Laryngoscope 2024-03-01

Variants in Genes Associated with Hearing Loss in Children: Prevalence in a Large Canadian Cohort

Emily R. Wener, Jacob D. McLennan, Blake C. Papsin, Sharon L. Cushing, Dimitri James Stavropoulos, Roberto Mendoza‐Londono, Nada Quercia, Karen A. Gordon

Publication date 01-03-2024


This study assessed the prevalence of genetic variants associated with hearing loss in a large cohort of children. A total of 485 children underwent genetic testing, which identified 923 variants, most of which were of uncertain significance. A genetic cause of hearing loss was found in 15% of children which is lower than typically reported.
Objective The objective of this study was to assess the prevalence of genetic variants associated with hearing loss in a large cohort of children in Canada using high throughput next generation sequencing (NGS).
MethodsA total of 485 children with hearing loss underwent NGS testing with an 80 gene panel of syndromic and non-syndromic variants known to be associated with hearing loss. Genetic variants were classified as pathogenic, likely pathogenic, likely benign, benign, or variants of uncertain significance (VUS), according to the American College of Medical Genetics and Genomics guidelines.
Results Across the 80 genes tested, 923 variants, predominantly in 28 genes, were identified in 324 children. Pathogenic variants occurred in 19/80 (23.8%) of the hearing loss related genes tested and confirmed the etiology of hearing loss in 73/485 (15.1%) of children. GJB2 was the most prevalent gene, affecting 28/73 (38.4%) children with confirmed genetic hearing loss in our cohort. Most identified variants (748/923, 81.0%, in 76/80 genes) were of uncertain significance.
Conclusion Genetic testing using NGS identified the etiology in approximately 15% of childhood hearing loss in a Canadian cohort which is lower than what is typically reported. GJB2 was the most common genetic cause of hearing loss. VUS are commonly identified, presenting clinical challenges for counseling.
Level of Evidence Level 4 Laryngoscope, 2024

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Bilateral Costal Cartilage Harvest for Auricle Reconstruction: A New Technique to Prevent Postoperative Thoracic Deformity

Peizhou Wang, Qi Chen, Bingqing Wang, Yue Wang, Qingguo Zhang, Pan Luo

Publication date 29-02-2024


Traditional unilateral costal cartilage harvesting for auricle reconstruction in children tends to cause thoracic deformities, our study develop a novel bilateral costal cartilage harvesting (BCCH) method to prevent and reduce thoracic deformities without increasing postoperative pain and cosmetic concerns for patients.
Hypothesis Unilateral costal cartilage harvesting (UCCH) for auricle reconstruction in children tends to cause thoracic deformities. Therefore, our study aimed to develop a novel bilateral costal cartilage harvesting (BCCH) method to prevent and reduce thoracic deformities.
Methods Patients with unilateral microtia who underwent either UCCH (n = 50) or BCCH (n = 46) were enrolled in this study. The grafts for the BCCH group were harvested from the 6th costal cartilage of the ipsilateral hemithorax and the 7th and 8th cartilage from the other hemithorax. Computed tomography and physical examination were performed to identify any physical deformities in the chest contours post-surgery. The cosmetic appearance of the thoracic scars post-surgery was evaluated using the Scar Cosmesis Assessment and Rating Scale (SCAR) and Visual Analogue Scales (VAS cosmetic). The numerical rating scale (NRS) was used to quantify the pain in donor sites. The reconstructed ears were assessed during the follow-up period.
Result None of the patients in the BCCH group developed thoracic deformities, while 16 patients within the UCCH group developed mild (n = 12) or severe (n = 4) thoracic deformities (p < 0.001). The SCAR (3.09 vs. 2.92, p = 0.580) and VAS scores (0.96 vs. 0.90, p = 0.813) did not differ significantly between the two groups. For both treatment arms, the NRS scores were highest on the first-day post-surgery and gradually dropped over the 10 days. No significant differences were found in the NRS scores and the aesthetic outcomes of the reconstructed ears between the two groups.
Conclusion The BCCH method effectively reduced the incidence of thoracic deformity at the donor site without increasing postoperative pain and cosmetic concerns for patients. It could be used clinically to improve patient outcomes of costal cartilage grafts.
Level of Evidence4 Laryngoscope, 2024

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

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

Publication date 28-02-2024


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

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The Impact of COVID‐19 Restrictions on Hospital Admissions of Common Head and Neck Infections

Matthew Urichuk, Jason Lee Azzi, Darren J. Leitao

Publication date 28-02-2024


This retrospective cohort study of 253 pediatric and 197 adult admissions indicates a significant decrease in pediatric croup/tracheitis and adult orbital disease admissions following COVID-19 restrictions. Overall pediatric admissions significantly decreased while adult admissions did not. The observed decline in specific diseases helps elucidate susceptibility and resistances to protective measures of certain diseases compared with others.
Introduction Following the emergence of COVID-19, multiple preventative measures were implemented to limit the spread of the disease. This study aims to elucidate the impact of COVID-19 restrictions on hospital admissions of otolaryngology-related infections.
Materials and MethodsA retrospective chart review was conducted to capture all admissions for otolaryngology-related infections in the 2 years pre- and post-COVID-19 at the Health Sciences Centre in Winnipeg, Manitoba. These infections included croup, tracheitis, neck abscess, peritonsillar abscess, otitis media, mastoiditis, sinus infection, orbital infection, pharyngotonsillitis, retro/parapharyngeal abscess, and acute epiglottitis. Demographic information and admission details were collected and analyzed to compare pre- and post-COVID-19 admissions. Further analysis was conducted to compare hospital admissions of patients from rural/remote regions.
Results Between March 2018 and March 2022, 253 pediatric patients and 197 adults were admitted for otolaryngology-related infections. Total pediatric admissions decreased post-COVID-19 (154 pre-COVID-19, 99 post-COVID-19; p < 0.001) whereas adult admissions remained stable (107 pre-COVID-19, 90 post-COVID-19; p = 0.25). No significant difference in mean patient age, admission duration, surgical rates or in the proportion of admissions from patients from rural/remote regions was observed in the pediatric or adult cohort when comparing pre-COVID-19 data to post-COVID-19 data. Diagnosis-specific changes in admissions were observed in pediatric croup (40 pre-COVID-19, 15 post-COVID-19; p < 0.001) and in adult orbital infections (30 pre-COVID-19, six post-COVID-19; p < 0.001).
Conclusion Following the implementation of COVID-19 restrictions, there was a decrease in admissions due to pediatric croup and adult orbital infections with an overall decrease in pediatric Otolaryngology-infection related admissions.
Level of Evidence3 Laryngoscope, 2024

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Endoscopic Versus Microscopic Tympanoplasty: A Systematic Review and Metanalysis

Eleni Gkrinia, Anna Maria Ntziovara, Alexandros G. Brotis, Konstantinos Tzimkas‐Dakis, Athanasios Saratziotis, Christos Korais, Jiannis Hajiioannou

Publication date 28-02-2024


Objective Endoscopic ear surgery is no longer a promising technique, but a well-established one. This study aims to compare endoscopic and microscopic tympanoplasty based on current literature evidence, in terms of their efficacy and safety characteristics.
Data Sources We conducted a systematic literature search of four medical databases (Pubmed, Cochrane Library, Scopus, Clinical Trials.gov), focusing on randomized controlled or observational studies comparing microscopic to endoscopic tympanoplasty.
Review Methods Data related to the efficacy and safety of each technique were extracted. Outcome data were summarized using pooled mean differences or pooled odds ratio along with their 95% confidence intervals. The risk of bias was estimated, by using the ROBINS-I and RoB-II assessment tools, while the overall quality of evidence was evaluated according to the GRADE working group.
Results Thirty-three studies, with 2646 patients in total, were included in the meta-analysis. Success rate was evaluated by estimating tympanic graft failure (pooled mean difference:−0.23; 95% CI: −0.61, 0.14, I2 = 33.42%), and air-bone gap improvement (pooled mean difference:−0.05; 95% CI:−0.23, 0.13, I2 = 52.69%), resulting in comparable outcomes for the two techniques. A statistically significant difference favoring the endoscopic technique was detected regarding postoperative wound infection (OR: −1.72; 95% CI: −3.39, −0.04, I2 = 0%), dysgeusia (OR: −1.47; 95% CI: −2.47, −0.47, I2 = 0%), otitis externa development (OR: −1.96; 95% CI: −3.23, −0.69, I2 = 0%), auricular numbness (OR: −2.56; 95% CI: −3.93, −1.19, I2 = 0%), as well as surgical duration (OR: −1.86; 95% CI: −2.70, −1.02, I2 = 43.95%), when compared to the postauricular microscopic approach.
Conclusion Endoscopic tympanoplasty is an innovative alternative to the microscopic technique, resulting in commensurate outcomes regarding success rate. Furthermore, it offers superior results concerning postoperative complications, while it presents a significant reduction in the duration of surgery, mainly when it is compared to the postauricular microscopic approach.
Level of EvidenceNA Laryngoscope, 2024

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Oral Sucrose in Infants Undergoing Flexible Nasolaryngoscopy: A Blinded Randomized Pilot Study

Nikolaus E. Wolter, Meghan E. Tepsich, Ellie S. Daien, Justin T. Levinsky, Mary‐Elizabeth Vanderpost, Evan J. Propst, Jennifer M. Siu

Publication date 28-02-2024


Flexible nasolaryngoscopy is a painful procedure performed on infants. Painful procedures are often undertreated in infants due to lack of physician awareness and time constraints and this has long-term implications on children. Oral sucrose given 2 min before flexible endoscopy successfully treated pain and did not prolong clinic visit duration.
Introduction Flexible nasolaryngoscopy (FNL) is a common, uncomfortable procedure performed to assess the upper airway in infants. Oral sucrose is used during various painful procedures in infants but has not been used during FNL. Our objective was to understand the impact of oral sucrose on discomfort in infants undergoing FNL.
Methods Infants (<12-months-old) undergoing FNL in the otolaryngology clinic were randomized to treatment (0.5 mL 24% oral sucrose) or standard management (no sucrose). Sucrose was administered <2 min prior to FNL performed by a single endoscopist.
Outcome measures included: EVENDOL pain scale and cry duration and visit duration. Infant discomfort was measured by a second observer who was blinded to treatment group.
Results Forty-seven infants were included, 23 were treated with sucrose and 24 with standard management. The median (IQR) age was 3.0 (2–5.7) months. There were no significant differences in age, weight, or sex across groups. The median (IQR) duration of FNL was 35.2 (26.5–58.4) and 36.4 (28.9–51.8) seconds for treatment and standard management groups, respectively. Mean (SD) EVENDOL scores were significantly lower in the sucrose group 4.9 (2.0) than standard group (6.7 2.1) (p = 0.003). Mean cry duration after FNL was significantly shorter in the sucrose group (29.9 20.4 seconds) than the standard group (52.7.0 40.6 seconds) (p = 0.02). Median (IQR) visit duration did not differ across groups (1.1 0.9–1.3 vs. 1.1 0.7–1.4 h p = 0.15).
Conclusion Oral sucrose given before FNL reduced EVENDOL scores and cry duration after FNL and did not prolong clinic visits in this randomized pilot study.
Level of Evidence2 Laryngoscope, 2024

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Table of contents

Publication date 27-02-2024


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Immune Profiling of Secreted Factors from Human Vestibular Schwannoma Cells and Tumor‐associated Macrophages

Konstantina M. Stankovic, Shelley Batts, D. Bradley Welling, Sasa Vasilijic

Publication date 27-02-2024


In patients with vestibular schwannoma (VS), different levels of immune factors were observed in schwannoma vs. Schwann cells, and in tumor-associated macrophages vs. blood-derived macrophages, some of which were correlated with worse hearing and larger tumors. Inflammation may play a key role in VS-associated hearing loss.
Objectives This study compared the immune-related secretory capacity of human vestibular schwannoma (VS) and tumor-assisted macrophages (TAMs) with their normal counterparts (Schwann cells SC and peripheral blood monocyte-derived macrophages Mo-MFs, respectively), and examined relationships with presurgical hearing and tumor size.
MethodsVS tumors (n = 16), auditory nerve (n = 1), blood (n = 9), and great auricular nerves (n = 3) were used. SCs (S100B+) and TAMs (CD68+) were isolated from VS tissue for culture. The secreted levels of 65 immune-related factors were measured and compared using unpaired t-tests with Welch correction (schwannoma vs. SCs) or Mann–Whitney tests (TAMs and Mo-MFs). Associations between factor concentration and word recognition (WR), pure-tone average (PTA), and tumor size were evaluated with Spearman correlation.
Results Secreted factors with significantly higher concentrations in schwannoma versus SC supernatants included IL-2 and BAFF, whereas MMP-1, IL-6, FGF-2, VEGF-A, MIP-3α, and GRO-α concentrations were significantly higher in TAMs versus Mo-MFs (all p < 0.05). Worse WR was significantly associated with higher secretion of fractalkine, eotaxin-3, CD30, and IL-16 by VS cells; IP-10, eotaxin-3, multiple interleukins, GM-CSF, SCF, and CD30 by TAMs; and TNF-α and MIP-1α by Mo-MFs (all p < 0.05). Worse PTA was significantly correlated with higher secretion of IL-16 by VS cells (p < 0.05). Larger tumor size was significantly correlated with higher secretion of eotaxin by VS cells, and of IL-7, IL-21, and LIF by TAMs (all p = 0.017).
Conclusions Differential secretion of immune-related factors was observed in schwannoma versus normal SCs and in TAMs versus Mo-MFs, some of which were correlated with worse hearing and larger VS tumors.
Level of EvidenceN/A Laryngoscope, 134:S1–S14, 2024

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

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

Publication date 27-02-2024


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

Tao Guo, Hui Xie

Publication date 27-02-2024


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Aesthetic Perceptions Regarding a Thyroidectomy Scar and Transvestibular Approach in Brazil

Guilherme Reimann Agne, Hugo Fontan Kohler, Renan Bezerra Lira, Marcelo Belli, Gustavo Nunes Bento, Acklei Viana, Luiz Paulo Kowalski

Publication date 27-02-2024


Objective We investigated motivation levels across the general Brazilian population and subgroups and their willingness to spend for surgery without a cervical scar.
Methods This random-sample survey was performed by a specialized third-party research institute. In this study, we created a hypothetical thyroidectomy scenario, and the transcervical and transoral endoscopic thyroidectomy vestibular approach (TOETVA) were used. The survey included sociocultural data and questions regarding participants surgical preferences.
Results Data were obtained from 1250 participants; 42.4% were of the opinion that a cervical scar affects social or professional life. Young and childless women were most likely to be affected (p <0.001). All respondents accepted the transoral approach to avoid cervical scarring. However, 30.7% and 31.9% of respondents maintained their preference for TOETVA despite understanding the risks of a hypothetical increase in complications and unfavorable oncological outcomes and 98.6% were of the opinion that this approach was likely associated with greater postoperative pain. Only 16.2% were unwilling to spend for TOETVA. The variable that most affected patients willingness to spend was a salary greater than 10 Brazilian minimum wages (odds ratio 9.797, 95% confidence interval, p <0.005). Upper class respondents were 10 times more likely to spend for TOETVA than lower class patients.
Conclusion This study highlights patients interest in TOETVA. Cervical scar perception is affected by concerned about appearance, particularly in certain societal subgroups. Our study population showed significant motivation to undergo TOETVA, which was emphasized by their acceptance of the complication rate, poor postoperative outcomes, greater postoperative pain, and willingness to spend on surgery with an invisible scar.
Level of Evidence4 Laryngoscope, 2024

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Prescribing Practices and Barriers of Biologics for Chronic Rhinosinusitis Amongst Otolaryngologists

Christopher M. Bell, Andrew V. Thamboo, Eric Monteiro, Jonathan Yip

Publication date 27-02-2024


Rhinologists are more comfortable with prescribing and managing biologics for CRSwNP compared with non-rhinologist colleagues. Clinicians prescribing biologic medications for CRSwNP should be familiar with guidelines, indications, and potential adverse events.
Objective(s)Biologics for chronic rhinosinusitis with nasal polyposis (CRSwNP) are an evolving therapeutic option, but there are limited data on physician experiences in prescribing them. The goal of this study was to gain a better understanding of these experiences including prescribing practices, patient factors which guide prescriber decision, and physician and patient-reported issues which might limit cost-effectiveness of these therapies.
MethodsA survey was distributed to attending otolaryngologists using the Canadian Society of Otolaryngology (CSOHNS) email distribution and e Survey program. Responses were tabulated for the entire cohort and compared between rhinologists and non-rhinologists where appropriate. Frequencies and proportions were expressed as a percentage of total respondents. Fishers exact test was used for statistical analysis between groups.
Results Seventy-nine total survey responses were recorded representing a response rate of 43%. Significantly more rhinologists reported prescribing biologic medications on their own (100% vs. 50%; p < 0.001) and a higher proportion (1 to 10% vs. <1%) of their patients were on biologics compared with non-rhinologists (p = 0.023). Rhinologists were more likely to consider poor response to medical therapies, need for rescue steroids, and comorbid type 2 conditions in their decision to pursue biologics than non-rhinologists, but they also experienced poorer assistance from patient support programs and less availability to medications.
Conclusion Rhinologists are more comfortable with prescribing and managing biologics for CRSwNP compared with non-rhinologist colleagues. Clinicians prescribing biologic medications for CRSwNP should be familiar with guidelines, indications, and potential adverse events.
Level of EvidenceN/A Laryngoscope, 2024

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Patterns of Care for T1 Glottic Squamous Cell Carcinomas from 2004–2020

Devesh Malik, Daniel Jacobs, Soraya Fereydooni, Henry S. Park, Saral Mehra

Publication date 27-02-2024


There is still debate on whether surgery or radiotherapy (RT) is superior as the first-line therapy for patients with T1 glottic squamous cell carcinomas (SCC). This study sought to describe recent national trends in overall treatment modalities for these cancers, and identify factors associated with treatment regimens. Dual-modality treatment with both surgery and radiotherapy for T1 glottic SCC has been declining while rates of surgery only have been increasing; patients with T1b disease were more likely to receive RT as the first and only treatment.
Objective(s)Describe recent national trends in overall treatment modalities for T1 glottic squamous cell carcinomas (SCC), and identify factors associated with treatment regimens.
Methods National Cancer Database from 2004–2020 was queried for all patients with glottic cT1N0M0 SCC. Treatment patterns over time were analyzed using the Cochran-Armitage test for trend. Multivariable logistic regressions were used to determine the factors associated with treatment regimens.
Results Of the 22,414 patients identified, most patients received RT only (57%), 21% received surgery only, and 22% received dual-modality treatment (“over-treatment”). Over the time period, there was a decreasing trend in rates of over-treatment for T1 glottic SCC (p < 0.001) and an increasing trend in surgery only (p < 0.001). Treatment in 2016–2018 (OR: 1.168 1.004 to 1.359), 2013–2015 (OR: 1.419 1.221 to 1.648), 2010–2012 (OR: 1.611 1.388 to 1.871), 2007–2009 (OR: 1.682 1.450 to 1.951), or 2004–2006 (OR: 1.795 1.548 to 2.081) versus 2019–2020 was associated with greater likelihood of over-treatment. T1b tumors were less likely to be over-treated (OR: 0.795 0.707 to 0.894) versus T1a tumors, and less likely to receive surgery first (OR: 0.536 0.485 to 0.592) versus T1a tumors.
Conclusion Over-treatment for T1 glottic SCC has been declining, with increasing rates of surgery only. Year of treatment was significantly associated with the receipt of dual-modality treatment. Finally, patients with T1b disease were more likely to receive RT as the first and only treatment.
Level of Evidence3 Laryngoscope, 2024

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

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

Publication date 26-02-2024


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

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

Duy Duong Nguyen, Jing‐Yin Pang, Daniel Novakovic

Publication date 26-02-2024


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

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

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

Publication date 26-02-2024


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

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Race and Ethnicity Independently Predict Adverse Outcomes Following Head and Neck Autograft Surgery

Tatiana Ferraro, Abdulla K. Ahmed, Esther Lee, Sean M. Lee, Peter M. Debbaneh, Punam Thakkar, Arjun Joshi, Neelima Tummala

Publication date 26-02-2024


Objective There is growing attention toward the implications of race and ethnicity on health disparities within otolaryngology. While race is an established predictor of adverse head and neck oncologic outcomes, there is paucity in the literature on studies employing national, multi-institutional data to assess the impact of race and ethnicity on head and neck autograft surgery.
Methods Using the National Surgical Quality Improvement Program (NSQIP) database, trends in 30 days outcomes were assessed. Patients with ICD-10 codes for malignant head and neck neoplasms were isolated. Autograft surgeries were selected using Current Procedural Terminology (CPT) codes for free flap and pedicled flap reconstruction. Primary outcomes included surgical complications, reoperation, readmission, extended length of stay and operation time. Each binary categorical variable was compared to racial/ethnic identity via binary logistic regression.
Results The study cohort consisted of 2447 patients who underwent head and neck autograft surgery (80.71% free flap reconstruction and 19.39% pedicled flap reconstruction). Black patients had significantly higher odds of overall surgical complications (odds ratio OR 1.583, 95% confidence interval CI 1.091, 2.298, p = 0.016) with much higher odds of perioperative blood transfusions (OR 2.291, 95% CI 1.532, 3.426, p = <.001). Hispanic patients were more likely to undergo reoperation within 30 days after surgery and were more likely to be hospitalized for more than 30 days post-operatively (OR 1.566, 95% CI 1.015, 2.418, p = 0.043 and OR 12.224, 95% CI 2.698, 55.377, p = 0.001, respectively).
Conclusions Race and ethnicity serve as independent predictors of complications in the post-operative period following head and neck autograft surgery.
Level of EvidenceIII Laryngoscope, 2024

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Head and Neck Merkel Cell Carcinoma: Therapeutic Benefit of Adjuvant Radiotherapy for Nodal Disease

Randall J. Harley, Megan Lyden, Seetha Aribindi, Leandro Socolovsky, Earl H. Harley Jr

Publication date 24-02-2024


Head and Neck Merkel cell carcinoma is an aggressive cutaneous neuroendocrine cancer typically treated with surgical excision followed by adjuvant radiotherapy. We found that while patients with positive nodal disease benefit from post-operative radiotherapy, those with negative lymph node involvement, confirmed by lymph node biopsy, do not show a survival benefit with the addition of post-operative radiotherapy.
Objectives To evaluate the therapeutic effect of post-operative radiotherapy (PORT) with respect to nodal status among patients with head and neck Merkel cell carcinoma (HNMCC).
Methods In this retrospective study, we queried Surveillance, Epidemiology, and End Results (SEER) dataset from 2000 through 2019. We included all adult patients who received primary surgical resection for histologically confirmed treatment naive HNMCC. Entropy balancing was used to reweight observations such that there was covariate balance between patients who received PORT and patients who received surgical resection alone. Doubly robust estimation was achieved by incorporating weights into a multivariable cox proportional hazards model. Planned post hoc subgroup analysis was performed to evaluate the impact of PORT by pathological node status.
Results Among 752 patients (mean age, 73.3 years SD 10.8; 64.2% male; 91.2% White; 41.9% node-positive), 60.4% received PORT. Among node-positive patients, we found that PORT was associated with improved overall survival (OS) (aHR, 0.55; 95% CI, 0.37–0.81; p = 0.003) and improved disease-specific survival (DSS) (aHR, 0.57; 95% CI, 0.35–0.92; p = 0.022). Among node-negative patients, we found that PORT was not associated with OS and was associated with worse DSS (aHR, 2.34; 95% CI, 1.30–4.23; p = 0.005).
Conclusions We found that PORT was associated with improved OS and DSS for node-positive patients and worse DSS for node-negative patients. For HNMCC treated with primary surgical resection, these data confirm the value of PORT for pathologically node-positive patients and support the use of single modality surgical therapy for pathologically node-negative patients without other adverse risk factors.
Level of Evidence Level 4 Laryngoscope, 2024

