Laryngoscope 2020-11-28

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

\nSarah Brookes, \nLujuan Zhang, \nTheodore J. Puls, \nJohn Kincaid, \nSherry Voytik‐Harbin, \nStacey Halum\n

Publicatie 28-11-2020


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

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

\nDiego Barbieri, \nPietro Indelicato, \nAlessandro Vinciguerra, \nFederico Marco, \nAnna Maria Formenti, \nMatteo Trimarchi, \nMario Bussi\n

Publicatie 28-11-2020


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

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

\nEric W. Wang, \nPaul A. Gardner, \nShannon Fraser, \nS. Tonya Stefko, \nJuan C. Fernandez‐Miranda, \nCarl H. Snyderman\n

Publicatie 28-11-2020


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

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Early Postoperative Magnetic Resonance in the Diagnosis of Persistent Juvenile Angiofibroma

\nAlberto Schreiber, \nMarco Ravanelli, \nMarco Ferrari, \nDavide Mattavelli, \nVittorio Rampinelli, \nAndrea Bolzoni Villaret, \nGiacomo Bertazzoni, \nMichele Tomasoni, \nTommaso Gualtieri, \nIvan Zorza, \nDavide Farina, \nRoberto Maroldi, \nPiero Nicolai\n

Publicatie 27-11-2020


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

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

\nJung Hsuan Jen, \nRoger W. Chan, \nChia‐Hsin Wu, \nChi‐Te Wang\n

Publicatie 24-11-2020


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

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

\nShigeharu Fujieda, \nShoji Matsune, \nSachio Takeno, \nMikiya Asako, \nMakiko Takeuchi, \nHiroyuki Fujita, \nYoshinori Takahashi, \nNikhil Amin, \nYamo Deniz, \nPaul Rowe, \nLeda Mannent\n

Publicatie 23-11-2020


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

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

\nGerhard Foerster, \nRosa Podema, \nOrlando Guntinas‐Lichius, \nRoger L. Crumley, \nAndreas H. Mueller\n

Publicatie 21-11-2020


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

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

\nYael Bensoussan, \nJeremy Pinto, \nMatthew Crowson, \nPatrick R. Walden, \nFrank Rudzicz, \nMichael Johns\n

Publicatie 21-11-2020


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

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Prevalence of olfactory dysfunction in coronavirus disease 2019 (COVID‐19): A meta‐analysis of 27492 patients

\nJeyasakthy Saniasiaya, \nMd Asiful Islam, \nBaharudin Abdullah\n

Publicatie 20-11-2020


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

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

\nNicholas B. Abt, \nAndrew J. Holcomb, \nAllen L. Feng, \nKrish Suresh, \nTara E. Mokhtari, \nChristopher I. McHugh, \nAnuraag S. Parikh, \nDaniel L. Faden, \nDaniel G. Deschler, \nMark A. Varvares, \nDerrick T. Lin, \nJeremy D. Richmon\n

Publicatie 19-11-2020


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

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

\nFatih M. Hanege, \nEsra Kocoglu, \nMahmut T. Kalcioglu, \nSerdal Celik, \nYasemin Cag, \nFehim Esen, \nEray Bayindir, \nSadrettin Pence, \nEmine Alp Mese, \nCanan Agalar\n

Publicatie 19-11-2020


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

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

\nGeorg Mathias Sprinzl, \nPhilipp Schoerg, \nStefanie Muck, \nMax Jesenko, \nSophie Speiser, \nMarlene Ploder, \nStefan Herwig Edlinger, \nAstrid Magele\n

Publicatie 19-11-2020


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

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Parosmia is Associated with Relevant Olfactory Recovery After Olfactory Training

\nDavid T. Liu, \nMaha Sabha, \nMichael Damm, \nCarl Philpott, \nAnna Oleszkiewicz, \nAntje Hähner, \nThomas Hummel\n

Publicatie 19-11-2020


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

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Sialographic Analysis of Radioiodine‐Associated Chronic Sialadenitis

\nRyan K. Thorpe, \nMegan J. Foggia, \nKathryn S. Marcus, \nBruno Policeni, \nJoan E. Maley, \nHenry T. Hoffman\n

Publicatie 17-11-2020


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

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Internal Auditory Canal Diverticula in Children: A Congenital Variant

\nThomas J. Muelleman, \nHannah Kavookjian, \nJulia Asmar, \nKirang Patel, \nDavid Nielsen, \nKyle Summers, \nMeghan Tracy, \nJanelle Noel‐MacDonnell, \nHinrich Staecker, \nLuke Ledbetter, \nRobert Weatherly\n

Publicatie 17-11-2020


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

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"Is Endolymphatic Sac Surgery Beneficial For Menieres Disease?"

\nMatthew W. Cooper, \nDavid M. Kaylie\n

Publicatie 17-11-2020


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What Is the Role of Laryngoscopy in Angioedema Isolated to the Lips, Without Laryngeal Symptoms?

\nTemitope A. Adeyeni, \nAaron Domack, \nChristopher Britt\n

Publicatie 17-11-2020


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Preoperative Sinus Computed Tomography Scan Review Checklist

\nDaniel B. Spielman, \nDavid A. Gudis\n

Publicatie 17-11-2020


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"The Utility of Flexible Esophagoscopy During Open Hypopharyngeal (Zenkers) Diverticulum Surgery"

\nRebecca J. Howell, \nLuke W. Edelmayer, \nGregory N. Postma\n

Publicatie 17-11-2020


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Nasal Airflow Changes With Bioabsorbable Implant, Butterfly, and Spreader Grafts

\nBryan M. Brandon, \nWesley H. Stepp, \nSaikat Basu, \nJulia S. Kimbell, \nBrent A. Senior, \nWilliam W. Shockley, \nJ. Madison Clark\n

Publicatie 17-11-2020


Objectives/HypothesisInternal nasal valve compromise is a major cause of nasal obstruction, with a growing number of ways to treat this condition. In this study, we compared the effects of butterfly graft, spreader graft, and the bioabsorbable nasal implant on nasal airflow resistance.Study DesignCadaver study.MethodsComputational fluid dynamics (CFD) simulations were completed from nine preoperative and postoperative cadaveric subjects. Each cadaveric head underwent placement of a bioabsorbable nasal implant (BNI) (Spirox Latera; Stryker ENT, Plymouth, MN), butterfly graft, or spreader graft. Pre‐ and postoperative computed tomography (CT) scans were used to generate three‐dimensional models of the nasal airway used in steady‐state CFD simulations of airflow and heat transfer during inspiration.ResultsButterfly graft placement resulted in a mean improvement in nasal airway resistance of 24.9% (±7.3), whereas BNI placement resulted in a 6.7% (±1.2) improvement, and spreader graft placement also resulted in a consistent improvement of 2.6% (±13.5). Pressure within the main nasal cavity was consistently lower following butterfly graft placement versus a spreader graft or BNI. Butterfly and spreader graft placement also resulted in modest improvements in airflow allocation, whereas BNI demonstrated more variation (−1% to 12%). Heat flux was not significantly different; however, a small improvement in total heat flux was seen with all three interventions.ConclusionsThe results of this study demonstrate reduction in nasal airway resistance in all three surgical interventions, with the butterfly graft demonstrating superiority to the other two techniques. However, these data only reflect a static environment and not dynamic changes in airflow seen during respiration.Level of EvidenceNA Laryngoscope, 130:E817–E823, 2020

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The Role of Spirometry and Dyspnea Index in the Management of Subglottic Stenosis

\nKevin Tie, \nRobert A. Buckmire, \nRupali N. Shah\n

Publicatie 17-11-2020


ObjectivesWe aimed to assess the role of spirometry measures and Dyspnea Index (DI) in response to treatment of subglottic stenosis (SGS) and ability to predict need for surgery. We also assessed correlations between spirometry measures, DI, and physical SGS parameters.MethodsThirty‐seven adult female SGS patients were prospectively enrolled. Spirometry data and DI were obtained at serial clinic visits; physical SGS parameters were obtained intraoperatively. PIFR, PEFR, EDI, FEV1/FVC, and DI were compared preoperatively to postoperatively for patients who underwent operative intervention. Spirometry data, DI, and physical SGS parameters were analyzed for correlations, and receiver operating characteristic (ROC) curves were created for spirometry measures and DI to determine optimal cutoffs for recommending surgery.ResultsMeans of all measured spirometry measures changed significantly from preoperative to postoperative visits (P < .05). Mean DIs changed significantly between preoperative (27.5, n = 13, SD = 8.6) and postoperative visits (8.6, n = 13, SD = 5.5, P < 5 × 10‐5). All Pearson correlations were negligible to moderate. The area under the curve (AUC) for peak inspiratory flow rate (PIFR) was 0.903 (95% CI, 0.832–0.974) with cutoff at 2.10 L/s; the AUC for DI was 0.874 (95% CI, 0.791–0.956) with cutoff between 22‐25; the AUC for peak expiratory flow rate (PEFR) was 0.806 (95% CI, 0.702–0.910) with cutoff at 2.5 L/s; all other ROC curves were less than good.ConclusionPIFR, PEFR, EDI, FEV1/FVC, and DIs significantly improve after treatment for SGS. No strong correlations exist between spirometry measures, DI, and physical SGS parameters. PIFR was the most sensitive and specific for predicting timing of operative intervention in our cohort.Level of Evidence1b Laryngoscope, 2019

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Orofacial Strength and Voice Quality as Outcome of Levodopa Challenge Test in Parkinson Disease

\nJérôme R. Lechien, \nBertil Delsaut, \nAnissa Abderrakib, \nKathy Huet, \nVeronique Delvaux, \nMyriam Piccaluga, \nMohamad Khalife, \nBernard Harmegnies, \nSven Saussez, \nSerge Blecic\n

Publicatie 17-11-2020


ObjectiveTo assess the usefulness of orofacial strength and voice quality as assessment of response to levodopa challenge test (LCT) used in the diagnosis of early idiopathic Parkinson disease (IPD).Study DesignControlled Prospective Study.MethodsFrom January 2014 to April 2019, patients with early IPD and healthy individuals were recruited and evaluated for clinical findings (Hoehn and Yahr scale; Unified Parkinsons Disease Rating Scale); Voice Handicap Index (VHI); grade of dysphonia, roughness, breathiness, asthenia, and strain and instability (GRBASI); maximal phonation time; phonation quotient; acoustic parameters; and orofacial muscle strength Oral Performance Instrument (IOPI; IOPI Medical, Woodinville, WA, USA) t) at baseline and 45 minutes after the levodopa intake (LCT).ResultsA total of 32 IPD patients and 20 healthy individuals completed the study. Healthy individuals exhibited better VHI, grade of dysphonia, breathiness, asthenia, strain, instability, and acoustic measurements (noise‐related, tremor, F0 short‐ and mid‐term and intensity short‐term parameters) than healthy subjects. The mean values of muscle strength of lips, cheeks, fundamental frequency (F0), highest F0, and shimmer significantly improved from pre‐ to post‐LCT in IPD patients. Healthy individuals did not exhibit significant changes of orofacial strength and voice quality assessment from pre‐ to post‐LCT. Significant associations were found between clinical, orofacial strength, and some aerodynamic and acoustic measurements.ConclusionOrofacial strength and acoustic voice quality measurements may be used as objective outcomes of the LCT responsiveness in patients with early IPD.Level of Evidence3A. Laryngoscope, 2020

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The Effect of Cochlear Implantation on Vestibular Evoked Myogenic Potential in Children

\nXin Li, \nShusheng Gong\n

Publicatie 17-11-2020


Objectives/HypothesisWe conducted this study to assess the effects of unilateral cochlear implantation (CI) on otolith function by observing the changes in ocular vestibular evoked myogenic potential (oVEMP) and cervical vestibular evoked myogenic potential (cVEMP) in children.Study Design: Prospective case series.MethodsThe oVEMP and cVEMP elicited by air‐conducted sound in 35 children were analyzed preoperatively and at 5 days, 1 month, and 2 months after surgery.ResultsBefore CI, the response rates of oVEMPs and cVEMPs were 81.4% and 91.4%, respectively. In the implanted side, oVEMPs and cVEMPs were reduced by 37.1% and 68.6%, respectively, 5 days after CI. One month after CI, oVEMPs and cVEMPs were 34.6% and 72%, respectively, with the device switched off, and 50% and 73.1%, respectively, with the device switched on. Two months after CI, the oVEMPs and cVEMPs were 36% and 80%, respectively, when the implant was turned off, and 70.8% and 75%, respectively, when the implant was turned on.ConclusionsThe study confirmed the value of VEMP testing in the clinical setting and that absent VEMPs could indicate impairment of otolith function after CI.Level of Evidence4 Laryngoscope, 2020

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Patient values regarding overlapping surgery: Identification of distinct patient subgroups

\nAlexander Langerman, \nAlexandra Arambula, \nKemberlee Bonnet, \nDavid G. Schlundt, \nKathleen M. Brelsford\n

Publicatie 17-11-2020


Objectives/HypothesisTo explore patient values associated with their comfort level with surgical trainees and attending surgeon absence from the operating room.Study DesignQualitative interviews with general medical patients.MethodsWe analyzed data from qualitative interviews with patients that included a quantitative rating on a visual analog scale (VAS) of comfort consenting to three surgical scenarios, including overlapping surgery, to identify subgroups of patients based on comfort level. After identifying subgroups, we compared qualitative responses from participants who were generally comfortable with overlapping surgery to those who were uncomfortable to identify themes associated with these perceptions.ResultsWe identified three subgroups of patients based on the patterns of VAS responses. Participants who were comfortable with overlapping surgery expressed trust in the surgeon and delegation process. Those who were most uncomfortable expressed a strong desire to know who was operating on them, and a desire for control over their surgical process. Subjects uncomfortable with overlapping surgery were also generally not sensitive to tradeoffs (cost, timing).ConclusionsWe identified distinct subgroups of patients based on their comfort level with trainee independence and primary attending availability. By examining the predominant values in these subgroups, we identified potential explanations for patient discomfort with attending absence. Strategies to enhance patients’ knowledge about the process of surgery and a sense of control over their own care may improve comfort with trainee participation and overlapping surgery.Level of Evidence6 Laryngoscope, 2019

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Predicting Obstructive Sleep Apnea Status With the Reflux Symptom Index in a Sleep Study Population

\nMeron Teklu, \nChristopher J. Gouveia, \nAmulya Yalamanchili, \nSaied Ghadersohi, \nCaroline P. E. Price, \nMichiel Bove, \nHrayr P Attarian, \nBruce K. Tan\n

Publicatie 17-11-2020


Objectives/HypothesisOtolaryngologic symptoms of obstructive sleep apnea (OSA) and their diagnostic utility are not well studied. We aimed to elucidate the prevalence of otolaryngologic symptoms among patients being evaluated for OSA. Given findings that the Reflux Symptom Index (RSI) was strongly associated with OSA status, we evaluated the diagnostic utility of the RSI for predicting OSA status.Study DesignCross‐sectional.MethodsWe recruited 101 adults presenting for ambulatory polysomnograms to the Northwestern Sleep Disorders Center from July 2017 to July 2018. The Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Leicester Cough Questionnaire (LCQ), RSI, Gastroesophageal Reflux Disease Questionnaire, Sino‐Nasal Outcome Test‐22, Nasal Obstruction Symptom Evaluation, Eustachian Tube Dysfunction Questionnaire 7, and Headache Impact Test were administered. Polysomnogram results were subsequently obtained. Patients with OSA (apnea‐hypopnea index ≥ 5) and without OSA were compared.ResultsOf the 101 participants, 98 had valid sleep study results. Of those, 72 were diagnosed with OSA and 26 were not. The two groups differed significantly in age and body mass index (BMI). Of the questionnaires, only the RSI and LCQ means differed significantly, with worse symptoms in the OSA group (P = .003 and .014, respectively). Upon univariate regression, age, BMI, and RSI were associated with OSA status. Using regression coefficients, a clinical score of 2 (RSI) + 1.5 (BMI) + age yielded a diagnostic model (C‐statistic = 0.807, P < .001). A threshold score of 104.21 was 76.4% sensitive and 73.1% specific.ConclusionsPatients with OSA have worse symptoms of laryngopharyngeal reflux as measured by the RSI. The addition of the RSI to the recognized factors of age and BMI improves diagnostic utility for OSA.Level of Evidence2 Laryngoscope, 2020

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A Comparison of the Bacterial Nasal Microbiome in Allergic Rhinitis Patients Before and After Immunotherapy

\nMelissa E. Bender, \nTimothy D. Read, \nThomas S. Edwards, \nMichelle Hargita, \nAnya J. Cutler, \nEmily F. Wissel, \nSarah K. Wise\n

Publicatie 17-11-2020


Objectives/HypothesisRecent research has examined the nasal microbiome in rhinosinusitis and nondiseased states. Given immunologic alterations in allergic rhinitis (AR) and after allergen immunotherapy (IT), we evaluated the nasal microbiome in these conditions.Study DesignCross‐sectional comparison.MethodsIn this cross‐sectional study, nasal swabs for microbiome analysis were collected from three patient groups: IT‐naïve AR patients, AR patients undergoing IT for greater than 12 months, and a control group without sinonasal inflammatory disease.ResultsNasal swabs were successfully collected for 14 IT‐naïve AR patients, 20 post‐IT patients, and 17 controls. The α diversity showed a statistical difference in evenness but not in richness amongst samples, whereas the β‐diversity was significantly different between groups. Corynebacterium and Staphylococcus were the most prevalent bacteria across all groups.Conclusionsβ‐diversity was found to be significantly different across the three groups, but the AR groups were found to be more similar to each other than to the controls. Although there is symptomatic improvement in the AR group undergoing IT, the microbiome does not appear to transition to a healthy microbiome composition.Level of Evidence4 Laryngoscope, 2020

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"Hearing Preservation and Speech Outcomes After Cochlear Implantation in Menieres Disease"

"\nMaheer M. Masood, \nDouglas R. Farquhar, \nKevin D. Brown, \nHarold C. Pillsbury, \nEnglish R. King, \nBrendan P. OConnell\n"

Publicatie 17-11-2020


Objectives/HypothesisTo evaluate speech perception outcomes and hearing preservation after cochlear implantation in patients with Menieres disease (MD).Study DesignRetrospective chart review.MethodsFifty‐one adult patients, accounting for a total of 63 implants, with MD treated at a tertiary care center were included in the study. Patients with unaided preoperative air‐conduction thresholds ≤80 dB at 250 Hz were included in hearing preservation analyses. The primary outcome measure was Consonant‐Nucleus‐Consonant (CNC) score. Hearing preservation was assessed as follows: 1) maintenance of functional hearing, defined as a postoperative unaided air‐conduction threshold ≤80 dB at 250 Hz and 2) low‐frequency pure‐tone average (LFPTA) shift.ResultsSpeech perception scores improved significantly postimplantation; specifically, the CNC mean score was 9% preoperatively and increased to 57% by 1 year postoperatively (P < .001). Eighteen ears were included in hearing preservation analysis; the mean preoperative LFPTA was 65 dB (standard deviation SD = 10). The mean postoperative LFPTA at activation was 93 dB (SD = 21), and at 1 year was 102 dB (SD = 11). Twenty‐seven percent of patients achieved short‐term functional hearing preservation, whereas the longer‐term outcomes were less favorable (11%).ConclusionsSpeech perception scores improve after implantation in patients with MD. Hearing preservation is possible in patients with MD, albeit at lower rates than reported non‐MD populations. Our data suggest that there can be degradation in acoustic hearing over time.Level of Evidence4 Laryngoscope, 2019

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Bridging the gap: Using 3D printed polycaprolactone implants to reconstruct circumferential tracheal defects in rabbits

\nDavid S. Chan, \nNathalie Gabra, \nAyesha Baig, \nJohn J. Manoukian, \nSam J. Daniel\n

Publicatie 17-11-2020


Objective1) To assess the feasibility of reconstructing 2‐cm‐long circumferential tracheal defects with a 3D printed polycaprolactone (PCL) implant in rabbits. 2) To evaluate endoscopic, histologic, and functional characteristics of a PCL tracheal implant over time.MethodsTen New Zealand rabbits were included in this study. A 2‐cm‐long 3D printed PCL tracheal implant was created. All rabbits underwent surgical excision of a 2‐cm‐long cm segment of cervical trachea, which was reconstructed with the implant. Rabbits were sacrificed at the following time points: 0, 4, 5, 6, and 7 weeks postoperatively. At these time points, a rigid bronchoscopy was performed, and blinded evaluators calculated the percentage of airway stenosis. The tracheas were then harvested and prepared for histologic analysis.ResultsAll rabbits survived to their date of sacrifice except for one. Rabbits were euthanized between 0 to 54 days postoperatively with a median of 30 days. All rabbits developed significant granulation tissue with an average percentage stenosis of 92.3% ± 6.1%. On histology, granulation was present with extensive neovascularization and mixed inflammatory cells. There was re‐epithelialization present on the luminal surface of the PCL implant near the anastomoses but absent at the center of the implant.ConclusionThis study demonstrates that our 2‐cm‐long 3D printed PCL tracheal implant can be used to reconstruct a tracheal defect of equivalent size in a New Zealand rabbit model in the short term. However, significant granulation tissue formation limits long‐term survival. Further research is warranted to limit the granulation tissue overgrowth.Level of EvidenceNALaryngoscope, 2019

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Therapeutic Efficacy of Basic Fibroblast Growth Factor in Patients With Vocal Fold Atrophy

\nAyako Okui, \nUjimoto Konomi, \nTakeharu Kanazawa, \nDaigo Komazawa, \nKazuhiro Nakamura, \nKoji Matsushima, \nYusuke Watanabe\n

Publicatie 17-11-2020


Objectives/HypothesisIn recent years, basic fibroblast growth factor (bFGF) injection has been used in the treatment of aging‐related vocal fold atrophy. This injection not only improves closure by increasing the mass of the vocal fold but also improves its viscoelasticity. However, it has been reported that fibroblasts targeted by bFGF treatment decrease in number with age. The purpose of this study was to examine the effects of local injection of bFGF on age‐related vocal atrophy as well as the influence of age on phonological outcomes.Study DesignRetrospective chart review.MethodsFifty‐three patients with age‐related vocal fold atrophy underwent single injections of bFGF in their vocal folds. Phonological outcomes were evaluated 3 and 6 months after injection by acoustic and aerodynamic measurements.ResultsVoice Handicap Index (VHI), maximum phonation time (MPT), jitter, shimmer, and pitch range improved after injection, and the effects continued for 6 months. In those over 70 years of age, VHI and MPT showed improvement at 3 and 6 months after injection. In addition, the degree of improvement in VHI and MPT did not differ significantly between those older than 70 years and those younger than 70 years.ConclusionsRegenerative treatments dependent on bFGF single injection was safe and effective for both early and late elderly patients suffering of vocal fold atrophy.Level of Evidence2c Laryngoscope, 2020

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Noise Exposure on the London Underground, an Observational Study over a Decade

\nT Singh, \nTimothy Biggs, \nEleanor Crossley, \nMorad Faoury, \nAbid Mahmood, \nAli Salamat, \nTom Patterson, \nNimeshi Jayakody, \nAlexander Dando, \nFabian Sipaul, \nKonstantinos Marinakis, \nHolger Sudhoff, \nPhillip Brown\n

Publicatie 17-11-2020


ObjectivesThere are no hearing protection regulations in place for passengers using public transport, such as the London Underground. In light of this, we sought to examine sound pressure levels experienced by regular users of the London Underground.MethodsSound pressure levels (A‐weighted decibels: dBA) were taken on moving London Underground carriages between Euston and South Wimbledon on the Northern Line, and between Euston and Vauxhall on the Victoria Line, during 2006 and 2018. In addition, carriage sound pressure levels travelling within Zone 1 of the London Underground were tested in 2019. Three experimental and three technical repeats were undertaken using a hand‐held calibrated multi‐function sound level meter.ResultsPassengers are routinely and consistently subjected to sound pressure levels exceeding 80 dBA, with levels sometimes reaching over 100 dBA.ConclusionThis study is unique within the literature, with no published studies outlining exposure levels for London Underground passengers. It provides evidence of elevated noise exposure to passengers, consistently along large stretches of the London Underground, over a prolonged study period (2006–2019).Key WordsSensorineural hearing losssound pressureexposureLondonundergroundtube.Level of EvidenceN/A Laryngoscope, 2020

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Outcomes of Combined Anterior Septal Reconstruction and Dorsal Hump Reduction

\nPriyesh N. Patel, \nCherian K. Kandathil, \nSam P. Most\n

Publicatie 17-11-2020


Objectives/HypothesisDeviations of the caudal nasal septum can impact airflow and aesthetics. The anterior septal reconstruction (ASR) technique, a modification of extracorporeal septoplasty, addresses this issue while preserving a segment of the dorsal septum. When ASR is combined with dorsal hump reductions and osteotomies, the keystone may be destabilized. This study evaluates the outcomes of this intervention.Study DesignRetrospective chart review.MethodsThis is a retrospective study evaluating the functional and aesthetic outcomes of 58 patients who underwent ASR combined with dorsal hump reductions (with or without osteotomies). The Nasal Obstruction Symptom Evaluation (NOSE) and Standardized Cosmesis and Health Nasal Outcomes Survey Obstructive/Cosmetic (SCHNOS‐O, SCHNOS‐C) scores were measured and compared pre‐ and postoperatively. Linear regression analysis was performed to determine the impact of sex, gender, osteotomies, and trauma on outcomes.ResultsMean improvement in NOSE, SCHNOS‐O, and SCHNOS‐C scores within the first 3 months after surgery were −41.8, −32.6, and −51.5 respectively (P < .05). At follow‐up >9 months, these improvements were also significant for NOSE and SCHNOS‐O scores and approached significance (P = .06) for SCHNOS‐C scores. A subanalysis of patients who underwent osteotomies yielded functional and aesthetic improvements across all follow‐up periods, all of which were significant with the exception of SCHNOS‐O scores at >9 months (P = .1). In a multiple linear regression analysis, osteotomies contributed significantly to change in SCHNOS‐C scores (β = −64.09, P = .001) at 3‐ to 9‐month follow‐up.ConclusionsThe combination of ASR, hump take down, and osteotomies is safe and efficacious with implications for patients who seek correction of caudal septal deviations in conjunction with changes in external contour deformities.Level of Evidence3 Laryngoscope, 2020

