated potential in reducing the risk of SNHL, their primary mechanism of action might not solely hinge on lowering triglycerides.
Background Recent insights suggest that lipids and statin medication play a role in the development of sensorineural hearing loss (SNHL), yet the exact role remains controversial. This research applied Mendelian randomization (MR) to assess whether lipids and statin medication are associated with an increased risk of SNHL.
MethodsA two-sample MR was used in this study. Genetic instruments were constructed from variants associated with risk factors. Data for lipids and statin medication were obtained from the IEU OpenGWAS project, and for SNHL from the Finngen research project, which comprises 32,487 individuals with SNHL and 331,736 control individuals.
Results Genetically predicted higher levels of triglycerides were associated with an increased risk of SNHL. The use of genetically predicted atorvastatin was associated with a lower risk of SNHL. Rosuvastatin has demonstrated potential in treating SNHL, yet further investigations are warranted to elucidate its relationship with SNHL. Insufficient evidence was available to suggest that the genetically predicted level of high-density lipoprotein cholesterol or low-density lipoprotein cholesterol or the use of simvastatin were associated with SNHL.
Conclusions The study provides genetic evidence suggesting that increased levels of triglycerides in the blood could be a risk factor for SNHL and that the use of certain statin medications, including atorvastatin and rosuvastatin, could reduce the risk of SNHL. These results align with findings from previous observational studies that have linked hyperlipidemia with the risk of SNHL.
Level of Evidence According to the Oxford Centre for Evidence-Based Medicine 2011 levels of Evidence, the study has a third level of Evidence Laryngoscope, 2024

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Airway and Voice Outcomes After Thyroarytenoid Myomectomy for Bilateral Vocal Fold Immobility

Zao M. Yang, Ronit Malka, Dylan Z. Erwin, Gregory Postma

Publication date 28-05-2024


Thyroarytenoid myomectomy demonstrated significant improvement in patient reported outcomes from bilateral vocal fold immobility while not significantly altering glottal structure. Data from this study suggest thyroarytenoid myomectomy improves dyspnea symptoms in patients with bilateral vocal fold immobility without impairing voice.
Introduction Type 4 posterior glottic stenosis and bilateral vocal fold paralysis are clinically challenging causes of bilateral vocal fold immobility (BVFI) that result in glottic airway obstruction. Established procedures for BVFI typically worsen dysphonia. We hypothesize the use of thyroarytenoid myomectomy (TAM) in the setting of BVFI will improve dyspnea with decreased detriment to voice.
Methods Eleven unilateral TAM procedures were performed between April 2021 and June 2023 at a single institution. Pre- and postoperative patient reported outcomes were compared. Representative images of maximal glottic opening were analyzed in ImageJ to calculate ipsilateral bowing index (BI), total BI, maximum glottic surface area (MGSA), and maximum opening angle (MOA). Statistical comparisons were performed with paired t-tests when normality was confirmed with Shapiro–Wilk test and otherwise with Wilcoxon signed-rank tests, with threshold for significance of α = 0.05. Interrater reliability for objective glottal measures was compared with intraclass correlation coefficient (ICC).
Results Dyspnea Index improved from mean (standard error) of 24.1 (3.8) to 9.1 (3.3), p = 0.004. Voice Handicap Index-10 improved from 20.0 (4) to 10.3 (3.8), p = 0.011. Glottal Function Index improved from 9.6 (1.4) to 6.3 (1.3), p = 0.017. There was no significant difference in ipsilateral BI, total BI, MOA, and median MGSA. There was good to excellent ICCs for all comparisons (0.83–0.95).
ConclusionsTAM demonstrated significant improvement in symptoms from BVFI while not significantly altering glottal structure. These data suggest TAM improves dyspnea in patients with BVFI without significantly impairing voice.
Level of Evidence4 Laryngoscope, 2024

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Sigmoid Sinus Wall Anomalies Can Progress and May Not Be Congenital