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

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

Publication date 24-02-2024


Adjuvant Gardasil use in recurrent respiratory papillomatosis patients older than 45 years significantly reduces the intersurgical interval. Current CDC recommendations include only patients ages 9 to 45, but this study provides evidence that RRP patients outside this age range may benefit from adjuvant HPV vaccination.
Objectives The primary objective was to examine the intersurgical interval (ISI) of recurrent respiratory papillomatosis (RRP) in patients older than 45 years before and after a Gardasil vaccination series.
Methods We conducted a retrospective chart review of adult patients >45 years of age diagnosed with RRP from 2012 to 2022. Patients were excluded if they did not receive at least two doses of the Gardasil vaccine series or if they underwent two or fewer surgeries during the study period.
Results Thirteen patients met the inclusion criteria, 11 males and two females. The age at initial diagnosis ranged from 46 to 80 years, with a mean of 59 years. There was a significant increase in the average ISI, from 126 ± 87 days pre-vaccination compared to 494 ± 588 days post-vaccination (p < 0.01). The average number of surgeries per patient was 6.8 ± 2.4 over an average follow-up of 49.7 ± 30.3 months.
Conclusion Adjuvant Gardasil use in RRP patients older than 45 years significantly increases the ISI. Current CDC recommendations include only patients ages 9 to 45, but this study provides evidence that RRP patients outside this age range may benefit from adjuvant HPV vaccination.
Level of Evidence.4 Laryngoscope, 2024

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17β‐estradiol Attenuates the Middle Ear Inflammatory Response to Nontypeable Haemophilus influenzae

Pawjai Khampang, Tina L. Samuels, Simon Blaine‐Sauer, Julliette Lucas, Ke Yan, Nikki Johnston, Joseph E. Kerschner

Publication date 24-02-2024


Objectives17β-estradiol (E2) is a steroidal hormone with immunomodulatory functions that play a role in infectious and inflammatory diseases. E2 was recently identified as the leading upstream regulator of differentially expressed genes in a comparative RNA sequencing study of pediatric patients with otitis media (OM) versus OM-free counterparts and may therefore play a role in the inflammatory response to bacterial otopathogens during pediatric OM. This study examined the effect of E2 on bacterial-induced inflammatory cytokine expression in an in vitro pediatric OM model.
Methods An immortalized middle ear (ME) epithelial cell line, ROM-SV40, was developed from a pediatric recurrent OM patient. The culture was exposed to E2 at physiological levels for 1–48 h prior to 6 h-stimulation with nontypeable Haemophilus influenzae (NTHi) whole cell lysate. TNFA, IL1B, IL6, and IL8 were assayed by qPCR and ELISA.
ResultsE2 pretreatment (24 h) abrogated NTHi induction of IL6; a longer pretreatment (1–10 nM, 48 h) abrogated IL1B induction (p < 0.05). E2 pretreatment (5 nM, 48 h) abrogated NTHi-induced IL8 secretion (p = 0.017).
ConclusionE2 pretreatment partially rescued NTHi-induced cytokine production by ME epithelia. These data support a role for E2 in moderating the excessive inflammatory response to middle ear infection that contributes to OM pathophysiology.
Levels of EvidenceNA Laryngoscope, 2024

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Decrease in Rates of Hearing Loss From Pediatric Bacterial Meningitis Over Time: A Database Review

Sarah Ann Gitomer, Juri Boguniewicz, Suhong Tong, Drew C. Gottman, Scott Hirsch, Brian William Herrmann

Publication date 24-02-2024


Treatment and prevention of bacterial meningitis have improved over time, but we have not re-evaluated neurologic outcomes of this disease recently. In this large, 12-year database review including over 6000 children with bacterial meningitis, S. pneumoniae, H. influenzae, and N. meningiditis remain most commonly associated with hearing loss, and dexamethasone is not associated with improved hearing outcomes. Both rates of mortality and hearing loss have improved over time, but remain high (2.1% and 4.5%, respectively).
Objectives Bacterial meningitis is a leading cause of acquired sensorineural hearing loss (SNHL). Treatment and prevention of bacterial meningitis have improved over time, but rates of neurologic complications have not been recently studied. The objective here is to present an updated population-based review of hearing loss as a sequela of bacterial meningitis.
MethodsA retrospective cohort study was conducted between 2010 and 2022 of children discharged with bacterial meningitis, using the Pediatric Health Information Systems (PHIS) database. Rates of hearing loss and mortality were evaluated over time.
ResultsA total of 6138 children with a primary diagnosis of bacterial meningitis were identified (3520 male 57.3%, mean age 5.8 months 2.0, 61.2). Of these, 277 (4.51%) were diagnosed with hearing loss. Children with hearing loss were significantly older (23.6 vs. 5.3 months, p < 0.01), but differences in gender, race, or ethnicity had no association with hearing loss. Streptococcus pneumoniae, Hemophilus influenzae, and Neisseria meningiditis were associated with significantly higher rates of hearing loss than other etiologies (p < 0.01). Children with hearing loss had a higher rate of receiving dexamethasone than children without hearing loss. Overall mortality rate was 2.1%. Hearing loss and mortality demonstrated significant decreases over the study period.
Conclusion Hearing loss remains a common sequela of bacterial meningitis despite widespread uptake of vaccines for preventing S. pneumoniae, H. influenzae, and N. meningitidis. Dexamethasone was not associated with decreased rates of hearing loss in this cohort. From 2010 to 2022, there was a significant decrease in overall rates of mortality and hearing loss for children with bacterial meningitis.
Level of Evidence Level 3: retrospective case–control series Laryngoscope, 2024

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

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

Publication date 24-02-2024


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

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Total Laryngectomy for Respiratory Complications From Advanced Duchenne Muscular Dystrophy

John Peleman, Jared S. Lin, Ho‐Sheng Lin

Publication date 24-02-2024


Due to respiratory weakness, late-stage Duchenne muscular dystrophy (DMD) patients may suffer from chronic aspiration, which is sometimes treated using tracheostomy. However, definitive laryngectomy has not been described in the literature as an aspiration prevention modality in DMD, especially in patients with contraindications to tracheostomy. A case is presented for a patient with advanced stage Duchenne muscular dystrophy suffering from chronic aspiration pneumonia and excessive oral secretions who became ventilator dependent. A tracheostomy was placed, but was noted to have excessive secretions and high cuff pressures, which have been known to be associated with worsened swallow dysfunction as well as tracheoinnominate fistula. The patient therefore was considered for total laryngectomy, which he underwent successfully. Post-operatively, the patient was noted to have improved subjective quality of life, engaged in an oral diet, and had less secretions surrounding his tracheostoma post-operatively. Aspiration prevention surgeries are done to improve quality of life by improving oral intake, decreasing the need for frequent suctioning, and can sometimes allow for speech. It is important to consider quality of life for DMD patients as more of these patients are living into their 30s with the aid of mechanical ventilation. Laryngectomy is a surgery that can definitively correct chronic aspiration while allowing for oral intake. Laryngoscope, 2024

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A Prognostic Model for Cancer‐Specific Survival Among Patients with Nodular Melanoma in Head and Neck

Fangli Fan, Juxiang Gou, Shulian Li, Qiang Ji

Publication date 24-02-2024


This study identified independent prognostic factors associated with CSS in NM patients in the head and neck and developed a nomogram that accurately predicts CSS probabilities at different time points. The nomogram holds great potential as a clinical tool for risk stratification, treatment decision-making, and patient counseling. Overall, these findings contribute to advancing the understanding and management of CSS in NM patients, ultimately leading to improved outcomes and quality of life.
Objectives This study aims to evaluate the correlation between risk factors and treatment methods affecting nodular melanoma (NM) in the head and neck, as well as cancer-specific survival (CSS), and provide personalized predictive tools for clinical physicians.
Methods The retrospective study data of 1848 patients were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. All variables were included in the correlation analysis using the Spearman method. Significant prognostic factors were extracted and integrated through Cox risk regression analysis to construct a nomogram. To assess the performance of the nomogram, Harrells concordance index (C-index) and a receiver operating characteristic (ROC) curve analysis were employed.
Results Spearmans correlation analysis revealed a positive correlation between radiotherapy and lymph node metastasis, whereas chemotherapy showed a stronger association with distant metastasis. However, Cox risk regression analysis demonstrated that Mohs surgery and wide excision with margins exceeding 1 cm yielded substantial therapeutic advantages. Five independent risk prognostic factors (Breslow thickness, ulceration, N classification, M classification, and surgery type) were employed to construct a nomogram. The C-index for this nomogram was 0.713 for the training set and 0.720 for the validation set. In the training set, the 3-, 5-, and 8-year areas under the curve (AUCs) for CSS were 0.752, 0.723, and 0.720, whereas the validation sets AUCs were 0.754, 0.763, and 0.760, respectively. Calibration curves indicated the nomograms strong discriminative ability for predicting CSS.
Conclusion In this study, we identified independent prognostic factors for patients with NM in head and neck and developed a relatively accurate model to predict the survival probability of them, which could contribute to the tumor assessment and clinical decision-making.
Level of Evidence Level 3 Laryngoscope, 2024

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The Association Between Obesity and Spontaneous Temporal Bone CSF Leak Outcomes: A Systematic Review and Meta‐Analysis

Dimitrios Spinos, Georgios Geropoulos, Georgios Vavoulis, Georgios Georgountzos, Manthia Papageorgakopoulou, Nina Rafailia Karela, Panagiotis Varoutis, Kyriacos Evangelou, Wai Sum Cho

Publication date 24-02-2024


This is a systematic review and meta-analysis on the impact of increased body mass index (BMI) in the presentation and outcomes of spontaneous cerebrospinal fluid (sCSF) leaks of the lateral skull base. Reviewing the current literature, there is no evidence of adverse outcomes of surgical repair on patients with high BMI, nor do they have more extensive disease on their initial presentation. There is not enough evidence supporting the routine use of lumbar drains in either group of patients.
Objective We undertook a systematic review of the literature with meta-analysis to identify the role of obesity (BMI ≥30) in the patient characteristics presenting with spontaneous cerebrospinal fluid (sCSF) leaks of the lateral skull base and the outcomes of their repair.
Data SourcesA Systematic Review of English Articles using MEDLINE, EMBASE, and Cochrane Library.
Review Methods The research algorithm included the following keywords: “spontaneous CSF leak,” “lateral skull base,” “temporal bone,” “meningocele,” “encephalocele,” and “otorrhea.” We also manually searched the references of included studies, to identify possible studies missed during our literature search.
Results More than two-thirds of the patients were female (69.2%) and often were obese (mean BMI 36.5 kg/m2) with a mean age of 57. Most common presenting symptoms were otorrhea and hearing loss. Most authors did not report a routine use of a post-operative lumbar drain. Most patients had a single skull base defect and encephaloceles prolapsing through, across obese and non-obese groups. Median length of stay in hospital was 3.2 days, and the majority of patients did not have any recurrence during their follow-up (89.6%), which was not affected by obesity.
Conclusion Obesity does not affect length of hospital stay or recurrence rate following surgical repair of lateral skull base sCSF leaks. Surgical repair is a safe and viable approach in the management of obese patients with sCSF leaks in the temporal bone.
Level of EvidenceN/A Laryngoscope, 2024

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Choice of Adjuvant Radiotherapy Facility in Major Salivary Gland Cancer

Aman M. Patel, Afash Haleem, Russell Maxwell, John N. Lukens, Alexander Lin, Robert M. Brody, Jason A. Brant, Ryan M. Carey

Publication date 24-02-2024


Undergoing surgery and adjuvant radiotherapy at the same academic facility is associated with higher overall survival in major salivary gland cancer. Academic physicians should consider same-facility treatment for complex patients who would most benefit from clear multidisciplinary communication.
Objective Undergoing surgery and adjuvant radiotherapy (aRT) at the same facility has been associated with higher overall survival (OS) in head and neck squamous cell carcinoma. Our study investigates whether undergoing surgery and aRT at the same academic facility is associated with higher OS in major salivary gland cancer (MSGC).
Methods The 2006–2018 National Cancer Database was queried for patients with MSGC undergoing surgery at an academic facility and then aRT. Multivariable binary logistic and Cox proportional hazards regression models were implemented.
Results Of 2801 patients satisfying inclusion criteria, 2130 (76.0%) underwent surgery and aRT at the same academic facility. Residence in a less populated area (adjusted odds ratio aOR 1.69, 95% confidence interval CI 1.16–2.45), treatment without adjuvant chemotherapy (aOR 1.97, 95% CI 1.41–2.76), and aRT duration (aOR 1.02, 95% CI 1.01–1.04) were associated with undergoing surgery and aRT at different facilities on multivariable logistic regression adjusting for patient demographics, clinicopathologic features, and adjuvant therapy (p < 0.01). Five-year OS was higher in patients undergoing surgery and aRT at the same academic facility (68.8% vs. 61.9%, p < 0.001). Undergoing surgery and aRT at different facilities remained associated with worse OS on multivariable Cox regression (aHR 1.41, 95% CI 1.10–1.81, p = 0.007).
Conclusion Undergoing surgery and aRT at the same academic facility is associated with higher OS in MSGC. Although undergoing surgery and aRT at the same academic facility is impractical for all patients, academic physicians should consider same-facility treatment for complex patients who would most benefit from clear multidisciplinary communication.
Level of Evidence4 Laryngoscope, 2024

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Relationship between Swallowing Pressure and Saliva Residue on Endoscopic Evaluation in Pharyngeal Dysphagia

Shun‐ichi Chitose, Mioko Fukahori, Takashi Kurita, Sachiyo Hamakawa, Kiminobu Sato, Taikai Kuroiwa, Takeharu Ono, Hirohito Umeno, Kiminori Sato

Publication date 23-02-2024


Amounts of post-swallow saliva residue (SR) in the valleculae and piriform sinuses were classified into four grades using SR scores based on flexible endoscopic evaluation of swallowing (FEES). SR scores and Hyodo scores related to SR were compared with high-resolution manometry pressure data. This study revealed that a higher amount of SR in the valleculae is associated with weaker pharyngeal pressure in pharyngeal dysphagia, especially at the oropharyngeal level.
Objective In pharyngeal dysphagia, poor pharyngeal contraction and upper esophageal sphincter (UES) dysfunction result in post-swallow saliva residue (SR). This study aimed to clarify the relationship between swallowing pressure and SR in the valleculae and piriform sinuses on flexible endoscopic evaluation of swallowing (FEES).
Methods Pharyngeal dysphagia patients with Wallenberg syndrome were included. Amounts of post-swallow SR in the valleculae and piriform sinuses were classified into four grades using SR scores based on FEES. The Hyodo score was also calculated to evaluate swallowing function. High-resolution manometric data in the nasopharyngeal, oropharyngeal, hypopharyngeal, oro-hypopharyngeal, and UES zones on swallowing were obtained for comparison with SR and Hyodo scores.
Results Of the 31 recruited, data from 26 patients who successfully underwent FEES and manometry were analyzed. Vallecular SR scores were strongly negatively correlated with a maximum pressure of the oropharynx (r = −0.52, p = 0.006), distal contractile integrals (DCI) of the oropharynx (r = −0.52, p = 0.007), and DCI of the oro-hypopharynx (r = −0.55, p = 0.004). Hyodo scores for parameters 1 and 4 (corresponding to salivary pooling and pharyngeal clearance, respectively) were strongly negatively correlated with a maximum hypopharyngeal pressure (r = −0.57, p = 0.002) and strongly positively correlated with peristaltic velocity (r = 0.53, p = 0.007), respectively. SR scores and Hyodo scores related to SR were not correlated with pressure data of the UES.
Conclusion Manometric analysis of our SR scoring method using FEES revealed that a higher amount of SR in the valleculae, but not in the piriform sinuses, is associated with weaker pharyngeal pressure in pharyngeal dysphagia, especially at the oropharyngeal level.
Level of Evidence4 Laryngoscope, 2024

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Timing of Complications in Open Airway Reconstruction

"Elizabeth A. Shuman, Yun J. Kim, Jack Rodman, Karla ODell"

Publication date 23-02-2024


A retrospective review of 69 tracheal and cricotracheal resections at a single institution was performed; nature and timing of complications—including hematoma, anastomotic dehiscence, reintubation, revision tracheostomy, and death—were reviewed. Most complications occur within 8 days of surgery, and restenosis usually occurs within 1–3 months post-operatively.
Objective Tracheal resection (TR) and cricotracheal resection (CTR) are performed for patients with airway stenosis, tracheal tumor, and tracheoesophageal fistula. Post-operative complications include airway edema requiring reintubation, hematoma, anastomotic dehiscence, restenosis, and death. Although these complications and associated risk factors have been well described, the time where clinical suspicion should be highest post operatively has not been characterized.
Methods Patients who underwent TR or CTR at a single center between 2015 and 2022 were reviewed. Variables including demographics and comorbidities were recorded. Rate, nature, and time in days of post-operative complications were evaluated.
Results Sixty-nine cases were reviewed. Average patient age was 46.8 years old and 63.8% were male. The average follow-up period was 625 ± 724 days. 19 (27.5%) patients experienced one or more major complications including four (5.8%) who died. Eight (11.6%) patients required reintubation and 4 (5.8%) patients underwent revision tracheostomy. Most complications occurred within 8 days of surgery. Restenosis was noted an average of 42.6 days after surgery, with no new restenosis occurring after 3 months.
Conclusions In this single-center study, most post-operative complications after TR or CTR, including hematoma and anastomotic dehiscence, occurred within 8 days post-operatively. Restenosis was noted approximately 1–3 months after surgery. This may inform clinical decision-making regarding patient monitoring and surveillance after open airway surgery.
Level of Evidence4 Laryngoscope, 2024

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The Role of Steroids in the Preservation of Hearing and Vestibular Function in Cochlear Implantation

"Catarina Pimentel de Morais, Pedro Branco, André Pereira, Luís Castelhano, Mariana Donato, Filipe Correia, Assunção ONeill, Ricardo Santos, Pedro Escada"

Publication date 21-02-2024


A systematic review was conducted to evaluate the benefit of perioperative steroids in cochlear implantation. In 12 out of 15 studies, a tendency towards greater hearing preservation and vestibular function in patients who underwent perioperative steroids was observed. Topical steroids appear to have the best risk–benefit profile, given the absence of adverse effects.
Objective Cochlear implant surgery is guided by principles of atraumatic insertion as to protect the inner ear. Previous studies suggest the potential benefit of steroids in patients undergoing cochlear implantation (CI), although the optimal route of administration has yet to be determined. We aim to systematically review the human studies of hearing and vestibular function preservation in patients undergoing CI receiving perioperative steroids and to discuss their role.
Data Sources Search performed in Pub Med, EMBASE, and CENTRAL databases in December 2023.
Review Methods Studies comparing several methods of steroid delivery and conventional management for patients undergoing CI were identified. Primary outcomes included hearing and vestibular function preservation. Secondary outcomes included reported adverse events, routes of steroid administration, and the presence of a control group without steroid administration.
ResultsA total of 15 studies (N = 659) met inclusion criteria. Methodology, doses, route of steroid administration, and follow-up duration differed between most studies. Audiometric, vestibular, and hearing preservation (HP) results were inconsistent. In 12 studies, perioperative steroids were associated with either increased HP or vestibular function preservation. Only two studies reported adverse events related to oral corticosteroid therapy.
Conclusions There is a tendency for perioperative steroids to have a positive impact, at least in the short term, on hearing and vestibular function preservation in CI. Topical corticosteroid therapy appears to have a superior risk–benefit profile. There is a need for future carefully designed randomized controlled trials to determine the ideal route of steroid administration and its real impact in the long term. Laryngoscope, 2024

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Bilateral Concha Bullosa Within Concha Bullosa: Unique Middle Concha Variation

M. İhsan Gülmez, Mustafa Emrah Kaya

Publication date 21-02-2024


Concha bullosa can be defined as the presence of an air gap inside the turbinate. It is the most common middle turbinate variation. It is often asymptomatic, but can sometimes cause nasal obstruction. In this study, an asymptomatic case with concha bullosa within concha bullosa in both middle turbinates, which has not been reported before in the literature, is presented.
The middle nasal turbinate is an important anatomical formation located on the lateral nasal wall. Concha bullosa can be defined as the presence of an air gap inside the turbinate. It is the most common middle nasal turbinate variation. It is often asymptomatic, but can sometimes cause nasal obstruction. In this study, an asymptomatic patient with concha bullosa within concha bullosa in both middle turbinates, which has not been reported before in the literature, is presented. Laryngoscope, 2024

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In Response to The Implications of AI Photo Enhancers in Facial Plastic and Reconstructive Surgery

Adam McCann, Neha Garg, Eric Fei, Meryem Guler, Ryan Heffelfinger

Publication date 21-02-2024


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

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

Publication date 21-02-2024


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

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

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

Publication date 21-02-2024


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

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

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

Publication date 20-02-2024


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

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Environmental Impact of a Direct Laryngoscopy: Opportunities for Pollution Mitigation

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

Publication date 20-02-2024


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

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Efficacy of Adjuvant Sublingual Immunotherapy After Septomeatoplasty

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

Publication date 19-02-2024


Sublingual immunotherapy(SLIT) may serve as an ideal adjuvant therapy after septomeatoplasty in patients with allergic rhinitis (AR), providing beneficial effects within a short timeframe. SLIT may prevent recurrence of AR symptoms, especially sneezing.
Background The efficacy of adjuvant sublingual immunotherapy (SLIT) in correcting structural problems in patients with allergic rhinitis (AR) caused by mite who have undergone septomeatoplasty (SMP) has not been studied.
Methods This non-randomized controlled study recruited patients with AR (caused by mite) and concurrent septal deviation and inferior turbinate hypertrophy, at a tertiary hospital in Taiwan. SMP was performed on all patients as a surgical intervention.
The patients were then divided into two groups: the control group, which underwent surgery only, and the experimental group, which received SLIT as an adjuvant treatment. Demographic data and rhinitis control assessment test (RCAT) results were analyzed.
ResultsA total of 96 patients were enrolled in the study (SMP + SLIT group, n = 52; SMP only group, n = 44). No significant differences were observed in any of the variables between the two groups before and one month after surgery. However, during evaluations at the third and sixth month, the SMP + SLIT group showed significant improvement in the total RCAT scores compared to the SMP only group (28.6 ± 1.56 vs. 24.5 ± 3.66, p < 0.001; 27.1 ± 2.87 vs. 19.9 ± 5.56, p < 0.001). In addition, significantly better control of all RCAT sub-categories was observed in the SMP + SLIT group at the third and sixth month evaluations.
ConclusionsSLIT may serve as an ideal adjuvant therapy after SMP in patients with AR.
Level of Evidence Level 3 Laryngoscope, 2024

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Decisional Conflict in Patients with Advanced Laryngeal Carcinoma: A Multicenter Study

Anne N. Heirman, Daan P. de Kort, Japke F. Petersen, Abrahim Al‐Mamgani, Simone E.J. Eerenstein, Bertram J. de Kleijn, Frank Hoebers, Bernard M. Tijink, Martijn M. Stuiver, Lisette van der Molen, Richard Dirven, Gyorgy B. Halmos, Michiel W.M. van den Brekel

Publication date 17-02-2024


Most patients with advanced larynx cancer experience high levels of Decisional Conflict. Low knowledge levels regarding treatment aspects indicate a need for better patient counseling.
Objectives Decision-making for patients with a locally advanced laryngeal carcinoma (T3 and T4) is challenging due to the treatment choice between organ preservation and laryngectomy, both with different and high impact on function and quality of life (QoL). The complexity of these treatment decisions and their possible consequences might lead to decisional conflict (DC). This study aimed to explore the level of DC in locally advanced laryngeal carcinoma patients facing curative decision-making, and to identify possible associated factors.
Methods In this multicenter prospective cohort study, participants completed questionnaires on DC, level of shared decision-making (SDM), and a knowledge test directly after counseling and 6 months after treatment. Descriptive statistics and Spearman correlation tests were used to analyze the data.
Results Directly after counseling, almost all participants (44/45; 98%) experienced Clinically Significant DC score (CSDC >25, scale 0–100). On average, patients scored 47% (SD 20%) correct on the knowledge test. Questions related to radiotherapy were answered best (69%, SD 29%), whilst only 35% (SD 29%) of the questions related to laryngectomy were answered correctly. Patients perceived level of SDM (scale 0–100) was 70 (mean, SD 16.2), and for physicians this was 70 (SD 1.7).
Conclusion Most patients with advanced larynx cancer experience high levels of DC. Low knowledge levels regarding treatment aspects indicate a need for better patient counseling.
Level of Evidence Level IV Laryngoscope, 2024