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Tegmen attenuation in patients with idiopathic intracranial hypertension is progressive

\nOphir Handzel, \nAdi Brenner‐Ullman, \nDana Niry, \nUri Neuman, \nOren Cavel, \nOron Yahav, \nDan M. Fliss, \nOmer J. Ungar\n

Publicatie 17-11-2020


ObjectivesTo prove that temporal bone tegmen attenuation in patients with idiopathic intracranial hypertension (IIH) is progressive.Study DesignRetrospective blind study at a tertiary academic medical center.MethodsEnrolled were medical records of patients with IIH that included at least two sequential computed tomography (CT) scans. The vertical distances between the floor of the middle fossa to the superior and lateral semicircular canals (SSC and LSC, respectively), to the scutum and minimal squama thickness were measured. The same measurements were made in scans of control subjects. The impact of demographics and metabolic variables including opening lumbar puncture (LP) pressure were evaluated.ResultsTwenty medical records were enrolled. Median age at diagnosis was 21 years; 16 were females. The median body mass index (BMI) was 32 kg/m2. Initial LP pressure was 195 mm cerebrospinal fluid (CSF). The median time interval between CT scans was 58 months. A median attenuation of 0.35 mm and 0.25 mm over the right and left LSC and of 0.5 mm and 0.3 mm over the right and left scutum, was found, respectively. The thicknesses of the SSC and squama remained stable. No attenuation was present in controls. The opening pressure on initial LP (median 195 mm CSF), was positively correlated with the degree of tegmen attenuation, but the age at diagnosis and BMI were not.ConclusionsTegmen attenuation may be progressive in patients with idiopathic increased intracranial pressure and correlated with the opening pressure on LP. Tegmen defects and CSF leak should be looked for in these patients.Level of Evidence4 Laryngoscope, 2020

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Effect of margin status and pathological grade in treatment of sinonasal mucoepidermoid carcinoma

\nSamuel R. Auger, \nTirth Patel, \nAshwin Ganti, \nAnish Raman, \nAryan Shay, \nHannah N. Kuhar, \nEdward C. Kuan, \nPeter Papagiannopoulos, \nPete S. Batra, \nBobby A. Tajudeen\n

Publicatie 17-11-2020


ObjectivesThe purpose of this study was to investigate the association of demographic factors, grade, margin status, and treatment modalities for overall survival in patients with sinonasal mucoepidermoid carcinoma (SNMEC).Study DesignRetrospective database review.MethodsThe National Cancer Database was queried for patients of all ages with SNMEC between 2004 and 2015. Univariate Kaplan‐Meier and multivariate Cox regression analyses were performed to evaluate the association of suspected prognostic factors with overall survival. Subgroup analysis by margin status and grade was performed.ResultsA total of 239 patients with SNMEC were included in the analysis. The 5‐year overall survival was 63.6%. Prognostic factors associated with decreased survival include age over 70 years (P = .027), sphenoid primary site (P = .002), and advanced‐stage malignancy (P = .024). Improved survival was associated with surgery achieving negative margins (P = .001). Adjuvant radiation was associated with improved survival (hazard ratio HR = 0.25, P = .015) in the negative‐margin group but was not found to be a statistically significant factor in the positive‐margin group (HR = 0.66, P = .509).ConclusionsThis investigation is the largest to date to analyze the association of treatment modalities with overall survival in SNMEC and subgroup analysis by histopathologic grade and surgical margin status of treatment outcomes. Surgery remains the mainstay of treatment in patients with SNMEC. However, administration of radiation may confer survival benefit to patients with negative margins.Level of Evidence4 Laryngoscope, 2020

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Surgery versus Imaging in Non‐Localizing Primary Hyperparathyroidism: A Cost‐Effectiveness Model

\nEthan Frank, \nWayAnne Watson, \nShannon Fujimoto, \nPedro De Andrade Filho, \nJared Inman, \nAlfred Simental\n

Publicatie 17-11-2020


ObjectiveTo determine whether advanced imaging is cost‐effective compared to primary bilateral neck exploration in the management of non‐localizing primary hyperparathyroidism.Study DesignCost‐effectiveness analysis.MethodsCost‐effectiveness analysis based on decision tree model and available Medicare financial data using data from 347 consecutive patients having parathyroidectomy for primary hyperparathyroidism with either 1) positive, concordant ultrasound and sestamibi or 2) negative sestamibi and negative ultrasound.ResultsBilateral neck exploration (BNE) costs $9578 and has a success rate of 97.3%. Single photon emission computed tomography (SPECT) + minimally invasive parathyroidectomy (MIP) was modeled to have a total cost of $8197 with a success rate of 98.6%. SPECT/computed tomography (CT) + MIP was modeled to have a total cost of $8271 and a 98.9% success rate. Four‐dimensional (4D)–CT + MIP was modeled to cost $8146 with a success rate of 99%. Incremental cost‐effectiveness ratios (IECR) (as compared to BNE) were −536.1, −605.5, and −701.6 ($/percent cure rate) for SPECT, SPECT/CT, and 4D‐CT respectively. One‐way sensitivity analyses demonstrate the change in IECR and cut‐off points (IECR = 0) for four major variables.ConclusionsIn patients with non‐localizing primary hyperparathyroidism, advanced imaging is associated with cost‐savings compared to routine bilateral neck exploration. Increased cost‐savings were predicted with increased imaging accuracy and decreased imaging costs. Increasing time for BNE or decreasing time for MIP were associated with increased cost savings.Level of EvidenceIII Laryngoscope, 2020

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Cystic Lateral Lymph Node Metastases From Papillary Thyroid Cancer Patients

\nJin Kyong Kim, \nMin Jhi Kim, \nSun Hyung Choi, \nSoon Min Choi, \nHye Ryeon Choi, \nCho Rok Lee, \nSang‐Wook Kang, \nJandee Lee, \nJong Ju Jeong, \nKee‐Hyun Nam, \nWoong Youn Chung\n

Publicatie 17-11-2020


Objectives/HypothesisPapillary thyroid carcinoma (PTC) tends to metastasize rather early to local lymph nodes (LNs). Incidences of cystic LN metastases is relatively rare compared with that of solid LN metastases. Few studies have attempted to assess the characteristics in these patients. This study aimed to compare the clinicopathologic characteristics and surgical outcomes between patients with cystic LN metastases and those with solid LN metastases.Study DesignRetrospective cohort study.MethodsWe retrospectively reviewed the data of 1,028 patients with N1b PTC who underwent bilateral total thyroidectomy with central compartment neck dissection and modified radical neck dissection between January 2005 and September 2011. Of these, 136 (13.2%) had cystic LN metastases and 892 (86.8%) had solid LN metastases. Clinicopathologic characteristics and surgical outcomes were compared between these two patient groups.ResultsThe proportion of patients with thyroid tumor multifocality was relatively higher in the cystic node cohort (19.9% vs. 12.7%, P = .048). The number of total metastatic LNs and positive lateral LNs was slightly higher in the cystic node cohort (11.3 ± 8.9 vs. 9.7 ± 7.5, P = .029 and 6.9 ± 6.3 vs. 5.5 ± 4.6, P = .018, respectively). The proportion of patients with recurrence was higher in the cystic node cohort (14.0% vs. 3.0%, P < .001). Multivariate analysis indicated that cystic nodes were a significant risk factor for recurrence (hazard ratio: 5.265, 95% confidence interval: 2.898‐9.563).ConclusionsThis study demonstrates that cystic lateral LN metastases are associated with aggressive tumor behavior in PTC patients. and that their presence is a significant independent prognostic factor for disease‐free survival.Level of Evidence2b Laryngoscope, 2020

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Total Thyroidectomy Versus Lobectomy in Small Nodules Suspicious for Papillary Thyroid Cancer: Cost‐Effectiveness Analysis

\nZaid Al‐Qurayshi, \nMahmoud Farag, \nMohamed A. Shama, \nKareem Ibraheem, \nGregory W. Randolph, \nEmad Kandil\n

Publicatie 17-11-2020


Objectives/HypothesisRecent American Thyroid Association Guidelines recommend either near‐total/total thyroidectomy or lobectomy for patients with a thyroid nodule suspicious for papillary thyroid cancer (PTC) on fine‐needle aspiration (FNA) biopsy (Bethesda V). In this analysis, we aim to assess the cost‐effectiveness of lobectomy in comparison to total thyroidectomy.Study DesignCost‐effectiveness analysis.MethodsA Markov model cost‐effectiveness analysis was performed for a base case followed for 20 years postoperatively. Cost and probabilities data were retrieved from the current literature. Effectiveness was represented by quality‐adjusted life year (QALY).ResultsTotal thyroidectomy protocol produced an incremental cost of $2,681.36 and incremental effectiveness of −0.24 QALY as compared to lobectomy protocol (incremental cost‐effectiveness ratio ICER = −$11,188.85/QALY). Sensitivity analysis demonstrated that total thyroidectomy becomes a cost‐effective strategy only if the risk of stages III and IV PTC is 82.4% among patients with suspicious PTC on preoperative FNA. Lobectomy is cost effective and preferred over total thyroidectomy as long as lobectomy complications are less than 50%.ConclusionsTotal thyroidectomy is not just cost prohibitive but also associated with a lower effectiveness compared to lobectomy.Level of Evidence2c Laryngoscope, 2020

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Septal Cartilage Traction Suture Technique for Correction of Caudal Septal Deviation

\nHyo‐Seok Seo, \nHan‐Seul Na, \nSung‐Dong Kim, \nKeun‐Ik Yi, \nSue‐Jean Mun, \nKyu‐Sup Cho\n

Publicatie 17-11-2020


ObjectiveCorrection of the caudal septum deviation is the most difficult part of the septoplasty and a common cause of revision septoplasty. The purpose of this study was to present authors’ preliminary results in the treatment of patients with caudal septal deviation using the septal cartilage traction suture technique.Study DesignProspective, single center, observational study.Materials and MethodsSixty‐seven patients with a caudal septal deviation underwent septal cartilage traction suture technique with endonasal septoplasty. After removal of excessive caudal cartilage, the caudal L‐strut was sutured at two or more points using 5–0 Vicryl on the modified Killian incision site. Subjective outcomes using visual analog scales (VAS) and Nasal Obstruction Symptom Evaluation (NOSE) scale, objective endoscopic examination, and acoustic rhinometry data were assessed.ResultsThere was significant symptomatic improvement in the VAS and NOSE scale at 1, 3, and 6 months postsurgery. Complete correction in the endoscopy was observed in the 91.0% of patients at 3 months postsurgery. The results of acoustic rhinometry increased from 0.3 and 4.3 preoperatively to 0.7 and 7.7 at 3 months postoperatively. Furthermore, no patient experienced septal hematoma, septal perforation, and loss of nasal tip support at 6 months follow‐up.ConclusionsThe septal cartilage traction suture technique obtained significant improvement in subjective and objective outcomes in patients with caudal septal deviation. This technique is a simple, safe, and effective method to treat caudal septal deviation.Level of Evidence4 Laryngoscope, 2020

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Characteristics of Olfactory Disorder With and Without Reported Flavor Loss

\nSimona Negoias, \nBenjamin Meves, \nYunpeng Zang, \nAntje Haehner, \nThomas Hummel\n

Publicatie 17-11-2020


Objectives/HypothesisQuality of life related to olfactory disorder (OD) depends on the perceived impairment. It is not known why some patients with OD report smell and flavor loss while others report smell loss only. In order to understand this, we compared the two clinical presentation forms in terms of demographics, clinical features, and orthonasal olfaction test results.Study DesignObservational, analytic, cross‐sectional study.MethodsA total of 401 patients with measured orthonasal OD presenting at a tertiary referral center were divided in 2 groups according to their subjective reports (smell loss only = 129 patients vs. smell and flavor loss = 272 patients). Groups were compared in terms of demographic (age, sex), clinical features (duration of disease, type of onset, etiology, degree of impairment due to the disorder) and test results (taste and orthonasal olfaction).ResultsGroups did not differ in terms of age, sex distribution, orthonasal olfactory, or taste function. Patients reporting smell and flavor loss were characterized by a mainly sudden onset of the disorder and a predominance of postinfectious olfactory loss. They also have a shorter disease duration and a higher disease impairment. For patients reporting smell loss only, disease duration is longer, they feel less impaired, the onset of the disorder is to a higher degree protracted and the main cause is idiopathic.ConclusionsPatients with orthonasal OD reporting smell and flavor loss feel more impaired and present significant different clinical features compared to patients reporting smell loss only. Future studies measuring retronasal olfaction are necessary to fully understand flavor perception in OD.Level of Evidence4 Laryngoscope, 130:2869–2873, 2020

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Appropriate medical management of chronic rhinosinusitis reduces use of antibiotics and oral corticosteroids

\nMarlene M. Speth, \nKatie M. Phillips, \nLloyd P. Hoehle, \nDavid S. Caradonna, \nStacey T. Gray, \nAhmad R. Sedaghat\n

Publicatie 17-11-2020


Objectives/HypothesisAntibiotics and oral corticosteroids are used in the treatment of acute exacerbations of chronic rhinosinusitis (AECRS) and reflect poor disease control. We sought to characterize utilization of these systemic medications after appropriate medical management of chronic rhinosinusitis (CRS).Study DesignProspective observational study.MethodsOne hundred fifty patients undergoing medical management for CRS were studied. Data were collected at enrollment and follow‐up 3 to 12 months later. All patients were asked to report the number of CRS‐related antibiotics and oral corticosteroids used in the last 3 months. CRS symptom burden was measured using the 22‐item Sino‐Nasal Outcome Test (SNOT‐22). Associations were sought between CRS‐related antibiotics and oral corticosteroids use at follow‐up compared to enrollment.ResultsFrom enrollment to follow‐up, the mean number of CRS‐related antibiotics courses used decreased by 0.2 courses (95% confidence interval CI: 0.1–0.4, P = .012), and the mean number of CRS‐related oral corticosteroid courses used also decreased by 0.2 courses (95% CI: 0.1–0.3, P = .029). The number of CRS‐related antibiotics used at follow‐up was associated with CRS‐related antibiotic use at enrollment (adjusted rate ratio RR = 1.58, 95% CI: 1.17–2.13, P = .003). The number of CRS‐related oral corticosteroids used at follow‐up was associated with reported CRS‐related oral corticosteroid use at enrollment (adjusted RR = 3.20, 95% CI: 1.69–6.07, P < .001). SNOT‐22 results at enrollment were also not predictive of future systemic medication use.ConclusionsAppropriate medical management of CRS is associated with decreased use of oral antibiotics and corticosteroids. Previous utilization of antibiotics and oral corticosteroids for CRS is associated with future use of these medications.Level of Evidence2c Laryngoscope, 2019

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Acute Exacerbations in Recurrent Acute Rhinosinusitis: Differences in Quality of Life and Endoscopy

\nDaniel M. Beswick, \nNoel F. Ayoub, \nJess C. Mace, \nAlia Mowery, \nPeter H. Hwang, \nTimothy L. Smith\n

Publicatie 17-11-2020


Objectives/HypothesisResearch surrounding outcome differences for patients with recurrent acute rhinosinusitis (RARS) is scarce. This investigation explored quality of life (QOL) and sinonasal attributes in patients during acute episodes (AEs) and in‐between AEs of RARS.Study DesignRetrospective outcomes research.MethodsData from patients with RARS were collected from two academic institutions between 2009 and 2017 using prospective and retrospective methodology. During clinical presentation, subjects were classified as with or without an AEs using guideline definitions of acute bacterial rhinosinusitis (ABRS). Between‐group differences in 22‐item Sino‐Nasal Outcome Test (SNOT‐22) survey and Lund‐Kennedy (LK) endoscopy scores were assessed.ResultsFour hundred twenty‐three clinical visits from 202 patients were included. Visits during an AE (168/423, 40%) were associated with significantly worse SNOT‐22 total scores compared to between AEs (255/423, 60%; median = 53.0 interquartile range (IQR) = 24.0 vs. 34.0 IQR = 29.5) and all SNOT‐22 subdomain scores (all P < .001). LK scores were available for 167 visits, with 56 (34%) completed during an AE. Compared to visits without an AE, endoscopy findings associated with an AE were less frequently normal (LK score = 0, 45% vs. 62%, P = .031) with worse median LK scores (2.0 IQR = 4.0 vs. 0.0 IQR = 2.0, P = .005).ConclusionsAEs are associated with significantly worse QOL and mildly worse endoscopic findings. Almost half of visits during AEs had negative endoscopy, identifying a disparity between patient symptoms and objective findings and calling into question alternative or concomitant diagnoses. Diagnostic criteria for ABRS or AEs in RARS do not require objective confirmation of inflammation, presenting a conundrum for clinicians. The potential for overdiagnosis of ABRS and AEs should be considered when determining the risk/benefit ratio of treatments for RARS.Level of Evidence2c Laryngoscope, 2019

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Emerging Trends in Nasal Surgery: What Is the Impact of a Bioabsorbable Nasal Implant?

\nMarshall Ge, \nJee‐hong Kim, \nBozena Wrobel, \nStephanie Shintani Smith, \nAmit Kochhar, \nElisabeth H. Ference\n

Publicatie 17-11-2020


BackgroundA bioabsorbable nasal valve implant (NVI) was introduced in 2016 as a minimally invasive solution to nasal valve collapse. Historically the introduction of less invasive procedures performable in‐office has resulted in an increase in volume. Our objective is to evaluate this trend as it relates to nasal vestibular repair, and its impact on healthcare utilization.MethodsWe interrogated the Medicare Part B national database for nasal vestibular repair (CPT code: 30465), Unlisted nasal procedure (30999) and septoplasty (30520) from 2010 to 2017. Septoplasty was used as a surrogate for overall nasal procedural rate. Linear regression modeling was used to examine the changes in reported vestibular repair rate adjusting for septoplasty rate.ResultsIn the Medicare population, the rate of septoplasty was stable from 2010 to 2017, increasing from 26,962 to 30,194 at an annual rate of 1.5%. Coding for unlisted nasal procedure increased from 272 to 333 at an adjusted annual rate of 1.1% over this time period. Coding for nasal vestibular repair increased from 2026 to 5331 over this interval at an adjusted annual rate of 0.9% from 2010 to 2016 but significantly increased to 5% between 2016 to 2017 (P < .0001).ConclusionThe reported volume of nasal vestibular repair increased significantly in the year following Food and Drug Administration approval of NVIs. In the absence of a corresponding increase in septoplasty, this temporal relationship suggests that the introduction of NVIs impacted the utilization of this procedural code.Level of EvidenceN/ALaryngoscope, 2020

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Relationship of Overall Cardiovascular Health and Hearing Loss in The Jackson Heart Study Population

"\nSteven A. Curti, \nJoseph A. DeGruy, \nChristopher Spankovich, \nCharles E. Bishop, \nDan Su, \nKaren Valle, \nEmily OBrien, \nYuan‐I Min, \nJohn M. Schweinfurth\n"

Publicatie 17-11-2020


ObjectivesTo evaluate the relationships among the overall cardiovascular health scoring tool, Lifes Simple 7 (LS7), and hearing in an African‐American cardiovascular study cohort.MethodsUsing the Jackson Heart Studys cohort of African Americans, the relationships between the LS7 scoring metric and hearing of 1314 individuals were assessed. Standard audiometric data was collected and hearing loss was defined as a four‐frequency average of 500, 1000, 2000, and 4000 Hz greater than 25 dBHL (PTA4). Measures of reported tinnitus and dizziness were also collected. The LS7 scoring tool, which consists of seven individual categories (abstinence from smoking, body mass index, physical activity, healthy diet, total cholesterol <200 mg/dL, normotension, and absence of diabetes mellitus), was used as measure of overall cardiovascular health. Each category of the LS7 was broken down into poor, intermediate, and ideal subgroups as in accordance with the American Heart Association Strategic Planning Task Force and Statistics Committee. Unadjusted and adjusted gamma regression and logistic regression models were constructed for determining relationships between LS7 and hearing loss.ResultsHigher total LS7 scores (per 1‐unit increase) were associated with lower PTA4 in gamma regression analyses (RR = 0.942, 95% CI, 0.926–0.958, P < .001). This held true even after adjustments for age, sex, education, and history of noise exposure. Using logistic regression analyses to compare LS7 scores to presence of hearing loss, tinnitus, and vertigo; only hearing loss showed a statically significant relationship after adjustments for age, sex, education, and history of noise exposure.ConclusionsThis study shows a significant, graded association between higher lifes simple seven scores and lower incidence of hearing loss.Level of Evidence2b. Laryngoscope, 2019

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The Shape of Things to Come: In‐Hospital Three‐Dimensional Printing for Mandibular Reconstruction Using Fibula Free Flap

\nEmanuele Zavattero, \nMassimo Fasolis, \nAndrea Novaresio, \nGiovanni Gerbino, \nClaudia Borbon, \nGuglielmo Ramieri\n

Publicatie 17-11-2020


Objectives/HypothesisThe aim of this study was to explore whether the production of in‐hospital, low‐cost surgical cutting guides would be possible and to assess different cutting guide shapes to facilitate the surgery and the application with instruments.Study DesignCohort study.MethodsUsing free computer‐aided design software, surgical cutting guides for the mandible and fibula were designed and used to perform virtual segmental osteotomies and fibula transplants in seven patients.ResultsFourteen virtual osteotomies were performed using the free software and the proposed workflow. Thirteen guides were then printed to transfer the virtual planning information to the operating room.ConclusionsVirtual planning and the three‐dimensional (3D) printing of guides for mandibular reconstruction is reliable with the aid of an in‐hospital 3D laboratory. We also demonstrated that different guides with different shapes could be produced with benefits during surgery.Level of Evidence4 Laryngoscope, 2020

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Lack of additive benefit of oral steroids on short‐term postoperative outcomes in nasal polyposis

\nClaudio Arancibia, \nCristóbal Langdon, \nJoaquim Mullol, \nIsam Alobid\n

Publicatie 17-11-2020


ObjectivesThere is a lack of evidence concerning the efficacy of oral corticosteroids (OCS) as a postoperative treatment for patients with chronic rhinosinusitis with nasal polyps (CRSwNP). The objective of our study was to determine the short‐term additive benefit of postoperative OCS in CRSwNP patients.MethodsWe prospectively randomized CRSwNP patients who were treated by endoscopic sinus surgery. All patients were resistant to maximum medical treatment according to European position paper on rhinosinusitis and nasal polyps 2012 guidelines. Treatment group received postoperative OCS in descending doses plus nasal douching over a period of 4 weeks, whereas the control group received only nasal douching. The efficacy of OCS was determined by a total 5 item symptoms score (T5SS), polyp size score, Barcelona Smell Test 24 and Medical Outcome Study Short Form‐36 questionnaire for quality of life (QoL).ResultsOf the 70 enrolled patients, 35 were in the treatment group and 35 in the control group. After 4 weeks of follow‐up, patients from both groups improved in T5SS, QoL, endoscopic findings (except for crusts that increased in both) and sense of smell, without significant differences between OCS and control groups.ConclusionPostoperative OCS as an add‐on treatment for CRSwNP patients does not improve sinonasal and QoL outcomes; thus, they should not be routinely recommended.Level of EvidenceIb Laryngoscope, 2019

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The development and validation of the laryngopharyngeal measure of perceived sensation

\nC. Claire Melancon, \nGregory B. Russell, \nKathryn Ruckart, \nSarah Persia, \nMargarita Peterson, \nS. Carter Wright, \nLyndsay L. Madden\n

Publicatie 17-11-2020


ObjectivesGlobus pharyngeus (GP) is described as the subjective sensation of having a “lump” in the throat in the absence of correlating physical findings or dysphagia. Historically, despite the frequency of patient complaints, GP has been difficult to quantify with current outcome measures. This is in large part due to lack of a user‐friendly, modernized, objective patient‐reported outcome measure (PROM) of symptom severity. The aim of this study is to develop a modernized, practical, validated PROM for evaluating GP symptom severity.MethodsThe Laryngopharyngeal Measure of Perceived Sensation (LUMP questionnaire) was created in three phases: 1) item generation by an expert panel involving two laryngologists and two speech language pathologists developed from common patient‐reported GP symptoms, with patient confirmation; 2) line‐item reduction based on internal consistency and reliability; 3) and instrument validity, which was assessed by administering the questionnaire to patients complaining of GP as well as patients without GP.ResultsA 19‐item questionnaire was developed from an expert panel, which was then administered to 110 patients, 100 of whom met inclusion criteria. After statistical analysis, less internally consistent or relevant questions were removed, leaving eight items with an internal consistency (Cronbach alpha) of 0.892. When administered to 54 patients with GP versus 31 normal patients, the mean score was found to be higher in those with GP versus normal patients (P value <0.0001).ConclusionPreliminary results suggest the eight‐item LUMP questionnaire is a valuable PROM for evaluating GP symptom severity.Level of EvidenceNALaryngoscope, 2019