Yue‐Lin Hsieh, Wuqing Wang

Publication date 28-05-2024


Sigmoid sinus wall anomalies (SSWA) are characterized by morphological progression over time, making it unlikely that SSWA is a congenital condition. Reduced bilateral venous outflow volume is strongly implicated as a contributing factor to the progression of SSWA. Individuals diagnosed with SSWA, particularly those with advanced progression, may experience noticeable alterations in pulsatile tinnitus sensation.
Objective Sigmoid sinus wall anomalies (SSWA) are closely linked to venous pulsatile tinnitus (PT). This study aims to demonstrate that SSWA develops progressively rather than being congenital.
Methods We retrospectively analyzed 42 PT patients with SSWA who had at least two non-operative CT scans at our clinic. CT images were longitudinally assessed to track SSWA progression, while MRI and Doppler ultrasound evaluated transverse sinus stenosis and venous hemodynamics. Changes in PT perception were tracked using the tinnitus handicap inventory (THI) questionnaire.
Results Among the 42 SSWA patients, 12 (28.6%) exhibited progression. Anastomosis between diploic vein and diverticulum was significantly higher compared to the dehiscence cohort (p < 0.01). Within the diverticulum group, seven individuals (30.4%) experienced enlargement, with a mean diverticular wall expansion of 5.9% ± 11.4%. Progressive erosion was observed in two cases (12.5%) in the dehiscence cohort, with a mean sigmoid plate erosion of 3.8% ± 10.1%. In cases progressing from dehiscence to diverticulum, three subjects transitioned, with a mean sigmoid sinus wall length expansion of 43.8% ± 31.9%. SSWA progression showed a significant negative correlation with QBILATERAL (r = −0.857, p = 0.014), and there was a significant difference between initial and revisit THI scores (p < 0.01).
ConclusionSSWA can undergo morphological progression, indicating it is a progressive clinical condition rather than congenital.
Level of Evidence4 Laryngoscope, 2024

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Voice Disorders and Hearing Loss May Be Additive Risk Factors for Depression in a National Cohort

Anaïs Rameau, Lauren H. Tucker, Michael W. Denham, Yung Jee Kang, Nayeon Choi, Mark Lachs, Tony Ehren Rosen, Michael Stewart, Sara Czaja, Justin S. Golub

Publication date 28-05-2024


This cross-sectional study using national Korean National Health and Nutrition Examination Survey (KNHANES) data supports independent associations between hearing loss (HL) and depression, as well as self-reported voice disorder and depression. Those with a combination of HL and self-reported voice disorder had nearly double the odds of depression compared to those with neither condition. Future research should highlight using both objective and subjective metrics for the exposures of HL and voice disorder.
Objectives Hearing loss (HL) (receptive communication impairment) is a known risk factor for depression. However, dysphonia (expressive communication impairment), has received little study. We study HL, self-reported voice disorder, and combined impairment as risk factors for depression in a large national cohort.
Methods This was a cross-sectional epidemiologic study. Data were analyzed from the Korean National Health and Nutrition Examination Survey (KNHANES) cycles 2008–2012 and 2019–2020. KNHANES uniquely contains both audiometry and voice disorder data. HL (yes/no) was defined as ≥25 dB pure tone average. Voice disorder (yes/no) was defined by self-report. Depression (yes/no) was defined by physician diagnosis. Odds ratios for depression were calculated using multivariable logistic regressions with HL and voice disorder.
Results8,524 individuals aged 19 to 80 years old had complete data. The mean age was 57.3 years (SD = 13.4) and 64% were women. All regressions were controlled for age and sex. Those with HL, versus those without, had 1.27 times the odds (95% CI = 1.07–1.52, p = 0.007) of depression. Those with self-reported voice disorder, versus those without, had 1.48 times the odds (1.22–1.78, p < 0.001) of depression. Those with HL and self-reported voice disorder, versus those with neither, had 1.79 times the odds (1.27–2.48, p < 0.001) of depression.
Conclusions This study demonstrates independent relationships between HL and depression and self-reported voice disorder and depression. Combined HL and self-reported voice disorder had nearly 1.8 times the odds of depression. This is likely due to the grossly additive effect of difficulty with incoming and outgoing communication streams.
Level of EvidenceII Laryngoscope, 2024

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Characterization of the MSAP Flap in Head and Neck Surgical Oncology: A 3D Cadaveric Study