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Automated Detection of Pediatric Foreign Body Aspiration from Chest X‐rays Using Machine Learning

Brandon Truong, Matthew Zapala, Bamidele Kammen, Kimberly Luu

Publication date 17-02-2024


Standard chest radiographs are a poor diagnostic tool for pediatric foreign body aspiration. Machine learning may improve upon the diagnostic capabilities of chest radiographs. Chest radiograph analysis augmented with machine learning can diagnose foreign body aspiration in pediatric patients at a level similar to a read performed by a pediatric radiologist despite only using single-view, fixed images.
Objective/Hypothesis Standard chest radiographs are a poor diagnostic tool for pediatric foreign body aspiration. Machine learning may improve upon the diagnostic capabilities of chest radiographs. The objective is to develop a machine learning algorithm that improves the diagnostic capabilities of chest radiographs in pediatric foreign body aspiration.
Method This retrospective, diagnostic study included a retrospective chart review of patients with a potential diagnosis of FBA from 2010 to 2020. Frontal view chest radiographs were extracted, processed, and uploaded to Google AutoML Vision. The developed algorithm was then evaluated against a pediatric radiologist.
Results The study selected 566 patients who were presented with a suspected diagnosis of foreign body aspiration. One thousand six hundred and eighty eight chest radiograph images were collected. The sensitivity and specificity of the radiologist interpretation were 50.6% (43.1–58.0) and 88.7% (85.3–91.5), respectively. The sensitivity and specificity of the algorithm were 66.7% (43.0–85.4) and 95.3% (90.6–98.1), respectively. The precision and recall of the algorithm were both 91.8% with an AuPRC of 98.3%.
Conclusion Chest radiograph analysis augmented with machine learning can diagnose foreign body aspiration in pediatric patients at a level similar to a read performed by a pediatric radiologist despite only using single-view, fixed images. Overall, this study highlights the potential and capabilities of machine learning in diagnosing conditions with a wide range of clinical presentations.
Level of Evidence3 Laryngoscope, 2024

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"Association Between Vestibular Aqueduct Morphology and Menieres Disease"

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

Publication date 17-02-2024


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

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

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

Publication date 17-02-2024


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

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Cost Analysis of High‐Signal Approach in Otolaryngology‐Head and Neck Surgery Residency

Taylor S. Erickson, Brooke R. Warren, Steven D. Pletcher

Publication date 17-02-2024


Objective The objective of this study is to analyze a high-signal approach for otolaryngology-head and neck surgery (OHNS) residency applicants and calculate cost savings for programs and applicants.
Methods Data from both the 2022–2024 Electronic Residency Application Service (ERAS) and a data model were used to demonstrate cost savings with a high-signal approach. Modeled data assumed that the number of applications per applicant would be equal to the number of signals allowed. Predicted and real-world cost savings across the five other specialties participating in a high-signal approach were calculated.
ResultsERAS data cost savings for the entire OHNS applicant pool amounted to $365,950. In the modeled data, cost savings amounted to $825,921. When extrapolated to include all five high-signal specialties, total cost savings amounted to $2,570,464 (ERAS data) and $6,359,478 (modeled data). Otolaryngology programs were predicted to experience significant time savings, resulting in cost savings of $437,883 and $1,113,342 for ERAS data and modeled data, respectively.
Conclusions The study highlights the advantages of a high-signal approach, including financial advantages or increased time for programs to engage in holistic review and diversify the pool of interview candidates. Cost savings in this study were shown to be significant when extrapolated across all specialties using a high-signal approach. Further research is needed to optimize the signaling system and confirm the favorable interview distribution and equity data from the low-signal OHNS experience with a high-signal approach.
Level of EvidenceN/A Laryngoscope, 2024

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Patterns of Olfactory Impairment Among Patients with Uncontrolled Chronic Rhinosinusitis

Junsheng Hong, Zhenlin Wang, Dawei Wu

Publication date 16-02-2024


Objectives Self-reported olfactory dysfunction is an assessment component criterion for chronic rhinosinusitis (CRS) disease control of the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS). No studies have objectively explored olfactory function across different psychophysical olfactory domains among patients with uncontrolled CRS. We aimed to investigate the patterns of olfactory impairment in patients with uncontrolled CRS with Sniffin Sticks test.
MethodsA total of 79 patients with CRS were prospectively recruited and assessed for disease control based on the EPOS criteria. Sniffin Sticks test scores, olfactory cleft computed tomography (CT) scores, olfactory cleft endoscopy scale (OCES), questionnaire of olfactory disorders-negative statements (QOD-NS), and sinonasal outcome test-22 (SNOT-22) were obtained. Multiple logistic regression was applied to explore risk factors of uncontrolled CRS.
Results Twenty-six percent of patients with CRS presented with uncontrolled status. The odor threshold (OT) (p = 0.005), odor identification (OI) (p = 0.041), and thresholds-discrimination-identification (TDI) (p = 0.029) scores were significantly lower in patients with uncontrolled CRS when compared with patients with controlled CRS. Furthermore, patients with uncontrolled CRS presented with a significantly increased percentage of anosmia (p = 0.014), olfactory cleft CT score (p = 0.038), OCES (p = 0.016), QOD-NS(p = 0.008), and SNOT-22 (p < 0.001) scores than patients with controlled CRS. After adjusting for patient demographics, as for the subdomain of olfaction, only the OT score was an independent risk factor for uncontrolled CRS (odds ratio = 0.604; p = 0.030). The OT scores less than 5.950 were the best predictor of uncontrolled CRS.
Conclusion Patients with uncontrolled CRS demonstrated distinct patterns of olfactory impairment, and a reduced olfactory threshold was highly associated with uncontrolled CRS.
Level of Evidence3 Laryngoscope, 2024

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Reconstruction of Vocal Fold Medial Surface 3D Trajectories: Effects of Neuromuscular Stimulation and Airflow

Patrick Schlegel, Hye Rhyn Chung, Michael Döllinger, Dinesh K. Chhetri

Publication date 16-02-2024


We analyzed vocal fold vibration as a function of neuromuscular stimulation and airflow levels. Oscillation patterns such as figure-eight and bent trajectories were linked to high nerve activation and flow. Further studies investigating longer sections of 3D reconstructed oscillations are needed to validate our findings.
Introduction Analysis of medial surface dynamics of the vocal folds (VF) is critical to understanding voice production and treatment of voice disorders. We analyzed VF medial surface vibratory dynamics, evaluating the effects of airflow and nerve stimulation using 3D reconstruction and empirical eigenfunctions (EEF).
Study Design In vivo canine hemilarynx phonation.
Methods An in vivo canine hemilarynx was phonated while graded stimulation of the recurrent and superior laryngeal nerves (RLN and SLN) was performed. For each phonatory condition, vibratory cycles were 3D reconstructed from tattooed landmarks on the VF medial surface at low, medium, and high airflows. Parameters describing medial surface trajectory shape were calculated, and underlying patterns were emphasized using EEFs. Fundamental frequency and smoothed cepstral peak prominence (CPPS) were calculated from acoustic data.
Results Convex-hull area of landmark trajectories increased with increasing flow and decreasing nerve activation level. Trajectory shapes observed included circular, ellipsoid, bent, and figure-eight. They were more circular on the superior and anterior VF, and more elliptical and line-like on the inferior and posterior VF. The EEFs capturing synchronal opening and closing (EEF1) and alternating convergent/divergent (EEF2) glottis shapes were mostly unaffected by flow and nerve stimulation levels. CPPS increased with higher airflow except for low RLN activation and very dominant SLN stimulation.
Conclusion We analyzed VF vibration as a function of neuromuscular stimulation and airflow levels. Oscillation patterns such as figure-eight and bent trajectories were linked to high nerve activation and flow. Further studies investigating longer sections of 3D reconstructed oscillations are needed.
Level of EvidenceN/A, Basic Science Laryngoscope, 134:1249–1257, 2024

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Management of Newborn Traumatic Nasal Deformity with a Nostril Retainer

Alyssa M. Civantos, Jacquelyn Callander, Josephine Czechowicz, Lia Jacobson, Kristina W. Rosbe

Publication date 16-02-2024


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Thoracic Duct Occlusion Leading to Intermittent Left Supraclavicular Swelling and Pancreatitis

Nikitha Jona, Bill S. Majdalany, Adam M. Klein

Publication date 16-02-2024


This case study focuses on a patient presenting with left supraclavicular swelling, dysphagia, and abdominal pain and found to have thoracic duct occupation after a lymphatic workup.
Intermittent left supraclavicular swelling is an uncommon and elusive condition that can lead to extensive diagnostic workups to determine the etiology and treatment. One potential cause is partial, intermittent, or complete thoracic duct occlusion (TDO). We report on a patient who presented with chronic, intermittent left supraclavicular swelling and abdominal pain that was relieved by thoracic duct angioplasty. Thoracic duct occlusion should be included in the differential diagnosis of left supraclavicular swelling. Lymphatic imaging can facilitate the diagnosis and allows for potential percutaneous treatment. Laryngoscope, 134:1313–1315, 2024

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Life‐Threatening Subglottic Thrombus Formation after Administration of Nebulized Tranexamic Acid

Andrew Awadallah, Michael Armstrong, Aisha Aden, Joshua Weidermann, Semirra L. Bayan, Dale C. Ekbom

Publication date 16-02-2024


We present a case of subglottic thrombus formation after administration of nebulized tranexamic acid (TXA) for postoperative hemoptysis following CO2 laser wedge excision of subglottic stenosis. Although other factors certainly could have resulted in postoperative bleeding and subsequent thrombus formation, the patients rapid decompensation following administration of nebulized TXA suggests a direct effect. We recommend implementing an airway action plan regarding TXA use for patients presenting to the emergency department with postoperative hemorrhage following otolaryngology procedures. Laryngoscope, 134:1356–1358, 2024

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Management of Tracheobronchial Stenosis in Chondrodysplasia Punctata

Joshua A. Lee, Krupa R. Patel, Alyssa J. Smith, Dana M. Thompson

Publication date 16-02-2024


Chondrodysplasia punctata featuring abnormal tracheobronchial calcification presents a rare and complex clinical scenario. Although the management of multilevel airway stenosis in this setting is not well described, tracheal dilation is a feasible surgical intervention.
Chondrodysplasia punctata (CDP) is a rare congenital syndrome characterized by aberrant, punctate deposition of calcium during endochondral bone formation, resulting in the characteristic finding of epiphyseal stippling on radiographs. While otolaryngologic manifestations such as nasomaxillary hypoplasia and mixed hearing loss are common, tracheobronchial calcification occurs rarely in neonates with CDP. The management of CDP-related airway stenosis is complex and there is limited literature pertaining to outcomes of airway interventions. Herein, we describe the clinical course and outcome of tracheal dilation for a newborn patient with CDP. Laryngoscope, 134:1464–1468, 2024

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A Minimally Invasive Endoscopic Transnasal and Transorbital Approach to Sinonasal Tumor Resection

Kendall Goodyear, Kelsey A. Roelofs, Brooke M. Su‐Velez, Liza M. Cohen, Kumkum Vadehra, Daniel M. Beswick, Daniel B. Rootman

Publication date 16-02-2024


A 35-year-old female with an extensive biphenotypic sinonasal sarcoma (BSNS) eroding through the left frontal sinus into the orbit required gross total resection of the tumor. We wanted to forgo an open approach and provide a less invasive alternative via combined endonasal and transorbital endoscopic techniques to allow for tumor removal through small, well-disguised incisions. We utilized three portals—nasal, transorbital, and anterior table window—to create interconnected orbit–sinonasal corridors, thus generating alternate pathways for visualization and manipulation of this extensive tumor. Laryngoscope, 134:1308–1312, 2024

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3D‐4K Exoscope‐Assisted CO2 Laser Supraglottoplasty for Severe Laryngomalacia in a Pediatric Patient

Michele Gaffuri, Ludovica Battilocchi, Simona Neri, Francesca Fraccaroli, Davide Tosini, Lorenzo Maria Gaini, Giovanna Cantarella, Lorenzo Pignataro

Publication date 16-02-2024


Laryngomalacia is the most frequent congenital laryngeal anomaly. Surgery is possible by means of cold knife, carbon dioxide (CO2) laser, microdebrider and coblation, traditionally under microscopic view. We here describe the use of the 3D-4K exoscope assisted CO2 laser supraglottoplasty in tubeless general anesthesia in spontaneous breathing in a 5 month-old patient with severe laryngomalacia. Laryngoscope, 134:1359–1362, 2024

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Glomangiopericytoma Presenting as a Middle Ear Mass

George S. Liu, Gerald J. Berry, Scott G. Soltys, Nikolas H. Blevins

Publication date 16-02-2024


Glomangiopericytomas (GPCs) have rarely been reported to present outside the sinonasal cavity. We share our experience with managing a challenging, multiply recurrent GPC primary tumor in the middle ear with surgery and stereotactic radiosurgery. To our knowledge, this is the first description in the English language literature of GPC presenting as a temporal bone primary tumor.
We describe an unusual case of glomangiopericytoma presenting as a mass filling the middle ear, enveloping the ossicles, and extending into the mastoid antrum without bony destruction. Management involved three surgeries and stereotactic radiosurgery, which achieved short-term local control with no evidence of disease on MRI imaging 12 months after radiation. Facial nerve function and hearing were preserved. This is the first report to our knowledge of a glomangiopericytoma presenting as a primary temporal bone lesion. Treatment with surgery and stereotactic radiosurgery for residual or recurrent disease is a reasonable approach to achieve local control and functional preservation. Laryngoscope, 134:1426–1430, 2024

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Laryngeal Manifestations of the Human Monkeypox Virus

Victor B. Hsue, Kaitlynne Pak, Estelle Viaud‐Murat, Martin L. Hopp, Anca M. Barbu

Publication date 16-02-2024


An HIV+ patient presented with human monkeypox and ENT was consulted to rule out a deep neck abscess. Flexible nasopharyngolaryngoscopy showed severe laryngeal edema and new findings consistent with laryngeal HMPX. The patient was monitored for a potential difficult airway situation, started on appropriate treatment, and showed symptom resolution. Laryngoscope, 134:1340–1342, 2024

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A Dynamic Endonasal Columellar Strut Placement

Jose R. Sanchez‐Perez, Edgar F. del Toro‐Diez, Soraya Abdul‐Hadi, Jorge Aldrich‐Novoa

Publication date 16-02-2024


The dynamic retrograde intercrural columellar strut graft placement is a novel technique for a columellar strut insertion via a hemi-transfixion incision in patients undergoing endonasal functional or cosmetic surgery. It has a maximally concealed incision and does not disrupt major or minor tip support mechanisms. In our article, we give a detailed description of this unique surgical technique. Laryngoscope, 134:1246–1248, 2024

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Masthead

Publication date 16-02-2024


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Table of contents

Publication date 16-02-2024


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Utilizing Histopathology to Predict Success with Macrolide Therapy in CRS Patients

Alan D. Workman, Jeremy Chang, David K. Lerner, Jadyn Wilensky, Kathleen T. Montone, John V. Bosso, James N. Palmer, Nithin D. Adappa, Michael A. Kohanski

Publication date 16-02-2024


There is currently interest regarding CRSsNP patients with refractory symptomatology following functional endoscopic sinus surgery, and which of these patients can derive benefit from low-dose macrolide therapy. In the present study, we analyze a cohort of over fifty CRSsNP patients on macrolide therapy; structured histopathological findings at the time of surgery were analyzed against the success of macrolide treatment. Independently, fibrosis, absence of squamous metaplasia, absence of eosinophilia, presence of neutrophilic infiltrate, and lymphoplasmocytic predominance were all associated with objective success of macrolide treatment; these findings may allow clinicians to more appropriately select patients for this therapy.

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Surgical Management of Airway Stenosis During Pregnancy: A Scoping Review

Katherine M. Miller, Kevin Y. Liang, Neil Nero, Michael S. Benninger, Rebecca C. Nelson, William S. Tierney, Robert R. Lorenz, Paul C. Bryson

Publication date 16-02-2024


This scoping review examines the available literature surrounding the management of subglottic and airway stenosis in pregnancy. It demonstrates that airway dilatations have been performed safely in the second and third trimesters. It also shows that airway managements typically results in a healthy and term delivery.
Objective There are several options for surgical management of subglottic stenosis, including endoscopic and open procedures. However, treatment algorithms, outcomes, and anesthetic management of subglottic stenosis during pregnancy are not well described.
Data SourcesMEDLINE, EMBASE, and the Cochrane databases.
Review MethodsA scoping review of management of subglottic stenosis during pregnancy was performed, and then reported in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria consisted of those with subglottic or tracheal stenosis aged greater than 18 years, those in whom management was performed during pregnancy, and those who reported delivery related outcomes.
Results After systematic review and detailed search of 330 identified articles, 15 articles met inclusion criteria and were included in the final analysis. All studies were case reports or case series (level 4 evidence). This study identified 27 patients. The median age was 29 and the median gestational age at intervention was 28 weeks. Left lateral positioning and fetal heart rate monitoring were used in nearly every case. The most common intervention performed was endoscopic balloon dilation. In many cases, jet ventilation or transnasal humidified rapid insufflation ventilatory exchange was satisfactory for maintenance of the airway. Three women ultimately required tracheostomy prior to labor and delivery. There was no fetal death or complications reported in these studies, and all but one woman proceeded to deliver at term.
Conclusion Endoscopic balloon dilation during pregnancy is safe and effective, resulting in optimized respiratory outcomes for the mother and safe delivery of the fetus. The third trimester appears to be safe for airway intervention. Laryngoscope, 134:1014–1022, 2024

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Isolated Fracture of the Malleus: An Overlooked Cause of Conductive Hearing Loss?

Benjamin D. Lovin, Joshua Cody Page, Eric N. Appelbaum, Daniel Gorelik, Kenny F. Lin, Jeffrey T. Vrabec

Publication date 16-02-2024


Retrospective cohort review and systematic review demonstrate that isolated malleus fractures appear to occur more often than historical data may suggest. Conductive hearing loss with air-bone gap (ABG) greater at higher frequencies is most often observed. Observation is unlikely to produce spontaneous improvements in hearing, while surgery demonstrates reliable decreases in ABG.
Objective To report the largest case series of isolated malleus fractures with systematic review to characterize the diseases presentation and natural history, and provide suggestions for management.
Data Sources Pub Med, Embase, Cochrane Library.
Review Methods Retrospective cohort study was performed on 12 patients with isolated malleus fractures. History, physical exam, pre- and post-treatment audiograms, and imaging were obtained. Systematic review of the literature was performed.
Results Including the cases herein, 58 isolated malleus fractures were identified, the majority of which were published in the 21st century. Mean time to presentation after injury was 34.4 months. Most common etiology was external auditory canal (EAC) manipulation. Physical exam and imaging did not identify any abnormality at presentation in 16% and 21% of cases, respectively. The majority of fractures involved the manubrium. Air-bone gap (ABG) at initial presentation ranged from 16 to 26 dB, and was greater at higher frequencies. Thirty-six cases underwent surgery. ABG improvement was greater at all frequencies for those who underwent surgery. Final ABG was significantly less than initial ABG at nearly every frequency for those who underwent surgery (p < 0.05), while not at any frequency for those who were observed.
Conclusions Isolated malleus fractures may occur more often than historical data suggests, and are perhaps underdiagnosed. Abrupt removal of a finger from the EAC with pain and hearing loss is nearly pathognomonic. Conductive hearing loss with ABG greater at higher frequencies is most often observed. Observation is unlikely to produce spontaneous improvements in hearing, while surgery demonstrates reliable decreases in ABG. Laryngoscope, 134:1032–1041, 2024

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Non‐Type 2 and Mixed Inflammation in Chronic Rhinosinusitis and Lower Airway Disease

Austin Heffernan, Amir Shafiee, Teffran Chan, Sydney Sparanese, Andrew Thamboo

Publication date 16-02-2024


Chronic rhinosinusitis (sinusitis) is an inflammatory disorder with multiple underlying aberrant inflammatory pathways. Patients with sinusitis and a lower airway disease have mixed inflammation or isolated type 1, 2 or 3 inflammation.
Objective The aim was to discuss the role of non-type 2 inflammation in patients diagnosed with chronic rhinosinusitis (CRS) and comorbid lower airway disease.
Data Sources Medline, Embase, National Institute for Health and Care Excellence, TRIP Database, Pro Quest, Clinicaltrials.gov, Cochrane Central Registry of Controlled Trials, Web of Science, government and health organizations, and graduate-level theses.
Review Methods This scoping review followed PRISMA-ScR guidelines. Search strategy was peer-reviewed by medical librarians. Studies were included if they utilized airway sampling, non-type 2 cytokines, and patients with CRS and lower airway disease.
Results Twenty-seven from 7060 articles were included. In patients with CRS and comorbid asthma, aspirin-exacerbated respiratory disease (AERD), and chronic obstructive pulmonary disease (COPD)/bronchiectasis, 60% (n = 12), 33% (n = 2), and 100% (n = 1), respectively, demonstrated mixed or non-type 2 endotypes. Comorbid CRS and asthma produced type 1 (n = 1.5), type 2 (n = 8), type 3 (n = 1), mixed type 1/2 (n = 1), and mixed type 1/2/3 (n = 8.5) endotype shifts. AERD demonstrated type 2 (n = 4), mixed type 2/3 (n = 1), and mixed type 1/2/3 (n = 1) endotype shifts. CRS with COPD or bronchiectasis demonstrated a mixed 1/2 (n = 1) endotype shift.
Conclusion Type 2 disease has been extensively reviewed due to advent biologics targeting type 2 inflammation, but outcomes may be suboptimal due to the presence of non-type 2 inflammation. A proportion of patients with CRS and comorbid lower airway disease demonstrated mixed and non-type 2 endotype shifts. This emphasizes that patients with unified airway disease may have forms of inflammation beyond classical type 2 disease which could inform biologic development. Laryngoscope, 134:1005–1013, 2024

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Molecular Factors in Carcinoma Ex Pleomorphic Adenoma: Systematic Review and Meta‐Analysis

Seraphina Key, Clemente Chia, Zubair Hasan, Purnima Sundaresan, Faruque Riffat, Raghav C. Dwivedi

Publication date 16-02-2024


Systematic review of the molecular literature pertaining to carcinoma ex pleomorphic adenoma (CXPA) shows a high incidence of common therapeutic targets. Limited prognostic and therapeutic discrete data pertaining to CXPA is reported. Future salivary gland malignancy trials may consider treating CXPA as a distinct entity.
Objective Carcinoma ex pleomorphic adenoma (CXPA) is a rare malignant salivary gland tumor. Although multiple reviews have been published on salivary gland malignancies, it has been a decade since the last dedicated systematic review pertaining to CXPA alone was published. This study examines molecular factors in CXPA diagnosis.
Data SourcesMEDLINE, CINAHL, Embase, Scopus, Web of Science (BIOSIS), Cochrane CENTRAL, Health Collection (Informit), OpenDOAR, and Grey Net International.
Review Methods Systematic review and meta-analysis from inception to October 31, 2022 for all English language studies pertaining to “carcinoma ex pleomorphic adenoma.” Predicted incidence of each biomarker was calculated with meta-analysis. Comparison against pleomorphic adenoma (PA) and salivary duct carcinoma (SDC) when reported within the same study are performed. Risk of bias performed with JBI tool for prevalence studies.
Results Of 19151 unique studies undergoing abstract screening, 55 studies (n = 1322 patients) underwent data analysis. Biomarkers with >3 studies were p53, HER2, AR, EGFR, PLAG1, ERBB, ER, PR, HMGA2, p16, p63, a-SMA, RAS, PTEN, PDL1, BRAF, PIK3CA, and c-kit. Highest incidence was seen in AR, EGFR, p16, and p53. Significant differences were demonstrated compared with PA and SDC. There was high heterogeneity and overall high risk of bias within studies.
Conclusion Molecular factors are an area of interest in the diagnosis of CXPA. Our study results support examining CXPA as a discrete cohort in future targeted therapy trials. Laryngoscope, 134:1042–1053, 2024

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Cough Sounds in Screening and Diagnostics: A Scoping Review

Siddhi Hegde, Shreya Sreeram, Isaac L. Alter, Chaya Shor, Tulio A. Valdez, Kara D. Meister, Anaïs Rameau

