Laryngoscope 2020-10-24

Characteristics of Early Internal Laryngeal Muscle Atrophy After Recurrent Laryngeal Nerve Injuries in Rats

\nHong Wang, \nHaizhou Wang, \nXueyan Li, \nWen Xu\n

Publicatie 24-10-2020


Objectives/HypothesisThe present study investigated the characteristics of early internal laryngeal muscle atrophy in recurrent laryngeal nerve injury (RLNI) rats.Study DesignTo observe the characteristics of early internal laryngeal muscle atrophy post RLNI.MethodsRats were divided into three groups: sham‐operated control group (n = 20), recurrent laryngeal nerve transverse injury group (RLNTI, n = 50), and recurrent laryngeal nerve blunt contusion group (RLNBC, n = 50). Five weeks after RLNI, certain rats were sacrificed weekly, and their laryngeal tissues were harvested. The atrophic features of internal laryngeal muscles were detected using hematoxylin and eosin. NF‐κB and MuRF‐1 levels were tested using IHC.ResultsThe atrophic degree and fibrosis of thyroarytenoid, posterior cricoarytenoid, and lateral cricoarytenoid muscles were related to the type of RLNI. The average myofiber cross‐sectional areas increased before an obvious decrease in the RLNTI and RLNBC groups. Muscle recovery occurred in the RLNBC group starting 4 weeks after RLNI, but only a weak trend was observed in the RLNTI group in the 5th week. During the muscle atrophy process, MuRF‐1 and NF‐κB were upregulated early and were maintained at a high level, which showed a trend similar to muscle atrophy. However, NF‐κB expression was opposite to MuRF‐1 expression and muscle atrophy when the muscles recovered.ConclusionThe atrophy degree of internal laryngeal muscles was associated with the type of RLNI. The NF‐κB/MuRF‐1 signaling pathway was involved in internal laryngeal muscle atrophy after RLNI, which is different from skeletal muscle after denervation.Level of EvidenceNA Laryngoscope, 2020

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Predicting Factors for Oncological and Functional Outcome in Hypopharyngeal Cancer

\nMiranda Visini, \nRoland Giger, \nMohamed Shelan, \nOlgun Elicin, \nLukas Anschuetz\n

Publicatie 24-10-2020


Objectives/HypothesisHypopharyngeal squamous cell carcinoma (SCC) is a rare but aggressive malignancy, with low survival rates and high incidence of tumor and treatment‐related morbidity. This study aims to analyze the long‐term oncologic and functional outcomes of a large cohort of patients and to determine prognostic factors.Study DesignRetrospective cohort study.MethodsThe records of all patients diagnosed with hypopharyngeal SCC and treated with curative intent at our tertiary referral center were reviewed. Patient and initial disease characteristics, features, and complications of primary treatment, recurrence patterns, and corresponding treatments and the oncologic and functional long‐term outcome were determined.ResultsFor a total of 179 patients, primary radiotherapy (RT) was the predominant treatment modality (78%), whereas 22% underwent primary surgery. The median, 2‐year, and 5‐year overall survival (OS) for the study cohort were 47 months, 64% and 43%. The median survival after first and second relapse was 7 and 6 months, respectively. The 2 and 5‐year relapse‐free survival (RFS) was 52% and 36%. The median RFS after first relapse and salvage treatment was 9 months. A nodal status of ≥cN2 (HR = 1.89, CI:1.21–3.05, P < .005) and any other primary tumor localization than pyriform sinus (HR = 1.60, CI: 1.04–2.42, P < .05) were identified as independent risk factors for shorter OS and RFS. Regarding functional outcome, the 2‐ and 5‐year laryngectomy‐free‐survival was 55% and 37%, respectively.ConclusionsIn this large cohort with long‐term follow‐up, any other primary tumor localization than pyriform sinus and a nodal status of ≥cN2 were identified as risk factors for reduced OS and RFS.Level of Evidence4 Laryngoscope, 2020

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Prognostic Impact of Metastatic Site and Pattern in Patients with Metastatic Head and Neck Cancer

\nCraig A. Bollig, \nChristopher I. Newberry, \nTabitha L. I. Galloway, \nRobert P. Zitsch, \nElyse K. Hanly, \nVivian L. Zhu, \nNitin Pagedar, \nRohit Nallani, \nAndres M. Bur, \nWilliam C. Spanos, \nJeffrey B. Jorgensen\n