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Effect of Timing of Intravenous Fentanyl Administration on the Incidence of Posttonsillectomy Nausea and Vomiting

\nHye Jin Kim, \nMin‐Soo Kim, \nHa Yan Kim, \nWyun Kon Park, \nWon Shik Kim, \nSungmi Kim, \nHyun Joo Kim\n

Publicatie 17-11-2020


Objective/HypothesisFentanyl is commonly administered toward the end of tonsillectomy to prevent emergence delirium and reduce postoperative pain. However, it can delay emergence from anesthesia and increase the risk of postoperative nausea and vomiting (PONV). The goal of our study was to compare the risk of PONV based on the timing of fentanyl administration at the end of tonsillectomy in children.Study Design: Prospective, double‐blind, randomized controlled trial.MethodsOne hundred forty patients aged 3 to 7 years undergoing tonsillectomy were divided into two groups. Fentanyl (1 μg/kg) was administered at the end of surgery in group 1 (n = 70) and at 10 to 15 minutes before the end of surgery in group 2 (n = 70). Time to regular breathing and time to emergence from anesthesia were measured from the end of surgery. PONV and pediatric anesthesia emergence delirium scale scores were assessed every 10 minutes after admission to the postanesthesia care unit.ResultsIncidences of PONV (2.9% vs. 2.9%, P > .99) and emergence delirium (11.4% vs. 5.7%, P = .23) were not significantly different between the two groups. Time to regular breathing (mean difference = 2.3 minutes; 95% confidence interval CI: 0.9 to 3.7 minutes) and time to emergence (median difference = 6.5 minutes; 95% CI, 2.5 to 10.5 minutes) were significantly longer in group 1 than in group 2.ConclusionsAlthough there was no beneficial effect on PONV, recovery of regular breathing and consciousness was quicker with earlier fentanyl administration. Emergence delirium was well‐controlled, similar to that with fentanyl administration at the end of surgery.Level of Evidence1b Laryngoscope, 2020

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Prevalence of Tinnitus and Associated Factors Among Asian Americans: Results From a National Sample

\nJanet S. Choi, \nAlison J. Yu, \nCourtney C. J. Voelker, \nJoni K. Doherty, \nJohn S. Oghalai, \nLaurel M. Fisher\n

Publicatie 17-11-2020


ObjectivesA previous study demonstrated low rates of high‐frequency hearing loss and noise exposure among Asian Americans (AAs). This study examined the prevalence of tinnitus and associated factors among AAs using the first nationally representative sample of AAs.Study DesignCross‐sectional analysis of a national health survey.MethodsWe analyzed data from the 2011 to 2012 National Health and Nutritional Examination Survey, during which 3,669 participants aged 20 to 69 years completed questionnaires on tinnitus (AA participants, n = 530). Tinnitus was defined as bothersome ringing lasting 5 minutes or more in the past 12 months. Prevalence of any tinnitus in the past 12 months was calculated incorporating sampling weights. Logistic regression was used to examine the associations with relevant factors.ResultsThe prevalence of any tinnitus was 6.6% (95% confidence interval CI: 4.5‐8.6) among AAs, significantly lower than the prevalence among the overall population at 16.5% (95% CI: 14.3‐18.8. After adjusting for audiometric hearing loss and demographics, AAs were less likely to report any tinnitus than whites (odds ratio OR = 0.43 95% CI: 0.24‐0.75), blacks (OR = 0.60 95% CI: 0.37‐0.95), and Hispanics (OR = 0.60 95% CI: 0.45‐0.78). Rates of tinnitus were not different from whites or blacks once comorbidities, noise exposure, and depression were taken into account. Among AAs, reporting exposure to work‐related noise (OR = 2.92 95% CI: 1.15‐7.41) and having a major depressive disorder (OR = 6.45 95% CI: 1.15‐36.12) were significant factors associated with tinnitus in a multivariate model.ConclusionsThe prevalence of tinnitus is significantly lower among AAs in comparison to other racial groups. Noise exposure and depression were significant factors associated with tinnitus among AAs.Level of Evidence2b Laryngoscope, 2020

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Correlation of sinonasal symptoms with the size and position of nasal septal perforations

\nGrace C. Khong, \nSamuel C. Leong\n

Publicatie 17-11-2020


ObjectiveTo assess the correlation of sinonasal symptoms and quality of life with size and position of nasal septal perforation (NSP).MethodThis is a prospective observational study in a tertiary referral center involving adult patients presented with NSP. The Sino‐Nasal Outcome Test‐22 (SNOT‐22) and its clinico‐psychometric domains were analyzed, including additional NSP‐specific symptoms (nasal crusting, epistaxis, and whistling noise during nasal breathing). The size of NSP was measured radiologically by calculating the area in cm2 and anteroposterior (AP) diameter. Position of perforation was determined clinically by distance from columella to the anterior edge of the perforation.ResultsForty patients were included in this study (22 males). The most common etiology of NSP was iatrogenic. The mean SNOT‐22 score was 50.8 (standard deviation 23.8), and mean NSP size was 3.0 cm2. No statistical correlation was observed between the total SNOT‐22 score with either position or size of NSP. As for NSP‐specific symptoms, there was a statistically significant negative correlation with the size of perforation (A‐P diameter) (r = −0.34, P = 0.03) and position of the perforation (r = −0.49, P = 0.0016), suggesting that these symptoms improved with posterior and larger perforations.ConclusionReported SNOT‐22 scores were comparable to patients with recalcitrant chronic rhinosinusitis, although the scores did not correlate with size and position of NSP. Sinonasal symptoms typically observed in NSP improved with more posteriorly placed and larger sized perforations. This study provides an insight into the quality‐of‐life impact of NSP and affirms the clinical observation that anterior NSP are more symptomatic.Level of Evidence4Laryngoscope, 2019

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Predictors of eustachian tube dysfunction improvement and normalization after endoscopic sinus surgery

\nThomas S. Higgins, \nZachary J. Cappello, \nArthur W. Wu, \nJonathan Y. Ting, \nRaj Sindwani\n

Publicatie 17-11-2020


ObjectiveStudies have demonstrated improvement in Eustachian tube dysfunction (ETD) symptomatology after functional endoscopic sinus surgery (FESS); however, factors associated with ETD symptom alteration have not been elucidated. This study evaluated factors associated with improvement and normalization of ETD symptoms after FESS.MethodsA case‐control study was performed of FESS patients who had clinically significant ETD symptoms based on the Eustachian Tube Dysfunction Questionnaire‐7 (ETDQ‐7 ≥ 2.1) without middle ear effusion (MEE) preoperatively. Study patients were identified as those with a normalized ETDQ‐7 at 2 months postoperatively. Controls were patients whose ETDQ‐7 did not normalize at 2 months. Demographics, surgery characteristics, chronic rhinosinusitis phenotype, Lund‐Mackay score, temporomandibular joint dysfunction (TMJD), preoperative ETDQ‐7 and SNOT‐22 scores, and tympanograms were analyzed. Univariate and multivariate analyses were performed comparing study cases and controls.ResultsData were collected on 165 patients, with 46% patients having clinically significant preoperative ETD and 60 patients meeting final study inclusion/exclusion criteria. FESS was associated with both SNOT‐22 and ETDQ‐7 improvement (P < 0.001). Nasal polyposis was associated with a higher probability of ETDQ‐7 normalization (OR 4.429, P = 0.035). Factors associated with failure of ETDQ‐7 normalization included TMJD (OR 0.086, P < 0.001, 95% CI 0.019–0.391) and high preoperative ETDQ‐7 (OR 0.140, P = 0.006, 95% CI 0.032–0.613).ConclusionIn patients with clinically significant ETD symptoms without MEE, FESS was associated with ETDQ‐7 improvement. Nasal polyposis was associated with an increased probability of normalization of ETD symptoms postoperatively, whereas TMJD had a negative association.Level of Evidence3b Laryngoscope, 2019

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Self‐reported mini olfactory questionnaire (Self‐MOQ): A simple and useful measurement for the screening of olfactory dysfunction

\nLai‐quan Zou, \nLena Linden, \nMandy Cuevas, \nMarie‐Luise Metasch, \nAntje Welge‐Lüssen, \nAntje Hähner, \nThomas Hummel\n

Publicatie 17-11-2020


ObjectivesOlfactory dysfunction is a common problem. However, too little attention has been paid to questionnaires used to evaluate quantitative olfactory dysfunction. Therefore, the current study aimed to develop a simple self‐reported Mini Olfactory Questionnaire (Self‐MOQ) for the screening of quantitative olfactory dysfunction in clinical practice.MethodsTwo hundred and eighty‐five patients who had subjective complaints of olfactory disorder participated. The Sniffin’ Sticks test score was used to define functional anosmia, hyposmia, or normosmia. We assessed the factor structure as well as internal consistency, convergent validity, and discrimination performance.ResultsThe results showed that the final version of the Self‐MOQ included only one factor with five items. The Self‐MOQ has a good internal reliability (Cronbachs α = 0.84) and validity (r = −0.60, P < 0.001). The receiver operating characteristic analyses indicated that the Self‐MOQ as compared to a visual analogue scale (VAS) is an effective measure for discriminating normosmic from hyposmic/anosmic patients, anosmic patients, and hyposmic patients.ConclusionThe Self‐MOQ is a simple, reliable and valid questionnaire to screen olfactory dysfunction in clinical practice that appears to be superior to the use of VASs but does not replace olfactory testing.Level of Evidence4Laryngoscope, 2019

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Is Continued Perioperative Antithrombotic Therapy Safe When Performing Direct Microlaryngoscopy?

\nElias S. Saba, \nMichelle K. Higgins, \nRichard Heyes, \nDavid G. Lott\n

Publicatie 17-11-2020


Objectives/HypothesisTo evaluate whether antithrombotic status impacts the incidence of perioperative or postoperative bleeding in direct microlaryngoscopy (DML).Study DesignRetrospective chart review.MethodsPatients undergoing DML in a single surgeons practice from September 2012 to September 2017 were studied. Included patients underwent DML with or without biopsy, balloon dilation, microsurgery, laser ablation, or vocal fold injection. Patients were stratified based on perioperative antithrombotic status and assessed for rates of peri‐ and postoperative bleeding and other complications.ResultsOf the 581 patients meeting inclusion criteria, 179 patients (31%) had a history of baseline antithrombotic therapy. Of these patients, 124 had perioperative continuation of their therapy. Medicated patients were older (P < .01), predominately male (P < .01), and increasingly comorbid (P < .01). Perioperative complications unrelated to bleeding occurred in 22 patients (4%), minor perioperative bleeding occurred in four patients (0.7%), and minor postoperative bleeding occurred in 12 of the 479 patients with recorded follow‐up (2.5%). There were no postoperative bleeds requiring intervention or readmission, and no recorded thrombotic events during the peri‐ and postoperative period. There was no difference in perioperative bleeding based on baseline antithrombotic status (P = .81). Patients on baseline antithrombotic therapy were more likely to have a postoperative bleed in comparison to patients without history of antithrombotic use (P < .01). However, there were no significant differences in postoperative bleeding between patients on baseline anticoagulation who continued or ceased their medication perioperatively (P = .45).ConclusionsPerioperative continuation of antithrombotic medications appears to be safe when performing routine DML.Level of Evidence4 Laryngoscope, 2020

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A Novel Laryngoscope With an Adjustable Distal Tip

\nAdam Honeybrook, \nWalter Lee, \nSeth Cohen\n

Publicatie 17-11-2020


ObjectivesVarious laryngoscopes are currently available for supraglottic, glottic, and cervical esophageal exposure, yet none allow for adjustable articulation of the laryngoscope distal tip. We sought to create a new laryngoscope to improve anatomic field of view exposure.Study DesignNovel laryngoscope device validation study.Materials and MethodsThree‐dimensional printed plastic and titanium prototype designs were created using Solidworks. Validation testing was performed in a cadaveric model. Optimal exposure of the cadaveric larynx and supraglottis was determined by ensuring the endoscope tip was exactly 2.5 cm from the level of the vocal cords. The prototype exposure (22‐cm adjustable tip laryngoscope) was compared to the Weerda (18‐cm distending laryngoscope) and Dedo (18‐cm operating laryngoscope) laryngoscope exposures. Anteroposterior (AP) and lateral (L) exposure measurements were obtained from analysis of endoscopic images. Objective millimeter quantification was performed by pixel calibration to the known width of the vocal cord.ResultsThe prototype provided 77.3‐mm AP and 40.6‐mm L exposure of the cadaveric larynx and supraglottis. These measurements were then compared to the exposure provided by the Weerda (49.9‐mm AP, 40.4‐mm L) and Dedo (15.7‐mm AP, 18.6‐mm L) laryngoscopes. The investigators found the prototype had similar handling characteristics to the Weerda laryngoscope and laryngeal instrumentation was enhanced due to a wider field of view.ConclusionThis novel laryngoscope with an adjustable distal tip provides improved exposure of the supraglottis and glottis in a cadaveric study and has the potential to be used for both supraglottic/glottic and proximal esophageal procedures.Level of Evidence5 Laryngoscope, 2020

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The use and cost‐effectiveness of intraoperative navigation in pediatric sinus surgery

\nNandini Govil, \nAmber D. Shaffer, \nAmanda L. Stapleton\n

Publicatie 17-11-2020


Objectives/HypothesisThere are consensus statements about when to use intraoperative navigation (IN) in adult sinus surgery. However, no corresponding guidelines exist for pediatrics. Our objectives included: 1) assess the demographic and operative factors associated with IN use and 2) calculate the cost‐effectiveness of IN use.Study DesignRetrospective chart review.MethodsOne hundred nineteen pediatric patients undergoing sinus surgery between 2003 and 2016 were reviewed. Demographic and surgical factors were collected from medical records. Costs associated with use of IN were gathered from billing records.ResultsOf the 119 patients, 60 underwent sinus surgery with navigation (wIN) and 59 underwent surgery without navigation (sIN). Children in the wIN group had more complex surgeries with more sinuses opened (P = .008). Individual attending surgeon and presence of trainee were associated with increased use of IN (P < .001 for both). IN resulted in a median of 31.5 minutes longer surgical time (P < .001). IN had an incremental cost/effectiveness ratio (ICER) of $22,378 for each year without revision surgery for patients with acute disease. However, for patients with chronic disease, the probability of undergoing a second surgery was the same between wIN and sIN groups, and navigation was not cost‐effective (ICER of −$3,583).ConclusionsIN use did not decrease complications or rates of revision surgery. It was used primarily as an educational tool or to increase confidence in intraoperative identification of landmarks. However, the use of IN added surgical time and was not cost‐effective. Further research must be completed to determine when IN is indicated in pediatric sinus surgery.Level of Evidence4Laryngoscope, 2019

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Validation and multidimensional analysis of the japanese penn acoustic neuroma quality‐of‐life scale

\nTakanori Nishiyama, \nNaoki Oishi, \nTakashi Kojima, \nKento Kasuya, \nMasaru Noguchi, \nToru Ishikawa, \nMakoto Hosoya, \nKaoru Ogawa\n

Publicatie 17-11-2020


ObjectivesIn the management of vestibular schwannoma (VS), patient‐perceived outcomes should be given as much attention as physician‐reported objective outcomes. Concomitant symptoms can be annoying for sufferers, lowering quality of life (QoL). However, it is difficult to determine the degree to which these symptoms lower QoL using only objective measures. The Penn Acoustic Neuroma Quality of Life Scale (PANQOL) is a validated disease‐specific questionnaire commonly used to assess QoL in VS patients. It was developed and published in English. In this study, we translated the PANQOL questionnaire into Japanese and validated its reliability and utility. We also evaluated patient factors that could influence PANQOL scores.Study DesignCross‐sectional study.MethodsSeventy‐two VS patients monitored conservatively were included in this study. They were assessed using the Japanese versions of PANQOL (PANQOL‐J) and questionnaires about specific symptoms related to VS. The PANQOL questionnaire was translated into Japanese according to the accepted standards. The reliability and utility of the PANQOL‐J questionnaire, as well as the relationship with VS‐specific symptoms, were statistically analyzed.ResultsThe mean total score was 78.7. Almost all of its domains had good internal consistency. Most PANQOL‐J domains were related to those of the Short Form‐36, with the exception of facial dysfunction domain. Scores of all PANQOL‐J domains were comparable to scores of other questionnaires related to the VS‐specific symptoms. Our analyses indicated tinnitus or facial palsy might affect the PANQOL‐J total score.ConclusionsWe confirmed the validity of the Japanese version of PANQOL questionnaire and its reliability and utility in the management of VS symptoms concerning facial function.Level of Evidence4 Laryngoscope, 2020

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Readability of Patient‐Reported Outcome Measures for Head and Neck Oncology

\nSaangyoung E. Lee, \nZainab Farzal, \nCharles S. Ebert, \nAdam M. Zanation\n

Publicatie 17-11-2020


Objectives/HypothesisPatient‐reported outcome measures (PROMs) are communication tools to help patients convey their disease experience to medical providers and guide management decisions. However, the utility of healthcare outcome measures is dependent on patient literacy and readability of PROMs. If written for a more advanced literacy level, they can misestimate symptoms and add significant barriers to care, especially in the underserved. However, readability of head and neck (H&N) oncology PROMs has not been assessed. The aim of this study was to evaluate the readability of H&N oncology PROMs to assess whether they meet recommended readability levels.Study DesignBibliometric review.MethodsThree readability measures: Gunning Fog, Simple Measure of Gobbledygook, and FORCAST were used to evaluate the readability level of commonly used H&N PROMs. PROMs with sixth grade readability level or lower were considered to meet the recommendations of health literacy experts.ResultsEight H&N oncology PROMs were reviewed. None of H&N PROMs met health literacy experts and National Institutes of Health recommended reading levels. Gunning Fog consistently estimated easiest readability and FORCAST the most difficult.ConclusionsPROMs are important clinical tools that drive patient‐centric care in H&N oncology. All H&N PROMs are written above recommended reading levels and do not meet suggested standards. Future PROMs should be written with easier readability to accurately convey patients H&N oncology disease experiences.Level of Evidence4 Laryngoscope, 2020

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The Nasal Swell Body and Septal Perforation Repair

\nSaba Ghorab, \nCullen M. Taylor, \nStephen F. Bansberg\n

Publicatie 17-11-2020


ObjectivesTo review our experience with secondary surgery for persistent nasal obstruction following successful septal perforation repair and describe the potential contribution of the nasal swell body (NSB) to obstruction.Study DesignRetrospective chart review.MethodsIRB‐approved retrospective chart review of perforation repairs utilizing bilateral mucosal flaps performed by the senior author from October 2008 through April 2019 was performed. Patients who underwent secondary surgery for persistent nasal obstruction were identified. Data regarding patient demographics, perforation characteristics, primary closure technique, and secondary surgical procedures for persistent postoperative obstruction were analyzed. Nasal Obstruction Symptom Evaluation (NOSE) scores were assessed pre and post revision surgery.ResultsThirty‐four patients (14.7% of 232 successful repairs) met study criteria. Of those, 30 patients underwent revision septal surgery. An inferiorly advanced NSB was surgically reduced in 9.9% (23/232) of patients following successful closure to improve persistent obstruction. There was no incidence of reperforation. All patients undergoing NSB reduction reported improved nasal airflow postoperatively and 13 completed the NOSE questionnaire. The mean preoperative NOSE score (95% CI) was 52.7 (42.2–63.2; median, 50). The mean postoperative NOSE score (95% CI) was 19.2 (12.8–25.6; median, 15). The difference between the preoperative and postoperative NOSE scores was statistically significant (P < .001).ConclusionsRepair of a septal perforation using a superior bipedicle flap carries the potential for the NSB to contribute to persistent postoperative nasal obstruction. The swell body can be surgically reduced, without re‐perforation, to relieve obstructive symptoms in the patient with a successful perforation repair.Level of EvidenceIV Laryngoscope, 2020

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Delivery of Interleukin‐4–Encoding Lentivirus Using Multiple‐Channel Bridges Enhances Nerve Regeneration

\nS. Ahmed Ali, \nJohn E. Hanks, \nAaron W. Stebbins, \nOsama Alkhalili, \nSamantha T. Cohen, \nJessica Y. Chen, \nDominique R. Smith, \nCourtney M. Dumont, \nLonnie D. Shea, \nNorman D. Hogikyan, \nEva L. Feldman, \nMichael J. Brenner\n

Publicatie 17-11-2020


Objectives/HypothesisFacial nerve injury is a source of major morbidity. This study investigated the neuroregenerative effects of inducing an anti‐inflammatory environment when reconstructing a facial nerve defect with a multichannel bridge containing interleukin‐4 (IL‐4)–encoding lentivirus.Study DesignAnimal study.MethodsEighteen adult Sprague‐Dawley rats were divided into three groups, all of which sustained a facial nerve gap defect. Group I had reconstruction performed via an IL‐4 multichannel bridge, group II had a multichannel bridge with saline placed, and group III had no reconstruction.ResultsQuantitative histomorphometric data were assessed 10 weeks after injury. On post hoc analysis, the IL‐4 bridge group demonstrated superior regeneration compared to bridge alone on fiber density (mean = 2,380 ± 297 vs. 1,680 ± 441 fibers/mm2, P = .05) and latency time (mean = 2.9 ms ± 0.6 ms vs. 3.6 ms ± 0.3 ms, P < .001). There was significantly greater regeneration in the IL‐4 bridge group versus unreconstructed defect for total fiber and density measurements (P ≤ .05). Comparison of facial motor‐evoked distal latencies between the IL‐4 bridge group versus bridge alone revealed significant electrophysiological improvement at week 8 (P = .02).ConclusionsInflammation has been implicated in a variety of otolaryngologic disorders. This study demonstrates that placement of a multichannel bridge with lentivirus encoding IL‐4 improves regenerative outcomes following facial nerve gap injury in rodents. This effect is likely mediated by promotion of an anti‐inflammatory environment, and these findings may inform future therapeutic approaches to facial nerve injury.Level of EvidenceNA Laryngoscope, 2020

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A New and Faster Method to Assess Vestibular Compensation: A Cross‐Sectional Study

\nCarlos Guajardo‐Vergara, \nNicolas Perez‐Fernandez\n

Publicatie 17-11-2020


Objectives/HypothesisCharacterize the state of vestibular compensation of subjects diagnosed with acute unilateral vestibulopathy (AUV) of peripheral origin according to the temporal organization pattern of the refixation saccades (Perez and Rey (PR) score).Study DesignRetrospective cross‐sectional study using previously collected clinical data from a tertiary referral center.MethodsFollowing the vestibular compensation criteria defined by Eisenman, we used the video head impulse test as the main vestibular function test and compared the results with other traditional tests: rotatory chair test (ROT), caloric test, videonystagmography, clinical situation (CLIN), and the Dizziness Handicap Inventory (DHI) questionnaire from 28 subjects (17 men, 11 women), average age 60.21 years, who were in a compensated and noncompensated vestibular situation. We used the PR score to measure the differences between the study groups. A cluster was developed to define a cutoff point that objectively distinguishes the vestibular compensation status.ResultsSignificant differences in the PR score were found in the state of vestibular compensation in the ROT test (P = .01), DHI (P = .04), and CLIN (P = .023). The vestibular compensation criteria that groups the original variables (PR‐CLUSTER) cutoff point was 55 (P = .019).ConclusionsThe PR score is a measure of temporal organization of the refixation saccades that enables us to distinguish clearly and objectively the vestibular situation of subjects with AUV. We suggest its clinical application.Level of EvidenceNA Laryngoscope, 2020

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Three‐dimensional analysis of the human pharyngoesophageal sphincter

\nDerrick R. Randall, \nDaniel J. Cates, \nE. Brandon Strong, \nPeter C. Belafsky\n

Publicatie 17-11-2020


ObjectivesDysfunction of the pharyngoesophageal segment (PES) is a common cause of oropharyngeal dysphagia. Surgical dilation of the PES uses cylindrical dilators that expand radially in a circular shape. Animal studies, however, suggest that the PES is kidney‐shaped. The purpose of this investigation was to evaluate the 3D shape of the human PES with a novel casting method.MethodsA platinum‐cured liquid silicone polymer was infused under pressure into the upper aerodigestive tract of nine fresh human cadavers to construct 3D casts of the maximally distended PES. Cross‐sectional and volumetric analysis were performed using computed tomography and serial sectioning of the models. Canonical variate analysis was used to identify the shape features that best distinguishes the PES from the cervical esophagus.ResultsThe mean age of the cadavers was 77.9 (SD ± 10.6) years, with 67% women. Analysis of the casts confirms that the human PES possesses a kidney‐shaped structure at maximal distention, which is discretely different from the adjacent esophagus (P < 0.001). The posterior body of the cricoid cartilage formed the anterior wall of the PES, which provided a rigid structure responsible for preservation of the kidney shape during distention. The diameter of the maximally distended PES at the cricopharyngeus was highly variable (range = 0.86–4.68 cm2; SD = 1.33 cm2).ConclusionThe data suggest that the human PES is not round and that targeted expansion at the level of the cricopharyngeus with an eccentrically shaped dilator may provide improved distention.Level of Evidence4 Laryngoscope, 2019