Publication date 16-02-2024


Cough sound analysis holds the promise of an accessible disease biomarker. We survey efforts in using cough sounds in adult, pediatric, and animal populations and examine evolution in hardware and analytics. Rapid acceleration is noted in the past decade, though with limitations.
Objective The aim of the study was to examine applications of cough sounds towards screening tools and diagnostics in the biomedical and engineering literature, with particular focus on disease types, acoustic data collection protocols, data processing and analytics, accuracy, and limitations.
Data Sources Pub Med, EMBASE, Web of Science, Scopus, Cochrane Library, IEEE Xplore, Engineering Village, and ACM Digital Library were searched from inception to August 2021.
Review MethodsA scoping review was conducted on screening and diagnostic uses of cough sounds in adults, children, and animals, in English peer-reviewed and gray literature of any design.
Results From a total of 438 abstracts screened, 108 articles met inclusion criteria. Human studies were most common (77.8%); the majority focused on adults (57.3%). Single-modality acoustic data collection was most common (71.2%), with few multimodal studies, including plethysmography (15.7%) and clinico-demographic data (7.4%). Data analytics methods were highly variable, with 61.1% using machine learning, the majority of which (78.8%) were published after 2010. Studies commonly focused on cough detection (41.7%) and screening of COVID-19 (11.1%); among pediatric studies, the most common focus was diagnosis of asthma (52.6%).
Conclusion Though the use of cough sounds in diagnostics is not new, academic interest has accelerated in the past decade. Cough sound offers the possibility of an accessible, noninvasive, and low-cost disease biomarker, particularly in the era of rapid development of machine learning capabilities in combination with the ubiquity of cellular technology with high-quality recording capability. However, most cough sound literature hinges on nonstandardized data collection protocols and small, nondiverse, single-modality datasets, with limited external validity. Laryngoscope, 134:1023–1031, 2024

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In reference to Orofacial Myofunctional Therapy for Obstructive Sleep Apnea: A Systematic Review and Meta‐Analysis

Eric J. Kezirian

Publication date 16-02-2024


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In response to Orofacial Myofunctional Therapy for Obstructive Sleep Apnea: A Systematic Review and Meta‐Analysis

Elias S. Saba, Hannah Kim, Pauline Huynh, Nancy Jiang

Publication date 16-02-2024


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Bacteriology of Different Phenotypes of Chronic Rhinosinusitis

Yu‐Ting Li, Shuang‐Shuang Huang, Jia‐Hung Ma, Bing‐Han Hsieh, Yung‐An Tsou, Chia‐Der Lin, Chih‐Jaan Tai, Liang‐Chun Shih

Publication date 16-02-2024


Objectives Chronic rhinosinusitis (CRS) reduces the health-related quality of life and subsequently causes a tremendous socio-economic impact. Although many studies have been conducted, few have identified a relationship between bacteriological characteristics and different phenotypes or endotypes. Therefore, this study aimed to elucidate the recent trends in bacterial cultures from different types of CRS in the Asian population.
Methods This retrospective case–control study recruited patients diagnosed with CRS who underwent functional endoscopic sinus surgery (FESS) at a tertiary hospital in Taiwan. The patients were classified into those with chronic rhinosinusitis with nasal polyps (CRSwNP)/chronic rhinosinusitis without nasal polyps (CRSsNP), eosinophilic chronic rhinosinusitis (eCRS)/non-eosinophilic chronic rhinosinusitis (NECRS), and central compartment atopic disease (CCAD)/lateral-dominant nasal polyp (LDNP) groups. The demographic data and bacteriological characteristics of the groups were analyzed.
Results We included 503 patients, identifying no significant difference between CRSwNP and CRSsNP for several common bacteria in CRS. The number of Staphylococcus epidermidis isolates in culture was significantly higher in the NECRS group (50.46% vs. 32.56%, p = 0.0003) than that in the eCRS group. The number of methicillin-resistant Staphylococcus aureus (MRSA; 8.51% vs. 2.35%, p = 0.0221) positive isolates was significantly higher in the CCAD group than that in the LDNP group.
Conclusions This was the first study in Asia to analyze the relationship between bacteriological characteristics and CCAD. MRSA is significantly higher in the CCAD group than that in the LDNP group. Recognizing the unique microbiology of CRSwNP, eCRS, and CCAD is crucial when selecting antimicrobial therapy to lessen the socio-economic impact.
Level of Evidence3 Laryngoscope, 134:1071–1076, 2024

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Virtual Reality for Pain Management During High‐Resolution Manometry: A Randomized Clinical Trial

Ilan Palte, Sarah Stewart, Hal Rives, James A. Curtis, Necati Enver, Andrew Tritter, Katerina Andreadis, Valentina Mocchetti, Felice Schnoll‐Sussman, Amir Soumekh, Rasa Zarnegar, Philip Katz, Anaïs Rameau

Publication date 16-02-2024


This article presents a randomized-control trial evaluating the effectiveness of Virtual Reality (VR) in pain and anxiety reduction in high-resolution esophageal manometry (HRM). Our findings include increased calmness and decreased rate of skin conductance increase across the palm during probe insertion in the VR group. This study supports the consideration of the use of VR as a distraction tool to improve patient comfort during HRM.
Objective High-resolution esophageal manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. HRM is typically performed in the office with local anesthesia only, and many patients find it unpleasant and painful. The aim of this study was to examine the effects of the use of a virtual reality (VR) headset on pain and anxiety outcomes in patients with dysphagia undergoing HRM.
Methods Patients with dysphagia were prospectively recruited and randomized to undergo HRM with and without VR distraction. Data collected included the State-Trait Anxiety Inventory-6 (STAI-6), the Short-Form Mc Gill Pain Questionnaire, heart rate, and galvanic skin response (GSR) tracings.
Results Forty subjects completed the study, including 20 subjects in the intervention arm and 20 in the control arm. There was evidence of a significant positive effect of VR on calmness (p = 0.0095) STAI-6 rating, as well as on physiologic measures of pain with significantly decreased GSR rise time (p = 0.0137) and average rate of change of conductance change (p = 0.0035).
Conclusion The use of VR during HRM catheter insertion increased calmness compared to control. Change of skin conductance was also reduced in the VR group, suggesting decreased physiologic pain. This study supports the consideration of the use of VR as a distraction tool to improve patient comfort during HRM.
Level of Evidence2 Laryngoscope, 134:1118–1126, 2024

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Trends in Twitter Utilization Among Academic Otolaryngologists

Radhika Duggal, Shadi Mehrabi, Paul C. Bryson, Sarah N. Bowe

Publication date 16-02-2024


As Twitter use increases among professionals, its utility in networking, advocacy, and information sharing is also increasing. We evaluated the relation between Twitter use and academic productivity. Our findings suggest Twitter is an underutilized resource in otolaryngology.
Objective To characterize Twitter utilization among academic otolaryngologists and evaluate the relationship between Twitter utilization and research productivity.
Methods Data were collected manually from accredited US otolaryngology residency programs from July–November 2021. Program and faculty demographics were documented, including citations and H-index for faculty and Doximity reputation and US News and World Report ranking for programs. Twitter metrics were also recorded. Descriptive analyses and multivariable logistic regression models were used to identify predictors of Twitter utilization.
Results Currently, 333 (16%) faculty and 70 (62%) programs have a Twitter account. Of these, 36 (11%) and 27 (39%), respectively, were created in 2020. The regression model indicates that for each 5 unit increase in H-index, the odds of having a Twitter account increase 22% (OR 1.22, 95% CI 1.10–1.34, p = 0.0009). The number of faculty with a Twitter account predicts the existence of program Twitter accounts (OR:1.49, 95% CI 1.01–2.19, p = 0.04). Finally, of the 323 faculty with a Twitter account and available Scopus profile, we found that the number of individuals with Twitter use out of proportion to their academic productivity was low (n = 8/323).
Conclusion The H-index is a significant predictor of faculty Twitter accounts, whereas the number of faculty with Twitter is a significant predictor of program Twitter utilization. Although Twitter utilization is increasing, especially during the coronavirus pandemic, the findings indicate that there is ample room for growth, particularly amongst faculty with strong academic portfolios.
Level of EvidenceNA Laryngoscope, 134:1190–1196, 2024

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Music Perception in Bone‐Anchored Hearing Implant Users

Nicole T. Jiam, Eric J. Formeister, Divya A. Chari, Abel P. David, Amer F. Alsoudi, Stephanie Purnell, Patpong Jiradejvong, Charles J. Limb

Publication date 16-02-2024


This cross-sectional, case-controlled study represents the first comprehensive study of basic music perception performance in bone-anchored hearing implant (BAHI) users. Our results demonstrate that BAHI users perform as well with their implanted ear as with their contralateral better-hearing ear and NH controls in the major elements of music perception.
Objective Music is a highly complex acoustic stimulus in both spectral and temporal contents. Accurate representation and delivery of high-fidelity information are essential for music perception. However, it is unclear how well bone-anchored hearing implants (BAHIs) transmit music. The study objective is to establish music perception performance baselines for BAHI users and normal hearing (NH) listeners and compare outcomes between the cohorts.
MethodsA case-controlled, cross-sectional study was conducted among 18 BAHI users and 11 NH controls.
Music perception was assessed via performance on seven major musical element tasks: pitch discrimination, melodic contour identification, rhythmic clocking, basic tempo discrimination, timbre identification, polyphonic pitch detection, and harmonic chord discrimination.
ResultsBAHI users performed comparably well on all music perception tasks with their device compared with the unilateral condition with their better-hearing ear. BAHI performance was not statistically significantly different from NH listeners performance. BAHI users performed just as well, if not better than NH listeners when using their control contralateral ear; there was no significant difference between the two groups except for the rhythmic timing (BAHI non-implanted ear 69% 95% CI: 62%–75%, NH 56% 95% CI: 49%–63%, p = 0.02), and basic tempo tasks (BAHI non-implanted ear 80% 95% CI: 65%–95%; NH 75% 95% CI: 68%–82%, p = 0.03).
Conclusions This study represents the first comprehensive study of basic music perception performance in BAHI users. Our results demonstrate that BAHI users perform as well with their implanted ear as with their contralateral better-hearing ear and NH controls in the major elements of music perception.
Level of Evidence3 Laryngoscope, 134:1381–1387, 2024

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The I‐STOP Program and Narcotic Prescriptions Following Facial Reconstructive Plastic Surgeries

Nadia Alexandra Debick, Danielle Wilson, Amar Suryadevara

Publication date 16-02-2024


New York States ISTOP program succeeded in reducing the number of postoperative narcotic prescriptions following facial plastic reconstructive surgeries at this academic institution. However, opioid medications can still be utilized for postoperative analgesia when clinically appropriate.
Objectives To explore the effect of e-prescribing requirements on narcotic dispersion in New York State.
Slicer Dicer was used to identify patient records based on CPT codes.
Methods We investigated the influence of New York State e-prescribing requirements on narcotic dispersion following five common facial plastics procedures. Slicer Dicer was used to identify patient records based on CPT codes.
We then looked at narcotic prescription rates following those surgeries between March 2014 and March 2018 at an academic institution.
Results Overall, between March 2014 and March 2018, 76.1% of the sample received a narcotic prescription following a facial reconstructive plastic surgery. Patients who underwent rhinoplasty were most likely to receive a prescription for postoperative narcotics. The implementation of ISTOP, CPT code, use of non-narcotic adjuvant, and insurance type were each significantly associated with prescription of postoperative narcotics. Surgery time and age in years were significantly associated with prescription of postoperative narcotics. Ultimately, when controlling for the aforementioned clinical and sociodemographic variables included in the study, those who underwent surgery after the implementation of ISTOP were 42.8% less likely to receive a prescription for postoperative narcotics, aOR = 0.572, 95% CI 0.356, 0.919, p = 0.021.
Conclusions New York States ISTOP program has succeeded in reducing the number of postoperative narcotic prescriptions following facial plastic reconstructive surgeries at this academic institution. However, opioid medications can still be utilized for postoperative analgesia when clinically appropriate.
Level of Evidence3 Laryngoscope, 134:1208–1213, 2024

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Quantifying Facial Distortion in Modern Digital Photography

Adeeb Derakhshan, Shekhar K. Gadkaree, Eric R. Barbarite, Michael M. Lindeborg, Prabhat K. Bhama, David A. Shaye

Publication date 16-02-2024


Vertical distortion of the midface occurs when photographs are captured at ‘selfie’ distances away from the subject. This should be taken into consideration when performing facial analysis and considering surgical candidates.
Background Advancements in digital cameras and the advent of smartphones have magnified the importance of clinical photography in facial plastic surgery. Here, we aim to examine the effect of different camera types, focal lengths, and distances from subjects on facial distortion.
Methods Twelve subjects underwent a series of frontal photographs using a smartphone camera and a full-frame digital single-lens reflex camera. Photos were captured at six distances from the subject. Seven focal lengths were used at each distance for the full-frame camera. Measurements of facial landmarks were made for each photo, with those made at 60 inches using the full-frame camera considered the gold standard and used for comparison.
Results Distortion of facial features using the full-frame camera occurred when photos were captured 8 inches away using short focal lengths. A 12%–19% increase in vertical stretching of the midface occurred when using focal lengths of 24, 35, and 50 mm (p < 0.05 for all). The same features were distorted when a smartphone camera was used at 8 inches (18% increase, p < 0.01) and 12 inches (12% increase, p < 0.03).
Conclusions Distortion of midfacial features using both smartphones and full-frame cameras occurs with short, ‘selfie’ distances between the camera and subject.
Level of Evidence2 Laryngoscope, 134:1234–1238, 2024

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The Serpentine Sign: A Reliable Endoscopic and Radiographic Finding in Empty Nose Syndrome

Sachi S. Dholakia, David Grimm, Rachel Daum, Dawn T. Bravo, Nicole Salvi, David Zarabanda, Jonathan B. Overdevest, Andrew Thamboo, Tsuguhisa Nakayama, Jayakar V. Nayak

Publication date 16-02-2024


We have identified novel radiographic and endoscopic imaging findings specific to patients with empty nose syndrome. These findings provide objective measurements highly specific to this group of patients and can help aid in the diagnosis of this challenging pathology.
Objective Empty nose syndrome (ENS) is a relatively uncommon disease that greatly impacts the quality of life and presents diagnostic challenges. We sought to identify objective clinical findings unique to patients with ENS, and in doing so identified compensatory mucosal hypertrophy in an alternating, undulating swelling on endoscopy and coronal computerized tomography (CT) that we have termed the “Serpentine Sign.” Here, we investigated whether this radiographic finding is a reliable manifestation in ENS patients.
Methods Retrospective review was undertaken to identify ENS patients with past turbinoplasty, an ENS6Q score of at least 11/30, and symptomatic improvement with the cotton placement test. Control patients without complaints of ENS symptoms (ENS6Q < 11) were identified for comparison. ENS and control patients had coronal CT imaging available to evaluate for the Serpentine Sign, as well as ENS6Q scores, and histologic analysis of nasal tissue.
Results34 ENS and 74 control patients were evaluated for the presence of the Serpentine Sign. Of the 34 patients with ENS, 18 exhibited this radiographic finding on CT imaging (52.9%) compared to 0 of the 74 control patients (p < 0.0001). Further analysis demonstrated that ENS patients with the Serpentine Sign had lower median scores on ENS6Q than ENS patients without (17.5 vs. 22, p = 0.033). Histology revealed disorganized subepithelium rich in seromucinous glands similar to the nasal septum swell body.
Conclusion The “Serpentine Sign” is a unique presentation of hypertrophic change to the nasal septum soft tissue that is specific to ENS patients and may serve as a reliable radiographic and endoscopic finding in diagnosis.
Level of Evidence4 Laryngoscope, 134:1089–1095, 2024

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Utility of Targeted Positron Emission Tomography Imaging to Predict Schwannoma Growth in a Murine Tumor Model

Jake Morgan, Sudhir Manickavel, Anna Sorace, Yolanda Hartman, Abbigael Eli, Adriana Massicano, Manuel Lora Gonzalez, Jason M. Warram, Erika Walsh

Publication date 16-02-2024


A mouse schwannoma model was used to determine if targeted positron emission tomography (PET) imaging with radiolabeled antibodies can predict tumor growth rate and ultimate tumor size. Immunotargeted PET imaging with anti-HER2/Neu antibodies significantly predicted tumor growth rate and final tumor size.
Objective To identify if targeted positron emission tomography (PET) imaging with radiolabeled antibodies can predict tumor growth rate and ultimate tumor size in a murine flank schwannoma model.
Study Design Animal research study.
Methods Rat schwannoma cells were cultured and implanted into 40 athymic nude mice. Once tumors reached 5 mm in diameter, 30 mice were injected with zirconium-89 labeled antibodies (HER2/Neu, vascular endothelial growth factor receptor 2 (VEGFR2), or IgG isotype). PET/CT was performed, and standardized uptake values (SUV) were recorded. Tumors were serially measured until mice were sacrificed per IACUC protocol. Statistical analysis was performed to measure correlations between SUV values, tumor size, and growth.
Results Mean tumor sizes in mm3 on Day 0 were 144 ± 162 for anti-HER2/Neu, 212 ± 247 for anti-VEGFR2, and 172 ± 204 for IgG isotype groups respectively. Mean growth rates in mm3/day were 531 ± 250 for HER2, 584 ± 188 for VEGFR2, and 416 ± 163 for the IgG isotype group. For both initial tumor size and growth rates, there was no significant difference between groups. There were significant correlations between maximum tumor volume and both the SUV max in the HER2 group (p = 0.0218, R2 = 0.5020), and we observed significant correlations between growth rate, and SUV values (p = 0.0156, R2 = 0.5394). Respectively, in the anti-VEGFR2 group, there were no significant correlations.
Conclusion In a murine schwannoma model, immunotargeted PET imaging with anti-HER2/Neu antibodies predicted tumor growth rate and final tumor size. Laryngoscope, 134:1372–1380, 2024

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Antibiotic Sensitivity and Nasal Microbiome in Patients with Acute Bacterial Rhinosinusitis

Ho‐Jin Gwak, Hyeon A. Lee, Jae Yeong Jeong, Yangsoon Lee, Mina Rho, Seok Hyun Cho

Publication date 16-02-2024


We found that acute bacterial rhinosinusitis (ABRS) patients had lower levels of Lactobacillaceae compared to healthy controls and patients with antibiotic-resistant ABRS had increased levels of of Acinetobacter and Massilia. However, we could not determine if notable changes exist in the middle meatal microbiome after short-term antibiotic use due to the small size of cohort.
Objectives Acute rhinosinusitis (ARS) is a common upper respiratory tract infection that is mostly of viral origin. However, little is known about the nasal microbiome profile at presentation and the changes caused by antibiotics in acute bacterial rhinosinusitis (ABRS).
Methods This was a prospective single-center study. Overall, 43 ARS patients were screened and were assessed with the symptom questionnaires, nasal endoscopy, and Waters view. Five healthy subjects were recruited as controls. Middle meatal mucus samples were obtained using a cotton swab (for bacterial culture and antimicrobial susceptibility testing) and the suction technique (for 16S rRNA sequencing). After 1 week of antibiotic use (amoxicillin with clavulanic acid), we enrolled 13 patients with ABRS with positive isolates and middle meatal samples for 16S rRNA sequencing were obtained again.
Results Overall, we demonstrated a significantly lower abundance of the Lactobacillaceae family in ABRS patients than in healthy controls.
Resistant ABRS had different characteristics of middle meatal microbiomes when compared to sensitive ABRS as follows: (1) lower proportion of lactic acid bacteria, (2) increased pathogens such as Rhodococcus sp., Massila sp., Acinetobacter sp., and H. influenza, and (3) increased beta diversity. However, no remarkable changes were observed in the middle meatal microbiome after antibiotic use.
Conclusion We showed the roles of Lactobacillaceae in ABRS, and Acinetobacter and Massilia in case of amoxicillin resistance.
Level of Evidence3 Laryngoscope, 134:1081–1088, 2024

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Risk of Aspiration Increased by Post‐swallow Residue in Infant Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Julia Chang, Tyler Okland, April Johnson, Noah Speiser, Aditya Seetharaman, Douglas Sidell

Publication date 16-02-2024


This is a retrospective matched-pairs cohort study demonstrating that post-swallow residue in Fiberoptic Endoscopic Evaluation of Swallowing (FEES) increases risk of aspiration in infants <1 year of age. Pyriform sinus and anterior commissure residue during infant FEES were associated with fivefold and twofold increased risk of aspiration, respectively. Anterior commissure residue had better accuracy for detecting aspiration in neonates <1 month of age than in older infants 1–12 months of age.
Objective To assess the risk of aspiration associated with post-swallow residue subsites in Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in bottle-fed infants <1 year of age.
Methods This is a retrospective matched-pairs cohort study at an academic tertiary childrens hospital. FEES and Videofluoroscopic Swallowing Study (VFSS) trials performed within the same infant <5 days apart were paired by matching bolus consistency and bottle flow rate. Positive aspiration was defined by the “or rule” in which aspiration is positive when either FEES or VFSS within a matched pair is positive.
Results Eighty-seven FEES-VFSS matched pairs from 29 patients (16 males; mean SD age, 2.9 2.8 months) were included. The rate of positive aspiration, as defined by the “or rule”, was 59% (51/87). In FEES, post-swallow pyriform sinus residue was present in 16% (14/87) and anterior commissure residue 27% (31/87). Risk of positive aspiration was increased by pyriform sinus residue (odds ratio OR 5.4, 95% confidence interval CI 1.9–19.3, p < 0.01) and anterior commissure residue in FEES (OR 2.5, 95% CI 1.1–6.1, p = 0.03). In the neonate subgroup, <1 month of age, multivariate-adjusted analysis showed that anterior commissure residue had better diagnostic accuracy for aspiration than in older infants (overall 70% vs. 42%, p < 0.01; sensitivity 60% vs. 10%, p < 0.01), whereas pyriform sinus residue had worse accuracy (overall 41% vs. 70%, p = 0.02; sensitivity 13% vs. 43%, p = 0.02).
Conclusion This study demonstrates that pyriform sinus and anterior commissure residue during infant FEES were associated with fivefold and twofold increased risk of aspiration, respectively.
Level of Evidence3. Using a retrospective matched-pairs cohort, this study assesses the diagnostic accuracy of post-swallow residue in FEES for predicting aspiration. Laryngoscope, 134:1431–1436, 2024

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Assessing the Biocompatibility and Regeneration of Electrospun‐Nanofiber Composite Tracheal Grafts

Lily Kreber, Lumei Liu, Sayali Dharmadhikari, Zheng Hong Tan, Coreena Chan, Joey Huddle, Zakarie Hussein, Kimberly Shontz, Christopher K. Breuer, Jed Johnson, Tendy Chiang

Publication date 16-02-2024


Composite tracheal grafts (CTG) combining decellularized scaffolds with external biomaterial support have been shown to support host-derived neotissue formation. In this study, we examine the biocompatibility, graft epithelialization, vascularization, and patency of three prototype CTG using a mouse microsurgical model.
Objective Composite tracheal grafts (CTG) combining decellularized scaffolds with external biomaterial support have been shown to support host-derived neotissue formation. In this study, we examine the biocompatibility, graft epithelialization, vascularization, and patency of three prototype CTG using a mouse microsurgical model.
Study Design Tracheal replacement, regenerative medicine, biocompatible airway splints, animal model.
MethodCTG electrospun splints made by combining partially decellularized tracheal grafts (PDTG) with polyglycolic acid (PGA), poly(lactide-co-ε-caprolactone) (PLCL), or PLCL/PGA were orthotopically implanted in mice (N = 10/group). Tracheas were explanted two weeks post-implantation. Micro-Computed Tomography was conducted to assess for graft patency, and histological analysis was used to assess for epithelialization and neovascularization.
Result Most animals (greater than 80%) survived until the planned endpoint and did not exhibit respiratory symptoms. MicroCT confirmed the preservation of graft patency. Grossly, the PDTG component of CTG remained intact. Examining the electrospun component of CTG, PGA degraded significantly, while PLCL+PDTG and PLCL/PGA + PDTG maintained their structure. Microvasculature was observed across the surface of CTG and infiltrating the pores. There were no signs of excessive cellular infiltration or encapsulation. Graft microvasculature and epithelium appear similar in all groups, suggesting that CTG did not hinder endothelialization and epithelialization.
Conclusion We found that all electrospun nanofiber CTGs are biocompatible and did not affect graft patency, endothelialization and epithelialization. Future directions will explore methods to accelerate graft regeneration of CTG.
Level of EvidenceN/A Laryngoscope, 134:1155–1162, 2024