Gianluca Sampieri, John Tran, Allen L. Feng, Anne Agur, Joel Davies

Publication date 28-05-2024


The medial sural artery perforator flap (MSAP) is a versatile free flap used for reconstruction of oral cavity defects. However, anatomy of the cutaneous perforators has not been well studied. Anatomical characterization of the MSAP flap using 3D analysis can assist reconstructive surgeons in understanding the relevant anatomy and optimizing the surgical technique for MSAP flap harvest.
Objectives The medial sural artery (MSA) perforator flap is a versatile free flap. However, the cutaneous perforators are not well characterized.
The objectives of this pilot anatomical study were to: (1) visualize in three-dimensions, as in-situ, the origin, course, and distribution of the cutaneous perforators, (2) characterize the number and frequency of the perforators, and (3) quantify mean pedicle length.
Methods Thirteen cadaveric specimens were dissected, digitized, and modeled in 3D. Three-dimensional models and dissection photographs were used to determine the origin, course, number, distribution, and pedicle length of MSA perforators.
Results The most common pattern consisted of three perforators (39% of specimens). The maximum number of perforators identified was four (23%). The majority of specimens (92%) had a cutaneous perforator originating from the lateral branch of the MSA and coursed most frequently in the second (43%) and third (37%) quartiles of the length of the tibia. Mean pedicle length was 19.1 ± 6.9 cm. Perforators originating from the medial branch of the MSA were significantly (p < 0.05) shorter than those from the lateral branch and were found to course only in the first quartile.
Conclusion The 3D models constructed in this study provide a comprehensive overview of the location and course of the perforators, enabling measurement of parameters in 3D-space. Anatomical characterization of the MSA perforator flap using 3D analysis can assist reconstructive surgeons in understanding the relevant anatomy and optimizing the surgical technique for flap harvest.
Level of EvidenceN/A Laryngoscope, 2024

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Investigation of the Position and Angle of the Vocal Fold Projected onto the Thyroid Cartilage

Koji Matsushima

Publication date 28-05-2024


The position and angle of the paralyzed vocal fold projected onto the thyroid plate and arytenoid cartilage position were examined using computed tomography before and after surgery. The paralyzed vocal fold angle was not parallel to baseline, but at an approximate 20° angle.
Objective To perform laryngeal framework surgery for unilateral vocal fold paralysis and obtain favorable voice improvement, it is necessary to accurately determine the vocal fold and arytenoid cartilage positions. Thus, the position and angle of the paralyzed vocal folds and arytenoid cartilage projected onto the affected thyroid plate were measured using computed tomography (CT) before and after surgery.
Methods Forty-six male patients with thyroid cartilage ossification observed on preoperative CT and vocal fold paralysis were included. Using Adobe Illustrator®, the thyroid plate on the affected side was reconstructed from the continuous images of the sagittal section of the CT examination during participants quiet breathing (reconstructed affected thyroid plate RATP).
Results The anterior commissure mean position was slightly cranial to the midpoint of the thyroid cartilage midline. The paralyzed vocal fold angle was not parallel to the baseline. The average unaffected vocal fold angle during vocalization projected onto the affected thyroid plate was 13.83°, which differed significantly from the average paralyzed vocal fold angle before surgery (19.05°). However, no significant difference was observed in comparison with the average angle of the paralyzed vocal fold after arytenoid adduction. The average distance from the inferior notch of the affected side thyroid cartilage to the affected arytenoid cartilage was 16.7 mm.
Conclusion By understanding the positional relationship between the thyroid cartilage plate and internal structure from preoperative CT images, more effective surgery can be performed according to individual differences.
Level of EvidenceIV Laryngoscope, 2024

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Listening to the Past, Predicting the Future: A Bibliometric Exploration of Hearing Loss Publications Over Four Decades