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Pediatric Endoscopic Ossiculoplasty Following Surgery for Chronic Ear Disease

\nChristen L. Caloway, \nRazan A. Basonbul, \nEvette A. Ronner, \nAnthony M. Tolisano, \nAngela W. Zhu, \nHarini Suresh, \nDaniel J. Lee, \nBrandon Isaacson, \nMichael S. Cohen\n

Publicatie 17-11-2020


ObjectiveRigid endoscopes can improve visualization of the tympanic space compared to traditional microscopic techniques. This study investigates whether use of transcanal endoscopic ossiculoplasty influences audiologic outcomes compared to microscopic ossiculoplasty following chronic ear surgery in children.Study DesignComparative cohort study at two tertiary care centers.MethodsRetrospective review of pediatric chronic ear cases where ossiculoplasty was performed from February 2009 to March 2018.ResultsWe identified 100 ears that underwent endoscopic ossiculoplasty and 100 ears that underwent microscopic ossiculoplasty. The mean age was 11 years (range, 4–18 years) with 63% males. There were no significant differences in these parameters between the two groups. Subjects underwent either primary ossiculoplasty or ossiculoplasty during second‐look procedures. There was no significant difference in air conduction pure tone average (PTA) after microscopic cases compared to endoscopic cases (−12.5 dB vs. −10.5 dB, P = .40). These results were independent of prosthesis type. Microscopic ossiculoplasty was significantly more likely to use a post‐auricular approach (P = .0001). There was no difference in complication rate between the two groups. The malleus was more likely to be absent or removed prior to endoscopic ossiculoplasty (P = .0004) with no significant difference in the change in PTA between groups.ConclusionsTranscanal endoscopic ossiculoplasty was found to have equivalent audiometric outcomes with significantly fewer post‐auricular approaches and no increase in complications compared to microscopic ossiculoplasty. While the malleus was more likely to be absent in endoscopic cases, this did not appear to influence the change in PTA.Level of Evidence4 Laryngoscope, 2020

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Palatopharyngoplasty Resolves Concentric Collapse in Patients Ineligible for Upper Airway Stimulation

\nStanley Yung‐Chuan Liu, \nMichael J Hutz, \nSasikarn Poomkonsarn, \nCorissa P Chang, \nMichael Awad, \nRobson Capasso\n

Publicatie 17-11-2020


ObjectiveTo determine if a modified tissue‐preserving palatopharyngoplasty could convert retropalatal concentric collapse to anteroposterior or lateral patterns of collapse on drug‐induced sleep endoscopy (DISE) in patients who are not candidates for upper airway stimulation due to complete circumferential collapse at the velum.MethodsA prospective, nonconsecutive, single‐blinded cohort study was performed by two sleep surgeons at a tertiary care center from 2015 to 2018. Inclusion criteria included adults > 18 years of age with a diagnosis of obstructive sleep apnea with an Apnea–Hypopnea Index (AHI) > 15, a body mass index (BMI) < 32, and < 25% central apneas on polysomnography. Twelve patients with complete circumferential collapse underwent a modified palatopharyngoplasty. Postoperatively, a repeat sleep study was performed. A repeat DISE was recommended for those with incomplete surgical response (clinically and/or AHI).ResultsTwelve patients with complete circumferential collapse were eligible for the study. Mean BMI was 30.5. Mean preoperative AHI was 54.0 events per hour. Following a modified palatopharyngoplasty, the mean AHI was reduced to 33.1 events per hour, and 100% (12 of 12) of the patients converted from a pattern of complete circumferential collapse to either no collapse at the level of the velum (3) or an anteroposterior pattern of collapse (9).ConclusionWe demonstrate that a modified palatopharyngoplasty can successfully convert collapse patterns in patients with complete circumferential collapse. Further studies are required to determine the outcome of these patients following upper airway stimulation implantation.Level of Evidence1B Laryngoscope, 2020

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Laryngeal Mucosa Alterations in Mice Model of Gastroesophageal Reflux: Effects of Topical Protection

\nAline A. Figueiredo, \nThiago M. A. L. Sales, \nLucas A. D. Nicolau, \nAndré A. A. Nunes, \nHumberto B. Costa‐Filho, \nRhubens L. R. Moreira, \nRenata R. Nascimento, \nMaria K. A. Sousa, \nLorena D. Silva, \nJoão P. Carmo‐Neto, \nFlávio M. N. O. Sidou, \nSuliana M. Paula, \nJand V. R. Medeiros, \nDurcilene A. Silva, \nDaniel Sifrim, \nMarcellus H. L. P. Souza\n

Publicatie 17-11-2020


Objectives/HypothesisThe objectives of this study were to evaluate laryngeal inflammation and mucosal integrity in a murine model of reflux disease and to assess the protective effects of topical agents including alginate, hyaluronic acid, and cashew gum.Study DesignAnimal study.MethodsA surgical murine model of reflux disease was evaluated at 3 or 7 days postsurgery, and laryngeal samples were collected to measure inflammation (wet weight and myeloperoxidase MPO) and mucosal integrity (transepithelial resistance TER and mucosal permeability to fluorescein). Additional groups of animals were administered one of several topical agents (alginate, hyaluronic acid, or cashew gum) daily, and laryngeal inflammation and mucosal integrity were evaluated at 3 days postsurgery.ResultsAt 3 days, and not 7 days postsurgery, we observed increased laryngeal wet weight and MPO, decreased laryngeal TER, and increased laryngeal mucosa permeability. Alginate partially decreased laryngeal inflammation (wet weight and not MPO) and dramatically improved laryngeal mucosal integrity. Conversely, hyaluronic acid eliminated the inflammation; however, it had no effect on laryngeal mucosal integrity impairment. Cashew gum eliminated laryngeal inflammation as well as the impairment in laryngeal mucosal integrity.ConclusionsThis study shows that a surgical model of reflux disease induced laryngeal inflammation and impairment in laryngeal barrier function. These observed alterations were partially attenuated by alginate and hyaluronic acid and completely reversed by cashew gum.Level of EvidenceNA Laryngoscope, 2020

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Validity testing of a three‐dimensionally printed endoscopic sinonasal surgery simulator

\nMohamedkazim M. Alwani, \nThomas J. Svenstrup, \nElhaam H. Bandali, \nDhruv Sharma, \nThomas S. Higgins, \nArthur W. Wu, \nTaha Z. Shipchandler, \nElisa A. Illing, \nJonathan Y. Ting\n

Publicatie 17-11-2020


Objectives/HypothesisTo assess the face, content, construct, and concurrent validity of the PHACON Sinonasal Surgery Simulator (SNSS).Study DesignProspective cohort study.MethodsA total of 12 otolaryngology residents were recruited to perform sinonasal surgery on the simulator followed by cadaveric heads. Resident performances were recorded and de‐identified. Face and content validities were evaluated based on 5‐point Likert scale questionnaires. The recordings were evaluated by extramural expert rhinologists based on a validated Global Rating Scale (GRS). These results were analyzed and compared to assess construct and concurrent validity.ResultsThe appearance of anatomic structures was rated as realistic by 75% of all participants, while only 30% and 41.7% rated the mucosal and bony tissues as realistic, respectively. A total of 91.7% of participants found the model useful for teaching anatomy, while 66.7% said it was useful for teaching operative technique. Construct validity was confirmed by showing significant differences in performance between the novice and experienced groups. Concurrent validity was confirmed by showing significant correlation between performance on the model and gold standard (i.e. cadaver head).ConclusionsThis study demonstrates the face, content, concurrent, and construct validity of a 3D‐printed SNSS. Although this model has the potential to be a valuable tool in endoscopic sinus surgery training for otolaryngology residents, improvements are required with respect to the quality of simulated mucosal tissue as well as the simulated anatomy of the fronto‐ethmoid compartmentLevel of Evidence: NALaryngoscope, 2019

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Effectiveness of a Home‐based Head and Neck Lymphedema Management Program: A Pilot Study

\nTheresa Yao, \nBeth Beadle, \nC. Floyd Holsinger, \nHeather M. Starmer\n

Publicatie 17-11-2020


ObjectiveThis study aimed to compare outcomes in patients with head and neck lymphedema receiving either a home‐based lymphedema treatment program or a hybrid approach including both home‐based treatment and regular clinical visits.MethodsOutcomes were assessed in patients receiving head and neck lymphedema rehabilitation. Baseline measures of neck, submental, and facial edema were obtained and repeated following treatment. A home program was recommended for all patients, and those receiving hybrid care received the same recommendations as well as a visit with the lymphedema therapist for additional treatment. Their outcomes were compared using standard statistical analysis.ResultsFifty consecutive individuals were included, 25 in each group. Adherence to at least 50% of recommended treatment was reported in 68% of those receiving home‐based treatment and 84% of those receiving hybrid care. Significant improvement was demonstrated for 66% of patients. There was no statistically significant difference between treatment groups with regard to clinically significant improvement (P = .15). Patients receiving hybrid therapy demonstrated treatment advantages regarding facial edema (P = .037). Adherence to treatment was associated with clinical improvement (P = .047).ConclusionsComparable benefits were observed regardless of whether patients had a home‐based or hybrid lymphedema treatment approach. These data suggest a home‐based treatment approach may be appropriate for patients unable to participate in clinical sessions. However, for patients with significant facial edema, a hybrid approach may be preferable. Adherence was associated with better outcomes. Given these findings, future investigations should consider strategies to improve adherence to optimize the outcomes lymphedema treatment.Level of Evidence3b Laryngoscope, 2020

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Neuromonitored Thyroid Surgery: Optimal Stimulation Based on Intraoperative EMG Response Features

\nNicholas B. Abt, \nSidharth V. Puram, \nDipti Kamani, \nRahul Modi, \nGregory W. Randolph\n

Publicatie 17-11-2020


ObjectivesTo evaluate/compare normative electrophysiologic electromyography (EMG) response characteristics of recurrent laryngeal, vagus, and external branch of superior laryngeal nerve evoked with different stimulators used in neuromonitored thyroid surgery.Study DesignProspective crossover studyMethodsEMG responses obtained via endotracheal tube surface electrodes in 11 patients undergoing thyroid surgery were recorded when stimulated with four stimulators: two monopolar (Prass standard and ball tip), one bipolar, and one dissecting instrument. Normative mean EMG results including latency, amplitude, threshold, saturation currents, and distance‐sensitivity were compared.ResultsThe Prass standard stimulator had shorter latency time when nerve was not covered with fascia (P = .04). The bipolar, dissecting instrument, and ball tip demonstrated similar latency times with and without nerve fascia. Pooled mean latency increased significantly from 1.86 ms to 2.16 ms when comparing nerves without fascia and nerves with fascia (P < .05). The Prass standard monopolar stimulator had the lowest mean threshold at 0.40 mA, with the dissecting instrument having the highest threshold at 0.89 mA for dissected nerve. Pooled mean threshold and saturation increased from 0.6 mA to 1.7 mA (P < .0001) and 1.57 mA to 4.15 mA (P < .001) with fascia covering nerve, respectively. The mean depolarization rate was 100% for monopolar and bipolar electrodes and 81% for dissecting instrument at 1 mA. Only 9% of monopolar electrodes generated an EMG response when stimulated from 2 mm away.ConclusionMonopolar stimulators are more sensitive for neural mapping, whereas bipolar instruments are more specific, thus reducing false positive stimulation. Dissecting instruments share many features of monopolar stimulators while being more specific, and thus are a viable alternative.Level of Evidence2b Laryngoscope, 2020

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Mode of action of carboplatin via activating p53/miR‐145 axis in head and neck cancers

\nAhsen Kilic, \nNeslisah Barlak, \nFatma Sanli, \nAbdulmelik Aytatli, \nOzel Capik, \nOmer F. Karatas\n

Publicatie 17-11-2020


ObjectivesIn this study, we aimed at investigating the expressions of miR‐145 and its well‐characterized direct targets on carboplatin treatment.Study DesignLaboratory study.MethodsThe effect of carboplatin and miR‐145 on the proliferative capacity of head and neck squamous cell carcinoma cells was evaluated using Cell Viability Detection Kit‐8. Expressions of miR‐145 and its targets were evaluated using quantitative real‐time polymerase chain reaction on carboplatin treatment and p53 inhibition. Western blot was used to measure the levels of p53 and its acetylated versions in cells treated with carboplatin and/or pifithrin‐α.ResultsWe demonstrated that carboplatin induced the expression of miR‐145 in a dose‐dependent manner and suppressed the expressions of miR‐145 direct targets. In addition, we showed that inhibition of p53 by pifithrin‐α in carboplatin‐treated cells reduced miR‐145 expression and reversed the suppression of miR‐145 direct targets.ConclusionsConsidering all these findings together, one of the proposed mechanisms of carboplatin to kill cells might be the induction of miR‐145 and deregulation of its targets in parallel, via p53 activation, which happens through carboplatins DNA‐damaging property. To the best of our knowledge, these findings are the first to reveal the relationship between carboplatin and miR‐145 in cancer cells.Level of EvidenceNALaryngoscope, 2019

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Inhibition of glutaminase to reverse fibrosis in iatrogenic laryngotracheal stenosis

\nHsiu‐Wen Tsai, \nKevin M. Motz, \nDacheng Ding, \nIoan Lina, \nMichael K. Murphy, \nDimitri Benner, \nMichael Feeley, \nJody Hooper, \nAlexander T. Hillel\n

Publicatie 17-11-2020


Objectives/HypothesisGlutamine metabolism is a critical energy source for iatrogenic laryngotracheal stenosis (iLTS) scar fibroblasts, and glutaminase (GLS) is an essential enzyme converting glutamine to glutamate. We hypothesize that the GLS‐specific inhibitor BPTES will block glutaminolysis and reduce iLTS scar fibroblast proliferation, collagen deposition, and fibroblast metabolism in vitro.Study DesignTest‐tube Lab Research.MethodsImmunohistochemistry of a cricotracheal resection (n = 1) and a normal airway specimen (n = 1) were assessed for GLS expression. GLS expression was assessed in brush biopsies of subglottic/tracheal fibrosis and normal airway from patients with iLTS (n = 6). Fibroblasts were isolated and cultured from biopsies of subglottic/tracheal fibrosis (n = 6). Fibroblast were treated with BPTES and BPTES + dimethyl α‐ketoglutarate (DMK), an analogue of the downstream product of GLS. Fibroblast proliferation, gene expression, protein production, and metabolism were assessed in all treatment conditions and compared to control.ResultsGLS was overexpressed in brush biopsies of iLTS scar specimens (P = .029) compared to normal controls. In vitro, BPTES inhibited iLTS scar fibroblast proliferation (P = .007), collagen I (Col I) (P < .0001), collagen III (P = .004), and α‐smooth muscle actin (P = .0025) gene expression and protein production (P = .031). Metabolic analysis demonstrated that BPTES reduced glycolytic reserve (P = .007) but had no effects on mitochondrial oxidative phosphorylation. DMK rescued BPTES inhibition of Col I gene expression (P = .0018) and protein production (P = .021).ConclusionsGLS is overexpressed in iLTS scar. Blockage of GLS with BPTES significantly inhibits iLTS scar fibroblasts proliferation and function, demonstrating a critical role for GLS in iLTS. Targeting GLS to inhibit glutaminolysis may be a successful strategy to reverse scar formation in the airway.Level of EvidenceNALaryngoscope, 2020

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Additional Injection Laryngoplasty for Patients With Unilateral Vocal Fold Paralysis

\nNayeon Choi, \nSeongjun Won, \nHokyung Jin, \nHack Jung Kim, \nWoori Park, \nYoung‐Ik Son\n

Publicatie 17-11-2020


ObjectivesIn case of insufficient voice improvement after injection laryngoplasty (IL), additional IL will be one of the next option of treatments. However, little is known about the voice outcomes regarding an additional IL.Study designRetrospective comparative study in single institution.MethodsWe enrolled the patients of unilateral vocal fold paralysis (UVFP), who received IL (N = 76) twice because of insufficient voice improvement. The etiologies of UVFP were related with thoracic and esophageal surgery (51.3%), neck surgery (30.3%), skull base surgery (7.9%), or unknown (10.5%). The subjective and objective voice parameters were collected before and after (mean: 5.3 months) each IL.ResultsAspiration, maximum phonation time (MPT), jitter percentage, shimmer percentage, and noise to harmonic ratio (NHR) were significantly improved after both the first and second rounds of IL (P < .05). Voice handicap index (VHI)–30 was also significantly improved after both the first and second rounds of IL (P < .001). Regarding GRBAS score, overall grade of dysphonia (G), roughness (R), and breathiness (B) were significantly improved after the first IL, but only G and R after the second IL (P < .05). In comparison between postprocedural voice parameters of the first and second ILs, MPT was significantly improved from 5.5 ± 3.5 seconds to 7.3 ± 7.5 seconds (P = .001). Grade of dysphonia (1.9 ± 0.8) and breathiness (1.7 ± 0.9) of post‐first IL were significantly (P < .001) improved to those of post‐second IL (1.3 ± 0.7 and 1.2 ± 0.7, respectively). VHI‐30 of post‐first IL (72.0 ± 20) was significantly improved (P < .001) to those of the second IL (57.2 ± 23.7).ConclusionsIn selected patients, additional IL could provide further improvement of voice in patient who had unsatisfactory voice results despite of initial IL.Level of Evidence4 Laryngoscope, 2020

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The state of diversity based on race, ethnicity, and sex in otolaryngology in 2016

\nCeisha C. Ukatu, \nLauren Welby Berra, \nQiwei Wu, \nChristine Franzese\n

Publicatie 17-11-2020


ObjectiveTo compare the representation of women and racial minorities among otolaryngology residents and faculty to other surgical specialties.MethodsInformation from 2016 regarding female and minority representation among medical school graduates, otolaryngology applicants, otolaryngology residents, otolaryngology faculty and residents, and faculty in other surgical specialties was obtained from the publicly available registries from the American Medical Association and the American Association of Medical Colleges. The data obtained was used to explore the differences between the various stages of training in otolaryngology and to compare the female and minority diversity of otolaryngology residents with residents in other surgical specialties.ResultsWomen and African Americans were underrepresented at the resident level compared with their level of representation as medical school graduates. Women were underrepresented in otolaryngology resident applicants (P < .001), but equally represented between otolaryngology residency applicants and residents (P = .582). African Americans were equally represented between medical school graduates and otolaryngology resident applicants (P = .871), but underrepresented in otolaryngology residents (P < .001). Asian Americans and Hispanics were underrepresented among otolaryngology faculty compared with their representation in otolaryngology residency programs (P < .001, P < .001, respectively). Otolaryngology has the lowest percentage of African‐American residents and faculty compared to other surgical specialties. The representation of women in otolaryngology residencies is higher than most surgical specialties but worse than general surgery, integrated plastics, and medical school graduates.ConclusionOtolaryngology lags behind other surgical specialties in representation of minorities and women. Continued efforts should be made to increase diversity in the field of otolaryngology, especially in regard to underrepresented minorities.Level of Evidence3 Laryngoscope, 2019

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Success of Hypoglossal Nerve Stimulation Using Mandibular Advancement During Sleep Endoscopy

\nGraeme B. Mulholland, \nRaj C. Dedhia\n

Publicatie 17-11-2020


Objectives/HypothesisHypoglossal nerve stimulation (HGNS) effectively treats obstructive sleep apnea in select patients. Drug‐induced sleep endoscopy (DISE) is required for HGNS candidacy. Data suggest that mandibular advancement (MA) devices and HGNS share similar target populations. We aimed to test the association between MAs effect on the velum and lateral walls during DISE in relation to the improvement in the apnea‐hypopnea index (AHI) with HGNS.Study DesignProspective case seriesMethodsAll patients completed preoperative polysomnography or home sleep study, DISE with MA prior to HGNS implantation, and full‐night efficacy sleep tests. Adult patients with body mass index (BMI) ≤ 35 and AHI ≥ 15 were included. Two independent reviewers scored DISE videos.ResultsForty‐six patients were included from October 2015 to January 2019. Mean BMI (standard deviation) was 28.5 (3.7) kg/m2. Patients with a reduced airway response to MA had greater AHI improvement than patients with a robust response (21.7, 95% confidence interval CI: 14.4 to 29.0 vs. 4.9, 95% CI: −8.9 to 18.6; P = .03). Patients with complete baseline collapse at the velum and lateral walls (n = 11) had less response compared to those with partial collapse (n = 35) (AHI reduction of 4.4 95% CI: −8.6 to 17.4 vs. 22.3 95% CI: 15.1 to 29.6; P = .02).ConclusionsPatients having significant airway improvement in the upper pharynx with MA during DISE appear less likely to succeed with HGNS. This phenomenon might be secondary to the worsened baseline obstruction of the upper pharynx in such patients.Level of Evidence4 Laryngoscope, 2020

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Respiratory Laryngeal Dystonia: Characterization and Diagnosis of a Rare Neurogenic Disorder

\nWilliam S. Tierney, \nPaul C. Bryson, \nRebecca Nelson, \nSeth E. Kaplan, \nMichael S. Benninger, \nClaudio F. Milstein\n

Publicatie 17-11-2020


Objectives/HypothesisRespiratory laryngeal dystonia (RLD) is poorly understood and rarely reported in the literature. Patients have atypical laryngeal movement resulting in airway obstruction. This motion is neurogenic in nature, is constant while awake, nonepisodic, and non–trigger dependent. Given its rarity, it is often misdiagnosed for inducible laryngeal obstruction; however, it is refractory to medical and behavioral management. Although this condition has been addressed in the literature, this report is the largest case series characterizing presenting symptomology, multimodal treatment outcomes, and longitudinal course of these patients, and proposes a set of diagnostic criteria to aid in clinical identification of RLD patients. Our objectives were to characterize RLD clinically and offer diagnostic guidelines to clinicians.Study DesignA prospective case series with a retrospective analysis at a tertiary referral center.MethodsA review of clinical records and videostroboscopic analysis of 16 patients treated for respiratory laryngeal dystonia from October 2005 to October 2018 was performed.ResultsSixteen patients with respiratory laryngeal dystonia were included. The common features of this group were persistent, nonepisodic dyspnea and stridor with laryngoscopic evidence of paradoxical vocal fold motion. Our patients had no structural neurologic abnormalities. These patients typically failed respiratory retraining therapy and medical management of laryngeal irritants. In our series, 100% of patients underwent respiratory retraining therapy, 68.8% received laryngeal botulinum toxin injection, and 31.3% required tracheostomy.ConclusionsRLD is a rare and challenging condition. The disorder can be severely disabling, and treatment options appear limited. A multidisciplinary approach may be helpful. Some patients responded to laryngeal botulinum injection and medical management, whereas others required tracheostomy for symptom control. Laryngoscope, 2020

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Machine Learning for Predicting Complications in Head and Neck Microvascular Free Tissue Transfer

\nEric J. Formeister, \nRachel Baum, \nP. Daniel Knott, \nRahul Seth, \nPatrick Ha, \nWilliam Ryan, \nIvan El‐Sayed, \nJonathan George, \nAndrew Larson, \nKarolina Plonowska, \nChase Heaton\n

Publicatie 17-11-2020


Objectives/HypothesisMachine learning (ML) is a type of artificial intelligence wherein a computer learns patterns and associations between variables to correctly predict outcomes. The objectives of this study were to 1) use a ML platform to identify factors important in predicting surgical complications in patients undergoing head and neck free tissue transfer, and 2) compare ML outputs to traditionally employed logistic regression models.Study DesignRetrospective cohort study.MethodsUsing a dataset of 364 consecutive patients who underwent head and neck microvascular free tissue transfer at a single institution, 14 clinicopathologic characteristics were analyzed using a supervised ML algorithm of ensemble decision trees to predict surgical complications. The relative importance values of each variable in the ML analysis were then compared to logistic regression models.ResultsThere were 166 surgical complications, which included bleeding or hematoma in 30 patients (8.2%), fistulae in 25 patients (6.9%), and infection or dehiscence in 52 patients (14.4%). There were 59 take‐backs (16.2%), and six total (1.6%) and five partial (1.4%) flap failures. ML models were able to correctly classify outcomes with an accuracy of 65% to 75%. Factors that were identified in ML analyses as most important for predicting complications included institutional experience, flap ischemia time, age, and smoking pack‐years. In contrast, the significant factors most frequently identified in traditional logistic regression analyses were patient age (P = .03), flap type (P = .03), and primary site of reconstruction (P = .06).ConclusionsIn this single‐institution dataset, ML algorithms identified factors for predicting complications after free tissue transfer that were distinct from traditional regression models.Level of Evidence2c Laryngoscope, 2020

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“Parachute” Technique for Reconstruction of Small Skull Base Defects of the Ventral Skull Base

\nValentin Favier, \nJohnny Youssef, \nRomain Kania, \nBenjamin Vérillaud, \nPhilippe Herman\n

Publicatie 17-11-2020


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Pediatric Epiglottopexy Using an Endoscopic Suturing Device

\nRyan K. Thorpe, \nSohit P. Kanotra\n

Publicatie 17-11-2020


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Ultrasound‐Guided Suture Lateralization in Pediatric Bilateral Vocal Fold Immobility

\nMichael D. Puricelli, \nJoseph Peterson, \nSohit P. Kanotra\n

Publicatie 17-11-2020


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Facial Fractures and the National Basketball Association: Epidemiology and Outcomes