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Sequential Wendler Glottoplasty and Laser Reduction Glottoplasty for Voice Feminization

Taner Yılmaz

Publication date 16-02-2024


If transgender women are unsatisfied with their voice after web (suturing of vocal folds to each other anteriorly) or laser, the addition of the alternative procedure may significantly feminize their voice.
Objective Voice feminizing surgery is frequently needed for transgender female patients. Among several surgical options, Wendler glottoplasty (WG) and laser reduction glottoplasty (LRG) are two endoscopic procedures. However, because a single procedure may not produce sufficient benefit, the two surgeries may sometimes be sequentially performed. This study was carried out to present the voice results of such sequential surgeries.
Methods This is an individual retrospective cohort study, performed at a tertiary referral center, that is a university hospital. 18 transgender patients were treated with WG initially and then underwent LRG; 17 had LRG first then WG. All 35 cases were performed during a 15-year period and followed for at least 1 year postoperatively. Voice Handicap Index (VHI-30), transsexual voice questionnaire (TVQ), and acoustic analysis with /a/ and running speech were obtained pre- and postoperatively.
ResultsVHI and TVQ improved significantly postoperatively (p < 0.05). Their preoperative, first, and second postoperative mean sF0 were 146, 175, and 215 Hz, respectively; these differences were statistically significant (p < 0.001). Their postoperative mean jitter percent, shimmer percent, noise to harmonic ratio (NHR), cepstral peak prominence (CPP), and cepstral spectral index of dysphonia (CSID) worsened significantly compared to preop values (p < 0.05); however, mean postoperative acoustic results were still within normal limits. Patients self-ratings of their postsurgery voices revealed all feminine, leading to a patient gratification score of 100%.
Conclusion If transgender female patients are unsatisfied with their voice after WG or LRG, the addition of the alternative procedure may significantly feminize their voice. Sequential WG and LRG is a successful surgical option for voice feminization.
Level of Evidence4 Laryngoscope, 134:1133–1138, 2024

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A Consistent Endoscopic Landmark to Identify the Anterior Ethmoidal Artery

David C. Mundy, Carol H. Yan, Matthew A. Tyler, Zara M. Patel

Publication date 16-02-2024


Surgeons continue to struggle to locate the anterior ethmoidal artery (AEA) with precision, especially when they are without the assistance of computer-guided navigation. We describe a consistent endoscopic landmark to identify the AEA, conserved across various clinical diagnoses and anatomic variations in sinus structure. The septation or ridge one step back along the ethmoid skull base from the posterior table of the frontal sinus is a consistent endoscopic landmark to identify the location of the AEA.
Objective The anterior ethmoidal artery (AEA) is an important structure to identify during endoscopic sinus surgery. Although identification on imaging is easily taught, a consistent endoscopic landmark for the AEA, independent of anatomic ethmoid cell variation, is lacking, leaving many surgeons unclear about the exact location without dependence on navigation. Here, we describe a consistent endoscopic landmark, regardless of anatomical ethmoid variation.
Methods We prospectively enrolled adult patients undergoing endoscopic surgery involving frontal and ethmoid sinuses in this observational study. The AEA landmark was defined simply as the septation or ridge one step back along the ethmoid skull base from the posterior table of the frontal sinus. The gold standard to calculate the sensitivity of our endoscopic landmark was an image-navigation system, registered to within 1.5 mm accuracy, locating the AEA within three planes. Both endoscopic and computerized tomography (CT) images of the pointer at the landmark were taken simultaneously. The concordance of endoscopic to navigation images was independently assessed by three blinded rhinologists.
Results Forty patients were included in our study with 73 sides analyzed. Diagnoses included chronic rhinosinusitis without polyps (52.5%), with polyps (22.5%), recurrent acute sinusitis (15%), sinonasal tumors (7.5%), and odontogenic sinusitis (2.5%). The AEA was accurately identified using our endoscopic landmark in 97.3% of the cases (71/73). Of the two cases in which the AEA was not found within the landmark, the artery was located ≤1 mm posteriorly.
Conclusion We describe a consistent endoscopic landmark to identify the AEA, conserved across various clinical diagnoses and anatomic variations in sinus structure.
Level of Evidence3 Laryngoscope, 134:1096–1099, 2024

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Development of Automated Tool for Electrode Array Insertion and its Study on Intracochlear Pressure

Aparna Zagabathuni, Kishore Kumar Padi, Mohan Kameswaran, Kanagaraj Subramani

Publication date 16-02-2024


The present work develops a simple, reliable, and compact device for automatically inserting the electrode array during cochlear implantation. The device actuates the electrode array by a roller mechanism, where the servomotor is used to convert the rotational motion into an axial motion leading to the forward movement of the electrode array. At an insertion speed of 0.15 mm/s, the peak intracochlear pressure is observed to be 133 Pa, which may not cause any damage to the inner ear system.
Cochlear implantation is the most successful approach for people with profound sensorineural hearing loss. Manual insertion of the electrode array may result in damaging the soft tissue structures and basilar membrane. An automated electrode array insertion device is reported to be less traumatic in cochlear implant surgery.
Objectives The present work develops a simple, reliable, and compact device for automatically inserting the electrode array during cochlear implantation and test the device to observe intracochlear pressure during simulated electrode insertion.
Methods The device actuates the electrode array by a roller mechanism. For testing the automated device, a straight cochlea having the dimension of the scala tympani and a model electrode is developed using a 3D printer. A pressure sensor is utilized to observe the pressure change at different insertional conditions.
Results The electrode is inserted into a prototype cochlea at different speeds without any pause, and it is noticed that the pressure is increased with the depth of insertion of the electrode irrespective of the speed of electrode insertion. The rate of pressure change is observed to be increased exponentially with the speed of insertion.
Conclusion At an insertion speed of 0.15 mm/s, the peak pressure is observed to be 133 Pa, which can be further evaluated in anatomical models for clinical scenarios.
Level of EvidenceN/A Laryngoscope, 134:1388–1395, 2024

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Use of Perioperative Virtual Reality Experiences on Anxiety and Pain: A Randomized Comparative Trial

Vivek C Pandrangi, Garren Low, Allison Slijepcevic, Suparna Shah, Maisie Shindo, Joshua Schindler, Alessa Colaianni, Daniel Clayburgh, Peter Andersen, Paul Flint, Mark K Wax, Ryan J Li

Publication date 16-02-2024


Prospective, randomized, comparative trial among patients undergoing outpatient head and neck surgery to compare the effect of two different virtual reality (VR) experiences on preoperative anxiety and postoperative pain. Group 1 utilized a preoperative VR gaming experience and a postoperative VR mindfulness experience, while Group 2 utilized the same interventions in the reverse order. Both groups demonstrated similar reductions in preoperative anxiety reduction (Group 1 vs. Group 2, median IQR: −12.0 15 vs. −10.5 13, p = 0.62) and postoperative pain reduction (−8.5 22.3 vs. −7.5 19.3, p = 0.95)Objective To evaluate the effect of different virtual reality (VR) experiences on perioperative anxiety and pain among patients undergoing head and neck surgery.
Methods Prospective, randomized, comparative trial among patients undergoing outpatient head and neck surgery from December 2021 to April 2022 at a single academic institution. Group 1 utilized a preoperative VR gaming experience and a postoperative VR mindfulness experience, while Group 2 utilized the same interventions in the reverse order. Anxiety and pain were measured using visual analog scales (VAS). Primary outcomes were changes in post-intervention anxiety and pain. Secondary outcomes included vital sign changes and subjective patient experiences using a 5-point Likert scale.
Results There were 32 patients randomized for inclusion, with 16 patients per group. The majority of patients were female (65.6%) and mean (standard deviation) age was 47.3 (16.7) years. After outlier exclusion, there were no differences in post-intervention preoperative anxiety reduction (Group 1 vs. Group 2, median IQR: −12.0 15 vs. −10.5 13, p = 0.62). There were minor differences in vital sign changes (p < 0.05). Among the 10 patients in Group 1 and 12 patients in Group 2 who completed postoperative VR use, there were no differences in post-intervention pain reduction (−8.5 22.3 vs. −7.5 19.3, p = 0.95) or vital sign changes (p > 0.05). There were no differences in questionnaire responses, with high satisfaction in both groups (p > 0.05). No adverse events encountered.
Conclusions Use of different VR experiences among patients undergoing outpatient head and neck surgery appears associated with similar reductions in perioperative anxiety and pain.
Level of Evidence2 Laryngoscope, 134:1197–1202, 2024

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How Does Oxymetazoline Change Nasal Aerodynamics and Symptomatology in Patients with Turbinate Hypertrophy?

Zachary T. Root, Thomas J. Lepley, Zhenxing Wu, Robbie J. Chapman, Aspen R. Schneller, Veronica L. Formanek, Kathleen M. Kelly, Bradley A. Otto, Kai Zhao

Publication date 16-02-2024


This single-blinded, longitudinal, prospective cohort study showed that while oxymetazoline broadly affects the entire length of the inferior and middle turbinates, its symptomatic improvement appears to be driven more by global nasal resistance and regional airflow properties, especially near the head of the inferior turbinate. Beyond providing additional insight into the effects of oxymetazoline, the study may prove valuable for future surgical targets.
Objectives Oxymetazoline relieves nasal obstructive symptoms via vasoconstriction, however, the changes in nasal structures and aerodynamics that impact symptoms the most remain unclear.
Methods This prospective, longitudinal, and single blinded cohort study applied Computational Fluid Dynamic (CFD) modeling based on CT scans at baseline and post-oxymetazoline on 13 consecutive patients with chronic nasal obstruction secondary to inferior turbinate hypertrophy from a tertiary medical center. To account for placebo effect, a sham saline spray was administered with subject blindfolded prior to oxymetazoline, with 30 min rest in between. Nasal Obstruction Symptom Evaluation (NOSE) and unilateral Visual Analogue Scale (VAS) scores of nasal obstructions were collected at baseline, after sham, and 30 min after oxymetazoline.
Results Both VAS and NOSE scores significantly improved from baseline to post-oxymetazoline (NOSE: 62.3 ± 12.4 to 31.5 ± 22.5, p < 0.01; VAS: 5.27 ± 2.63 to 3.85 ± 2.59, p < 0.05), but not significantly from baseline to post-sham. The anatomical effects of oxymetazoline were observed broadly throughout the entire length of the inferior and middle turbinates (p < 0.05). Among many variables that changed significantly post-oxymetazoline, only decreased nasal resistance (spearman r = 0.4, p < 0.05), increased regional flow rates (r = −0.3 to −0.5, p < 0.05) and mucosal cooling heat flux (r = −0.42, p < 0.01) in the inferior but not middle turbinate regions, and nasal valve Wall Shear Stress (WSS r = −0.43, p < 0.05) strongly correlated with symptom improvement.
Conclusion Oxymetazoline broadly affects the inferior and middle turbinates, however, symptomatic improvement appears to be driven more by global nasal resistance and regional increases in airflow rate, mucosal cooling, and WSS, especially near the head of the inferior turbinate.
Level of Evidence3: Well-designed, prospective, single blinded cohort trial. Laryngoscope, 134:1100–1106, 2024

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Early Postoperative Complications in Microtia Reconstruction: An Analysis of the NSQIP‐P Database

Rahul K. Sharma, Nicole G. DeSisto, Alexandra S. Ortiz, Kelly C. Landeen, Shiayin F. Yang, Scott J. Stephan, Priyesh N. Patel

Publication date 16-02-2024


The use of alloplastic implants may confer an increased risk of early complications for microtia repair. The long-term clinical implications of these findings are unclear relative to aesthetic benefits.
Objectives Microtia and anotia repair require techniques that consider both aesthetics and function. The outcomes of different reconstructive frameworks such as costal cartilage or a porous polyethylene implant have not been evaluated on a national scale. We aim to understand differences in outcomes/complication rates and operative times between different reconstructive frameworks used in microtia/anotia reconstruction.
Methods This was a retrospective review of the National Surgical Quality Improvement Program Pediatric database between 2012–2019. Patients with ICD-9/10 codes for microtia/anotia were isolated. Reconstruction methods were identified using CPT codes for rib graft, ear cartilage graft, and alloplastic implants (biocompatible implants, porous polyethylene, etc). Outcomes included operative-time, wound complications, and unplanned re-operations within 30 days of surgery. Multivariable logistic regression was performed to control for confounders.
Results We included 593 patients for analysis. Reconstruction with rib grafts (N = 506, 85%) was the most common. In 58 patients (9.8%), an implant was used for the auricular framework, whereas in 47 (7.9%) ear cartilage grafts were used. The overall wound complication rate was 3.4%. On univariate analysis, alloplastic implants exhibited a higher rate of wound complications (8.6% vs. 2.8%, p = 0.037) and longer operative times (350 min vs. 235 min, p < 0.001). After controlling for demographics and comorbidities, implants conferred an independently increased risk of wound complications (OR 3.52, 1.10–9.54, p = 0.020).
Conclusion Although the use of alloplastic implants (e.g., porous polyethylene) may confer an increased risk of early complications, the long-term clinical implications of these findings are unclear relative to aesthetic benefits. Multi-institutional studies are needed to validate these findings using patient-specific and surgeon-specific data.
Level of Evidence3 Laryngoscope, 134:1214–1219, 2024

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Age‐Related Histologic and Biochemical Changes in Auricular and Nasal Cartilages

Sul Gi Kim, Deanna C. Menapace, Mark M. Mims, William W. Shockley, J. Madison Clark

Publication date 16-02-2024


Non-cadaveric histological exploration of nasal and auricular cartilages showed a decline in glycosaminoglycans with age but an increase in collagen with age for nasal cartilages. For auricular cartilage, there was a decline in elastin with age.
Objective Analyze age-related changes in histologic features and biochemical properties of human auricular cartilage and two subsites of nasal cartilages (quadrangular cartilage and dorsal septal articulation with upper lateral cartilages).
Study Design Prospective cross-sectional study of nasal and auricular cartilages from seventy-three (73) live donors.
Methods Auricular cartilage (AC), quadrangular cartilage (QC), and dorsal septal cartilage articulation (DSA) with the upper lateral cartilage (ULCs) were collected intraoperatively.
Histochemical staining was used: Safranin O for glycosaminoglycans (GAGs), Verhoeffs for elastin, and Massons trichrome for collagen. ImageJ2 software was used to calculate cell count and percent stained for each cartilage type. R studio “ggplot” package was used to visualize age versus cell count or percent stained.
Results Participant ages ranged from 20 to 77 years, average 46.5 years. There was a significant decline in GAGs with age for the DSA subsite, (n = 64, p < 0.001). Significant increase in collagen content with age was observed for DSA subsite (n = 66, p < 0.001) and the QC subsite (n = 64, p < 0.05). There was a statistically insignificant decline in elastin with age (n = 41, p = 0.309) for AC. Cell count declined with age at all cartilage subsites.
Conclusion Our findings confirm that there were age-related decreases in cartilage glycosaminoglycan content, and chondrocyte cell count in both auricular and nasal cartilages. We have also confirmed that collagen content increases with age for both auricular and nasal cartilage. The histologic findings while not statistically significant in all comparisons, provides additional evidence that there is some loss of structural integrity and flexibility in nasal and auricular cartilage with aging.
Level of EvidenceNA Laryngoscope, 134:1220–1226, 2024

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Incidental Thyroid Tissue in Sentinel Nodes From Oral Squamous Cell Carcinoma

Clare Schilling, Lisette Collins, Adrian Farrow, Mark McGurk, Brian Bisase, Cyrus Kerawala, Simon Wan, Gill Hall, Selvam Thavaraj

Publication date 16-02-2024


Incidental thyroid cells (TC) in sentinel nodes pose a management dilemma. This study assesses the prevalence of TC in oral cancer patients staged by sentinel node biopsy and the clinical significance of this finding.
Objective Sentinel node biopsy (SNB) is a surgical staging test in which sentinel nodes (SNs) undergo intensive histological analysis. SNB diagnoses early cancer spread, but can also reveal unexpected findings within the SNs. We review cases of incidental thyroid cells (TC) found in SNs from patients with oral squamous cell carcinoma (OSCC) to assess the prevalence of TC, and the clinical significance of these.
Methods Multicenter retrospective review of SNB performed for cT1-T2N0 OSCC. Incidental TC were identified by TTF-1 or thyroglobulin positivity. Anatomical location of nodes containing TC, TC morphology, and ongoing management/follow up of this incidental finding was recorded. Neck dissections performed during the same period were reviewed to establish the expected incidence of TC in neck nodes without serial sectioning analysis.
Results278 SNB cases were reviewed. Ten procedures detected TC in nine patients (10/278, 3.6%). During the same time period 725 neck dissections were performed, six containing TCs (6/725, 0.8%). One patient underwent SNB twice with TC identified on both occasions. Three patients had both OSCC metastasis and thyroid cells. All SNB patients with TC identified underwent thyroid USS with no primary tumours identified. Three patients underwent thyroidectomy, in all cases no primary thyroid tumour was found.
Conclusion Prevalence of incidental TC in SNs appears to be higher than that reported in neck dissections, these are not likely to be clinically relevant and can be managed on a conservative basis in the absence of clear metastatic features.
Level of Evidence Multicentre retrospective cohort study, 3 Laryngoscope, 134:1278–1281, 2024

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Racial Disparities in 30‐day Readmissions after Surgery for Head and Neck Cancer

Alice E Huang, Jonathan J. Shih, John B. Sunwoo, Erqi Pollom, Kekoa Taparra

Publication date 16-02-2024


In this retrospective cohort study that included 365,834 adult patients with the most common head and neck cancers, Native Hawaiians and other Pacific Islanders (NHPI) patients had the highest risk of unplanned 30-day readmissions after oncologic surgery compared with White patients, a trend not observed with the other federally recognized racial groups. This disparity highlights the importance of disaggregating NHPI race in clinical studies.
Background Native Hawaiians and other Pacific Islanders (NHPI) patients with head and neck cancer are often aggregated with Asian individuals despite evidence of heterogeneous health outcomes and mortality. The aim of this study was to determine the association of race with unplanned 30-day hospital readmission rate after head and neck surgery across the five federally recognized racial categories.
Methods This retrospective cohort study used a national hospital-based database and included patients ≥18 years old with diagnostically confirmed, nonmetastatic head and neck cancer of any subsite treated surgically between 2004 and 2017. The primary endpoint was unplanned readmission within 30 days of discharge after primary surgery.
ResultsA total of 365,834 patients were included who were predominantly White (87%), treated at academic cancer centers (47%), lower income (63%), with early-stage disease (60%), and with thyroid (47%) or oral cavity (23%) cancers. Median follow-up duration was 47 months. Of the 10,717 (3%) readmissions, 5,845 (1.6%) were unplanned. Adjusted for confounders and compared with White patients, NHPI patients had the highest likelihood of unplanned (aOR 2.07, 95%CI 1.16–3.40, p = 0.008) readmissions. Within the NHPI group, patients with lower income (aOR 4.27, 95%CI 1.28–20.4, p = 0.035) and those residing in an urban or rural area (aOR 7.42, 95%CI 1.14–49.5, p = 0.034) were more likely to be readmitted.
ConclusionsNHPI patients with head and neck cancers experience significantly higher 30-day readmissions following definitive surgical treatment. These results highlight the importance of racial disaggregation in clinical studies.
Level of Evidence4 Laryngoscope, 134:1282–1287, 2024

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Fluorescent Guided Sentinel Lymph Mapping of the Oral Cavity with Fluorescent‐Labeled Tilmanocept

Theresa Guo, Sophie S. Jang, Ryotaro Ogawa, Morgan Davis, Edward Ashworth, Christopher V. Barback, David J. Hall, David R. Vera

Publication date 16-02-2024


This study investigates the feasibility of fluorescently labeled tilmanoscept in SLNB in an oral cancer rabbit model. Evaluation of fluorescent-labeled tilmanocept demonstrates high feasibility and accuracy in oral cavity cancer and for identification of cervical sentinel nodes. Use of intraoperative fluorescence imaging can enhance identification of cervical nodes through real-time visual feedback.
Objective With the shift toward utilization of sentinel lymph node biopsy (SLNB) in oral cavity cancer, improved techniques for intraoperative sentinel node identification are needed. This study investigates the feasibility of fluorescently labeled tilmanoscept in SLNB in an oral cancer rabbit model.
Methods An animal study was designed using 21 healthy male New Zealand rabbits. Gallium-68-labeled tilmanocept labeled with IRDye800CW was injected submucosally into the buccal mucosa (n = 6) or lateral tongue (n = 7) followed by PET imaging. One hour after injection, SLNB was performed using fluorescence imaging followed by a bilateral neck dissection and sampling of non-nodal surrounding tissue. All tissues were measured for radioactivity and fluorescence. In addition, eight rabbits were injected with delayed SLNB performed 48 h after injection.
Results Buccal injections all had ipsilateral SLN drainage and tongue injections exhibited 18.2% contralateral drainage. An average of 1.9 ± 1.0 SLN (range 1–5) were identified. In addition, an average of 16.9 ± 3.3 non-sentinel lymph nodes were removed per animal. SLNs had an average of 0.69 ± 0.60 percent-of-injected dose (%ID) compared with non-sentinel nodes with 0.012 ± 0.025 %ID and surrounding tissue with 0.0067 ± 0.015 %ID. There was 98.0% agreement between sentinel lymph nodes identified using fluorescence compared to radioactivity with Cohens kappa coefficient of 0.879. In 48-h delayed SLNB, results were consistent with 97.8% agreement with radioactivity and Cohens Kappa coefficient of 0.884. Fluorescence identified additional lymph nodes that were not identified by radioactivity, and with one false negative.
Conclusion Fluorescent-labeled Tc-99 m-tilmanocept represents a highly accurate adjunct to enhance SLNB for oral cavity cancer.
Level of EvidenceN/A Laryngoscope, 134:1299–1307, 2024

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Further Validity Evidence for Patient‐Specific Virtual Reality Temporal Bone Surgical Simulation

Steven Arild Wuyts Andersen, Brad Hittle, Maria Värendh, Julian Lee, Varun Varadarajan, Kimerly A. Powell, Gregory J. Wiet

Publication date 16-02-2024


Patient-specific virtual reality simulation potentially enables preoperative rehearsal and planning. Supporting validity evidence for the system was determined based on the manual rating of performance of trainees and attendings as well as drilled volumes. A novel approach to compare drilled volumes in the simulator with actual postoperative imaging is presented.
Objective Patient-specific virtual reality (VR) simulation of cochlear implant (CI) surgery potentially enables preoperative rehearsal and planning. We aim to gather supporting validity evidence for patient-specific simulation through the analysis of virtual performance and comparison with postoperative imaging.
Methods Prospective, multi-institutional study. Pre- and postoperative cone-beam CT scans of CI surgical patients were obtained and processed for patient-specific VR simulation. The virtual performances of five trainees and four attendings were recorded and (1) compared with volumes removed during actual surgery as determined in postoperative imaging, and (2) assessed using the Copenhagen Cochlear Implant Surgery Assessment Tool (CISAT) by two blinded raters. The volumes compared were cortical mastoidectomy, facial recess, and round window (RW) cochleostomy as well as violation of the facial nerve and chorda.
Results Trainees drilled more volume in the cortical mastoidectomy and facial recess, whereas attendings drilled more volume for the RW cochleostomy and made more violations. Except for the cochleostomy, attendings removed volumes closer to that determined in postoperative imaging. Trainees achieved a higher CISAT performance score compared with attendings (22.0 vs. 18.4 points) most likely due to lack of certain visual cues.
Conclusion We found that there were differences in performance of trainees and attendings in patient-specific VR simulation of CI surgery as assessed by raters and in comparison with actual drilled volumes. The presented approach of volume comparison is novel and might be used for further validation of patient-specific VR simulation before clinical implementation for preoperative rehearsal in temporal bone surgery.
Level of Evidencen/a Laryngoscope, 134:1403–1409, 2024