Gülay Aktar Uğurlu, Burak Numan Uğurlu

Publication date 28-05-2024


This article aims to analyze the scientific literature on hearing loss (HL) in the field of Otorhinolaryngology published from the past to the present. A comprehensive dataset comprising 8013 articles on HL, spanning from 1980 to 2023, was retrieved from the Web of Science database and analyzed using various statistical and bibliometric methods.
Objectives This article aims to analyze the scientific literature on hearing loss (HL) in the field of Otorhinolaryngology published from the past to the present.
MethodsA comprehensive dataset comprising 8013 articles on HL, spanning from 1980 to 2023, was retrieved from the Web of Science database and analyzed using various statistical and bibliometric methods.
Results The leading countries in productivity were the United States, Japan, and Germany. The top productive journals included the International Journal of Pediatric Otorhinolaryngology (n = 652), Otology & Neurotology (579), and Acta Oto-Laryngologica (512). The journals with the highest h-index on hearing loss were Hearing Research (h = 65), Ear and Hearing (60), and Laryngoscope (55).
Factor analysis revealed that the HL literature consisted of four constructs: main topics, speech/sound, genetics, and pharmaceutical therapies. Sudden sensorineural HL, sensorineural HL, cochlear implant, unilateral, noise-induced and conductive HL, pediatric and age-related HL, tinnitus, auditory brainstem response, audiometry, and prognoses for hearing health were the most researched topics from past to present. In recent years, the trending topics are genomic analysis, gene mutations, whole-exome sequencing, genetic sequencing technique, the use of machine learning in HL, and the effect of COVID-19 on hearing health.
Conclusion The bibliometric analysis results clearly indicate significant progress in the field of hearing loss over the past 40 years. The 8013 articles published between 1980 and 2023 encompass a wide range of research in this area. These analyses can assist in identifying priority areas and focal points for future research.
Level of EvidenceN/A Laryngoscope, 2024

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In Reference to Treatment Outcome in Head and Neck Cancer with Distant Metastasis at Initial Diagnosis

Erkan Topkan, Efsun Somay, Ugur Selek

Publication date 27-05-2024


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Multi‐Instance Learning for Vocal Fold Leukoplakia Diagnosis Using White Light and Narrow‐Band Imaging: A Multicenter Study

Cheng‐Wei Tie, De‐Yang Li, Ji‐Qing Zhu, Mei‐Ling Wang, Jian‐Hui Wang, Bing‐Hong Chen, Ying Li, Sen Zhang, Lin Liu, Li Guo, Long Yang, Li‐Qun Yang, Jiao Wei, Feng Jiang, Zhi‐Qiang Zhao, Gui‐Qi Wang, Wei Zhang, Quan‐Mao Zhang, Xiao‐Guang Ni

Publication date 27-05-2024


In our study, we trained a multi-instance learning (MIL)-based artificial intelligence (AI) model on multi-center white light imaging (WLI) and narrow band imaging (NBI) images. This model aims to assist in distinguishing the benign or malignant nature of vocal fold leukoplakia (VFL).
Objectives Vocal fold leukoplakia (VFL) is a precancerous lesion of laryngeal cancer, and its endoscopic diagnosis poses challenges. We aim to develop an artificial intelligence (AI) model using white light imaging (WLI) and narrow-band imaging (NBI) to distinguish benign from malignant VFL.
MethodsA total of 7057 images from 426 patients were used for model development and internal validation. Additionally, 1617 images from two other hospitals were used for model external validation. Modeling learning based on WLI and NBI modalities was conducted using deep learning combined with a multi-instance learning approach (MIL). Furthermore, 50 prospectively collected videos were used to evaluate real-time model performance. A human-machine comparison involving 100 patients and 12 laryngologists assessed the real-world effectiveness of the model.
Results The model achieved the highest area under the receiver operating characteristic curve (AUC) values of 0.868 and 0.884 in the internal and external validation sets, respectively. AUC in the video validation set was 0.825 (95% CI: 0.704–0.946). In the human-machine comparison, AI significantly improved AUC and accuracy for all laryngologists (p < 0.05). With the assistance of AI, the diagnostic abilities and consistency of all laryngologists improved.
Conclusions Our multicenter study developed an effective AI model using MIL and fusion of WLI and NBI images for VFL diagnosis, particularly aiding junior laryngologists. However, further optimization and validation are necessary to fully assess its potential impact in clinical settings.
Level of Evidence3 Laryngoscope, 2024

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Outcomes of Radial Forearm Free Flap Closure With Split‐Thickness Skin Graft Versus Primary Closure

Dorsa Mousa‐Doust, Anat Bahat Dinur, Sena Turkdogan, J. Scott Durham, Donald Anderson, Eitan Prisman