\nParsa P. Salehi, \nAlyssa Heiser, \nSina J. Torabi, \nBabak Azizzadeh, \nJonathan Lee, \nYan H. Lee\n

Publicatie 17-11-2020


Objectives/HypothesisTo identify the epidemiology and impact of facial fractures on player performance and return to play (RTP) in the National Basketball Association (NBA).Study DesignRetrospective case–control seriesMethodsFifty‐three NBA players who sustained facial fractures between 1984 and 2018 were identified. Players with pre‐ and postinjury statistics were included in the performance analysis. A control group was matched by age, body mass index (BMI), position, NBA experience, and player efficiency rating. Fisher exact tests and Student t tests were performed to analyze player demographics and performance variables.ResultsAt the time of injury, the average players age was 26.17 years, BMI was 24.80 kg/m2, and NBA experience was 4.97 years. Players missed an average of 3.77 games and 18.21 days prior to RTP. Forty‐eight players (90.6%) did RTP the subsequent season, whereas 43 of those players (81.1%) met inclusion criteria for performance analysis. There was no significant change in performance between pre‐ and postinjury seasons. Players managed operatively missed significantly more games (8.15 vs. 1.85; P = .034) and days (51.08 vs. 5.53; P = .003) than players managed nonoperatively, whereas performance was not impacted. Average career length following facial fracture was significantly shorter compared to controls (5.14 vs. 6.42 years; P = .010) and a decrease in three‐pointer percentage (P = .004) was observed.ConclusionsThe majority of players who suffer facial fractures RTP in the NBA and do not experience significant decline in performance following injury. These results should aid physicians caring for basketball players at any level, and may help inform future guidelines for treatment and injury prevention.Level of Evidence3b Laryngoscope, 2020

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Efficacy and safety of steroid‐impregnated implants following sinus surgery: A meta‐analysis

\nWanpeng Li, \nHanyu Lu, \nHuan Wang, \nXicai Sun, \nDehui Wang\n

Publicatie 17-11-2020


ObjectivesThe purpose of this meta‐analysis was to discuss the efficacy and safety of bioabsorbable steroid‐impregnated implants following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) patients.MethodsPubMed, Cochrane, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials were comprehensively searched for studies comparing the experimental group (bioabsorbable steroid‐impregnated implants) with the control group (bioabsorbable nonsteroid‐impregnated implants). Lund‐Kennedy scores, Perioperative Sinus Endoscopy (POSE) scores, polyp change, significant adhesion, middle turbinate lateralization, and adverse events were extracted from the final eligible studies. RevMan 5.3 software was used to analyze the data.ResultsEight randomized controlled trials were included in our analysis. The experimental group showed no significant differences from the control group in Lund‐Kennedy scores (weighted mean difference (WMD) −0.40; 95% confidence interval confidence interval (CI) −1.05 to −0.62; P = 0.23). The experimental group had lower POSE scores compared with the control group, and there was a significant difference (WMD −1.88; 95% CI −2.32 to −1.43, P < 0.00001). The pooled results also demonstrated significant differences in polyp change, significant adhesion, and middle turbinate lateralization between the two groups. In addition, there was no significant difference with respect to adverse events between the two groups (odds ratio (OR) 0.38; 95% CI: 0.07 to 2.03; P = 0.26).ConclusionBioabsorbable steroid‐impregnated implants following ESS are effective in improving the endoscopic appearance of the healing process, and the safety profile appears to be favorable for the treatment of CRS patients.Level of Evidence1A Laryngoscope, 2019

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Tonsillar surface swab bacterial culture results differ from those of the tonsillar core in recurrent tonsillitis

\nAmy Dickinson, \nHanna Kankaanpää, \nSuvi Silén, \nSeppo Meri, \nAaro Haapaniemi, \nJukka Ylikoski, \nAntti Mäkitie\n

Publicatie 17-11-2020


Objectives/HypothesisWe aimed to determine whether there was a difference between core and surface bacteriology of Finnish adults with recurrent or chronic tonsillitis to understand whether a surface swab is worthwhile and which bacteria are involved.Study DesignCase series.MethodsUninflamed tonsillar surface swabs and core biopsies were taken prior to and during surgery, respectively, in 103 patients aged 16 to 66 years undergoing tonsillectomy for recurrent or chronic tonsillitis. The McNemar test was used to determine differences between the surface and core in the most prevalent bacterial species.ResultsTwenty‐seven bacterial species were isolated in addition to normal flora and were more commonly found in the core (1.11 surface and 4.75 core bacteria isolated per patient). Viridans group streptococci were the most commonly detected bacteria, found in 88% of the patients, mainly in the core. The bacteria in general were mainly isolated from the core. Of the 10 most prevalent bacteria, only group C β‐hemolytic streptococci showed no difference between detection from core and surface swabs. Other bacteria found mainly in the core include Prevotella melaninogenica, Staphylococcus aureus, and fusobacteria.ConclusionsThere is discord between the surface and core bacteria. A different population of bacteria exists in the core, especially anaerobic bacteria, suggesting that a core sample may be useful in evaluating recurrent and chronic tonsillitis.Level of Evidence4 Laryngoscope, 2019

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Diffusion Kurtosis Imaging and Intravoxel Incoherent Motion in Differentiating Nasal Malignancies

\nZebin Xiao, \nZuohua Tang, \nChunquan Zheng, \nJianfeng Luo, \nKeqing Zhao, \nZhongshuai Zhang\n

Publicatie 17-11-2020


Objectives/HypothesisTo evaluate the usefulness of diffusion kurtosis imaging (DKI) and intravoxel incoherent motion (IVIM) in the differentiation of sinonasal malignant tumors (SNMTs) with different histological types.Study DesignRetrospective observational and diagnostic study.MethodsSixty‐five patients with SNMTs who underwent DKI and IVIM were enrolled in this retrospective study, including 27 squamous cell carcinomas (SCCs), 13 olfactory neuroblastomas (ONBs), 14 malignant melanomas (MMs) and 11 lymphomas. The kurtosis (K) and diffusion coefficient (Dk) from DKI and the pure diffusion coefficient (D), pseudodiffusion coefficient (D*), perfusion fraction (f), and the product of D* and f (f∙D*) from IVIM were measured. Kruskal‐Wallis and Dunn multiple comparison tests with Bonferroni correction, receiver operating characteristic curve, and logistic regression analyses were used for statistical analysis.ResultsLymphomas demonstrated the highest K values but lowest Dk, D, D*, f, and f∙D* values among these four malignant tumors. ONBs exhibited high K values and MMs had highest D*, f, and f∙D* values. The cutoff value of ≤0.887 × 10−3 mm2/sec for f∙D* provided a sensitivity, specificity, and an accuracy of 100%, 98.1%, and 98.5%, respectively, for differentiating lymphomas from the other three entities. The combination of f∙D* and D values showed a sensitivity of 92.9% and a specificity of 92.5% for the discrimination of MMs from ONBs and SCCs. The K value was useful for differentiating ONBs from SCCs, with a threshold value of 0.942 (sensitivity, 84.6%; specificity, 63.0%).ConclusionsThe combined use of DKI and IVIM is helpful for differentiating among four histological types of SNMTs.Level of Evidence3 Laryngoscope, 2019

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The Safety and Efficacy of Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange for Laryngologic Surgery

\nVladimir Nekhendzy, \nAmit Saxena, \nBrita Mittal, \nEric Sun, \nKwang Sung, \nKaruna Dewan, \nEdward J. Damrose\n

Publicatie 17-11-2020


ObjectivesTransnasal humidified rapid‐insufflation ventilatory exchange (THRIVE) is an intraoperative ventilatory technique that allows avoidance of tracheal intubation (TI) or jet ventilation (JV) in selected laryngologic surgical cases. Unimpeded access to all parts of the glottis may improve surgical precision, decrease operative time, and potentially improve patient outcomes. The objective of this prospective, randomized, patient‐blinded, 2‐arm parallel pilot trial was to investigate the safety and efficacy of THRIVE use for adult patients undergoing nonlaser laryngologic surgery of short‐to‐intermediate duration.MethodsTwenty adult, American society of anesthesiology class 1‐3 patients with body mass index (BMI) < 35 kg/m2 were randomly assigned to either an experimental THRIVE group or active comparator conventional ventilation group (TI or supraglottic high‐frequency JV SHFJV). Primary outcomes included intraoperative oxygenation, anesthesia awakening/extubation time, time to laryngoscopic suspension, number of intraoperative suspension adjustments, and operative time. Secondary patient outcomes including postanesthesia and functional patient recovery were investigated.ResultsCompared to TI/SHFJV, THRIVE use was associated with significantly lower intraoperative oxygenation (SpO2 93.0 ± 5.6% vs. 98.7 ± 1.6%), shorter time to suspension (1.8 ± 1.1 minutes vs. 4.3 ± 2.1 minutes), fewer suspension adjustments (0.4 ± 0.5 vs. 1.7 ± 0.9), and lower postoperative pain scores on recovery room admission (1.3 ± 1.9 vs. 3.7 ± 2.9) and discharge (0.9 ± 1.3 vs. 2.7 ± 1.8). The study was underpowered to detect other possible outcome differences.ConclusionWe confirm the safe intraoperative oxygenation profile of THRIVE for selected patients undergoing nonlaser laryngologic surgery of short‐to‐intermediate duration. THRIVE facilitated surgical exposure and improved early patient recovery, suggesting a potential economic benefit for outpatient laryngologic procedures. The results of this exploratory study provide a framework for designing future adequately powered THRIVE trials.Trial RegisterClinicalTrials.gov (NCT03091179).Level of EvidenceII Laryngoscope, 2020

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Smoking and Alcohol Consumption Are Associated With the Increased Risk of Peritonsillar Abscess

\nSo Young Kim, \nHyoseob Lim, \nHyo Geun Choi\n

Publicatie 17-11-2020


Objectives/HypothesisThe purpose of this study was to evaluate the relationship among smoking, alcohol consumption, and peritonsillar abscess in a Korean population.Study DesignIndividuals ≥40 years old from the Korean National Health Insurance Service‐Health Screening Cohort were assessed from 2002 to 2013.MethodsIn total, 1,285 peritonsillar abscess participants were matched with 5,140 controls at a ratio of 1:4 with respect to age group, sex, income group, region of residence, hypertension, diabetes, and dyslipidemia. We analyzed the participants previous histories of smoking (current smokers vs. nonsmokers or past smokers) and alcohol consumption (drinkers vs. nondrinkers) in the peritonsillar abscess and control groups. Peritonsillar abscess was defined using the International Classification of Disease‐10 code J36 combined with claim codes for incision and drainage or aspiration. Crude and adjusted odds ratios (ORs) were analyzed using unconditional logistic regression analyses, and 95% confidence intervals (CI) were calculated.ResultsThe rates of smoking and consuming alcohol were higher in the peritonsillar abscess group than in the control group. The adjusted OR of smoking for peritonsillar abscess was 1.23 (95% CI = 1.06–1.44, P = .009), and that of alcohol consumption was 1.18 (95% CI = 1.02–1.36, P = .024).ConclusionThe odds of smoking and alcohol consumption were increased in peritonsillar abscess patients compared to those in the control group.Level of EvidenceNA Laryngoscope, 2020

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Surgical Site Infection Affects Length of Stay After Complex Head and Neck Procedures

\nNicole L. Lebo, \nAlexandra E. Quimby, \nLisa Caulley, \nKednapa Thavorn, \nNatasha Kekre, \nSarah Brode, \nStephanie Johnson‐Obaseki\n

Publicatie 17-11-2020


Objectives/HypothesisQuality improvement (QI) initiatives emphasize a need for reduction in hospital length of stay (LOS). We sought to determine the impact of surgical site infections (SSIs) on LOS after complex head and neck surgery (HNS).Study DesignRetrospective cohort analysis.MethodsAn analysis of the American College of Surgeons National Surgical Quality Improvement Program was undertaken. All adult patients undergoing complex HNS from 2005 to 2016 were included in the analysis. Our main outcomes were SSI incidence and increase in hospital LOS attributable to SSI.ResultsOf 4,014 patients identified, 16.5% developed SSI. History of smoking, diabetes, preoperative wound infection, contaminated or dirty wound classes, and prolonged operative time were found to significantly predict postoperative SSI. Adjusting for significant pre‐ and postoperative factors, SSI was associated with significantly increased LOS (hazard ratio = 0.486, 95% confidence interval: 0.419‐0.522).ConclusionsSSI following complex HNS is associated with significantly increased hospital LOS. This result supports the need for institutional QI strategies that target SSIs after head and neck procedures in an effort to provide the highest quality care at the lowest possible cost. Our analysis identifies risk factors that can allow identification of patients at high risk of SSI and prolonged hospitalization.Level of Evidence2b Laryngoscope, 2020

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Clinical Experience of Vibroplasty With Direct Coupling to the Oval Window Without Use of a Coupler

\nSang Hyun Kwak, \nYoung Min Moon, \nGi‐Sung Nam, \nSeong Hoon Bae, \nSung Huhn Kim, \nJinsei Jung, \nJae Young Choi\n

Publicatie 17-11-2020


Objectives/HypothesisTo investigate the efficacy of direct implantation of a Vibrant Soundbridge (VSB) implant in the oval window (OW) without the use of an OW coupler in patients with severe mixed hearing loss.Study DesignRetrospective chart reviewMethodsA total of 62 patients underwent VSB implantation between July 2016 and December 2018 at Severance Hospital in Seoul, South Korea. Among them, eight patients (nine ears) with moderate‐to‐severe mixed hearing loss were implanted with a VSB directly in the OW. A floating mass transducer (FMT) was attached to the stapes footplate and covered with tragal cartilage. The outcomes were evaluated using pure‐tone audiogram and speech audiogram preoperatively and postoperatively. Word recognition score (WRS; % correct) were measured at the most comfortable loudness (MCL) level to evaluate speech perception.ResultsAll cases posed difficulty with round window vibroplasty during surgery, and eventually, an FMT was appropriately placed in the OW without a coupler. Preoperative and postoperative bone conduction thresholds were not different. VSB‐aided threshold improved in terms of functional and effective gains. Interestingly, four cases showed improved air conduction thresholds without the use of a VSB. In addition, MCL level with a VSB was significantly lower than that with a hearing aid, and VSB‐aided WRS improved over time.ConclusionsDirect implantation of a VSB in the OW without the use of a coupler showed favorable hearing outcomes, and the OW vibroplasty was safe. Direct OW vibroplasty without a coupler is a reliable procedure and can be a good option for hearing rehabilitation in patients with severe mixed hearing loss.Level of Evidence4 Laryngoscope, 2020

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Endoscopic Fluorescence‐Guided Surgery for Sinonasal Cancer Using an Antibody‐Dye Conjugate

\nZachary P. Hart, \nNaoki Nishio, \nGiri Krishnan, \nGuolan Lu, \nQuan Zhou, \nShayan Fakurnejad, \nPeter John Wormald, \nNynke S. Berg, \nEben L. Rosenthal, \nFred M. Baik\n

Publicatie 17-11-2020


ObjectiveEndoscopic resection of sinonasal squamous cell carcinoma has become the standard of care, but challenges remain in obtaining clear resection margins. The current study evaluated the feasibility of endoscopic fluorescence‐guided surgery (FGS) to improve surgical resection in a human sinus surgical model.MethodsA fluorescence endoscope optimized for near‐infrared (NIR) fluorescence detection was evaluated in a phantom study. Various endoscope diameters (4 and 10 mm) and viewing angles (0, 30, and 45 degrees) were evaluated to determine the sensitivity of the system for IRDye800CW detection at various working distances (1–5 cm). Endoscopic FGS was then validated in a three‐dimensional human sinus surgical model to which squamous cell tumors derived from mice were inserted. Mice had received intravenous panitumumab‐IRDye800CW and upon fluorescence‐guided tumor resection, mean fluorescence intensity (MFI) and tumor‐to‐background ratio (TBR) were calculated in in situ and ex vivo settings.ResultsA significantly higher fluorescence intensity was found when using the 10‐mm diameter endoscope compared to the 4mm diameter endoscope (P < .001). No significant difference in MFI was found among the viewing angles of the 4‐mm diameter endoscope. Using the human sinus model, the highest MFI and TBR were obtained at a 1‐cm working distance compared to longer working distances.ConclusionWe demonstrate that clinically acceptable TBRs were obtained with several working distances to discriminate tumor tissue from adjacent normal tissue in a human sinus model, and that endoscopic FGS may have great potential in identifying residual tumor tissue regions during surgery. Laryngoscope, 2019

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Outcomes and Predictive Value of Post‐adjuvant Therapy PET/CT for Locally Advanced Oral Squamous Cell Carcinoma

\nDavid C. Qian, \nKelly R. Magliocca, \nAshley H. Aiken, \nKristen L. Baugnon, \nDavid C. Brandon, \nWilliam A. Stokes, \nMark W. McDonald, \nMihir R. Patel, \nHarry M. Baddour, \nAzeem S. Kaka, \nConor E. Steuer, \nNabil F. Saba, \nDong M. Shin, \nJonathan J. Beitler\n

Publicatie 17-11-2020


Objectives/HypothesisFor locally advanced oral squamous cell carcinoma (OSCC) treated by surgery and adjuvant therapy, consensus has yet to be reached on whether the optimal time to initiate surveillance positron emission tomography/computed tomography (PET/CT) scan is before or after adjuvant therapy. In this study, we characterize the utility of PET/CT scans obtained 3 months after adjuvant therapy.Study DesignPET/CT scans were obtained for 220 patients with stage III, IVA, or IVB OSCC who underwent resection followed by adjuvant radiotherapy or chemoradiotherapy.MethodsUsing the Neck Imaging Reporting and Data System, PET/CT scans were dichotomized as suspicious (primary or neck category ≥3, or distant lesion present) versus nonsuspicious. We then computed differences in locoregional progression, distant progression, and overall survival; positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity; and success rate of salvage.ResultsSixty‐seven patients (30%) had suspicious PET/CT scans, which were significantly associated with local failure (hazard ratio HR 14.0, 95% confidence interval CI 7.3–26.6), distant failure (HR 18.4, 95% CI 9.6–35.3), and poorer overall survival (HR 9.5, 95% CI 5.0–17.9). Overall PPV, locoregional PPV, NPV, sensitivity, and specificity were 85%, 79%, 73%, 58%, and 92%, respectively. Among those with biopsy‐confirmed progression, 37 patients (65%) underwent salvage therapy; four (11%) were without evidence of disease at last follow‐up.ConclusionsFor locally advanced OSCC, PET/CT scan 3 months after adjuvant therapy is strongly predictive of disease recurrence and survival, demonstrating improved performance over postoperative imaging in previous studies. Following a suspicious post‐adjuvant therapy PET/CT scan, cure of locoregional recurrence is possible but unlikely.Level of Evidence4 Laryngoscope, 2020

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Pediatric Subperiosteal Abscess Secondary to Acute Sinusitis: A Systematic Review and Meta‐analysis

\nEelam A. Adil, \nMolly E. Muir, \nKosuke Kawai, \nNatasha D. Dombrowski, \nMichael J. Cunningham\n

Publicatie 17-11-2020


Objectives/HypothesisThe surgical versus medical management of subperiosteal abscess can be controversial. The purpose of this study was to summarize current literature and provide pooled analyses to help direct management decisions.Study DesignSystematic review and meta‐analysis.MethodsPatients <18 years old with subperiosteal abscess secondary to acute sinusitis were reviewed, and a meta‐analysis was conducted. Studies including five or more patients written in English were the primary search focus.ResultsThirty‐eight studies met inclusion criteria for the systematic review, and seven studies contained sufficient data for the meta‐analysis. A total of 1,167 patients between the ages of 10 days and 18 years were included. Eleven sign/symptom categories were identified, with restricted ocular motility (n = 289, 45.9%), proptosis (n = 277, 44%), and fever (n = 223, 35.4%) being most frequent. Staphylococcus aureus was the most common pathogen isolated from cultures. Patients with abscess volume greater than the threshold specified in each individual study were over three times more likely to require surgical intervention compared to those with smaller abscess volume (pooled risk ratio RR = 3.61, 95% confidence interval CI: 2.40‐5.44). Proptosis and gaze restriction also significantly predicted surgical intervention (pooled RR = 1.65: 95% CI: 1.29‐2.12 for proptosis/pooled RR = 1.90; 95% CI: 1.20‐3.00 for gaze restriction).ConclusionsApproximately half of patients with a subperiosteal abscess undergo surgical drainage. Abscess volume appears to be the most significant predictive risk factor. Detailed data from future studies regarding radiologic and ophthalmologic parameters are needed to provide more definitive values predictive of which patients are likely to fail medical therapy.Level of Evidence2a Laryngoscope, 2020

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Secondary Tracheoesophageal Puncture After Laryngectomy Increases Complications With Shunt and Voice Prosthesis

\nClaudia Scherl, \nJulia Kauffels, \nAnne Schützenberger, \nMichael Döllinger, \nChristopher Bohr, \nStephan Dürr, \nRainer Fietkau, \nMarlen Haderlein, \nMichael Koch, \nMaximilian Traxdorf, \nKonstantinos Mantsopoulos, \nSarina Müller, \nHeinrich Iro\n

Publicatie 17-11-2020


Objectives/HypothesisTo evaluate the demographics, clinical features, management, and prognostic indicators of tracheoesophageal puncture complications in patients undergoing placement of voice prosthesis following cancer treatment.Study DesignRetrospective analysis.MethodsA retrospective analysis was conducted of cases from a tertiary referral center diagnosed between 1996 and 2015. Multivariate logistic regression was used to determine factors associated with tracheoesophageal puncture (TEP) and voice prostheses–complication‐free survival (TEP/VP‐CFS).ResultsOne hundred fourteen cases were identified. Most patients were males (92.9%) with pT3 (26.8%) or pT4 (58.1%) N+ (53.6%) tumors. All patients received laryngectomy as the primary treatment, with 75% of patients receiving adjuvant radiation therapy or chemoradiotherapy. Complications with TEP were common (65.2%). The most frequent problem was salivary leakage (50.0%), which at the same time was the most common reason for changing the prosthesis. On univariate regression analysis, prosthesis placement time after adjuvant radiotherapy (hazard ratio HR: 4.17, 95% confidence interval CI: 2‐8.69), secondary prosthesis placement after primary surgery (HR: 3.97, 95% CI: 1.99‐7.9), and laryngectomy with flap reconstruction (HR: 1.96, 95% CI: 0.99‐3.89) were significant prognosticators for complications. Multivariate regression analysis revealed secondary prosthesis placement after adjuvant radiotherapy (HR: 3.66, 95% CI: 1.39‐9.68) or after primary surgery (HR: 2.57, 95% CI: 0.92‐7.2) to be the strongest predictors of reduced TEP/VP‐CFS.ConclusionsSecondary prosthesis placement after primary surgery, placement after previous irradiation, and laryngectomy with flap reconstruction are predictors of poor TEP/VP‐CFS. Planned adjuvant radiotherapy is not a contraindication for TEP with prosthetic placement, but it is very important to place the prosthesis during the primary surgery or at least before scheduled radiotherapy.Level of Evidence4 Laryngoscope, 2020

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Distinct Biomarker Profiles and Clinical Characteristics in T1‐T2 Glottic and Supraglottic Carcinomas

\nJan E. Wachters, \nEmiel Kop, \nLorian Slagter‐Menkema, \nMirjam Mastik, \nJacqueline E. Wal, \nBert Vegt, \nGeertruida H. Bock, \nBernard F.A.M. Laan, \nEd Schuuring\n

Publicatie 17-11-2020


BackgroundIn early stage laryngeal squamous cell carcinoma (LSCC) radiotherapy with curative intent is a major treatment modality. TNM classification is used to define patients eligible for radiotherapy. Studies in early stage glottic LSCC identified several predictive biomarkers associated with local control. However, we recently reported that this predictive value could not be confirmed in supraglottic LSCC.ObjectiveTo examine whether clinical behavior and protein expression patterns of these biomarkers differ between glottic and supraglottic LSCC.Study DesignRetrospective cohort study.MethodsTumor tissue sections of 196 glottic and 80 supraglottic T1‐T2 LSCC treated primarily with RT were assessed immunohistochemically for expression of pAKT, Ki‐67 and β‐Catenin. Expression data of HIF‐1α, CA‐IX, OPN, FADD, pFADD, Cyclin D1, Cortactin and EGFR in the same cohort of glottic and supraglottic LSCC, were retrieved from previously reported data. The relationship between glottic and supraglottic sublocalization and clinicopathological, follow‐up, and immunohistochemical staining characteristics were evaluated using logistic regression and Cox regression analyses.ResultsGlottic LSCC were correlated with male gender (P = .001), hoarseness as a primary symptom (P < .001), T1 tumor stage (P < .001), negative lymph node status (P < .001), and an older age at presentation (P = .004). Supraglottic LSCC patients developed more post‐treatment distant metastasis when adjusted for gender, age, and T‐status. While supraglottic LSCC was associated with higher expression of HIF‐1α (P = .001), Cortactin (P < .001), EGFR (P < .001), and Ki‐67 (P = .027), glottic LSCC demonstrated higher expression of CA‐IX (P = .005) and Cyclin D1 (P = .001).ConclusionDifferences in clinicopathological and immunohistochemical staining characteristics suggest that T1‐T2 glottic and supraglottic LSCC should be considered as different entities.Level of EvidenceN/A. Laryngoscope, 2020