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Accelerometry May be Superior to EMG for Early Evaluation of Vocal Cord Function After Nerve Injury in a Pig Model

E. Setså, Ø.S. Svendsen, B. Henriksen, L. Stangeland, P. Husby, K. Brauckhoff

Publication date 16-02-2024


There is a high correlation between electromyography and vocal cord movement during nerve injury and a moderate correlation during early nerve recovery. Electromyography recovery after recurrent laryngeal nerve injury ensures sufficient vocal cord function as assessed by accelerometry.
Objective Vocal cord (VC) movement has been demonstrated by the use of accelerometry (ACC) to decrease in parallel with the electromyographic amplitude (EMG) during ongoing traction injury to the recurrent laryngeal nerve (RLN). When RLN function recovers, discrepancies between EMG and VC movement have been reported in clinical and experimental studies. The present study was conducted to clarify the actual relationship between EMG and VC movement measured by ACC during nerve recovery.
MethodsEMG obtained by continuous nerve monitoring (C-IONM) was compared with ACC during traction injury to the RLN, and throughout 40-min nerve recovery. A three-axis linear accelerometer probe was attached to the VC, and ACC data were registered as described. Traction damage was applied to the RLN until there was a 70% amplitude decrease from baseline EMG, or until loss of signal (LOS), that is, EMG values ≤100 μV.
Results Thirty-two RLN from 16 immature pigs were studied. Correlation between EMG and ACC were calculated during nerve injury and nerve recovery. The mean correlations were for the 70% and LOS group from start to end of traction: 0.82 (±0.17) and 0.87 (±0.17), respectively. Corresponding correlation coefficients during 40-min recovery was 0.50 (±0.48) in the 70% group and 0.53 (±0.33) in the LOS group.
Conclusion There is a high correlation between EMG and VC movement during nerve injury, and a moderate correlation during early nerve recovery. EMG recovery after RLN injury ensures sufficient VC function as assessed by ACC.
Level of EvidenceN/A Laryngoscope, 134:1485–1491, 2024

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Intra‐cochlear Flushing Reduces Tissue Response to Cochlear Implantation

"Tayla Razmovski, Kate M. Brody, Dimitra Stathopoulos, Dongcheng Zhang, Ellie Cho, Amy J. Hampson, Aaron Collins, Christofer Bester, Stephen OLeary"

Publication date 16-02-2024


This manuscript examines the feasibility of an intra-cochlear flushing protocol for the removal of blood during cochlear implantation. The results from a chronic animal study showed that intra-cochlear flushing reduced the tissue response in the basal half of the cochlea, even when compared with the control group.
Introduction Intraoperative trauma leading to bleeding during cochlear implantation negatively impacts residual hearing of cochlear implant recipients. There are no clinical protocols for the removal of blood during implantation, to reduce the consequential effects such as inflammation and fibrosis which adversely affect cochlear health and residual hearing. This preclinical study investigated the implementation of an intra-cochlear flushing protocol for the removal of blood.
Methods Three groups of guinea pigs were studied for 28 days after cochlear implantation; cochlear implant-only (control group); cochlear implant with blood injected into the cochlea (blood group); and cochlear implant, blood injection, and flushing of the blood from the cochlea intraoperatively (flush group). Auditory brainstem responses (ABRs) in addition to tissue response volumes were analyzed and compared between groups.
Results After implantation, the blood group exhibited the highest ABR thresholds when compared to the control and flush group, particularly in the high frequencies. On the final day, the control and blood group had similar ABR thresholds across all frequencies tested, whereas the flush group had the lowest thresholds, significantly lower at 24 k Hz than the blood and control group. Analysis of the tissue response showed the flush group had significantly lower tissue responses in the basal half of the array when compared with the blood and control group.
Conclusions Flushing intra-cochlear blood during surgery resulted in better auditory function and reduced subsequent fibrosis in the basal region of the cochlea. This finding prompts the implementation of a flushing protocol in clinical cochlear implantation.
Level of EvidenceN/A Laryngoscope, 134:1410–1416, 2024

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A Nationwide Population‐Based Study for the Recurrence and Comorbidities in Sudden Sensorineural Hearing Loss

Hye Yeon Ko, Hae Jeong Nam, Min Hee Kim

Publication date 16-02-2024


We found that 6.7% (17,270/257,123) of the patients had at least one recurrence of SSNHL. The recurrence rate appeared to decrease with age and increase with an increase in the number of recurrences and over time. We found an increase in the incidence of ankylosing spondylitis and a decrease in the incidence of type 2 diabetes mellitus, myocardial infarction, and hemorrhagic stroke in patients with recurrence.
Objectives The aims of this study were to investigate the cumulative recurrence rate of SSNHL and to determine association between comorbidities and recurrence of SSNHL by comparing patients with and without recurrence.
Methods Using the National Health Insurance Claims Database (NHICD) from 2009 to 2020, we conducted a population-based study. We only enrolled patients whose records showed a prescription for steroid and audiometry findings as well as an appropriate diagnostic code. Recurrence of SSNHL was defined as an episode of SSNHL greater than or equal to 3 months after the first episode of SSNHL. We compared the recurrence rate of SSNHL according to age and number of SSNHL recurrences. We also explored comorbidities including autoimmune, metabolic, chronic renal diseases, cancer, and migraine associated with recurrent SSNHL.
ResultsA total of 257,123 patients were identified. We found that 6.7% (17,270/257,123) of the patients had at least one recurrence of SSNHL. The recurrence rate increases with the number of recurrences and over time. The incidence per 100,000 people tended to increase with age, and the recurrence rate appeared to decrease with age. We found an increase in the incidence of ankylosing spondylitis (AS) and a decrease in the incidence of type 2 diabetes mellitus (T2DM), myocardial infarction (MI), and hemorrhagic stroke in patients with recurrence.
Conclusion For patients with recurrence or AS, considerable efforts should be made to prevent recurrence. As SSNHL is an emergent otologic condition, when symptoms occur, they should receive immediate treatment. Additional well-designed population-based studies are required to generalize our results.
Level of Evidence3 Laryngoscope, 134:1417–1425, 2024

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The Water Swallow Test and EAT‐10 as Screening Tools for Referral to Videofluoroscopy

Jonna Kuuskoski, Jaakko Vanhatalo, Jami Rekola, Leena‐Maija Aaltonen, Pia Järvenpää

Publication date 16-02-2024


Water swallow test is more accurate than the Eating Assessment Tool (EAT-10) questionnaire in predicting dysphagia findings in videofluoroscopy. Coughing and drinking bolus size are the most important variables in water swallow test.
Background Videofluoroscopy (VFS) is the gold standard in evaluating dysphagia. Water swallow tests (WST) and the Eating Assessment Tool (EAT-10) are commonly used in dysphagia screening. We aimed to determine the feasibility of WST and EAT-10 as screening tools for referral to VFS.
Methods Patients (n = 150, median age: 70.0 years, range: 19–92 years, 58.7% female) referred to VFS completed the WST and EAT-10 before the examination. In the WST, we evaluated both the qualitative parameters (coughing, possible change in voice) and quantitative parameters (average drinking bolus size, swallowing speed). Correlations of EAT-10 total scores and WST parameters to the VFS findings were analyzed both individually and combined.
Results In the WST, the most specific (89.7%) predictor of normal VFS findings was the absence of coughing, and the most sensitive (79.1%) parameter to predict abnormal findings was a bolus size of ≤20 mL. Using a combination of coughing and a bolus size ≤20 mL (simplified WST), the sensitivity of predicting abnormal findings increased to 83.5%. The most sensitive (84.6%) predictor of penetration/aspiration was failing any parameter in the WST. Lack of coughing indicated an absence of penetration/aspiration with an 82.5% specificity. Swallowing speed or combining the EAT-10 results with the WST results did not enhance the sensitivity or specificity of the WST for predicting the VFS results.
Conclusions Coughing and average drinking bolus size are the most important parameters in WST when screening for referral to VFS, whereas the swallowing speed does not seem to be useful. The WST is superior to EAT-10 in predicting VFS findings.
Level of Evidence4 Laryngoscope, 134:1349–1355, 2024

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Evaluation of Social Determinants of Health on Dysphagia Care Pathways at a Tertiary Care Facility

Maie M. Zagloul, Jonathan M. Bock, Joel H. Blumin, David R. Friedland, Jazzmyne A. Adams, Ling Tong, Kristen I. Osinksi, Masoud Khani, Jake Luo

Publication date 16-02-2024


African American patients and those with public insurance had significantly higher utilization of subsequent testing and intervention in dysphagia care in our tertiary academic care network, while no significant differences were seen in dysphagia evaluation modalities based on zip code analysis.
Objectives Limited research exists evaluating the impact of social determinants of health in influencing care pathways for patients with dysphagia. A better understanding of whether these determinants correlate to altered care and resource utilization is essential as it relates to patient outcomes.
Study Design Retrospective chart review.
Methods All adult patients seen at a tertiary midwestern hospital were screened for ICD codes of dysphagia diagnoses from 2009 to 2019. Demographic information was collected from these patients with dysphagia including sex, race, ethnicity, and insurance status. Subgroup analysis was performed to assess referral pattern rates and types of diagnostic interventions ordered (none, videofluoroscopic swallow study, esophagram, and esophagogastroduodenoscopy).
ResultsA total of 31,858 patients with dysphagia were seen at our institution during the study period, with a majority being female (56.36%), Caucasian (79.83%), and publicly insured (63.16%), at a median age of 60.35 years. There were no significant care delivery pattern differences based on geography/zip code analyses. African American patients were significantly more likely to have imaging or interventions performed (odds ratio OR 1.463, p = 0.005). Patients with public insurance also had higher rates of diagnostic study utilization (OR 1.53, p = 0.01). Only 3% of all patients with dysphagia were seen by laryngologists.
Conclusion No significant differences were seen in dysphagia evaluation modalities based on zip code analyses surrounding this tertiary care facility. African American patients and those with public insurance had significantly higher utilization of subsequent testing and intervention for dysphagia care. Further studies are necessary to delineate causes and outcome differences for these measurable differences in dysphagia care pathways.
Level of Evidence4 Laryngoscope, 134:1139–1146, 2024

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Comparison of Hemodynamics in Jet Ventilation vs. Intermittent Apnea for Airway Stenosis Surgery

Leah Sax, Shaan Sharma, Jacob Benedict, Kevin Guy, Ian Mandybur, Michael Bittner, John Sinacori, Benjamin Rubinstein

Publication date 16-02-2024


The objective of this study is to assess the impact of two different ventilation techniques, jet ventilation and apneic anesthesia with intermittent ventilation (AAIV), on patient hemodynamics and operative time during endoscopic laryngotracheal stenosis surgery.
Objective The objective of this study is to assess the impact of two different ventilation techniques, jet ventilation and apneic anesthesia with intermittent ventilation (AAIV), on patient hemodynamics and operative time during endoscopic laryngotracheal stenosis surgery.
Methods Retrospective chart review of patients who underwent airway dilation for laryngotracheal stenosis by a single surgeon at a single institution from October 1, 2000 through January 2, 2020. Logistic regression, Mann–Whitney U tests and chi square analysis were used to determine statistical significance.
ResultsA total of 157 patients, 43 (27.4%) male and 114 (72.6%) female, and 605 total encounters were included for analysis. There were no significant differences in hemodynamic outcomes when comparing the AAIV and jet ventilation groups. Specifically, there was no significant difference in either peak end-tidal CO2 or nadir O2 saturation between the AAIV and jet ventilation groups (p = 0.4016) and (p = 0.1357), respectively. The patients in the AAIV group had a significantly higher median BMI 32.93 (27.40–39.40) compared with 28.80 (24.1–32.65) (p = 0.0001). Although not necessarily clinically significant, patients with higher BMI had lower median O2 nadirs (97.8%) than non-obese patients (99.2%) (p < 0.0001). The median total procedure time was equivalent when comparing the two ventilation techniques.
ConclusionAAIV is a safe method of ventilation for patients undergoing endoscopic laryngotracheal stenosis surgery with no significant differences in patient hemodynamics or procedure time when compared with jet ventilation. AAIV was the preferred method of ventilation for obese patients undergoing endoscopic laryngotracheal stenosis surgery.
Level of Evidence3 Laryngoscope, 134:1343–1348, 2024

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Effects of Thyroarytenoid Activation Induced Vibratory Asymmetry on Voice Acoustics and Perception

Hye Rhyn Chung, Yoonjeong Lee, Neha K. Reddy, Zhaoyan Zhang, Dinesh K. Chhetri

Publication date 16-02-2024


Although thyroarytenoid (TA) muscle activation plays a crucial role in regulating VF vibration, how TA activation asymmetry relates to voice acoustics and perception is unclear. We evaluated the relationship between TA activation asymmetry and the resulting acoustics and perception. We found that whereas increasing vibratory asymmetry is correlated with decreased perceptual ratings, mild asymmetries are perceptually tolerated.
Introduction Asymmetry of vocal fold (VF) vibration is common in patients with voice complaints and also observed in 10% of normophonic individuals. Although thyroarytenoid (TA) muscle activation plays a crucial role in regulating VF vibration, how TA activation asymmetry relates to voice acoustics and perception is unclear. We evaluated the relationship between TA activation asymmetry and the resulting acoustics and perception.
Methods An in vivo canine model of phonation was used to create symmetric and increasingly asymmetric VF vibratory conditions via graded stimulation of bilateral TA muscles. Naïve listeners (n = 89) rated the perceptual quality of 100 unique voice samples using a visual sort-and-rate task. For each phonatory condition, cepstral peak prominence (CPP), harmonic amplitude (H1-H2), and root-mean-square (RMS) energy of the voice were measured. The relationships between these metrics, vibratory asymmetry, and perceptual ratings were evaluated.
Results Increasing levels of TA asymmetry resulted in declining listener preference. Furthermore, only severely asymmetric audio samples were perceptually distinguishable from symmetric and mildly asymmetric conditions.
CPP was negatively correlated with TA asymmetry: voices produced with larger degrees of asymmetry were associated with lower CPP values. Listeners preferred audio samples with higher values of CPP, high RMS energy, and lower H1-H2 (less breathy).
Conclusion Listeners are sensitive to changes in voice acoustics related to vibratory asymmetry. Although increasing vibratory asymmetry is correlated with decreased perceptual ratings, mild asymmetries are perceptually tolerated. This study contributes to our understanding of voice production and quality by identifying perceptually salient and clinically meaningful asymmetry.
Level of EvidenceN/A (Basic Science Study) Laryngoscope, 134:1327–1332, 2024

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Comparing Sleep Patterns and Clinical Features between Preschool and School‐Age Children with OSA

Le Chen, Jingjing Huang, Tao Jiang, Huiping Luo, Chunsheng Wei, Haitao Wu, Jun Shao, Wenyan Li

Publication date 16-02-2024


The evidence from our findings indicates a heightened incidence of respiratory events in school-aged children in comparison with their preschool counterparts, with alterations in sleep structure appearing more prominent. It is probable that adenoid hypertrophy serves as the primary instigator of obstructive sleep apnea (OSA) in preschool children, whereas for school-aged children, the predominant causes are likely obesity or an excessive weight issue.
Objective This study aimed to evaluate sleep patterns and investigate differences in clinical features among young individuals with snoring and obstructive sleep apnea (OSA).
Methods Data from 213 children and adolescents who underwent polysomnography (PSG) for primary snoring or OSA were collected between July 2017 and December 2021. To analyze differences in sleep architecture, hypoxia levels, and other clinical features, the participants were divided into two age groups: a preschool group and a school-age group.
Results The school-age group had significantly higher apnea-hypopnea index, obstructive apnea index, oxygen desaturation index, and body mass index than the preschool group. Both the lowest and average oxygen saturation levels were lower in the school-age group. Adenoid hypertrophy was more prevalent in the preschool group. The rate of overweight or obesity was 35.6% in the preschool group and even 94.2% in the school-age group. There were higher percentages of N1 and N2 sleep stages, and lower percentages of N3 and REM sleep stages in the school-age group. The groups exhibiting moderate to severe OSA demonstrated significant alterations in the difference between sleeping and waking diastolic blood pressure.
Conclusion There is a higher frequency of respiratory events among school-age children compared with their preschool peers. Moreover, alterations in sleep structure are more prominent in the school-age group. Adenoid hypertrophy may serve as the primary instigator of OSA in preschool children, whereas the predominant causes in school-age children may be obesity or excessive weight.
Level of Evidence Retrospective chart review, 3 Laryngoscope, 134:1472–1478, 2024

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Current Practices in Voice Data Collection and Limitations to Voice AI Research: A National Survey

Emily Evangelista, Rohan Kale, Desiree McCutcheon, Anais Rameau, Alexander Gelbard, Maria Powell, Michael Johns, Anthony Law, Phillip Song, Matthew Naunheim, Stephanie Watts, Paul C. Bryson, Matthew G. Crowson, Jeremy Pinto, Bridge2AI‐Voice, E. Bensoussan Yael, Elemento Olivier, Rameau Anaïs, Sigaras Alexandros, Ghosh Satrajit, E. Powell Maria, Johnson Alistair, Ravitsky Vardit, Bélisle‐Pipon Jean‐Christophe, Dorr David, Payne Phillip, Yael Bensoussan

Publication date 16-02-2024


Introduction Accuracy and validity of voice AI algorithms rely on substantial quality voice data. Although commensurable amounts of voice data are captured daily in voice centers across North America, there is no standardized protocol for acoustic data management, which limits the usability of these datasets for voice artificial intelligence (AI) research.
Objective The aim was to capture current practices of voice data collection, storage, analysis, and perceived limitations to collaborative voice research.
MethodsA 30-question online survey was developed with expert guidance from the voicecollab.ai members, an international collaborative of voice AI researchers. The survey was disseminated via REDCap to an estimated 200 practitioners at North American voice centers. Survey questions assessed respondents current practices in terms of acoustic data collection, storage, and retrieval as well as limitations to collaborative voice research.
Results Seventy-two respondents completed the survey of which 81.7% were laryngologists and 18.3% were speech language pathologists (SLPs). Eighteen percent of respondents reported seeing 40%–60% and 55% reported seeing >60 patients with voice disorders weekly (conservative estimate of over 4000 patients/week). Only 28% of respondents reported utilizing standardized protocols for collection and storage of acoustic data. Although, 87% of respondents conduct voice research, only 38% of respondents report doing so on a multi-institutional level. Perceived limitations to conducting collaborative voice research include lack of standardized methodology for collection (30%) and lack of human resources to prepare and label voice data adequately (55%).
Conclusion To conduct large-scale multi-institutional voice research with AI, there is a pertinent need for standardization of acoustic data management, as well as an infrastructure for secure and efficient data sharing.
Level of Evidence5 Laryngoscope, 134:1333–1339, 2024

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Quality of Life Improvement in Concurrent Septorhinoplasty and Endoscopic Sinus Surgery

Olcay Cem Bulut, Burkard M. Lippert, Frank Riedel, Michaela Plath, Ralph Hohenberger

Publication date 16-02-2024


Objectives Septorhinoplasty (SRPL) and functional endoscopic sinus surgery (FESS) are two frequently performed surgeries to improve quality of life (QoL) in patients with nasal symptoms. It has been demonstrated as a safe combination regarding complication rates, but patient satisfaction in concurrent surgery has not been adequately studied yet.
Methods Patients undergoing sole FESS due to chronic rhinosinusitis (n = 57), sole SRPL (n = 148), and concurrent surgery (n = 62) were prospectively evaluated for their disease-specific QoL before and one year after surgery. Each procedure was performed by the same surgeon (OCB). For SRPL, the patient-reported outcome measures Rhinoplasty Outcomes Evaluation (ROE) and Functional Rhinoplasty Outcome Inventory (FROI-17) were utilized, and for chronic rhinosinusitis, the Sino-Nasal Outcome Test-22 (SNOT22).
Results All three groups showed significant improvement in the postoperative QoL measurements (all p < 0.01). The postoperative improvements were slightly smaller in the concurrent surgery group compared with the single surgery groups measured with ROE (combined: +55.2 ± 9.3, single: +58.8 ± 9.8, p = 0.02), FROI total score (combined: +47.6 ± 5.2, single: +49 ± 5.4; p = 0.08) and SNOT22 (combined: +33.1 ± 6.7, single +34.5 ± 7, p = 0.26).
ConclusionsSRPL, FESS, and combined surgery improve disease-specific QoL. When applicable, surgeons may offer the benefits of a combined procedure without compromising the QoL gain.
Level of Evidence3 Laryngoscope, 134:1239–1245, 2024

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Complications and Functional Outcomes After Esophageal Reconstruction with an Intact Larynx

Aarti Agarwal, Ramez Philips, Michele Fiorella, Dev R. Amin, Howard Krein, Ryan Heffelfinger

Publication date 16-02-2024


Background Esophageal defects can result from primary pathologies such as malignancy or stricture, or secondary ones such as perforation due to trauma or iatrogenic injury. Techniques, management, and outcomes of reconstruction in this setting are poorly understood. Herein, we aim to highlight surgical outcomes in patients undergoing local and free flap reconstruction of esophageal defects in the setting of an intact larynx.
Methods Retrospective review of patients who underwent esophageal reconstruction with an intact larynx between 2009 and 2022 at our institution was performed.
Results Ten patients met inclusion criteria. Esophageal reconstruction was performed for extruded spinal hardware (n = 8), and esophageal stricture (n = 2). Four patients underwent reconstruction with free tissue transfer, and six with local pedicled flaps. There were no cases of flap failure, esophageal fistula, hematoma, or wound dehiscence. One patient had post-operative bleeding requiring return to the operating room. Three patients had a postoperative wound infection, two of whom required washout. There were no unplanned 30-day readmissions. At three months after operation, all patients who were not tube feed-dependent prior to surgery returned to oral intake. Of the four patients who were tube feed-dependent preoperatively, three were tolerating oral intake at nine months postoperatively. Nine patients (90%) had stable flexible laryngoscopy exams pre- and postoperatively with no voice changes.
Conclusions Reconstruction of esophageal defects in the setting of an intact larynx can be challenging. In this series, surgical intervention with free tissue transfer and local pedicled flaps was effective in returning patients to oral intake with low long-term morbidity.
Level of Evidence4 Laryngoscope, 134:1227–1233, 2024

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Respiratory Sensing Lead Malfunction in Upper Airway Stimulation: A Single Institution Report

Albina S. Islam, Graham Pingree, Andrew Chafin, Thomas H. Fitzpatrick IV, Ryan S. Nord

Publication date 16-02-2024


This study investigates the incidence of sensing lead malfunction with the Inspire device for obstructive sleep apnea, utilizing a retrospective review of 190 patients from a single institution as well as reviews adverse events associated with the sensing lead component via an analysis of the FDA Manufacturer and User Facility Device Experience (MAUDE) database. Results indicate a 2.1% rate of sensing lead malfunction, with cases demonstrating internal component issues and sensing lead tip separation. Such malfunctions put patients at risk for migration of the isolated tip, emphasizing the importance of understanding failure scenarios for optimal patient management.
Objectives Upper airway stimulation (UAS) is an effective treatment for patients with obstructive sleep apnea. The device consists of a stimulating electrode, an internal pulse generator, and a respiratory sensing lead. The purpose of this study is to characterize the incidence of sensing lead malfunction necessitating revision surgery in a high-volume center in conjunction with a review of the FDA Manufacturer and User Facility Device Experience (MAUDE) database reports on adverse events associated with the sensing lead component.
Methods Patients age ≥18 implanted with the device were reviewed between July 2017 and June 2022. Those determined to have sensing lead malfunction were analyzed. The FDA MAUDE database was reviewed for reports associated with “Inspire Model 4323 Respiratory” and “Inspire Model 4340 Respiratory” between January 2014 and September 2022.
Results One hundred ninety patients underwent UAS at our institution during the study period and four (2.1%) patients were found to have sensing lead malfunction. Analysis of the MAUDE database revealed 122 reports of adverse events associated with the sensing lead component, with 72% (88/122) of these requiring revision surgery. The most frequently reported adverse event was sensing lead tip separation from lead body, noted in 46% of these reports (56/122).
Conclusion The functionality of the sensing lead component is vital to the integrity of the UAS device and is measurable through waveform analysis. To provide optimal care after device implantation, it is essential to have a comprehensive understanding of the scenarios in which this component fails, the incidence of such events, and appropriate management.
Level of Evidence4 Laryngoscope, 134:1479–1484, 2024