Publication date 24-05-2024


This study compares patient-reported functional and aesthetic outcomes of split-thickness skin graft (STSG) versus hatchet flap closure of radial forearm free flapdonor site using the Patient-Observer Scar Assessment Scale and Michigan Hand Outcome Questionnaire. In total, 81 patients participated in the study (39 STSG patients and 42 hatchet flap patients). STSG appeared to have less compromise in activities of daily living, better satisfaction and improved scar quality than hatchet flap, but a higher rate of tendon exposure.
Background This study compares patient-reported functional and aesthetic outcomes of split-thickness skin graft (STSG) versus hatchet flap closure of radial forearm free flap (RFFF) donor site.
Methods Patients with RFFF (2015–2020) were retrospectively identified. Those willing to participate in patient-reported outcomes (PRO) filled out Patient-Observer Scar Assessment Scale (POSAS) and Michigan Hand Outcome Questionnaire (MHOQ).
Results198 patients met our inclusion criteria and 81 participated in PRO. There was a higher rate of tendon exposure in STSG versus hatchet flap (11 vs. 1, p = 0.0019), but a lower rate of skin necrosis (5 vs. 16, p = 0.0190) and epidermolysis (1 vs. 12, p = 0.0028). Scar quality in STSG was superior to hatchet flap in all domains of POSAS. MHOQ scores were similar between both groups with no statistical difference in overall scores (p = 0.2165).
ConclusionsSTSG appeared to have less compromise in activities of daily living, better satisfaction and improved scar quality than hatchet flap, but a higher rate of tendon exposure.
Level of Evidence3 Laryngoscope, 2024

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Next‐generation Sequencing of MicroRNA in Acquired Middle Ear Cholesteatoma

Sung Jun Han, Sung Kyun Kim, Seok Min Hong

Publication date 22-05-2024


This was the first study investigating small non-coding RNAs in human acquired cholesteatoma using NGS technique. We were able to identify new miRNAs and pathways related to cholesteatoma.
Objectives/Hypothesis The pathophysiology of cholesteatoma is not precisely understood, and research on the associated microRNAs (miRNAs) is also deficient. We demonstrated the expression of miRNA in normal skin and middle ear cholesteatoma by next-generation sequencing (NGS) technology. The profiles of miRNA and relevant molecular interaction pathways were investigated.
Study Design Case–control experimental study.
Methods Middle ear cholesteatoma and post-auricular skin tissue specimens were collected from 13 adult patients. Total RNA was extracted, and miRNA expression profiles were analyzed by NGS technology. Functional gene classification to predict target genes and relevant biological pathways was performed using DIANA-microT-CDS and the Kyoto Encyclopedia Gene and Genome database (KEGG) pathways.
Results The expression of 2588 miRNAs from middle ear cholesteatoma and skin tissue samples was analyzed. The expression of 76 upregulated and 128 downregulated miRNAs was identified in the cholesteatoma samples compared to normal skin (FC ≥2 and p < 0.05). Ninety-nine differentially expressed miRNAs (FC ≥4 and p < 0.05) were used to explore the biological pathways involved in the etiopathogenesis of cholesteatoma. The most predicted pathway in cholesteatoma in the upregulated miRNA group was the ErbB signaling pathway and it was extracellular matrix (ECM)–receptor interaction in the downregulated miRNA group.
Conclusions This was the first study investigating small miRNAs in human acquired cholesteatoma using NGS technique. We were able to identify new miRNAs and pathways related to cholesteatoma. The results of this study are expected to be helpful in revealing new pathophysiologies of cholesteatoma.
Level of EvidenceN/A Laryngoscope, 2024

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Esophageal Baseline Impedance is Associated with Laryngopharyngeal Reflux and Treatment Response