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Round Cell Sarcoma with EWSR1‐PATZ1 Gene Fusion in the Neck: Case Report and Review of the Literature

\nKi W. Park, \nYi Cai, \nTania Benjamin, \nAmir Qorbani, \nJonathan George\n

Publicatie 17-11-2020


EWSR1‐PATZ1 is a rare gene fusion recently recognized to occur in round and spindle cell sarcomas. To date, fewer than 20 cases have been described in the literature. However, no dedicated case reports have detailed its presentation in the head and neck region. We recently cared for a 52‐year‐old woman with an isolated, single right level 5A cervical mass. Excisional biopsy at an external hospital revealed pathology results consistent with EWSR1‐PATZ1 polyphenotypic round and spindle cell sarcoma. The patient subsequently underwent surgical excision of the tumor and right neck lymph node dissection followed by adjuvant chemoradiation. Laryngoscope, 2020

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Head and Neck Dystonia Following Chimeric‐Antigen Receptor T‐Cell Immunotherapy: A Case Report

\nDaniel D. Lee, \nYufan Lin, \nLisa T. Galati, \nStanley M. Shapshay\n

Publicatie 17-11-2020


Chimeric antigen receptor T‐cell therapy (CAR‐T) is a novel immunotherapy used for the treatment of refractory B‐cell leukemias and lymphoma. As clinical trials continue to expand, multiple treatment toxicities have been documented. Treatment‐associated toxicities are typically systemic, however, focal manifestations have been described. We present a unique case of a 55‐year‐old female who developed oropharyngeal and laryngeal dystonia following CAR‐T therapy. This case points to a possible association between CAR‐T therapy and focal head and neck dystonia. Laryngoscope, 2020

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Paraganglioma of the recurrent laryngeal nerve

\nNyall R. London, \nMark Hopkins, \nSimon R. Best, \nLisa M. Rooper, \nCarole Fakhry\n

Publicatie 17-11-2020


Paragangliomas of the head and neck are rare, and most frequently benign, slow growing, and nonsecretory. The most frequent locations these tumors arise in the head and neck include the carotid body, jugular bulb, vagus nerve, tympanic branch of the glossopharyngeal nerve, and sympathetic chain. Here we present, to our knowledge, the second reported case of paraganglioma of the recurrent laryngeal nerve. This case is unique given the patient presentation due to ipsilateral vocal fold paralysis, which has not previously been reported, lack of previous surgery, and demonstration of loss of succinate dehydrogenase iron‐sulfur subunit B expression. Laryngoscope, 2019

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Induced Hypoglossal Dysfunction as a Cause of Obstructive Sleep Apnea in Mefloquine‐Exposed Veterans

\nRemington L. Nevin\n

Publicatie 17-11-2020


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In Response to Letter: DISE, Tonsil Size, Surgical Outcome

\nKenny P. Pang, \nBrian W. Rotenberg\n

Publicatie 17-11-2020


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In Reference to Does Drug‐Induced Sleep Endoscopy Affect Surgical Outcomes? A Multicenter Study of 326 Obstructive Sleep Apnea Patients

\nEric J. Kezirian\n

Publicatie 17-11-2020


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In Response to Method of Lateral Osteotomy to Reduce Eyelid Ecchymosis After Rhinoplasty: A Meta‐analysis

\nSe Hwan Hwang\n

Publicatie 17-11-2020


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

\nNavid Naghdi, \nSepideh Soheilifar, \nHoma Fathi\n

Publicatie 17-11-2020


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In Response to the Management of Nontuberculous Mycobacterial Cervicofacial Lymphadenitis: A View Beyond Surgery

\nJennifer L. Harb, \nRebecca A. Compton, \nH. Cody Meissner, \nAndrew R. Scott\n

Publicatie 17-11-2020


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In Reference to The Management of Nontuberculous Mycobacterial Cervicofacial Lymphadenitis: A View Beyond Surgery

\nPetra Zimmermann, \nNicole Ritz, \nNigel Curtis, \nMarc Tebruegge\n

Publicatie 17-11-2020


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Pediatric Otolaryngology

\nSamuel H. Selesnick\n

Publicatie 17-11-2020


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Masthead

Publicatie 17-11-2020


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Table of contents

Publicatie 17-11-2020


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Management of Laryngopharyngeal Reflux Around the World: An International Study

\nJerome R. Lechien, \nJacqueline E. Allen, \nMaria R. Barillari, \nPetros D. Karkos, \nHuan Jia, \nFabio P. Ceccon, \nRui Imamura, \nOsama Metwaly, \nCarlos M. Chiesa‐Estomba, \nJonathan M. Bock, \nThomas L. Carroll, \nSven Saussez, \nLee M. Akst\n

Publicatie 17-11-2020


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

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

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

Publicatie 16-11-2020


ObjectivesIn 2009, the Food and Drug Administration approved the use of the surgical robotic system for removal of benign and malignant conditions of the upper aerodigestive tract. This novel application of robotic‐assisted surgery, termed transoral robotic surgery (TORS), places robotic instruments and camera system through the mouth to reach recessed areas of the pharynx and larynx. Over the successive decade, there was a rapid adoption of TORS with a surgical growth rate that continues to increase. Despite the rapid clinical acceptance, the field of TORS has not yet seen substantive changes or advances in the technical shortcomings, the lack of which has restricted objective TORS‐specific surgical skills assessment as well as subsequent skills improvement efforts. One of the primary technical challenges of TORS is operating in a confined space, where the robotic system is maneuvered within the restrictive boundaries of the mouth and throat. Due to these confined boundaries of the pharynx, instruments can frequently collide with anatomic structures such as teeth and bone, producing anatomic collisions. Therefore, we hypothesized that anatomic collisions negatively impact TORS surgical performance. Secondarily, we hypothesized that avoidance of unwanted anatomic collisions could improve TORS surgical proficiency.MethodsDesign and fidelity testing for a custom TORS training platform with an integrated anatomic collision‐sensing system providing real‐time tactile feedback is described. Following successful platform assembly and testing, validation study using the platform was carried through prospective surgical training with trial randomization. Twenty otolaryngology–head and neck surgery residents, each trainee performing three discrete mock surgical trials (n = 60), performed the initial system validation. Ten of the 20 residents were randomized to perform the surgical trials utilizing the real‐time feedback system. The remaining 10 residents were randomized to perform the surgical trials without the feedback system, although the system still could record collision data. Surgical proficiency was measured by Global Evaluative Assessment of Robotic Skills (GEARS) score, time to completion, and tumor resection scores (categorical scale ranging 0–3, describing the adequacy of resection).ResultsMajor anatomic collisions (greater than 5N of force) negatively affected GEARS robotic skills. A mixed model analysis demonstrated that for every additional occurrence of a major collision, GEARS robotic skills assessment score would decrease by 0.29 points (P = .04). Real‐time collision awareness created significantly fewer major (> 5 N) anatomic collisions with the tactile feedback system active (n = 30, mean collisions = 2.9 ± 4.2) as compared with trials without tactile feedback (n = 30, mean collisions = 12.53 ± 23.23) (P < .001). The second assessment measure of time to completion was unaffected by the presence of collisions or by the use of tactile feedback system. The third proficiency assessment was measured with tumor resection grading. Tumor resection scores was significantly (P = .02) improved with collision awareness system activated than trials without collision awareness.ConclusionIn order to test our primary hypothesis, a novel TORS training platform was successfully developed that provides collision force measurements including frequency, severity, and duration of anatomic collisions. Additionally, the platform was modulated to provide real‐time tactile feedback of the occurrence of out‐of‐field collisions. Utilizing this custom platform, our hypothesis that anatomic collisions during TORS diminishes surgical performance was supported. Additionally, our secondary hypothesis that subsequent reduction of anatomic collisions improves TORS proficiency was supported by the surgical trial. Dedicated investigation to characterize the effect size and clinical impact is required in order to translate this finding into training curriculums and into clinical utilization.Level of EvidenceII (Randomized trial) Laryngoscope, 130:S1–S17, 2020

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Table of contents

Publicatie 16-11-2020


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Masthead

Publicatie 16-11-2020


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

\nChad W. Whited, \nJonathan Lubin, \nNicholas Marka, \nIan J. Koszewski, \nMatthew R. Hoffman, \nStephen Schoeff, \nSeth H. Dailey\n

Publicatie 16-11-2020


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

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Rising Costs of Otic Drops: Review of a National Database

\nAndrew E. Bluher, \nStephanie Moody‐Antonio\n

Publicatie 16-11-2020


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

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Promoting Tobacco Use Among Students: The U.S. Smokeless Tobacco Company College Marketing Program

\nZ. Jason Qian, \nMatthew J. Hill, \nDivya Ramamurthi, \nRobert K. Jackler\n

Publicatie 13-11-2020


Objectives/HypothesisFrom the 1970s–1990s the U.S. Smokeless Tobacco Company (USST) conducted aggressive campaigns to solicit college students to buy their smokeless tobacco (ST) products. The scope, scale, methods, and impact of this youth marketing campaign have yet to be analyzed in the academic literature.Study DesignHistorical research study.MethodsInternal industry documents describing the USST campaigns were obtained via the University of California, San Franciscos repository of tobacco company records. Marketing materials were obtained from Stanford Universitys Research Into the Impact of Tobacco Advertising (SRITA) collection of 657 USST advertisements.ResultsUSSTs College Marketing Program (1978–mid 1980s) sponsored events in some 350 campuses and hired student representatives in at least 175 colleges and universities across America. College representatives were trained to provide free samples to fellow students. Over a typical school year approximately a quarter million Happy Days, Skoal, and Skoal Bandits samples were handed out to undergraduates. USST paid their student representatives well and offered them a variety of incentives based upon sales growth. During the 1990s, USSTs Skoal Music program engaged students on campuses and at “spring break” venues such as Daytona Beach.ConclusionsTargeting of college students on campus was a common tobacco industry practice between the 1940s and early 1960s. From the 1970s through 1990s USST resurrected the method and pursued it with vigor including: distribution of free samples; sponsored events and concerts, branded intramural teams; visits by sports celebrities; logo wearables and merchandise; contests and incentives; and displays and promotions in stores on and surrounding campuses. Laryngoscope, 2020

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A Dizzying Complaint: Investigating the Intended Meaning of Dizziness Among Patients and Providers

\nJohn M. Sommerfeldt, \nJakob L. Fischer, \nDanielle A. Morrison, \nEdward D. McCoul, \nCharles A. Riley, \nAnthony M. Tolisano\n

Publicatie 13-11-2020


Objective/HypothesisTo assess for semantic differences regarding the definition of dizziness among otolaryngology patients, otolaryngologists, and non‐otolaryngologist providers.Study DesignCross‐sectional survey.MethodsBetween March and May 2020, a survey consisting of 20 common descriptors for dizziness within five domains (lightheadedness, motion sensitivity, imbalance, vision complaints, and pain) was completed by patients at two outpatient otolaryngology clinics. Surveys were subsequently obtained from otolaryngology and non‐otolaryngology providers attending a multidisciplinary dizziness lecture. The primary outcome measure was to assess for differences in definition of dizziness between patients and providers. Secondary outcome measures included assessing differences between otolaryngologists and non‐otolaryngologists.ResultsAbout 221 patients and 100 providers participated. Patients selected a median of 7 terms compared to 8 for providers (P = .375), although providers had a larger overall distribution of number of terms selected (P = .038). Patients were more likely than providers to define dizziness according to the following domains: lightheadedness (difference 15.0%; 95% confidence interval CI 5.5%–25.3%), vision complaints (difference 21.6%, 95% CI 12.0%–29.6%), and pain (difference 11.5%, 95% CI 4.7%–17.1%). Providers were more likely to define dizziness according to the motion sensitivity domain (difference 13.8%, 95% CI 6.8%–19.6%). Otolaryngology and non‐otolaryngology providers defined dizziness similarly across symptom domains.ConclusionAlthough patients and providers both view dizziness as imbalance, patients more commonly describe dizziness in the context of lightheadedness, vision complaints, and pain, whereas providers more frequently define dizziness according to motion sensitivity. These semantic differences create an additional barrier to effective patient‐provider communication.Level of Evidence4. Laryngoscope, 2020

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Malnutrition as a Risk Factor in Cleft Lip and Palate Surgery

\nPaul J. Escher, \nHanan Zavala, \nDaniel Lee, \nBrianne Barnett Roby, \nSivakumar Chinnadurai\n

Publicatie 12-11-2020


Objectives/HypothesisTo assess the prevalence of acute and chronic malnutrition at the time of surgery in patients with cleft lip and/or palate (CLP) at our institution, and to quantify nutrition as a risk factor for postsurgical complications following CLP surgery.Study DesignRetrospective cohort study.MethodsRetrospective review of 855 children undergoing initial cleft lip or palate surgery, or revision surgery after fistula/dehiscence of initial cleft repair. We measured acute and chronic malnutrition using World Health Organization Z‐scores of weight‐for‐age and height‐for‐age, respectively, and noted any postsurgical fistula or dehiscence.ResultsAmong patients with cleft lip, 22.3% were at least moderately chronically malnourished at the time of initial repair, and 17.5% were at least moderately acutely malnourished. Among patients undergoing initial repair of cleft palate, 20.9% were at least moderately chronically malnourished, and 8.1% were at least moderately acutely malnourished. Increasing nutritional status, as measured by height‐for‐age, predicts decreased odds of fistula (OR 0.78, P = .01) after cleft palate surgery.ConclusionsChronic malnutrition significantly increases the risk of fistula formation in patient with cleft palate. Preoperative strategies to manage this risk and influence surgical timing can avoid morbid and costly postoperative complications.Level of Evidence4 Laryngoscope, 2020

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Clinical Swallowing Profile Change in HNC Patients Treated with C/RT

\nIkjae Im, \nGiselle D. Carnaby, \nNoriaki Takahashi, \nSarah Dungan, \nMichael A. Crary\n

Publicatie 12-11-2020


Objectives/HypothesisTo demonstrate utility of the Mann Assessment of Swallowing Ability‐Cancer (MASA‐C) to describe change in swallowing ability in a cohort of HNC patients from pre‐C/RT to post‐C/RT to follow up at 3 months post‐C/RT. An exploratory analysis compared patients treated with radiotherapy (RT) only to patients treated with chemoradiation (CRT).Study DesignProspective Cohort.MethodsThe MASA‐C and Functional Oral Intake Scale (FOIS) were completed on 85 HNC patients within the first 5 days of CRT initiation, at the completion of C/RT (6 weeks), and 3 months after completion of C/RT. MASA‐C total scores and clinical profiles were used to describe change in swallowing performance at each time point.ResultsMASA‐C and FOIS scores were significantly lower at 6 weeks and 3 months compared to baseline. Patients treated with CRT demonstrated more frequent and more severe dysphagia. Post C/RT items demonstrating the most deterioration included taste, diet level, oral mucosa, saliva, weight loss, and pharyngeal functions. Significant recovery was observed between 6 weeks and 3 months on both the MASA‐C and FOIS. MASA‐C items revealing the greatest recovery included taste, diet level, oral mucosa, tongue movement, weight loss, oral transit, voice, and pharyngeal phase. Few significant differences were noted between RT and CRT cases at 3 months.ConclusionsSwallowing functions deteriorate significantly following C/RT with incomplete recovery at 3 months. Few differences were noted between RT and CRT treated patients at 3 months. Clinical profiling with the MASA‐C provides a standard, simple method to document swallow function change over time in these patients.Level of Evidence2 Laryngoscope, 2020

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Tertiary Lymphoid Organs: A Primer for Otolaryngologists

\nSathish Paramasivan, \nAlkis J. Psaltis, \nPeter‐John Wormald, \nSarah Vreugde\n

Publicatie 12-11-2020


Objectives/HypothesisLymphoid neogenesis or the development of organised, de novo lymphoid structures has been described increasingly in chronically inflamed tissues. The presence of tertiary lymphoid organs (TLOs) has already been demonstrated to result in significant consequences for disease pathology, severity, prognosis and patient outcomes. Whilst the wider medical community has embraced TLOs as important markers of disease and potential therapeutic targets, the otolaryngology field has only begun turning to these entities in an academic capacity. This review aims to outline the role of tertiary lymphoid organs in disease and summarise key early findings in the ENT field. We also an overview of TLOs, their developmental process and clinicopathological implications.Study designLiterature review.MethodsA literature search for all relevant peer‐reviewed publications pertaining to TLOs and ENT diseases. Search was conducted using PubMed, Embase and CINAHL databases.ResultsA total of 24 studies were identified relevant to the topic. The majority of TLO research in ENT fell into the areas of oral squamous cell carcinoma (SCC) and chronic rhinosinusitis (CRS).ConclusionsEarly research into both oral SCC and CRS suggests that TLOs have significant roles within ear, nose and throat (ENT) diseases. At this point in time, however, TLOs remain somewhat a mystery amongst otolaryngologists. As information in this field increases, we may develop a better understanding of how lymphoid neogenesis can influence disease outcomes amongst our patients and, ultimately, how they can be utilised in an immunotherapeutic manner. Laryngoscope, 2020

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Predictors of Completion of Sublingual Immunotherapy

\nNanki Hura, \nSophia Song, \nRebecca J. Kamil, \nGerdline Pierre, \nSandra Y. Lin\n

Publicatie 12-11-2020


ObjectivesSublingual immunotherapy (SLIT) has emerged as an effective treatment alternative to subcutaneous immunotherapy (SCIT) given its improved safety profile and more convenient dosing. However, SLIT still relies on daily dosing for many years to optimize effectiveness. This study sought to investigate factors that influence patient completion of SLIT.MethodsWe performed an institutional retrospective review of patients who received SLIT (2008–2020). Completion was defined as completing at least 36 months of SLIT. Patient demographics and characteristics, including the number of allergens treated, history of asthma and sinus surgery, number of clinic visits, and total time undergoing SLIT, were documented. Multivariate models were used to analyze predictors of SLIT completion. Subgroup analysis was performed among pediatric patients and patients who discontinued SLIT.ResultsOf the 404 total patients, 249 (61.6%) discontinued, 47 (11.6%) completed, and 108 (26.7%) were currently undergoing SLIT. The mean duration of therapy was 11.2 months for those who discontinued and 49.4 months for patients who completed SLIT. The odds of SLIT completion were twice as high with each additional clinic visit (P < .001), and twice as high when the dosage was increased during therapy (P = .06). Pediatric patients younger than age 12 with a history of asthma were over five times more likely to complete therapy (P = .045). Patients with more clinic visits (P < .001) and higher associated costs (P = .003) were less likely to be lost to follow‐up.ConclusionIncreasing the frequency of clinic visits, improving therapy availability, and mitigating concerns about clinical efficacy may increase patient completion of SLIT.Level of Evidence4 Laryngoscope, 2020

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Prevalence of Multidrug‐Resistant Organisms in Patients Undergoing Free Flap Reconstruction

"\nChelsea S. Hamill, \nVusala Snyder, \nKevin J. Sykes, \nThomas OToole\n"

Publicatie 12-11-2020


Objectives/HypothesisThe purpose of this study is to evaluate the relationship between antibiotic prophylaxis and prevalence of multidrug‐resistant organisms (MDRO) in patients undergoing head and neck cancer reconstruction.Study DesignRetrospective Chart Review.MethodsRetrospective review of patients who underwent head and neck free flap reconstruction at our institution between 2009 to 2016.ResultsOf the 145 patients that underwent head and neck tumor removal surgery using free tissue flaps to cover the defect and therafter received antibiotic prophylaxis, 30 (20.7%) developed postoperative surgical site (n = 17, 55.7%) or distant (n = 13, 43.4%) infections. Seven had a multidrug‐resistant infection, the most common with Methicillin‐Resistant Staphylococcus aureus (MRSA). There was no significant relationship between antibiotic spectrum or duration to the development of postoperative infections or MDRO. Pseudomonas and MRSA infections were low overall with only one multidrug‐resistant Pseudomonas infection.ConclusionsThe choice of antibiotic prophylaxis should cover organisms these patients are at highest risk for including anaerobes and Gram‐negative organisms. A shorter duration of antibiotic prophylaxis should be considered given no increased risk of postoperative infection nor MDRO. Finally, one must be aware of the potential threat of multidrug‐resistant Pseudomonas and MRSA amongst this vulnerable population and identity these with culture driven treatment.Level of EvidenceIV Laryngoscope, 2020

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A Multispecialty Critical Airway Simulation Course for Medical Students

\nSarah M. Dermody, \nMaria Masciello, \nSonya Malekzadeh\n

Publicatie 11-11-2020


ObjectivesTo develop a novel multispecialty simulation‐based course that teaches both technical and nontechnical skills in the management of adult and pediatric critical airways to graduating medical students and 2) to encourage a collaborative, multispecialty approach to the management of a difficult airway amongst fourth‐year medical students who have enrolled in otolaryngology, anesthesia, and emergency medicine residency programs.MethodsFourth‐year medical student who had matched into otolaryngology, anesthesia, and emergency medicine participated in an intensive half‐day course consisting of a series of hands‐on skills stations with increasing complexity, followed by simulated complex patient scenarios designed for shared management of airway emergencies. Participants completed questionnaires prior to and immediately after the course. Fischers exact test was utilized to compare data between the precourse and postcourse surveys. Free‐text responses were qualitatively assessed to inform course development.ResultsThirty‐four medical students were enrolled (6 otolaryngology, 15 anesthesia, 13 emergency medicine), and 30 students completed both surveys. Fishers exact test demonstrated improved confidence (P < .05) for every skill. More than 85% of participants strongly agreed or agreed that the intervention was useful in developing their knowledge, technical skills, and self‐confidence and in improving clinical performance prior to residency.ConclusionsThis critical airway course introduces a multispecialty simulation‐based course designed to impart graduating medical students with the necessary knowledge, skills, and behaviors for critical airway management while fostering interprofessional collaboration. Our course was successful in improving confidence and was perceived as useful in developing knowledge, technical skills, self‐confidence, and clinical performance prior to residency.Level of evidenceNA. Laryngoscope, 2020

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When Should Elective Neck Dissection Be Performed for Parotid Gland Malignancy?

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

Publicatie 11-11-2020


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Spontaneous Involution of Juvenile Nasopharyngeal Angiofibromas: Report of a Case

\nJanice T. Chua, \nJoseph A. Choy, \nRonald Sahyouni, \nJack L. Birkenbeuel, \nDillon C. Cheung, \nEdward C. Kuan, \nNaveen D. Bhandarkar\n

Publicatie 11-11-2020


Juvenile nasopharyngeal angiofibroma (JNA) is a locally aggressive tumor that predominantly affects adolescent males. Surgical resection is generally considered the standard treatment for both primary and recurrent tumors, regardless of staging. The natural history of these tumors, particularly when untreated or in the setting of residual tumor, is not well characterized. In this article, we report a case of true spontaneous JNA involution. Although the involution of residual tumor after surgical resection has previously been reported, to our knowledge, this is the first documented case of spontaneous JNA involution following a period of tumor growth post‐treatment. Laryngoscope, 2020

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Communication Chaos from Discrepancies in Personal Protective Equipment and Preoperative Guidelines

\nNancy Wang, \nMary Jue Xu, \nAdrian E. House, \nMadeleine P. Strohl, \nAndrew N. Goldberg, \nAndrew H. Murr\n

Publicatie 11-11-2020


Objectives/HypothesisTo compare personal protective equipment (PPE) guidelines, specifically respirator use, among international public health agencies, academic hospitals, and otolaryngology‐head and neck surgery (OHNS) departments in the United States for the care of coronavirus‐19 (COVID‐19) patients.Study DesignCross sectional survey.MethodsReview of publicly available public health and academic hospitals guidelines along with review of communication among otolaryngology departments.ResultsAmong 114 academic institutions affiliated with OHNS residencies, 20 (17.5%) institutions provided public access to some form of guidance on PPE and 73 (64%) provided information on screening or diagnostic testing. PPE guidelines were uniquely described based on several variables: location of care, COVID‐19 status, involvement of aerosol generating or high‐risk procedures, and physical distance from the patient. Six hospital guidelines were highlighted. Across these six institutions, there was agreement that N95 respirators were needed for high‐risk patients undergoing high‐risk procedures. Variations existed among institutions for scenarios with low‐risk patients. Definitions of the low‐risk patient and high‐risk procedures were inconsistent among institutions. Three of the highlighted institutions had OHNS departments recommending higher level of airway protection than the institution.ConclusionsOHNS departments typically had more stringent PPE guidance than their institution. Discrepancies in communicating PPE use were frequent and provide inconsistent information on how healthcare workers should protect themselves in the COVID‐19 pandemic. Identification of these inconsistencies serves as an opportunity to standardize communication and develop evidence‐based guidelines.Level of EvidenceV Laryngoscope, 2020

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Digital Otoscopy Videos Versus Composite Images: A Reader Study to Compare the Accuracy of ENT Physicians

\nHamidullah Binol, \nMuhammad Khalid Khan Niazi, \nGarth Essig, \nJay Shah, \nJameson K. Mattingly, \nMichael S. Harris, \nCharles Elmaraghy, \nTheodoros Teknos, \nNazhat Taj‐Schaal, \nLianbo Yu, \nMetin N. Gurcan, \nAaron C. Moberly\n

Publicatie 10-11-2020


Objectives/HypothesisWith the increasing emphasis on developing effective telemedicine approaches in Otolaryngology, this study explored whether a single composite image stitched from a digital otoscopy video provides acceptable diagnostic information to make an accurate diagnosis, as compared with that provided by the full video.Study DesignDiagnostic survey analysis.MethodsFive Ear, Nose, and Throat (ENT) physicians reviewed the same set of 78 digital otoscope eardrum videos from four eardrum conditions: normal, effusion, retraction, and tympanosclerosis, along with the composite images generated by a SelectStitch method that selectively uses video frames with computer‐assisted selection, as well as a Stitch method that incorporates all the video frames. Participants provided a diagnosis for each item along with a rating of diagnostic confidence. Diagnostic accuracy for each pathology of SelectStitch was compared with accuracy when reviewing the entire video clip and when reviewing the Stitch image.ResultsThere were no significant differences in diagnostic accuracy for physicians reviewing SelectStitch images and full video clips, but both provided better diagnostic accuracy than Stitch images. The inter‐reader agreement was moderate.ConclusionsEqual to using full video clips, composite images of eardrums generated by SelectStitch provided sufficient information for ENTs to make the correct diagnoses for most pathologies. These findings suggest that use of a composite eardrum image may be sufficient for telemedicine approaches to ear diagnosis, eliminating the need for storage and transmission of large video files, along with future applications for improved documentation in electronic medical record systems, patient/family counseling, and clinical training.Level of Evidence3 Laryngoscope, 2020

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Socioeconomic Status Drives Racial Disparities in HPV‐negative Head and Neck Cancer Outcomes

\nNicholas R. Lenze, \nDouglas Farquhar, \nSiddharth Sheth, \nJose P. Zevallos, \nJeffrey Blumberg, \nCatherine Lumley, \nSamip Patel, \nTrevor Hackman, \nMark C. Weissler, \nWendell G. Yarbrough, \nAdam M. Zanation, \nAndrew F. Olshan\n

Publicatie 10-11-2020


Objectives/HypothesisTo determine drivers of the racial disparity in stage at diagnosis and overall survival (OS) between black and white patients with HPV‐negative head and neck squamous cell carcinoma (HNSCC).Study DesignRetrospective cohort study.MethodsData were examined from of a population‐based HNSCC study in North Carolina. Multivariable logistic regression and Cox proportional hazards models were used to assess racial disparities in stage at diagnosis and OS with sequential adjustment sets.ResultsA total of 340 black patients and 864 white patients diagnosed with HPV‐negative HNSCC were included. In the unadjusted model, black patients had increased odds of advanced T stage at diagnosis (OR 2.0; 95% CI 1.5–2.5) and worse OS (HR 1.3, 95% CI 1.1–1.6) compared to white patients. After adjusting for age, sex, tumor site, tobacco use, and alcohol use, the racial disparity persisted for advanced T‐stage at diagnosis (OR 1.7; 95% CI 1.3–2.3) and showed a non‐significant trend for worse OS (HR 1.1, 95% CI 0.9–1.3). After adding SES to the adjustment set, the association between race and stage at diagnosis was lost (OR: 1.0; 95% CI 0.8–1.5). Further, black patients had slightly favorable OS compared to white patients (HR 0.8, 95% CI 0.6–1.0; P = .024).ConclusionsSES has an important contribution to the racial disparity in stage at diagnosis and OS for HPV‐negative HNSCC. Low SES can serve as a target for interventions aimed at mitigating the racial disparities in head and neck cancer.Level of Evidence4 Laryngoscope, 2020

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What is the Role of Trans‐Oral Robotic Surgery (TORS) in HPV Negative Oropharyngeal Cancer?