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Sialendoscopy Findings Associated with Positive Minor Salivary Gland Biopsy

Jessica Bertram, Chad Nieri, Leighton Reed, M. Boyd Gillespie

Publication date 16-02-2024


Objectives To determine the sialendoscopy findings associated with positive findings on minor salivary gland biopsy.
Study Design Single-center retrospective study.
Methods Patients ≥18 years old who underwent sialendoscopy from 2016 to 2022 and were evaluated for SS via labial minor salivary gland biopsy. Biopsy positive and negative patients were compared on the primary outcome measure of sialendoscopy findings. Data were abstracted from the sialendoscopy operative notes and included involved gland, location of ductal pathology, and the presence of scarring, stenosis, mucus plugs, webs, and dilations. Additional characteristics included demographics, presenting symptoms, caffeine or tobacco, use of drying medications, and need for additional treatments.
Results The final cohorts included 22 biopsy positive and 21 biopsy negative patients with a total of 42 glands in the biopsy positive and 37 glands in the biopsy negative groups. Biopsy positive patients were found to require dilation at the hilum and distal duct at significantly higher rates than biopsy negative patients (p < 0.0001). However, there was no statistical difference in scarring, stenosis severity, mucus, webs, or dilations between each group.
Conclusion The outcomes of this study suggest that there are no distinct sialendoscopy findings associated with biopsy positive patients. The presence of significant distal stenosis on sialendoscopy may be associated with positive minor salivary biopsy. Other endoscopic parameters are likely more consistent with non-specific chronic sialadenitis.
Level of Evidence3 Laryngoscope, 134:1183–1189, 2024

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Endoscopic Endonasal Transpterygoid Approach and the Need for Myringotomy

Mark A. Damante, Stephen T. Magill, Daniel Kreatsoulas, Ben G. McGahan, Douglas Hardesty, Ricardo L. Carrau, Daniel M. Prevedello

Publication date 16-02-2024


Objective The expanded endonasal transpterygoid approach (EETA) is used to access the middle and posterior fossa through the pterygoid process. Traditionally, the eustachian tube (ET) was resected during EETA, which often required subsequent myringotomy for inner ear drainage. Anterolateral transposition of the ET was proposed to decrease potential morbidity associated with resection. However, a comparison of resection versus transposition regarding the need for subsequent myringotomy has not been reported.
Methods This is a retrospective cohort study of patients who underwent an EETA. Patient demographics, tumor characteristics, management of ET with resection versus transposition, and need for subsequent myringotomy were collected. Analysis was performed with JMP software in standard fashion and univariate and multivariate logistic regression analysis performed with a p < 0.05 was considered significant.
Results Ninety-one patients underwent EETA for various malignant and benign tumors. Twenty-seven patients required myringotomy, with tumors of the pterygopalatine fossa accounting for the most common location (n = 8). Malignant pathology had the highest myringotomy rate compared to benign tumors (48.9% vs. 10.9%, p < 0.001), as did receiving postoperative radiation (p < 0.001), ET resection (p < 0.001), and increasing CPK class. Multivariate analysis of these variables suggests that only ET resection significantly correlated with the need for myringotomy (LR 7.97, p = 0.005).
ConclusionsET resection during EETA can lead to ET dysfunction and require myringotomy post-operatively, and patients should be counseled of this risk. Radiation treatment, malignant pathology, and CPK class, all reflecting situations where more extensive surgery was needed, were associated with the need for myringotomy on univariate analysis but did not reach significance with multivariate analysis.
Level of Evidence4 Laryngoscope, 134:1203–1207, 2024

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Cough and Swallowing Therapy and Their Effects on Vocal Fold Bowing and Laryngeal Lesions

Can Doruk, James A. Curtis, Avery E. Dakin, Michelle S. Troche

Publication date 16-02-2024


Expiratory muscle strength training (EMST) and sensorimotor training of airway protection (smTAP) are effective cough training exercises that require repetitive tasks. The present study indicates that these training modalities do not have any positive effects on vocal fold bowing or negative effects on vocal folds.
Objective Expiratory muscle strength training (EMST) and sensorimotor training of airway protection (smTAP) are two exercises intended to improve cough and swallowing in people with Parkinsons Disease (PwPD). The aims of this study were to (1) examine whether EMST or smTAP elicit changes to vocal fold bowing; and (2) describe the safety of EMST and smTAP as it relates to the development of vocal fold lesions.
Method(s)This was a secondary analysis of data from PwPD who completed EMST or smTAP as part of a prospective randomized controlled trial. Vocal fold bowing (BI) and the presence of laryngeal lesions were blindly analyzed from flexible endoscopic evaluation of swallowing (FEES) using ImageJ software and operational definitions. Linear regression was used to examine the influence time (pre- vs. post-therapy) and therapy (EMST vs. smTAP) on vocal fold bowing. Descriptive statistics were used to describe the presence of laryngeal lesions.
Result(s)Overall, 56 participants were included, 28 per group. The median BI scores pre- and post-therapy were 8.2% and 8.3% for the EMST group and 11.3% and 8.4% for the smTAP group, respectively. Statistical analyses revealed insufficient evidence to suggest an effect of time and treatment type on BI (p > 0.05) or on the presence of vocal fold lesions (p > 0.05).
Conclusion Based on these and previous findings, it appears that changes in vocal fold bowing do not drive treatment effects following EMST and smTAP. Also, this study further supports the safety of smTAP and EMST despite the required forceful exhalation and repetitive coughing.
Level of Evidence4 Laryngoscope, 134:1127–1132, 2024

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Otolaryngologic Side Effects After COVID‐19 Vaccination

Salma Ahsanuddin, Ryan Jin, Aatin K. Dhanda, Kirolos Georges, Soly Baredes, Jean Anderson Eloy, Christina H. Fang

Publication date 16-02-2024


Objectives With widespread vaccination against COVID-19, concerns regarding side effects have been raised. We aim to assess the frequency of otolaryngologic adverse events (AEs) following COVID-19 vaccination as compared with other vaccines in a national database.
Study Design Retrospective analysis of national registry.
Methods The Food and Drug Administrations Vaccine Adverse Event Reporting System (VAERS) database was queried from December 2020 to May 2021 for all COVID-19 vaccination AEs. Complaints were categorized as otolaryngologic and sub stratified into different anatomic components. Reporting odds ratios (ROR) and proportional reporting ratios (PRR) were determined for AEs of clinical significance.
Results The total number of AEs reported from vaccination with the Moderna, Pfizer-BioNTech, and Janssen vaccines equaled 1,280,950. Of these, 62,660 (4.9%) were otolaryngologic in nature, with 32.6% associated with the oropharynx/larynx, 18.3% with the nasal cavity/sinuses, 17.1% with the ears/vestibular system, 10.0% with the oral cavity, and 21.9% miscellaneous. Signal ratios reached significance levels for dysgeusia (n = 2124, PRR: 17.33, ROR: 16.36), ageusia (n = 1376, PRR: 2.81, ROR: 2.81), anosmia (n = 983, PRR: 4.01, ROR: 4.01), rhinorrhea (n = 2203, PRR: 2.99, ROR: 3.00), throat tightness (n = 3666, PRR: 4.99, ROR: 5.00), throat irritation (n = 3313, PRR: 4.51, ROR: 4.52), dysphagia (n = 2538, PRR: 2.07, ROR: 2.07), tinnitus (n = 4377, PRR: 3.97, ROR: 3.98), and vertigo (n = 2887, PRR: 3.93, ROR: 3.93). Signal ratios were not significant for facial paralysis, Bells palsy, anaphylaxis, sinusitis, hearing disability, and ear pain.
Conclusions Although several otolaryngologic symptoms were reported, few were found to be clinically significant. Of note, facial paralysis, Bells palsy, and anaphylaxis did not meet signal thresholds to be determined significant.
Level of Evidence4 Laryngoscope, 134:1163–1168, 2024

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Role of Microplastics in Chronic Rhinosinusitis Without Nasal Polyps

Burak Mustafa Taş, Ayşegül Tuna, Gökben Başaran Kankılıç, Furkan Melih Koçak, Ziya Şencan, Ela Cömert, Nuray Bayar Muluk

Publication date 16-02-2024


We found more microplastics in nasal lavage in patients with chronic rhinosinusitis without nasal polyps. According to this result, we can say that there is a relationship between chronic rhinosinusitis and microplastics.
Objective We aimed to examine the relationship between chronic rhinosinusitis without nasal polyps and microplastics.
MethodsA total of 80 patients participated in this prospectively planned study. The patients were divided into two groups. Group 1 had 50 patients with chronic rhinosinusitis without nasal polyps, whereas Group 2 had 30 healthy volunteers. The age and gender of the participants were noted. Nose Obstruction Symptom Evaluation questionnaire was applied to the patients. The patients performed nasal lavage with saline. Microplastics were examined in the collected nasal lavage fluids, and their numbers were noted. The groups were compared on these values.
Results The mean age was 38.06 ± 14.15 years in the chronic rhinosinusitis group without nasal polyps and 33.60 ± 11.68 years in the control group. There was no significant difference between the groups in terms of age and gender. There was a significant difference in the number of microplastics between the chronic rhinosinusitis group without nasal polyps and the control group (p < 0.001). Microplastics were detected in all participants.
Conclusions We found more microplastics in patients with chronic rhinosinusitis without nasal polyps. According to this result, we can say that there may be a relationship between chronic rhinosinusitis and microplastics.
Level of Evidence3 Laryngoscope, 134:1077–1080, 2024

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Fungal and Bacterial Microbiome in Sinus Mucosa of Patients with and without Chronic Rhinosinusitis

Jivianne T. Lee, Carra A. Simpson, Hong‐Ho Yang, Jeffrey D. Suh, Marilene B. Wang, Venu Lagishetty, Fengting Liang, Jonathan P. Jacobs

Publication date 16-02-2024


Dysbiosis of the nascent sinonasal microbiome has been implicated in the pathogenesis of chronic rhinosinusitis (CRS). In our study, reduced mycobiota diversity in CRS patients in comparison to healthy controls suggest that alterations in the mycobiome may contribute to disease pathogenesis. Our findings also confirmed that diminished diversity among bacterial communities is associated with CRS, and that significant differences are present in microbial composition between CRSwNP and CRSsNP patients.
Objectives Dysbiosis of the sinonasal microbiome has been implicated in the pathogenesis of chronic rhinosinusitis (CRS). However, the mycobiome remains largely understudied, and microbial alterations associated with specific CRS subtypes have yet to be delineated. The objective of this study is to investigate the fungal and bacterial microbiome of sinus mucosa in CRS patients with and without nasal polyposis (CRSwNP and CRSsNP) versus healthy controls.
Methods Sinus mucosa was obtained from 92 patients (31 CRSsNP, 31 CRSwNP, and 30 controls) undergoing endoscopic sinus/skull base surgery. Data regarding demographics, Lund-Mac Kay scores, and histopathology were collected. Fungal and bacterial microbiome analysis was performed utilizing internal transcribed spacer amplicon and 16S rRNA sequencing.
Results Beta diversity of the sinonasal mycobiome differed significantly between CRS and controls (p = 0.001) and between CRSwNP and controls (p = 0.049), but not between CRSwNP and CRSsNP (p = 0.32) nor between CRSsNP and controls (p = 0.06). With respect to the bacterial microbiome, significantly lower alpha diversity was observed between CRS and controls (p < 0.001), CRSwNP versus controls (p < 0.001), and CRSsNP versus controls (p < 0.001). Beta diversity was also significantly different at the genus level between CRSwNP and CRSsNP (p = 0.019), CRSwNP and controls (p = 0.002)), and CRSsNP and controls (p < 0.001). However, alpha and beta diversity did not differ significantly between CRS patients with/without eosinophils or correlate with Lund-Mac Kay scores.
Conclusions Differences in mycobiota diversity in CRS patients in comparison with controls suggest that alterations in the mycobiome may contribute to disease pathogenesis. Our findings also confirmed that diminished diversity among bacterial communities is associated with CRS and that significant differences are present in microbial composition between CRSwNP and CRSsNP.
Level of Evidence3 Laryngoscope, 134:1054–1062, 2024

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Temperature Profile Measurement From Radiofrequency Nasal Airway Reshaping Device

Eric H. Abello, Theodore V. Nguyen, Katelyn K. Dilley, Donggyoon Hong, Justin S. Kim, Pranav S. Nair, Benjamin F. Bitner, Wangcun Jia, Brian J. F. Wong

Publication date 16-02-2024


Current trends have led to internal nasal valve collapse treatment for nasal obstruction through radiofrequency heating. This study demonstrates that the temperature profile of this device may cause thermal damage at a cellular level.
Objective Nasal airway obstruction (NAO) is caused by various disorders including nasal valve collapse (NVC). A bipolar radiofrequency (RF) device (Viv Aer®, Aerin Medical, Sunnyvale, CA) has been used to treat NAO through RF heat generation to the upper lateral cartilage (ULC). The purpose of this study is to measure temperature elevations in nasal tissue, using infrared (IR) radiometry to map the spatial and temporal evolution of temperature.
Study Design Experimental and computational.
Methods Composite porcine nasal septum was harvested and sectioned (1 mm and 2 mm). The device was used to heat the cartilage in composite porcine septum. An IR camera (FLIR® ExaminIR, Teledyne, Wilsonville, OR) was used to image temperature on the back surface of the specimen. These data were incorporated into a heat transfer finite element model that also calculated tissue damage using Arrhenius rate process.
ResultsIR temperature imaging showed peak back surface temperatures of 49.57°C and 42.21°C in 1 and 2 mm thick septums respectively. Temperature maps were generated demonstrating the temporal and spatial evolution of temperature. A finite element model generated temperature profiles with respect to time and depth. Rate process models using Arrhenius coefficients showed 30% chondrocyte death at 1 mm depth after 18 s of RF treatment.
Conclusion The use of this device creates a thermal profile that may result in thermal injury to cartilage. Computational modeling suggests chondrocyte death extending as deep as 1.4 mm below the treatment surface. Further studies should be performed to improve dosimetry and optimize the heating process to reduce potential injury. Laryngoscope, 134:1063–1070, 2024

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Environmental Risk Factors for Pediatric Epistaxis vary by Climate Zone

Eric X. Wei, Allen Green, Michael T. Chang, Peter H. Hwang, Douglas R. Sidell, Z. Jason Qian

Publication date 16-02-2024


Introduction and Objective Prior studies have provided variable results regarding environmental risk factors for epistaxis. These studies were conducted in varying climate zones, which may explain discrepancies in results. The objective of this study is to investigate correlations between season, temperature, and humidity on frequency of pediatric epistaxis across climate zones.
Methods Children seen in the outpatient setting for epistaxis were identified from the 2007–2010 IBM Market Scan database. Climate zones were assigned according to International Energy Conservation Code (IECC) classification, where temperature zones in the United States and territories were assigned on an ordinal scale from 1 (tropical) to 8 (subarctic), and humidity zones were categorized as moist, dry, or marine. The control population was a sample of all well-child visits matched by age and county.
Results We identified 184,846 unique children seen for epistaxis and 1,897,012 matched controls. Moderate temperature zones were associated with lower odds of epistaxis compared with the hottest and coldest zones. Humidity was associated inversely with epistaxis rates in moderate temperature zones but was not a significant predictor of epistaxis in climates with extreme heat. Additionally, summer was associated with lower odds of epistaxis compared to winter. Interestingly, however, there were significantly higher rates of cautery procedures during summer months, driven largely by increased procedures performed in clinic, as opposed to the operating room or emergency room.
Conclusions Environmental risk factors for epistaxis vary by climate zone. The model presented reconciles prior reports and may allow for more personalized clinical management based on regional climate.
Level of Evidence3 Laryngoscope, 134:1450–1456, 2024

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Pediatric Inferior Turbinate Hypertrophy: Diagnosis and Management. A YO‐IFOS Consensus Statement

Antonino Maniaci, Christian Calvo‐Henriquez, Giovanni Cammaroto, Carlos Garcia‐Magan, Vanesa Garcia‐Paz, Giannicola Iannella, Ignacio Jiménez‐Huerta, Ignazio La Mantia, Jérome R. Lechien, Samuel C. Leong, David Lobo‐Duro, Juan Maza‐Solano, Ron Mitchell, Andrea Otero‐Alonso, You Peng, Thomas Radulesco, François Simon, Natasha Teissier, Salvatore Cocuzza, Alberto M. Saibene

Publication date 16-02-2024


This article presents a clinical consensus statement aimed at providing a diagnosis and management framework for pediatric inferior turbinate hypertrophy (PedTH), a frequently overlooked cause of nasal breathing difficulties in children. The statement was developed by a panel of 20 contributors from 5 different European and North American countries using the modified Delphi method and is based on shared clinical experience and analysis of the strongest evidence currently available. The statement emphasizes the importance of considering PedTH as a nasal obstructive disease and recommends less invasive treatment options.
Objective Pediatric inferior turbinate hypertrophy (PedTH) is a frequent and often overlooked cause or associated cause of nasal breathing difficulties. This clinical consensus statement (CCS) aims to provide a diagnosis and management framework covering the lack of specific guidelines for this condition and addressing the existing controversies.
MethodsA clinical consensus statement (CCS) was developed by a panel of 20 contributors from 7 different European and North American countries using the modified Delphi method. The aim of the CCS was to offer a multidisciplinary reference framework for the management of PedTH on the basis of shared clinical experience and analysis of the strongest evidence currently available.
ResultsA systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria was performed. From the initial 96 items identified, 7 articles were selected based on higher-evidence items such as randomized-controlled trials, guidelines, and systematic reviews. A 34-statement survey was developed, and after three rounds of voting, 2 items reached strong consensus, 17 reached consensus or near consensus, and 15 had no consensus.
Conclusions Until further prospective data are available, our CCS should provide a useful reference for PedTH management. PedTH should be considered a nasal obstructive disease not necessarily related to an adult condition but frequently associated with other nasal or craniofacial disorders. Diagnosis requires clinical examination and endoscopy, whereas rhinomanometry, nasal cytology, and questionnaires have little clinical role. Treatment choice should consider the specific indications and features of the available options, with a preference for less invasive procedures.
Level of Evidence5 Laryngoscope, 134:1437–1444, 2024

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Cochlear Nucleus Transcriptome of a Fragile X Mouse Model Reveals Candidate Genes for Hyperacusis

Hitomi Sakano, Michael S. Castle, Paromita Kundu

Publication date 16-02-2024


This study utilized a Fmr1 knock-out mouse model to identify candidate genes in the development of auditory hypersensitivity in Fragile X Syndrome, a hereditary form of autism spectrum disorder. We identified a gene encoding a potassium channel subunit, KCNAB2, as a promising candidate for further study.
Objective Fragile X Syndrome (FXS) is a hereditary form of autism spectrum disorder. It is caused by a trinucleotide repeat expansion in the Fmr1 gene, leading to a loss of Fragile X Protein (FMRP) expression.
The loss of FMRP causes auditory hypersensitivity: FXS patients display hyperacusis and the Fmr1- knock-out (KO) mouse model for FXS exhibits auditory seizures. FMRP is strongly expressed in the cochlear nucleus and other auditory brainstem nuclei. We hypothesize that the Fmr1-KO mouse has altered gene expression in the cochlear nucleus that may contribute to auditory hypersensitivity.
MethodsRNA was isolated from cochlear nuclei of Fmr1-KO and WT mice. Using next-generation sequencing (RNA-seq), the transcriptomes of Fmr1-KO mice and WT mice (n = 3 each) were compared and analyzed using gene ontology programs.
Results We identified 270 unique, differentially expressed genes between Fmr1-KO and WT cochlear nuclei. Upregulated genes (67%) are enriched in those encoding secreted molecules. Downregulated genes (33%) are enriched in neuronal function, including synaptic pathways, some of which are ideal candidate genes that may contribute to hyperacusis.
Conclusion The loss of FMRP can affect the expression of genes in the cochlear nucleus that are important for neuronal signaling. One of these, Kcnab2, which encodes a subunit of the Shaker voltage-gated potassium channel, is expressed at an abnormally low level in the Fmr1-KO cochlear nucleus. Kcnab2 and other differentially expressed genes may represent pathways for the development of hyperacusis. Future studies will be aimed at investigating the effects of these altered genes on hyperacusis.
Level of EvidenceN/A Laryngoscope, 134:1363–1371, 2024

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The Impact of Early‐Life Recurrent Otitis Media in Children on the Psychological Well‐Being of Caregivers

Ali A. H. Altamimi, Monique Robinson, Eman M. A. Alenezi, Robyn S. M. Choi, Christopher G. Brennan‐Jones

Publication date 16-02-2024


Aim Children with early-life recurrent otitis media (OM) will often endure pain, sleep disturbances, and other developmental setbacks that impact the surrounding family system. The aim of this study was to investigate the psychological well-being and family functioning of caregivers of children with early-life recurrent OM (rOM).
Methods Data from a longitudinal pregnancy cohort were used to categorize children into two groups: those with a history of recurrent OM (rOM group) and those without a history of rOM (reference group) by the age of 3 years. The psychological well-being of caregivers and the family functioning status were assessed using the Affect Balance Scale and the General Functioning Scale of the Mc Master Family Assessment Device (FAD-GF), respectively, at the three-, five-, and eight-year follow-up appointments. Multiple linear regression models were used to analyze the data and were adjusted for potential confounding variables.
Results There were significant associations between having a child with an early history of rOM and the Affect Balance Scale of caregivers for the negative affects subscale at the three- (p < 0.001) and five- (p = 0.018) year follow-ups, and the Affect Balance subscale at the three-year (p = 0.007) and the five-year follow-ups (p = 0.047). There were no significant associations measured during the 8-year follow-up period for the FAD-GF.
Conclusion The findings of this study further highlight the impact of caring for a child with rOM in early childhood on caregivers psychological well-being in the first five years of a childs life. The impact, however, did not appear to influence the longer-term functioning of the family as a whole.
Level of Evidence3 Laryngoscope, 134:1445–1449, 2024

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Can Ganciclovir and Quercetin‐P188 Ameliorate Cytomegalovirus Induced Hearing Loss?