Christopher M. Kurylo, Jacob Noel, Joel H. Blumin, Jonathan M. Bock

Publication date 22-05-2024


Mean nocturnal baseline impedance (MNBI) is a value calculated on multichannel intraluminal impedance-pH studies and provides a functional measure of the esophageal epithelial barrier. MNBI has been shown to help with the diagnosis, characterization, and management of patients with gastroesophageal reflux disease. We analyzed its utility in patients with laryngopharyngeal reflux (LPR) symptoms and found it to be predictive of LPR and responsiveness to antireflux treatment.
Objective To evaluate the efficacy of distal esophageal mean nocturnal baseline impedance (MNBI), a general marker of esophageal mucosal barrier integrity, in predicting laryngopharyngeal reflux (LPR) and symptomatic response to acid reflux therapy.
Methods This retrospective study analyzed 173 patients who presented with symptoms of laryngopharyngeal reflux and underwent 24-h multichannel intraluminal impedance-pH (MII-pH) testing. Mean nocturnal baseline impedance values were calculated and assessed for their association and ability to predict LPR symptoms, MII-pH results, treatment response, and other markers of LPR.
Results Notably, 153 of the 173 patients were tested off acid suppression medication and included in statistical analysis. Based on the MII-pH probe data, 108 (71%) patients had LPR, 8 (5%) had gastroesophageal reflux disease (GERD), and 37 (24%) were without pathologic reflux. Distal esophageal MNBI of LPR patients was significantly lower in LPR patients than patients with negative studies (1332 ± 94.8 vs. 2158 ± 173.5, p = 0.001). Among 118 patients who trialed antireflux therapy, a distal esophageal MNBI cutoff value of <1580 Ω was an independent predictor of treatment response (OR = 4.148 1.877–9.189). This value better predicted improvement with antireflux therapy for LPR than other objective MII-pH probe data, which were not independent predictors of treatment response.
Conclusion Distal esophageal MNBI values may have value in the diagnosis of LPR and potentially predict medication responsiveness in LPR patients.
Level of Evidence3 Laryngoscope, 2024

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POSTN Regulates Fibroblast Proliferation and Migration in Laryngotracheal Stenosis Through the TGF‐β/RHOA Pathway

Zhiqiang She, Huiying Chen, Xiaoyu Lin, Chao Li, Jiping Su

Publication date 21-05-2024


This study confirmed that POSTN can promote the proliferation and migration of tracheal fibroblasts and cause the formation of laryngotracheal scars. This effect is related to the activation of the TGFβ1/RHOA pathway. POSTN and the TGFβ1/RHOA pathway may key factors in the pathogenesis of Laryngotracheal stenosis.
Objectives To investigate the role of periostin (POSTN) and the transforming growth factor β (TGF-β) pathway in the formation of laryngotracheal stenosis (LTS) scar fibrosis and to explore the specific signaling mechanism of POSTN-regulated TGF-β pathway in tracheal fibroblasts.
Methods Bioinformatics analysis was performed on scar data sets from the GEO database to preliminarily analyze the involvement of POSTN and TGF-β pathways in fibrosis diseases. Expression of POSTN and TGF-β pathway-related molecules was analyzed in LTS scar tissue at the mRNA and protein levels. The effect of POSTN on the biological behavior of tracheal fibroblasts was studied using plasmid DNA overexpression and siRNA silencing techniques to regulate POSTN expression and observe the activation of TGF-β1 and the regulation of cell proliferation and migration via the TGF-β/RHOA pathway.
Results The bioinformatics analysis revealed that POSTN and the TGF-β pathway are significantly involved in fibrosis diseases. High expression of POSTN and TGF-β/RHOA pathway-related molecules (TGFβ1, RHOA, CTGF, and COL1) was observed in LTS tissue at both mRNA and protein levels. In tracheal fibroblasts, overexpression or silencing of POSTN led to the activation of TGF-β1 and regulation of cell proliferation and migration through the TGF-β/RHOA pathway.
ConclusionPOSTN is a key molecule in scar formation in LTS, and it regulates the TGF-β/RHOA pathway to mediate the formation of cicatricial LTS by acting on TGF-β1. This study provides insights into the molecular mechanisms underlying LTS and suggests potential therapeutic targets for the treatment of this condition.
Level of EvidenceNA Laryngoscope, 2024

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Creating Patient‐Specific 3D‐Printed Airway Models for Slide Tracheoplasty

Jennifer Siu, Clare M. Richardson, D. Michael McMullan, Matthew Files, Seth Friedman, Sanjay Parikh, Kaalan Johnson

Publication date 21-05-2024


This protocol describes the method for creating 3D-printed trachea models for use in high-fidelity simulation-based training and advanced surgical planning for pediatric patients undergoing slide tracheoplasty. The goal is to provide a template and methodology to allow for replicability and more widespread dissemination of these models to improve clinical training and patient care. Laryngoscope, 2024

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