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

Publicatie 10-11-2020


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Auditory Feedback Control of Vocal Pitch in Spasmodic Dysphonia

\nArthur Thomas, \nNatasha Mirza, \nSteven J. Eliades\n

Publicatie 10-11-2020


Objectives/HypothesisHearing plays an important role in the maintenance of vocal control in normal individuals. In patients with spasmodic dysphonia (SD), however, the ability to maintain sustained control of phonation is impaired. The origins of SD are unknown, and it is unclear whether auditory feedback‐dependent vocal control is compromised in these patients.Study DesignProspective case‐control study.MethodsWe tested 15 SD patients and 11 age‐matched controls. Voice recordings were performed while subjects repeated the vowel /e/ and auditory feedback of their vocal sounds was altered in real‐time to introduce a pitch‐shift (±2 semitones), presented back to subjects using headphones. Recordings were analyzed to determine voice changes following the pitch‐shifted feedback. Results were further compared with patient demographics and subjective measures of dysphonia, including the Voice Handicap Index (VHI).ResultsDespite considerable pitch variability and vocal breaks, SD patients exhibited significantly higher average vocal pitch compensation than control subjects. SD patients also exhibited greater variability than controls. However, there were no significant correlations between vocal compensation and patient demographics, although there was a significant inverse correlation with VHI.ConclusionsIn this pilot study, patients with SD exhibited increased sensitivity to altered auditory feedback during sustained phonation. These results are consistent with recent theories of SD as a disorder of sensory‐motor feedback processing, and suggest possible avenues for future investigation.Level of Evidence3 Laryngoscope, 2020

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Modeling Hearing Loss Progression and Asymmetry in the Older Old: A National Population‐Based Study

\nRahul K. Sharma, \nAnil K. Lalwani, \nJustin S. Golub\n

Publicatie 08-11-2020


ObjectiveThe progression and asymmetry of age‐related hearing loss has not been well characterized in those 80 years of age and older because public datasets mask upper extremes of age to protect anonymity. We aim to characterize the progression, severity, and asymmetry of hearing loss in those 80 years of age and older using a representative, national database.MethodsCross‐sectional, multicentered U.S. epidemiologic analysis using the National Health and Nutrition Examination Survey (NHANES) 2005 to 2006, 2009 to 2010, and 2011 to 2012 cycles. Subjects included noninstitutionalized, civilian adults aged 80 years and older (n = 621). Federal security clearance was granted to access publicly restricted age data. Outcome measures included pure‐tone average (PTA) air conduction thresholds and the 4‐frequency PTA.ResultsSix hundred and twenty‐one subjects were 80 years old or older (mean = 84.2 years, range = 80–104 years), representing 10,600,197 Americans. The average PTA was 38.9 dB (95% confidence interval CI = 37.8, 40.0). Hearing loss exhibited constant acceleration across the adult lifespan at a rate of 0.0052 dB/year2 (95% CI = 0.0049, 0.0055). This model predicted mean PTA within 2 dB of accuracy for most ages between 20 and 100 years. From age 80 years to approximately 100 years, the average PTA difference between the better and worse ear was 6.75 dB (95% CI = 5.8, 7.1). This asymmetry was relatively constant (i.e., nonsignificant linear regression coefficient of asymmetry over age = 0.07 95% CI = −0.01, 0.2).ConclusionHearing loss steadily and predictably accelerates across the adult lifespan to at least age 100 years, becoming near universal. These population‐level statistics will guide treatment and policy recommendations for hearing health in the older old.Level of Evidence3 Laryngoscope, 2020

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In Reference to Telemedicine in Otorhinolaryngology Practice in Developing Nations

\nPirabu Sakthivel, \nTashi Negi, \nKapil Sikka\n

Publicatie 07-11-2020


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In Response to Telemedicine in Otorhinolaryngology Practice in Developing Nations

\nAmrita K. Singh, \nDavid A. Kasle, \nNikita Kohli\n

Publicatie 07-11-2020


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Scalar Translocation Comparison Between Lateral Wall and Perimodiolar Cochlear Implant Arrays ‐ A Meta‐Analysis

\nSaad Jwair, \nAdrianus Prins, \nInge Wegner, \nRobert J. Stokroos, \nHuib Versnel, \nHans G. X. M. Thomeer\n

Publicatie 07-11-2020


Objectives/HypothesisTwo types of electrode arrays for cochlear implants (CIs) are distinguished: lateral wall and perimodiolar. Scalar translocation of the array can lead to intracochlear trauma by penetrating from the scala tympani into the scala vestibuli or scala media, potentially negatively affecting hearing performance of CI users. This systematic review compares the lateral wall and perimodiolar arrays with respect to scalar translocation.Study DesignSystematic review.MethodsPubMed, Embase, and Cochrane databases were reviewed for studies published within the last 11 years. No other limitations were set. All studies with original data that evaluated the occurrence of scalar translocation or tip fold‐over (TF) with postoperative computed tomography (CT) following primary cochlear implantation in bilateral sensorineuronal hearing loss patients were considered to be eligible. Data were extracted independently by two reviewers.ResultsWe included 33 studies, of which none were randomized controlled trials. Meta‐analysis of five cohort studies comparing scalar translocation between lateral wall and perimodiolar arrays showed that lateral wall arrays have significantly lower translocation rates (7% vs. 43%; pooled odds ratio = 0.12). Translocation was negatively associated with speech perception scores (weighted mean 41% vs. 55%). Tip fold‐over of the array was more frequent with perimodiolar arrays (X2 = 6.8, P < .01).ConclusionsScalar translocation and tip fold‐overs occurred more frequently with perimodiolar arrays than with lateral wall arrays. In addition, translocation of the array negatively affects hearing with the cochlear implant. Therefore, if one aims to minimize clinically relevant intracochlear trauma, lateral wall arrays would be the preferred option for cochlear implantation. Laryngoscope, 2020

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Risk of Stroke and Myocardial Infarction After Sudden Sensorineural Hearing Loss: A Meta‐Analysis

\nMarc J. W. Lammers, \nEmily Young, \nBrian D. Westerberg, \nJane Lea\n

Publicatie 06-11-2020


Objectives/HypothesisThe pathophysiology of idiopathic sudden sensorineural hearing loss (ISSNHL) is still unknown, but labyrinthine artery infarction has been proposed. The objective of this study was to perform a systematic review and conduct a meta‐analysis assessing the risk of developing stroke and myocardial infarction after presentation with ISSNHL.MethodsA systematic literature review was conducted using Pubmed, Embase, Web of Science, and Cochrane Libraries. All studies investigating an association between ISSNHL and stroke and/or myocardial infarction (MI) were included. Adhering to the MOOSE guideline, two independent reviewers extracted data, assessed risk of bias, and evaluated the relevance and quality of evidence.ResultsThree observational studies evaluating the risk of stroke in ISSNHL were included (n = 6,521 patients). All individual study results indicated an increased relative risk of stroke after ISSNHL (unadjusted relative risk range 1.21–1.63). Pooled adjusted hazard ratios revealed a 1.42‐fold increased risk of stroke after ISSNHL (hazard ratio HR 1.42; 95% confidence interval CI 1.15–1.75, I2 = 55%). Subgroup analysis of one study demonstrated that the increased risk is only present in adults aged above 50 years (HR 1.23; 95% CI 1.07–1.42). Five observational studies evaluating the risk of MI in patients with ISSNHL were included (n = 61,499 patients). Pooled analyses demonstrated that ISSNHL was not associated with MI (HR 1.08, 95% CI 0.87–1.34).ConclusionISSNHL may be an independent risk factor for the subsequent development of stroke especially in a subgroup of elderly patients. More studies are needed to confirm this association and to assess whether such patients would benefit from cardiovascular risk assessment and management to prevent future strokes. Laryngoscope, 2020

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A Meta‐Analysis of 67 Studies with Presenting Symptoms and Laboratory Tests of COVID‐19 Patients

\nManish Mair, \nHitesh Singhavi, \nAmeya Pai, \nJinesh Singhavi, \nPrachi Gandhi, \nPeter Conboy, \nAndrew Baker, \nSudip Das\n

Publicatie 06-11-2020


Objectives/HypothesisThe objective of this meta‐analysis was to look at the pooled prevalence of symptoms, laboratory tests, and imaging of all COVID‐19 infected patients. This will allow better identification of potential COVID‐19 patients and take appropriate precautions.Study designMeta analysis.MethodsWe searched three databases, PubMed, EMBASE, and Ovid to identify studies published between Dec‐2019 and May‐2020. All studies reporting upper‐aerodigestive symptoms of COVID‐19 infection were included. The meta‐analysis was conducted following meta‐analyses of observational studies in epidemiology (MOOSE) guidelines, which have evaluated the pooled prevalence of 14 symptoms and nine laboratory investigations.ResultsBased on inclusion criteria, 67 publications consisting of 8302 patients were included. Among adults, the pooled proportion of hypertensive and diabetic patients was 18% and 7%. Cough (53% 0.46–0.61), anosmia (38% 0.19–0.58), loss/distortion of taste (31% 0.17–0.45), and nasal obstruction (26% 0.12–0.39) were the most common ear, nose & throat (ENT) symptoms. Fever (69% 0.62–0.76) and fatigue (31% 0.26–0.37) were the commonest generalized symptoms. C‐reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were raised in 56% (0.41–0.71) and 49% (0.21–0.77), respectively. Interestingly, lymphopenia (41% 0.30–0.53) and leucopenia (22% 0.16–0.29) were more common than lymphocytosis (33% 0.02–0.64) and leucocytosis (12% 0.09–0.16). Fever (69% vs. 44%), cough (53% vs. 33%), and dyspnea (20% vs. 4%) were more common in adults as compared to the pediatric population. Diarrhea was more common among the pediatric cases (12%) versus (9%). The pooled estimate of fatality was 4%.ConclusionsThe most commonly experienced ENT symptom was cough followed by anosmia and dysguesia. Raised ESR and CRP with leukopenia and lymphopenia are common laboratory findings. Majority of the infected patients had abnormal computed tomography findings. COVID infection is less severe in pediatric patients. Laryngoscope, 2020

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A Comparison of the Localization of Integral Membrane Proteins in Human and Rabbit Vocal Folds

\nGary J. Gartling, \nLea Sayce, \nEmily E. Kimball, \nShintaro Sueyoshi, \nBernard Rousseau\n

Publicatie 06-11-2020


ObjectivesThis studys objective was to identify and compare the localization of Aquaporin (AQP) 1, 4, 7, Na+/K + ‐ATPase, E‐cadherin, zona occludin (ZO)‐1, and occludin in human and rabbit vocal folds (VF)s to inform the design of future studies to explore the function of these proteins in the regulation of VF homeostasis.MethodsFour human larynges and five New Zealand white rabbit larynges were used. Samples were immunolabeled for primary antibodies against AQP1, AQP4, AQP7, the alpha subunit of Na+/K + ‐ATPase, E‐cadherin, and ZO‐1 and occludin and then captured digitally using a Nikon Eclipse 90i microscope and Hamamatsu C10600 Camera. Two raters familiar with human and rabbit VF histology identified positive labeling in tissue structures, including the apical epithelium, basal epithelium/basement membrane, and lamina propria (LP).ResultsSamples from both species showed positive labeling for AQP1 in the basal epithelium/basement membrane, superficial LP, and deep/intermediate LP. Aquaporin 4, Aquaporin 7, Na+/K + ‐ATPase, and E‐cadherin were primarily localized to the epithelium of both species. Zona occludin‐1 was primarily localized apical epithelium and the superficial LP of both species. Occludin was primarily present in the apical epithelium in rabbit samples but not human.ConclusionThese data provide evidence of the presence of key ion transport channels and cell adhesion proteins in human and rabbit VFs. Aquaporin 1, 4, 7, Na+/K + ‐ATPase, E‐cadherin, and ZO‐1 were similarly localized in both species. These findings will be useful to investigators interested in the exploration of VF homeostasis and barrier integrity in future studies.Level of EvidenceN/A Laryngoscope, 2020

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Suspension Microesophagoscopy for Foreign Body Removal in Children

\nEvan J. Propst, \nBlake C. Papsin, \nNikolaus E. Wolter\n

Publicatie 06-11-2020


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Predicting Need for Surgery in Recurrent Laryngotracheal Stenosis Using Changes in Spirometry

\nTyler Crosby, \nAndrew McWhorter, \nLee McDaniel, \nMelda Kunduk, \nLacey Adkins\n

Publicatie 05-11-2020


Objectives/HypothesisWe sought to identify changes that occur in spirometric values between surgical interventions in patients with recurrent laryngotracheal stenosis and assess the utility of tracking those changes in predicting the need to return to surgery.MethodsThis is a retrospective, case‐control study of laryngotracheal stenosis. Charts from a 10 year period were reviewed, and 80 patients were identified with recurrent laryngotracheal stenosis and serial spirometry. Recorded forced expiratory volume in 1 second (FEV1), forced inspiratory volume in 1 second (FIV1), peak expiratory flow (PEF), and peak inspiratory flow (PIF), and body mass index (BMI) were tabulated. Calculations were then performed to determine deviations in spirometric measurements from maximums. Comparing the patients who required intervention to those who did not, we used a regression analysis to generate a decision tree based on factors with the strongest predictive power. We then calculated receiver operating characteristic (ROC) curves for all calculated variables.ResultsDeviations in PEF, PIF, and FIV1 from each patients maximums had strong predictive power in determining return to surgery. PIF was the only fixed measurement found to have a statistically significant role in predicting return to surgery. BMI did not play a role.ConclusionFor each patient, the deviation from their overall spirometric maximums had the statistically strongest predictive power in determining need to return to surgery. This suggests the importance of the trends in spirometric measures for each individual, and implies these trends have greater import than fixed measures alone.Level of EvidenceIV. Laryngoscope, 2020

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Predictors of Stricture and Swallowing Function Following Salvage Laryngectomy

\nAri D. Schuman, \nAndrew C. Birkeland, \nJanice L. Farlow, \nTeresa Lyden, \nAnna Blakely, \nMatthew E. Spector, \nAndrew J. Rosko\n

Publicatie 05-11-2020


BackgroundLong‐term functional outcomes are poorly characterized for salvage laryngectomy. We identified predictors of esophageal stricture and swallowing function after salvage laryngectomy in a large cohort.MethodsA retrospective study of 233 patients who underwent salvage total laryngectomy for recurrent/persistent squamous cell carcinoma of the larynx or hypopharynx after radiation (XRT) or chemoradiation (CRT) was performed. Primary outcomes were esophageal dilation within 1 year, time to dilation, and gastrostomy tube dependence. Multivariate logistic and Cox regressions were used for statistical analysis.ResultsDilation was performed in 29.9% of patients. Dilation was twice as likely in patients with post‐operative fistula compared to those without (Hazard Ratio (HR) 2.10, 95% Confidence Interval (CI) 1.06–4.13, P = .03). Every year between XRT/CRT and salvage was associated with 10% increase in dilation (HR 1.09, 95% CI 1.03–1.17, P = .01). No factors were associated with dilation by 1 year. About 10% of patients were at least partially gastrostomy tube‐dependent 1 year post‐operatively. At last follow‐up (median 29 months), this rate was 13%. Patients with supraglottic recurrence had an increased risk of gastrostomy tube dependence at 1 year compared to glottic (OR 16.7, 95% CI 1.73–160, P = .02). For every 10 pack years pre‐salvage, the OR of requiring tube feeds at last follow‐up was 1.24 (95% CI 1.04–1.48, P = .02).ConclusionsFistula and pre‐salvage smoking were associated with stricture post‐salvage laryngectomy. No factors were associated with dilation by 1 year. Supraglottic recurrence and smoking were associated with gastrostomy tube dependence. These findings are important for pre‐operative counseling prior to salvage laryngectomy.Level of EvidenceLevel 4. Laryngoscope, 2020

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Detection of Respiratory Pathogens Does Not Predict Risks After Outpatient Adenotonsillectomy

\nDonald M. Vickers, \nArundathi Reddy, \nChary Akmyradov, \nKesley M. Brown, \nBobby L. Boyanton, \nHeather D. Wright, \nJay A. Taylor, \nSherry H. Childress, \nLarry D. Hartzell, \nAdam B. Johnson, \nJames M. Key, \nAbby R. Nolder, \nGresham T. Richter, \nAndre’ M. Wineland, \nGraham M. Strub\n

Publicatie 05-11-2020


Objectives/HypothesisTo determine whether the presence of detectable upper respiratory infections (URIs) at the time of adenoidectomy/adenotonsillectomy is associated with increased morbidity, complications, and unexpected admissions.Study DesignProspective double‐blinded cohort.MethodsIn this prospective cohort study, nasopharyngeal swabs were obtained intraoperatively from 164 pediatric patients undergoing outpatient adenoidectomy/tonsillectomy with or without pressure equalization tubes (PETs) and were analyzed with PCR for the presence of 22 known URIs, including SARS‐CoV‐2. Surgeons and families were blinded to the results. At the conclusion of the study, rates of detectable infection were determined and intraoperative and postoperative events (unexpected admissions, length of PACU stay, rates of laryngospasm/bronchospasm, oxygen desaturation, bradycardia, and postoperative presentation to an emergency department) were compared between infected and uninfected patients.ResultsOf the 164 patients (50% male, 50% female, ages 8 mo‐18 y), 136 patients (82.9%) tested positive for one or more URI at the time of surgery. Forty one patients (25.0%) tested positive for three or more URIs concurrently, and 11 (6.7%) tested positive for five or more URIs concurrently. There were no significant differences in admission rates, length of PACU stay, rates of laryngospasm/bronchospasm, oxygen desaturation, bradycardia, or postoperative presentation to an emergency department between positive and negative patients. No patients tested positive for SARS‐CoV‐2.ConclusionsA recent positive URI test does not confer any additional intraoperative or postoperative risk in the setting of outpatient adenoidectomy/tonsillectomy in healthy patients. There is no utility in preoperative URI testing, and delaying surgery due to a recent positive URI test is not warranted in this population.Level of evidence3 Laryngoscope, 2020

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Balloon Eustachian Tuboplasty in Pediatric Patients: Is it Safe?

\nAnthony Howard, \nSeilesh Babu, \nMichael Haupert, \nPrasad John Thottam\n

Publicatie 05-11-2020


Objectives/HypothesisThe objective of this study is to demonstrate that balloon eustachian tuboplasty (BET) is safe and had limited complications in the pediatric patient population.Study DesignRetrospective chart review.MethodsThis study analyzed the medical records of 43 consecutive encounters of patients under the age of 18 years old who underwent attempted BET. Charts of patients postoperative appointments and appointments 30 days following the procedure were reviewed. Any complications that were reported by the surgeons operative report or documented postoperatively were stratified by the Classification of Surgical Complications as outlined by the American College of Surgeons. Additional data points that were analyzed included concomitant surgical procedures, estimated blood loss, and demographic information.ResultsA cohort of 43 pediatric patient encounters were investigated. There was a total of two complications from BET (4.7%) and one aborted case. The complications included epistaxis controlled with oxymetazoline and pressure, and vertigo that was later attributed to vestibular migraines. One case was aborted due to inadequate exposure. The average age of patients evaluated was 12.4 ± 3.2 years old with a range of 6.6 to 17.7 years old.ConclusionsIn this retrospective cohort, BET was demonstrated to be a relatively safe intervention with an overall complication rate of 4.7% in patients as young as 6.6 years old with recurrent or chronic eustachian tube dysfunction and/or related issues.Level of Evidence4 Laryngoscope, 2020

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Which Ultrasound Classification System is Best at Reducing Unnecessary Thyroid Nodule Biopsies?