Daniel Suarez, Andrew Kjar, Boston Scott, Katrina Hillam, Elizabeth Vargis, Christopher Nielson, Elizabeth Sommer, Emily Zhang, Anna Holley, Abigail Traxler, Maura Hughes, Yong Wang, Matthew A. Firpo, David Britt, Albert H. Park

Publication date 16-02-2024


In this study, we report for the first time that combination therapy using a poloxamer 188, quercetin, a flavonoid with antioxidant and anti-CMV replication and the antiviral drug, ganciclovir (GCV) resulted in significantly lower viral counts and lower hearing thresholds in a mouse model. These results suggest an attractive approach to CMV mediated hearing loss by reducing the dose-dependent adverse effects from single GCV therapy while maintaining potent and effective antiviral effects in CMV infected infants.
Objective Determine whether combination therapy with ganciclovir (GCV) and a Quercetin-P188 solution improves hearing outcomes in a murine cytomegalovirus (CMV) model.
MethodsBALB/c mice were infected with murine CMV on postnatal day 3 (p3). Quercetin was solubilized in saline using P188 (QP188). Treatment groups received either GCV, QP188, GCV and QP188, or P188 delivery vehicle BID at 12-hour intervals via intraperitoneal injection. All treatment groups were treated for 14 days starting at p3. Uninfected controls were treated with the combined regimen, saline or P188 delivery vehicle. Auditory thresholds were assessed using distortion product otoacoustic emission (DPOAE) and auditory brainstem response (ABR) testing at 4, 6, and 8 weeks of age. Temporal bones from separate CMV-infected groups were harvested at p10, and viral load was determined by quantitative polymerase chain reaction.
ResultsCMV-infected mice receiving combination therapy GCV+QP188 demonstrated statistically significant lower ABR (p < 0.001) and DPOAE thresholds (p < 0.001) compared with mice treated with GCV monotherapy, QP188 monotherapy, and P188 delivery vehicle at 4, 6, and 8 weeks of age. GCV+QP188 combination therapy, GCV monotherapy, and QP188 monotherapy resulted in a nonsignificant reduction in mean viral titers compared to P188 monotherapy (p = 0.08).
Conclusion Combining GCV with the excipients quercetin and P188 effectively ameliorated CMV-induced sensorineural hearing loss in a murine model. This result may be partially explained by a reduction in viral titers in mouse temporal bones that correlate with in vitro studies demonstrating additive antiviral effect in cell culture.
Level of EvidenceNA Laryngoscope, 134:1457–1463, 2024

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sPLA2GIB Promotes PGD2 and IL‐13 Production in Eosinophilic Chronic Rhinosinusitis with Nasal Polyps

Yi‐Fan Kang, Jin‐Xin Liu, Kai Xu, Xue‐Li Li, Xiang Lu

Publication date 16-02-2024


Increased secretion of sPLA2GIB by epithelial cells may promote eosinophilic inflammation in CRSwNP by enhancing PGD2 and IL-13 production in mast cells via binding to PLA2R. These results provide new insight into the pathophysiological mechanisms of CRSwNP and highlight the potential value of sPLA2GIB as a therapeutic target.
Objective Secreted phospholipase A2 Group IB (sPLA2GIB) regulates the release of arachidonic acid, prostaglandins, and other inflammatory lipid mediators. Although it has been well involved in extensive inflammatory diseases, its specific mechanism in chronic rhinosinusitis with nasal polyps (CRSwNP) remains unclear. In this study, we investigated the role of sPLA2GIB in the pathophysiology of CRSwNP.
Methods Quantitative PCR, immunofluorescence staining, western blotting, and enzyme-linked immunosorbent assay (ELISA) were used to analyze the expression of sPLA2s, phospholipase A2 receptor (PLA2R), and prostaglandin D2 (PGD2) in nasal samples. Human nasal epithelial cells (HNECs) were cultured at an air-liquid interface (ALI) and stimulated with various cytokines. The human mast cell line HMC-1 was stimulated with sPLA2GIB, and the expression of PGD2 and cytokines in the culture supernatant was detected by ELISA.
Results The mRNA and protein levels of sPLA2GIB were significantly higher in eosinophilic CRSwNP than in control tissues. sPLA2GIB was predominantly expressed in the nasal epithelial cells. PLA2R mRNA and protein levels were upregulated in both eosinophilic and non-eosinophilic CRSwNP compared with the control groups. IL-4, IL-13, TNF-α, and IL-1β upregulated the expression of sPLA2GIB in ALI-cultured HNECs. sPLA2GIB induced PGD2 and IL-13 production in HMC-1 cells in a hydrolytic activity-independent manner. PGD2 protein expression was elevated in tissue homogenates of eosinophilic CRSwNP, and PGD2 upregulated the expression of IL-13 in HMC-1 cells.
Conclusion Increased secretion of sPLA2GIB by epithelial cells may promote eosinophilic inflammation in CRSwNP by enhancing PGD2 and IL-13 production in mast cells via binding to PLA2R.
Level of EvidenceN/A Laryngoscope, 134:1107–1117, 2024

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Impact of Dementia on the Postoperative Outcomes in Patients Undergoing Surgery for Head and Neck Cancers: A National Study

Rema Anisha Kandula, Grant Borne, Sandeep Kandregula, Robbie Beyl, Cherie‐Ann O. Nathan

Publication date 16-02-2024


Background Dementia, a growing concern among the elderly, has an increased poor postoperative outcome that goes unrecognized by many. Our study aims to establish if dementia plays a role in the outcomes of head and neck cancer patients that undergo resections.
Methods We queried the National Inpatient Sample (NIS) database from 2016 to 2019 with a primary diagnosis of head and neck cancer who underwent surgical resection. Outcomes analyzed include postoperative delirium, ICU stay, complications, length of stay, and non-routine discharge.
ResultsA total of 77095 patients were included, of which 1140 patients had dementia. The mean age of the patients with dementia was 77.5 years (±9.1) versus 63.2 years (±12.1) with no dementia. Dementia patients had a higher non-home discharge rate (77.2% vs 46.8%, p = <0.001), extended length of stay (10.9 days ±14.7 vs 7.9 days ±8.8), postoperative delirium (15.4% vs 1.5%, p = <0.001), and longer ICU stay (8.3% vs 5.8%) as compared with patients with no dementia. A higher number of patients with Dementia were placed in long-term facilities (53.5% vs 14.6%) postoperatively. More dementia patients (7.9% vs 0.9%) were transferred in from another health care facility for surgery. Dementia was associated with higher odds of delirium (OR, 6.36; 95% CI, 5.2–7.77), non-routine discharge (OR, 2.05; 95% CI, 1.76–2.3), ventilation (OR, 0.8; 95% CI, 0.6–1.05), and length of stay (estimate 3.01, 95% CI, 1.84–4.184).
Conclusion Preoperative dementia significantly impacts postoperative delirium, non-home discharge, and extended length of stay in head and neck cancer patients undergoing surgery.
Level of Evidence3 Laryngoscope, 134:1258–1264, 2024

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A Survey of Microvascular Technique Preferences Among American Head Neck Society Members

Ramez Philips, Keisha A. Best, Aarti Agarwal, Hamad Sagheer, Yamil Selman, Larissa Sweeney, Mark Wax, Howard Krein, Ryan Heffelfinger, Adam Luginbuhl, Joseph Curry

Publication date 16-02-2024


In arterial and venous anastomosis, respondents felt that kinking was the riskiest challenge for flap failure. Kinking was handled by loose sutures or native tissue/dissolvable biomaterial to orient pedicle. Most surgeons use pressors as needed, but reserve transfusions in cases of hemodynamic instability. More senior surgeons reported placing more suture to address leaks and perform end-to-side anastomosis on larger vein in case of venous mismatch. In cases of tension, higher volume surgeons perform more extensive dissection and end to side coupling.
Objective To identify practices in microvascular techniques in routine and challenging scenarios.
Study Design Cross-sectional study.
MethodsA national survey addressing practices related to microvascular free flap reconstruction was distributed to AHNS members between October and November 2021.
Results The respondents encompassed 95 microvascular surgeons. Median years of practice was 6 (interquartile range, 2–13) and median flaps per year was 35 (22–50). Common practices in arterial anastomosis included limited cleaning of artery (84.2%), use of a double approximating clamp (64.2%), and use of interrupted suture (88.4%). Common practices in venous anastomosis included limited cleaning (89.5%), downsizing the coupler (53.7%), and coupling to two independent venous systems (47.4%). In arterial anastomosis, respondents felt that kinking (50.5%) and tension (24.2%) were the riskiest challenges. Kinking was handled by loose sutures or native tissue/dissolvable biomaterial to orient pedicle. Excess tension was handled by additional dissection. With regards to associated practices, most surgeons perform anastomosis after partial inset (52.6%), give aspirin immediately postoperatively (66.3%), reserve transfusion for hemodynamic instability (69.5%), and utilize intraoperative pressors when needed (72.6%). More senior surgeons reported placing more suture to address leaks (p = 0.004) and perform end to side anastomosis on larger vein in case of venous mismatch (p = 0.012). In cases of tension, higher volume surgeons perform more extensive dissection (p = 0.035) and end to side coupling (p = 0.029).
Conclusions This survey of AHNS members indicates patterns of microvascular techniques in routine and challenging scenarios. There exists a variation in approaches amongst surgeons based on volume and practice length.
Level of Evidence5 Laryngoscope, 134:1265–1277, 2024

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Round Window Niche Veil is Visible on High‐Resolution Computed Tomography and a Predictor of Local Drug Efficacy to Inner Ear

Shipei Zhuo, Yong Li, Bozhen Cui, Yuxiang Liu, Jingman Deng, Jintao Lou, Jianpeng Yuan, Yu Si, Zhigang Zhang

Publication date 16-02-2024


Diagnostic criteria for RWNV for the first time direct assessment of delivery efficacy is critical to understanding drug therapeutics but challenging. In this study, we summarized the morphologies of RWNVs and directly assessed the effect of the presence of RWNVs on drug delivery efficacy by measuring perilymph concentrations, found that RWNV could reduce local dexamethasone diffusion efficacy to the perilymph and proposed CT diagnostic criteria for RWNV for the first time.
Objectives To determine the morphologies and effect of the round window niche veil (RWNV) on local drug delivery efficacy and develop diagnostic criteria on high-resolution computed tomography (HRCT).
Methods Patients diagnosed with otosclerosis, bilateral profound sensorineural hearing loss or vestibular schwannoma were enrolled from 2019 to 2022, receiving temporal bone HRCT scanning, and anatomic variations of RWMV were summarized intraoperative. For patients with vestibular schwannoma, 1 mL of dexamethasone solution (4 mg/mL) was administered via facial recess during operation, and samples of perilymph were collected to analyze. The diagnostic criteria of RWNV on HRCT were developed and verified.
ResultsA total of 85 patients were enrolled. RWNV was observed in 54 cases intraoperatively with an incidence of 63.5% (95% CI, 52.9%–73.0%). The median perilymph concentrations were 4.86-fold higher in the group without RWNV than with RWNV (p < 0.0001). RWNV could be visualized on HRCT with a window width of 3500–4500 HU and a window level of 300–500 HU.
The characteristic features were as follows: (1) a thin soft tissue shadow could be seen at the entrance of the round window niche (RWN); (2) it was visible in at least 2 consecutive layers along the upper margin of RWN from top to bottom; (3) it was discontinuous with the adjacent bone margin. The sensitivity and specificity of the diagnostic criteria were 77.8% and 93.6%, respectively.
ConclusionRWNV could reduce local dexamethasone diffusion efficacy to the inner ear, which could be diagnosed on HRCT and used as a predictor of local drug delivery efficacy to the inner ear.
Level of Evidence3 Laryngoscope, 134:1396–1402, 2024

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Survival Benefit from Cancer‐Directed Surgery for Metastatic Head and Neck Cancer

Runqiu Zhu, Huiyong Zhu

Publication date 16-02-2024


Currently, the survival benefit of cancer-directed surgery (CDS) in distant metastatic head and neck cancer (M1 HNC) remains unclear. This study aimed to gather evidence for the survival benefit of CDS in M1 HNC and identify which patients will benefit most from CDS.
Objectives This study aimed to gather evidence for the survival benefit of cancer-directed surgery (CDS) in metastatic head and neck cancer (M1 HNC) and identify which patients will benefit most from CDS.
Methods Patients with M1 HNC were identified within the SEER database. According to whether received CDS, patients were divided into the CDS and non-CDS groups. The bias between the two groups was minimized using Propensity Score Matching (PSM), and the prognostic role of CDS was investigated using Kaplan–Meier analysis, log-rank test, and Cox proportional hazard models. The primary endpoint was overall survival (OS), and the secondary endpoint was cancer-specific survival (CSS).
ResultsA total of 3215 patients with M1 HNC were extracted, including 566 patients who received CDS that were 1:1 propensity score-matched with patients who did not receive CDS. In the matched dataset, the median OS and CSS in CDS groups were significantly higher than in non-CDS groups (OS: 19.0 vs. 9.0 months, p < 0.001; CSS: 21.0 vs. 9.0 months, p < 0.001). Meanwhile, multivariable Cox regression analysis also revealed that CDS was a favorable prognostic factor for both OS and CSS. Furthermore, subgroups of patients with M1 HNC (younger age, being married, grade I–II, oropharynx site, earlier T/N stage, radiotherapy) were inclined to benefit from CDS, while those patients who received chemotherapy failed to benefit from CDS.
Conclusions This study indicated that CDS was associated with improved survival in M1 HNC, especially for those subpopulations that benefit more from CDS treatment.
Level of Evidence3 Laryngoscope, 134:1288–1298, 2024

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The Development of Head and Neck Cancer in Patients with the Isolated Complaint of Globus Pharyngeus

Nicole Maronian, Claudia Cabrera, John Dewey, Tanya Meyer

Publication date 16-02-2024


The aim of this study was to identify the incidence of head and neck cancer (HNC) in patients diagnosed with globus pharyngeus. Overall, 4/377 patients ultimately developed HN cancer, for an overall incidence of 1% for the 4-year period of 2015–2019. Given the long term follow-up of this population, the overall incidence of developing a head and neck cancer with a presenting symptom of globus is low. This is the largest study to date to report the percentage of patients endorsing globus pharyngeus to then subsequently develop HNC. This helps otolaryngologists to reassure patients who have a normal comprehensive exam, flexible endoscopy, and targeted studies.
Objectives Globus pharyngeus (GP) is a perplexing problem that accounts for 4% of referrals to otolaryngologists. Workup can be extensive and may not be definitive in terms of etiology. The concern that lingers is that of a subtle cancer, which can prolong anxiety and increase testing cost. The aim of this study was to identify the incidence of head and neck cancer (HNC) in patients diagnosed with GP.
Methods Longitudinal data were captured from two academic institutions, identifying patients with a new diagnosis of globus pharyngeus in 2015. The patient cohort was tracked for at least 4 years to assure follow-up and ability to determine if a HNC developed. Additional demographic data was also collected to determine most common consults, treatments, and testing employed.
Results Excluding patients with previous diagnosis of HNC, 377 patients were identified who presented with GP in 2015 that had at least 4 years of follow-up. Demographics were predominantly women (64.65%), with a mean age of 56.48 years at diagnosis, and the most common provider specialty on the first visit was otolaryngology (39.52%). Four patients ultimately developed HN cancer, for an overall incidence of 1% for the 4-year period of 2015–2019.
Conclusions Given the long-term follow-up of this population, the overall incidence of developing a head and neck cancer, with a presenting symptom of globus, is low. This is the largest study to date to report the percentage of patients endorsing GP to then subsequently develop HNC. This helps otolaryngologists to reassure patients who have a normal comprehensive exam, flexible endoscopy, and targeted studies.
Level of Evidence4 Laryngoscope, 134:1147–1154, 2024

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Venous Thromboembolism Prophylaxis in Otolaryngologic Patients Using Caprini Assessment

Michael A. Edwards, Emily Brennan, Amy L. Rutt, Divya Muraleedharan, John D. Casler, Aaron Spaulding, Dorin Colibaseanu

Publication date 16-02-2024


This study aimed to determine the utilization of Caprini guideline indicated VTE prophylaxis and impact on VTE and bleeding outcomes in patients after ORL surgeries.
Objective The aim was to determine the utilization of Caprini guideline-indicated venous thromboembolism (VTE) prophylaxis and impact on VTE and bleeding outcomes in otolaryngology (ORL) surgery patients.
Methods Elective ORL surgeries performed between 2016 and 2021 were retrospectively identified. Logistic regression models were used to examine the association between patient characteristics and receiving appropriate prophylaxis, inpatient, 30- and 90-day VTE and bleeding events.
ResultsA total of 4955 elective ORL surgeries were analyzed. Thirty percent of the inpatient cohort and 2% of the discharged cohort received appropriate risk-stratified VTE prophylaxis. In those who did not receive appropriate prophylaxis, overall inpatient VTE was 3.5-fold higher (0.73% vs. 0.20%, p = 0.015), and all PE occurred in this cohort (0.47% vs. 0.00%, p = 0.005). All 30- and 90-day discharged VTE events occurred in those not receiving appropriate prophylaxis. Inpatient, 30- and 90-day discharged bleeding rates were 2.10%, 0.13%, and 0.33%, respectively. Although inpatient bleeding was significantly higher in those receiving appropriate prophylaxis, all 30- and 90-day post-discharge bleeding events occurred in patients not receiving appropriate prophylaxis. On regression analysis, Caprini score was significantly positively associated with likelihood of receiving appropriate inpatient prophylaxis (odds ratio OR 1.05, confidence interval CI 1.03–1.07) but was negatively associated in the discharge cohort (OR 0.43, CI 0.36–0.51). Receipt of appropriate prophylaxis was associated with reduced odds of inpatient VTE (OR 0.24, CI 0.06–0.69), but not with risk of bleeding.
Conclusion Although Caprini VTE risk-stratified prophylaxis has a positive impact in reducing inpatient and post-discharge VTE, it must be balanced against the risk of inpatient postoperative bleeding.
Level of Evidence3 Laryngoscope, 134:1169–1182, 2024

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Effects of Short‐term Electronic(e)‐Cigarette Aerosol Exposure in the Mouse Larynx

Meena Easwaran, Chloe Santa Maria, Joshua D. Martinez, Barbara Hung, Xuan Yu, Joanne Soo, Akari Kimura, Eric R. Gross, Elizabeth Erickson‐DiRenzo

Publication date 16-02-2024


Objectives The effects of electronic cigarettes (e-cigarettes) on the larynx are relatively unknown. This study examined the short-term effects of e-cigarette inhalation on cellular and inflammatory responses within the mouse laryngeal glottic and subglottic regions after exposure to pod-based devices (JUUL).
Methods Male C57BL6/J mice (8–9 weeks) were assigned to control (n = 9), JUUL flavors Mint (JMi; n = 10) or Mango (JMa; n = 10). JUUL mice were exposed to 2 h/day for 1, 5, and 10 days using the in Expose inhalation system. Control mice were in room air. Vocal fold (VF) epithelial thickness, cell proliferation, subglandular area and composition, inflammatory cell infiltration, and surface topography were evaluated in the harvested larynges. Mouse body weight and urinary nicotine biomarkers were also measured. Chemical analysis of JUUL aerosols was conducted using selective ion flow tube mass spectrometry.
ResultsJUUL-exposed mice had reduced body weight after day 5. Urinary nicotine biomarker levels indicated successful JUUL exposure and metabolism. Quantitative analysis of JUUL aerosol indicated that chemical constituents differ between JMi and JMa flavors. VF epithelial thickness, cellular proliferation, glandular area, and surface topography remained unchanged after JUUL exposures. Acidic mucus content increased after 1 day of JMi exposure. VF macrophage and T-cell levels slightly increased after 10 days of JMi exposures.
Conclusions Short-term e-cigarette exposures cause minimal flavor- and region-specific cellular and inflammatory changes in the mouse larynx. This work provides a foundation for long-term studies to determine if these responses are altered with multiple e-cigarette components and concentrations.
Level of EvidenceN/A Laryngoscope, 134:1316–1326, 2024

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Is Laryngeal Reinnervation Recommended for Pediatric Unilateral Vocal Fold Paralysis?

Kirsten Meenan, Pranati Pillutla, Dinesh K. Chhetri

Publication date 16-02-2024


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Is the Competency‐Based Education Model Effective in Otolaryngology Training?

Amir A. Hakimi, Sonya Malekzadeh

Publication date 16-02-2024


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Posterior Septal Artery Flap for Endoscopic Repair of Large Nasal Septal Perforation: How I Do It

Yury Rusetsky, Zhanna Mokoyan, Anna Elumeeva, Olga Chernova

Publication date 16-02-2024


Endoscopic repair of large nasal septal perforation (SP) remains a rather challenging procedure. The presented modification of vascularized flap, which is supplied with branches of posterior septal artery, has proven to be convenient and effective in closure of SPs larger than 2 cm. Laryngoscope, 2024

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An Integrative Model of ENT Healthcare for the Homeless Population

Evan A. Patel, Swapnil V. Shah, Trevor A. Poulson, Ashok A. Jagasia

Publication date 16-02-2024


Our aim is that the development of this type of system for delivering otolaryngology care utilizing both telemedicine and in-person visitation will act as a model system, later translatable to other specialties. By doing so, we seek to improve access to health care, reduce overall costs, and provide timely and effective care to the residents of homeless shelters—a vulnerable population that deserves equal access to the same resources as the rest of society.
Objective Our aim was to determine the need for otolaryngology care within the homeless population, identify barriers to access that the homeless population may face, and develop a model system which would address these needs with respect to the barriers.
MethodsA retrospective chart review of 812 patients seen between 1/25/16–3/21/2020 was performed. Charts were obtained from homeless patients seen at free general clinics held shelters in Chicago, IL (781 charts) and in Champaign, IL (31 charts). Records reporting at least one otolaryngology disease in a patient experiencing homelessness were included in this study. Patients were considered homeless if they resided at the shelter at the time of their appointment. To determine common barriers to care, a simple yes/no questionnaire was administered to residents at west-side Chicago homeless shelters. Questions addressed barriers to health care access that had been mentioned by patients seen at free clinics.
Results Chart review findings demonstrated that 14.3% (n = 142) of all homeless patients seen at free in-shelter clinics were seen for ENT-related disorders. Survey results revealed that 76.3% (n = 71) of respondents believed that telemedicine services would be useful in shelters. 74.2% (n = 69) stated they were unable to afford prescribed medications. 93.5% (n = 87) stated that better access to transportation would increase their likelihood of seeking care.
Conclusions In our attempt to bridge this inequity, we have launched a hybrid in-person/virtual care program to improve access to otolaryngology care for the homeless community.
Level of EvidenceN/A Laryngoscope, 2024

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Gender Disparities in Academic Otolaryngology

Beth L. Ladlie, Hannah F. Case, Priyanka Perisetla, Andrew W. Austin, Emily C. Craver, Erica Engelberg‐Cook, Amy L. Rutt

Publication date 15-02-2024


This manuscript takes a glance at gender parity in otolaryngology by examining authorship of research publications and presentations, awards, research grants, leadership and membership in related organizations. While the proportion of women receiving awards and holding leadership positions is increasing, the percentage continues to lag. Efforts should be made to promote diverse-gender professional networks in otolaryngology that increase womens representation.
Objective The aim was to evaluate representation of women in otolaryngology by examining authorship of research publications and presentations, awards, research grants, leadership, and membership in related organizations.
Methods Authorship was reviewed from articles published in three otolaryngology journals from 2000 through 2021 to assess the frequency and percentages of female and combination of male and female gender authorship. Gender was evaluated for poster and scientific abstract presentations from 2007 to 2021. Gender representation was reviewed for institutional and society leadership positions, award, and grant recipients in the American Laryngological Society (ALA). Changes in the frequency of female and combination of male and female gender authorship over time were examined with Cochran-Armitage test for trend.
ResultsA total of 16,921 articles, 1,017 presentations, 480 leadership positions, 129 president positions, and 1,137 awards and grants were studied. Women were first authors in 4,153 (24.9%) and last authors in 2,935 (17.8%) published articles for which gender could be determined. Women were first authors in 372 (37.4%) presentations and last authors in 199 (20.2%). Most presentations had a combination of male and female presentation authorship (630, 68%). Women held 69 (14.4%) leadership positions. Of the award and grant recipients, 327 (28.8%) were female. Significant trends were observed for increasing female representation (first authorship publications increased 69.9% from 2000 to 2020, first authorship presentations increased 73.9% from 2007 to 2013, p < 0.001; leadership and awards from 3% to 18% representation, p = 0.02).
Conclusion The proportion of women receiving awards and holding leadership positions is increasing. Efforts that promote gender diversity may further increase representation of women in otolaryngology literature and among the grant and award winners.
Level of Evidence Level N/A Laryngoscope, 2024

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

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

Publication date 12-02-2024


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

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

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

Publication date 09-02-2024


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

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

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

Publication date 09-02-2024


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

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

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

Publication date 08-02-2024


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

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Improved Recovery after Vestibular Schwannoma Excision with Intratympanic Gentamicin Prehabilitation

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

Publication date 08-02-2024


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

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

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

Publication date 07-02-2024


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

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

Sang‐Yoon Han, Young Ho Kim

Publication date 05-02-2024


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

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

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

Publication date 05-02-2024


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

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

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

Publication date 03-02-2024


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

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

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

Publication date 03-02-2024


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

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

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

Publication date 02-02-2024


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

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In reference to Evaluation of Oropharyngeal Cancer Information from Revolutionary Artificial Intelligence Chatbot

Pingping Yang, Jiuliang Jiang

Publication date 01-02-2024


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In Response to Evaluation of Oropharyngeal Cancer Information from Revolutionary Artificial Intelligence Chatbot

Niels C. Kokot, Ryan J. Davis

Publication date 01-02-2024


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In Response to The Dubai Definition and Diagnostic Criteria of Laryngopharyngeal Reflux: The IFOS Consensus

Jerome R. Lechien, Thomas L. Carroll, Walter W. Chan, Jonathan M. Bock, Michael F. Vaezi, Lee M. Akst

Publication date 01-02-2024


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In Reference to The Dubai Definition and Diagnostic Criteria of Laryngopharyngeal Reflux: The IFOS Consensus

Jinrang Li

Publication date 01-02-2024


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

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

Publication date 31-01-2024


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

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

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

Publication date 31-01-2024


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

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