\nJuliette O. Flam, \nVikas Mehta, \nRichard V. Smith\n

Publicatie 04-11-2020


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A Review of Otolaryngology Malpractice Cases with Associated Court Proceedings from 2010 to 2019

\nJohn Ceremsak, \nLauren E. Miller, \nErnest D. Gomez\n

Publicatie 04-11-2020


Objectives/HypothesisTo report key characteristics of the landscape of malpractice litigation with associated court proceedings in otolaryngology over the previous decade.Study DesignRetrospective database review.MethodsThe LexisNexis database was queried to identify otolaryngology‐related malpractices cases that yielded court opinions, jury verdicts, and settlements from federal and state courts across the United States from 2010 to 2019. Cases settled outside of court were not identifiable. Provider subspecialty, procedures, error type, legal allegations, and case outcomes were recorded. Frequency of error type was compared between otolaryngology subspecialties using Fisher exact tests.ResultsNinety‐four medical malpractice cases related to otolaryngology with evidence of court proceedings were identified for the period between 2010 and 2019. An otolaryngologist was named as the sole defendant in 39 cases (41%). Rhinology was the most frequently implicated subspecialty (28% of all cases), followed by head and neck surgery (17%) and facial plastics (7%). Improper surgical performance was cited in nearly half of the identified cases (49%), followed by failure to diagnose/refer/treat (32%). Outcome and liability data were available for 56 cases (60%). Of these 56 cases, 50 (89%) were ruled in favor of the defendant otolaryngologist. Of the cases ruled in favor of the plaintiff, the average indemnity was $4.24 M (range, $150,000 M–$10.25 M). Fisher exact tests demonstrated statistically significant differences in consent issues (P = .040), failure to diagnose/refer/treat (P = .024), and improper surgical performance (P = .026) between subspecialties.ConclusionsIn a limited, database‐derived sample of medical malpractice cases involving otolaryngologists, trends in error type by subspecialty may warrant further investigation to identify specialty‐wide and subspecialty‐specific areas of practice improvement and education.Level of EvidenceN/A Laryngoscope, 2020

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Post‐Tonsillectomy Hemorrhage and the Diagnosis of Occult Pediatric Coagulopathies

\nStephen R. Chorney, \nRena Weinberger, \nAri Y. Weintraub, \nAdva Buzi\n

Publicatie 04-11-2020


Objectives/HypothesisThe primary objective of this investigation was to determine rates of abnormal coagulation panels and diagnoses of coagulopathies in children with post‐tonsillectomy hemorrhage (PTH). Secondary objectives identified patient demographics and hemorrhage event characteristics that correlated with a coagulopathy diagnosis.Study DesignCase series with chart review.MethodsPatients requiring operative control of PTH at a tertiary childrens hospital between 2015 and 2019 were included. Details of tonsillectomy procedures and hemorrhage events were reviewed along with screening labs for coagulopathy, referrals to hematology and bleeding disorder diagnoses.ResultsThere were 250 children included. Mean age was 8.8 years (95% CI: 8.2–9.4) and 53.6% were males. PTH events occurred at a median of postoperative day six (mean: 5.9, 95% CI: 5.4–6.3), and 14.8% occurred within 24 hours of surgery. In this series, 23 patients (9.2%) had a second PTH, and three (1.2%) had a third PTH. Single and multiple PTH patients were similar with respect to age, gender, postoperative day, and technique (P > .05). Screening coagulation panels were obtained on presentation in 67.8% of children with one PTH and abnormally elevated in 38.3%. All children with multiple PTHs had labs drawn with 34.8% having elevated levels. No child with a single PTH was diagnosed with a bleeding disorder. Conversely, 87.0% of children with multiple PTHs saw hematology and three (13.0%) were diagnosed with a bleeding disorder (P < .001).ConclusionsObtaining coagulation panels in pediatric patients presenting with PTH is rarely useful and diagnosing a coagulopathy is uncommon. However, among children with a second PTH, referral to hematology is reasonable as this group has a significantly higher, albeit small, incidence of undiagnosed bleeding disorders.Level of Evidence4 Laryngoscope, 2020

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Influences of GABAergic Inhibition in the Dorsal Medulla on Contralateral Swallowing Neurons in Rats

\nShota Kinoshita, \nYoichiro Sugiyama, \nKeiko Hashimoto, \nShinya Fuse, \nShigeyuki Mukudai, \nToshiro Umezaki, \nMathias Dutschmann, \nShigeru Hirano\n

Publicatie 04-11-2020


ObjectivesWe aimed to examine the effect of unilateral inhibition of the medullary dorsal swallowing networks on the activities of swallowing‐related cranial motor nerves and swallowing interneurons.MethodsIn 25 juvenile rats, we recorded bilateral vagal nerve activity (VNA) as well as unilateral phrenic and hypoglossal activity (HNA) during fictive swallowing elicited by electrical stimulation of the superior laryngeal nerve during control and following microinjection of the GABA agonist muscimol into the caudal dorsal medulla oblongata in a perfused brainstem preparation. In 20 animals, swallowing interneurons contralateral to the muscimol injection side were simultaneously recorded extracellularly and their firing rates were analyzed during swallowing.ResultsIntegrated VNA and HNA to the injection side decreased to 49.0 ± 16.6% and 32.3 ± 17.9%, respectively. However, the VNA on the uninjected side showed little change after muscimol injection. Following local inhibition, 11 out of 20 contralateral swallowing interneurons showed either increased or decreased of their respective firing discharge during evoked‐swallowing, while no significant changes in activity were observed in the remaining nine neurons.ConclusionThe neuronal networks underlying the swallowing pattern generation in the dorsal medulla mediate the ipsilateral motor outputs and modulate the contralateral activity of swallowing interneurons, suggesting that the bilateral coordination of the swallowing central pattern generator regulates the spatiotemporal organization of pharyngeal swallowing movements.Level of EvidenceNA Laryngoscope, 2020

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Reduced Recovery Times with Total Intravenous Anesthesia in Patients with Obstructive Sleep Apnea

\nMatthew Stewart, \nLeonard Estephan, \nAdam Thaler, \nTingting Zhan, \nKevin Connors, \nKabir Malkani, \nPatrick Hunt, \nMaurits Boon, \nColin Huntley\n

Publicatie 03-11-2020


Objectives/HypothesisThere is currently no standard of care in terms of anesthesia modality for patients receiving upper airway surgery with comorbid obstructive sleep apnea (OSA). Although both total intravenous anesthesia (TIVA) and volatile gas anesthesia are commonly utilized in ambulatory otolaryngology surgery, it is currently unclear if there are any advantages with one modality over the other. We hypothesize that patients receiving upper airway surgery with comorbid OSA will have quicker recovery times with TIVA.Study DesignRetrospective chart review from January 2019 to December 2019.MethodsAll patients aged 18 and older receiving upper airway surgery (upper airway stimulation, nasal surgery, modified uvulopalatopharyngoplasty) were included. Patients were excluded when there was incomplete or missing data in the electronic medical record.ResultsEighty‐six patients received gas anesthesia and 62 patients received TIVA. Phase I recovery times were significantly reduced by surgery and by severity of OSA: nasal surgery, upper airway stimulation, and modified uvulopalatopharyngoplasty had a reduction of 35.5 minutes (P < .001), 42.5 minutes (P < .001), and 36 minutes (P = .022), respectively. In terms of severity, mild, moderate, and severe OSA had reductions of 23.5 minutes (P = .004), 52 minutes (P = .004), and 47 minutes (P < .001), respectively. The severity of OSA generally correlated with increased time spent in Phase I: as severity increased, Phase I time increased by 16.8 minutes for the gas cohort (P < .001), whereas in the TIVA cohort, it increased only 4.3 minutes (P = .489).ConclusionPatients having upper airway surgery with comorbid OSA that received TIVA (propofol and remifentanil) spent significantly less time in Phase I and the recovery room overall compared to those receiving volatile gas anesthesia in the form of sevoflurane, and this correlated with the severity of OSA.Level of Evidence3. Laryngoscope, 2020

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Implantable Doppler Ultrasound Monitoring in Head and Neck Free Flaps: Balancing the Pros and Cons

\nRaymond Hayler, \nTsu‐Hui (Hubert) Low, \nKevin Fung, \nAnthony C. Nichols, \nS. Danielle MacNeil, \nJohn Yoo\n

Publicatie 03-11-2020


Objectives/HypothesisFree flap transfer offers a versatile option for reconstruction in head and neck surgery, with success rates over 95%. There remains a substantial re‐exploration rate of roughly 5% to 15%, with early recognition of compromise essential to flap survival. Monitoring techniques are highly desirable, with the gold standard being clinical monitoring. The Cook‐Swartz Doppler (CSD) probe utilizes Doppler technology to inform clinicians about real‐time flow. We aim to describe our adoption of this technology in 100 consecutive free flaps.Study DesignProspective case series.MethodsProspective data were collected from July 2014 to June 2015 on 100 consecutive free flaps performed at a head and neck unit in London, Ontario. All patients had a CSD inserted for arterial and venous monitoring.ResultsA total of 100 free flaps were performed on 99 patients. Sensitivity was 87.1% and specificity was 85.7%. Positive predictive value was 98.8% and negative predictive value was 33.3%. False‐negative and false‐positive rate were 1.0% and 12.0%, respectively. The exploration rate was 12%, with no flap loss and two partial debridements. The CSD was helpful in management in 9% of cases and was clinically unhelpful in 11% of cases, with 10 of 11 abnormal signals ignored. There were three unique CSD complications; one retained wire, one pedicle laceration during extraction, and one clot around the probe interrupting signal.ConclusionsThe CSD is a helpful adjunct to clinical monitoring but has unique complications, which were not previously described. Pros and cons must be considered for new centers adopting this technology.Level of Evidence4 Laryngoscope, 2020

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Radiotherapy in Metastatic Oropharyngeal Cancer

\nSusanna Nguy, \nCheongeun Oh, \nJerome M. Karp, \nShengyang Peter Wu, \nZujun Li, \nMichael J. Persky, \nKenneth S. Hu, \nBabak Givi, \nMoses M. Tam\n

Publicatie 03-11-2020


ObjectivesThe role of locoregional radiotherapy for metastatic oropharyngeal squamous cell cancer (OPSCC) is unclear. We investigated the impact of head and neck radiotherapy on survival in de novo metastatic OPSCC patients who received systemic therapy.MethodsWe queried the NCDB from 2004–2015 for metastatic OPSCC patients at diagnosis with known HPV‐status who received systemic therapy. The association of head and neck radiotherapy with overall survival was analyzed using the Kaplan–Meier method, Cox proportional hazards model, and propensity score‐matched analysis adjusting for demographic and disease‐specific prognostic factors.ResultsOf the 2,139 patients with metastatic OPSCC who presented with metastases and received systemic treatment, we identified 556 patients with known HPV‐status. Among these 556 patients, 49% were HPV‐positive and 56% received head and neck radiotherapy. With a median follow‐up of 17.5 months (IQR 6.0–163.4 months), radiotherapy was associated with significantly improved 1‐year OS (67% vs 58%, log‐rank P < .001) which remained significant on MVA (HR 0.78 95% CI 0.62–0.97 P = .029). In HPV‐status subgroup analysis, a survival benefit was identified in HPV‐positive patients (1‐year OS 77% vs 67%, log‐rank P < .001) but not in HPV‐negative patients. Results were consistent on a propensity score‐matched analysis of 212 HPV‐positive matched patients (HR 0.66, 95% CI 0.49–0.83, P < .001).ConclusionThe survival of metastatic OPSCC remains limited. In this large series of patients with known HPV‐status, head and neck radiotherapy was associated with longer survival in those with HPV‐associated disease. These data could guide management of this challenging group of patients for head and neck cancer practitioners.Level of Evidence3 Laryngoscope, 2020

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Predictors of Long‐Term Nasal Obstruction Symptom Evaluation Score Stability Following Septoplasty With Inferior Turbinate Reduction

\nRichard H. Law, \nTalal D. Bazzi, \nMeredith Van Harn, \nJohn R. Craig, \nRobert H. Deeb\n

Publicatie 03-11-2020


Objectives/HypothesisDetermine the postoperative Nasal Obstruction Symptom Evaluation (NOSE) score stability between 1 and ≥6 months after septoplasty with inferior turbinate reduction (ITR). Education level and occupation were evaluated to determine their effects on NOSE score stability during the postoperative period.Study DesignRetrospective case series.MethodsThis was a retrospective case series. Patients were included if they underwent septoplasty with ITR for nasal obstruction due to septal deviation and inferior turbinate hypertrophy. NOSE scores were collected preoperatively, and at 1 and ≥6 months postoperatively. Education level and occupation were collected postoperatively via telephone survey. Changes in NOSE scores were compared between the different time points. Education level and occupation were analyzed to determine if they affected NOSE scores.ResultsThere were 98 patients included, and 56 were male (57.1%). Mean NOSE scores preoperatively and at 1 and ≥6 months postoperatively were 72.1, 17.1, and 12.0, respectively. Patients demonstrated a statistically and clinically significant reduction in NOSE score at 1 month (−54.9, P < .001) and at ≥6 months postoperatively (−60.0, P < .001). The mean 6.2‐point decrease in NOSE score from 1 to ≥6 months was statistically, but not clinically significant. There were no significant differences in NOSE score changes based on educational level and occupation.ConclusionsPatients achieved statistically and clinically significant reductions in NOSE scores at 1 months, with no clinically significant differences in NOSE scores at ≥6 months, suggesting NOSE score stability between these postoperative time points. Neither education level nor occupation influenced NOSE scores.Level of Evidence4. Laryngoscope, 2020

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Needlestick Injury in Otolaryngology–Head and Neck Surgery Resident Programs

\nEmily N. Ahadizadeh, \nLourdes Quintanilla‐Dieck, \nHailey Pfeifer, \nMark K. Wax\n

Publicatie 03-11-2020


Objectives/HypothesisUp to 800,000 percutaneous injuries involving healthcare workers occur each year. The morbidity of needlestick injuries (NSIs) ranges from nothing to death. The incidence of NSI in otolaryngology residency is deemed to be high based on prior studies. This study aimed at defining the trends in otolaryngology residents regarding sharps exposure.Study DesignCross‐sectional study using survey/questionnaire.MethodsOtolaryngology accredited residency programs in North America were surveyed in 2013 and 2017 regarding their experience with NSI and perceived risk of acquiring a blood‐borne infection.ResultsSurveys were received from 314 residents (31 programs). There was a total of 509 needlesticks, primarily occurring during junior years (post‐graduate year 1–3, 81%). Sixty‐eight percent of residents had experienced an NSI. Of the residents that had an injury, the mean number of sticks was 2.37 sticks/resident. Junior residents were less likely to report their injury compared to senior residents (50% vs. 30%). The primary reason for not reporting was the time commitment. Residents underestimated their risk of acquiring human immunodeficiency virus (51% of residents) and overestimated their risk of acquiring hepatitis C virus (90% of residents).ConclusionsOccupational exposure is high in healthcare and particularly high in surgical trainees. The majority of otolaryngology trainees undergo a needlestick injury in their junior years. There continues to be underreporting of these injuries by residents, who report that the process is too time‐consuming. Most residents do not have an accurate understanding of their actual risk of acquiring a blood‐borne disease. These findings emphasize the need for education regarding risks and development of strategies to encourage reporting of injuries.Level of EvidenceVI Laryngoscope, 2020

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"Sialendoscopy and Sjogrens Disease: A Systematic Review"

\nKimberly K. Coca, \nM. Boyd Gillespie, \nNicholas A. Beckmann, \nRongshun Zhu, \nTamara M. Nelson, \nRobert L. Witt\n

Publicatie 03-11-2020


Objectives/HypothesisThis study is a systematic review of the literature which seeks to estimate the expected treatment outcomes of a patient with Sjogrens syndrome (SS) undergoing therapeutic sialendoscopy.Study DesignSystematic Review.MethodsPubMed, Scopus, and Cochrane library databases were used to search for studies published as of August 2020 regarding the treatment outcomes of SS with sialendoscopy. The key search terms included “Sjogrens syndrome” and “sialendoscopy.” Only studies in the English language involving more than one human patient were included. PRISMA guidelines were followed in study inclusion and data extraction. The primary outcome assessed was improvement in patient symptoms.ResultsSix studies met criteria and were analyzed in this review, including 125 patients undergoing sialendoscopy of parotid and/or submandibular glands as well as 25 controls. Of these patients, 90% were female with an age range of 18 to 79 years. There was significant diversity in outcome reporting tools. The outcomes of symptom improvement were pooled qualitatively based on improvement noted in each study. Outcomes were defined as partial improvement if the measured outcomes improved and complete improvement if measured outcomes resolved entirely. Despite the limited number of studies on this topic, this meta‐analysis suggests that a similar study of therapeutic sialendoscopy could expect to provide at least temporary improvement of symptoms 90% to 99% of the time.ConclusionsThis review provides support for the application of sialendoscopy in the treatment of SS salivary disease. Larger studies with consistent outcome reporting tools and control groups are needed to validate these results and provide a consistent therapy protocol. Laryngoscope, 2020

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A Comparison of Triamcinolone Acetonide Econazole Cream and Nystatin Suspension in Treatment of Otomycosis

\nQingguo Chen, \nHanqi Chu, \nYanling Tao, \nLiyan Peng, \nLiangqiang Zhou, \nLei Liu, \nXiaohui Wu\n

Publicatie 03-11-2020


Objectives/HypothesisTo compare the efficacy and adverse effects of triamcinolone acetonide econazole cream and nystatin suspension in the treatment of otomycosis, and to determine the clinical features, predisposing factors, and etiology of otomycosis.Study DesignA prospective study.MethodsA prospective clinical trial was conducted on 786 patients diagnosed with otomycosis. The study population was randomly divided into two treatment groups of triamcinolone acetonide econazole cream (TAEC) and nystatin suspension in a 1:1 ratio. After clearing all fungal deposits in the external auditory canal, the antimycotic drugs were locally applied for at least 2 weeks. The efficacy and adverse effects were compared between the two antifungal reagents by statistical analysis. Meanwhile, patient clinical data were collected to find out the clinical features, predisposing factors, and etiology.ResultsPruritis was the most common symptom and Aspergillus niger was the leading fungal pathogen. There was high association (44.5%) of otomycosis with a history of unclean ear picking. The cure rate was 97.6% in the TAEC group and 73.5% in the nystatin group (P < .01). Treatment with TAEC resulted in 2.4% of patients complaining of discomforts (irritant dermatitis, otalgia, or headache) versus 59.8% of patients complaining discomforts treated with nystatin (P < .01). The residue rate of antifungals was 1.9% in the TAEC group and 89.9% in the nystatin group (P < .01) at the end of treatment.ConclusionsThoroughly cleaning of the external auditory canal followed by local use of TAEC under endotoscope is an effective, convenient, and well‐tolerated treatment for otomycosis.Level of Evidence1 Laryngoscope, 2020

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Anterior Pedicled Lateral Nasal Wall Flap for Endonasal Lining: A Radiologic and Anatomical Study

\nCristóbal Langdon, \nKathy Yuen‐Ato, \nCarla Pereira‐Perez, \nClaudio Arancibia, \nIsam Alobid\n

Publicatie 03-11-2020


Objectives/HypothesisThe objective of this radiological/anatomical study was to evaluate the feasibility of a new endoscopic technique that uses the anterior pedicled lateral nasal flap (APLNW) for the endonasal lining in complex nasal reconstructions.Study DesignAn anatomical study was performed on 20 nasal fossae of cadaverous specimens to measure the area and lengths of the anterior pedicled nasal lateral wall flap. In addition, a radiological analysis with computed tomography was performed in 150 nostrils to determine the potential donor of the simple and extended flap in the nasal fossa floor. Complex nasal reconstruction with nasofrontal flap and internal lining using the lateral wall pedicled flap was performed in 3 patients.ResultsComplete reconstruction for the inner lining of the nasal tip and lateral nasal wall was achieved in the cadaveric study (10 specimens). The surface areas of the simple and extended APLNW flaps were 7.53 (standard deviation SD 1.25) cm2 and 24.6 (SD 3.14) cm2, respectively. Using computed tomography scans, we determined that to reconstruct defects secondary to full‐thickness nasal defects, the APLNW flap surface for the simple and extended versions was 7.90 (SD 1.68) cm2 and 23.64 (SD 4.7) cm2. We present one case were the APLNW flap was used.ConclusionsThe simple or expanded APLNW flap represents a feasible option to reconstruct the internal lining in complex nasal reconstruction.Level of EvidenceNA. Laryngoscope, 2020

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Regional Peak Mucosal Cooling Predicts Radiofrequency Treatment Outcomes of Nasal Valve Obstruction

\nZhenxing Wu, \nJillian P. Krebs, \nBarak M. Spector, \nBradley A. Otto, \nKai Zhao, \nAlexander A. Farag\n

Publicatie 03-11-2020


Objectives/HypothesisLow energy radiofrequency may offer effective treatment for narrow or obstructed nasal valve, yet its precise mechanism is not fully understood.Study DesignProspective, nonrandomized, case series.MethodsTwenty prospective patients with internal nasal valve obstruction underwent office‐based Vivaer treatment (Aerin Medical, Inc) under local anesthesia. Computational fluid dynamics (CFD) models were constructed based on the pre‐ and 90 days post‐procedure computed tomography (CT) scans to identify salient changes in nasal airflow parameters.ResultsPatients Nasal Obstruction Symptom Evaluation score (NOSE: pre‐treatment 78.89 ± 11.57; post‐treatment 31.39 ± 18.30, P = 5e‐7) and Visual Analog Scale of nasal obstruction (VAS: pre‐treatment 6.01 ± 1.83; post‐treatment 3.44 ± 2.11, P = 1e‐4) improved significantly at 90 days after the minimally invasive approach. Nasal airway volume in the treatment area increased ~7% 90 days post‐treatment (pre‐treatment 5.97 ± 1.20, post‐treatment 6.38 ± 1.50 cm3, P = .018), yet there were no statistically significant changes in the measured peak nasal inspiratory flowrate (PNIF, pre‐treatment: 60.16 ± 34.49; post‐treatment: 72.38 ± 43.66 ml/s; P = .13) and CFD computed nasal resistance (pre‐treatment: 0.096 ± 0.065; post‐treatment: 0.075 ± 0.026 Pa/(ml/s); P = .063). As validation, PNIF correlated significantly with nasal resistance (r = 0.47, P = .004). Among all the variables, only the peak mucosal cooling posterior to the nasal vestibule significantly correlated with the NOSE at baseline (r = −0.531, P = .023) and with post‐treatment improvement (r = 0.659, P = .003).ConclusionMinimal remodeling of the nasal valve (7% in this study) may have a profound effect on perceived nasal obstruction, despite little effect on nasal resistance, or PNIF. The results corroborated our previous findings that subjective relief of nasal obstruction correlates with regional mucosal cooling rather than nasal resistance or peak flow rate, a potential target for future effective, personalized therapeutic approaches.Level of Evidence4. Laryngoscope, 2020

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Cholesteatoma Localization Using Fused Diffusion‐Weighted Images and Thin‐Slice T2 Weighted Images

\nJohn C. Benson, \nMatthew L. Carlson, \nLinda Yin, \nJohn I. Lane\n

Publicatie 03-11-2020


BackgroundFusion of diffusion‐weighted imaging (DWI) to computed tomography (CT) has been touted as a possible technique to improve cholesteatomas localization. This study set out to assess the ability of DWI images fused with thin‐slice heavily T2‐weighted images to similarly localize surgically‐confirmed cholesteatomas.Materials and MethodsA retrospective review was completed of consecutive patients that underwent MR temporal bone imaging (9/2011–3/2020) with both DWI and thin‐slice T2‐weighted imaging. Included patients underwent surgical resection of primary or recidivistic cholesteatoma after preoperative MR imaging. A neuroradiologist, who was blinded to operative and clinical notes, localized each lesion on both DWI and fused DWI‐T2 images in 11 anatomic subdivisions of the temporal bone. Surgical confirmation of cholesteatoma location was used as the gold standard for comparison.ResultsOf 24 included examinations, the average age at time of MR was 48.2 ± 24.7 years; 12/24 (50.0%) were female. Five of 24 had primary cholesteatoma, while the remainder had recidivistic disease. Sensitivity, specificity, and accuracy of unfused DWI images were 52.1%, 88.9%, and 75.8%, respectively. Sensitivity, specificity, and accuracy of fused DWI‐T2 images were 57.1%, 94.8%, and 81.8%, respectively.ConclusionFused DWI‐T2 images outperformed unfused DWI images in the anatomic localization of temporal bone cholesteatomas. This method represents a potential alternative to MR‐CT fusion for pre‐operative cholesteatoma evaluation, and warrants future investigations. Opposed to MR‐CT fusion, this method only necessitates MR sequences and removes the need for additional CT acquisition.Level of Evidence3 Laryngoscope, 2020

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"Endoscopic Denkers Approach for the Treatment of Extensive Sinonasal Tumors: Our Experience"

\nMarios Stavrakas, \nPetros D. Karkos, \nZinovia Tsinaslanidou, \nJannis Constantinidis\n

Publicatie 03-11-2020


ObjectivesSurgical management of large sinonasal tumors, spreading to the pterygopalatine, and infratemporal fossae have always been a challenge for the ENT surgeon and the multidisciplinary team.MethodsEndoscopic Denkers approach allows complete exposure of the anterior, inferior, and lateral recesses of the maxillary sinus, without necessitating a gingivobuccal or a transseptal incision. Moreover, endoscopic Denkers approach facilitates direct, straight entry to the pterygopalatine and infratemporal fossae.ResultsTwenty‐two patients with extensive sinonasal pathology underwent resection via an endoscopic Denkers approach at our institution, with the majority of them being diagnosed with JNA and inverted papilloma. Denkers procedure facilitated wide exposure of the surgical field and total tumor resection, without significant perioperative complications and good disease‐free results in follow up.ConclusionsOur experience is in accordance with the literature, where this approach seems to be superior to alternative options for accessing the pterygopalatine and infratemporal fossae. We believe that adequate expertise in endoscopic sinonasal surgery is necessary prior to embarking on this technique, but in general, it represents a valuable tool in the surgeons armamentarium.Level of Evidence4 Laryngoscope, 2020

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The Potential Protective Effects of Statins in Chronic Rhinosinusitis: A Case–Control Study

\nSapideh Gilani, \nNeil Bhattacharyya\n

Publicatie 03-11-2020


Objectives/HypothesisTo determine the potential protective effect of prior statin use on the subsequent diagnosis of chronic rhinosinusitis (CRS).Study DesignRetrospective, case‐controlMethodsElectronic medical records for all patients seen in the otolaryngology clinic in 2019 and receiving a diagnosis of CRS were reviewed for the presence or absence of active prior statin use within 365 days of the visit. Similarly, prior statin use in a control group of patients without any diagnosis of CRS was also determined. Statin exposure in CRS patients was compared to statin exposure in control patients with 1:2 matching on age and sex with chi‐square and odds ratios were computed.ResultsIn 2019, 3655 patients (mean age, 52.9 years, 56.4% female) were identified with a diagnosis of chronic rhinosinusitis versus 41,636 patients without any diagnosis of CRS. All chronic rhinosinusitis patients were successfully matched to 7310 controls. 6.3% of CRS patients (229 patients) had prior statin use, versus 8.5% (624 patients) of control patients. The average mean duration of statin use prior to visit was not significantly different between CRS and control patients (mean days, 202.3 days versus 205.6 days, respectively; P = .697). The presence of a statin medication in use was associated with a significant protective effect against a subsequent diagnosis of CRS with and odds ratio for CRS diagnosis of 0.716 (95% confidence interval, 0.612–0.838) in those patients taking a statin medication (P < .001).ConclusionsThe use of a statin medication was associated with a significant reduction in subsequent diagnosis of chronic rhinosinusitis.Level of Evidence3 Laryngoscope, 2020

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