Publicatie 24-10-2020


Objectives/HypothesisInvestigate the relationship between site and pattern of distant metastasis (DM) and overall survival (OS) in a multi‐institutional cohort of patients with DM head and neck cancer (HNC).Study DesignRetrospective review.Methods283 patients treated at 4 academic centers in the Midwest HNC Consortium between 2000 and 2015 were retrospectively reviewed. Disease patterns were divided between solitary metastatic versus polymetastatic (≥2 sites) disease. Survival functions for clinically relevant variables were estimated using Kaplan‐Meier and Cox proportional hazards models.ResultsMedian OS for all patients was 9.0 months (95% confidence interval CI: 7.4–10.6). Lung (n = 220, 77.7%) was the most common site of DM, followed by bone (n = 90, 31.8%), mediastinal lymph nodes (n = 55, 19.4%), liver (n = 41, 14.5%), and brain (n = 17, 6.0%). Bone metastases were independently associated with the worst prognosis (hazard ratio HR = 1.6, 95% CI: 1.3–2.1). On univariate analysis, brain metastases were associated with improved prognosis (HR = 0.5, 95% CI: 0.3–0.9), although this was not statistically significant on the multivariate analysis. Polymetastatic disease was present in the majority of patients (n = 230, 81.3%) and was associated with a worse prognosis compared to solitary metastatic disease (HR = 1.4, 95% CI: 1.0–2.0).ConclusionOur large, multi‐institutional review indicates that both the metastatic pattern and site of DM impact OS. Polymetastatic disease and bone metastasis are associated with worse prognosis, independent of treatment received.Level of Evidence4 Laryngoscope, 2020

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Management of Head and Neck Cancers With or Without Comorbid HIV Infection in Botswana

\nGwendolyn J. McGinnis, \nMatthew S. Ning, \nMemory Bvochora‐Nsingo, \nSebathu Chiyapo, \nDawn Balang, \nTlotlo Ralefala, \nAlexander Lin, \nNicola M. Zetola, \nSurbhi Grover\n

Publicatie 24-10-2020


Objectives/HypothesisHead and neck cancer (HNC) is the fifth most common malignancy in sub‐Saharan Africa, a region with hyperendemic human immunodeficiency virus (HIV)‐infection. HIV patients have higher rates of HNC, yet the effect of HIV‐infection on oncologic outcomes and treatment toxicity is poorly characterized.Study DesignProspective observational cohort study.MethodsHNC patients attending a government‐funded oncology clinic in Botswana were prospectively enrolled in an observational cohort registry from 2015 to 2019. Clinical characteristics were analyzed via Cox proportional hazards and logistic regression followed by secondary analysis by HIV‐status. Overall survival (OS) was evaluated via Kaplan–Meier.ResultsThe study enrolled 149 patients with a median follow‐up of 23 months. Patients presented with advanced disease (60% with T4‐primaries), received limited treatment (19% chemotherapy, 8% surgery, 29% definitive radiation RT), and had delayed care (median time from diagnosis to RT of 2.5 months). Median OS was 36.2 months. Anemia was associated with worse survival (HR 2.74, P = .001). Grade ≥ 3 toxicity rate with RT was 30% and associated with mucosal subsite (OR 4.04, P = .03) and BMI < 20 kg/m2 (OR 6.04, P = .012). Forty percent of patients (n = 59) were HIV‐infected; most (85%) were on antiretroviral therapy, had suppressed viral loads (90% with ≤400 copies/mL), and had immunocompetent CD4 counts (median 400 cells/mm3). HIV‐status was not associated with decreased receipt or delays of definitive RT, worse survival, or increased toxicity.ConclusionsDespite access to government‐funded care, HNC patients in Botswana present late and have delays in care, which likely contributes to suboptimal survival outcomes. While a disproportionate number has comorbid HIV infection, HIV‐status does not adversely affect outcomes.Level of Evidence2c Laryngoscope, 2020

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Unilateral Sialendoscopy for Juvenile Recurrent Parotitis: What Happens to the Other Side?

\nKonstantinidis Iordanis, \nDogantzis Panagiotis, \nChatziavramidis Angelos, \nMetzikofis Antonios, \nDelides Alexander, \nAlataki Sofia, \nPapadopoulou‐Alataki Efimia\n

Publicatie 24-10-2020


Objective/HypothesisCurrent literature has confirmed the benefits of sialendoscopy for the treatment of juvenile recurrent parotitis (JRP). However, this procedure is often performed unilaterally, although the disease can affect both sides. This article investigated the clinical course of the contralateral parotid (CL) gland in children requiring unilateral sialendoscopy with the goal of clarifying the necessity of primary bilateral sialendoscopy.Study DesignProspective cohort study in a tertiary center.MethodsOver an eight‐year period, 77 children with JRP underwent unilateral sialendoscopy. We observed the clinical course of the CL parotid over a minimum follow‐up period of 24 months. New episodes of sialadenitis were recorded on both sides along with the need for a second sialendoscopy. These data were correlated with the preoperative symptoms of the contralateral side as well as ultrasound (U/S) findings at baseline assessment.ResultsIn total, six children required sialendoscopy on the CL side (7.8%), 62 children remained asymptomatic or with scarce swellings (80.5%), and nine children improved (11.7%). The preoperative U/S findings on the CL side positively correlated with the number of postoperative swellings. The proportion of children needing CL sialendoscopy was higher (21.4%) among children needing a second sialendoscopy on the operated side.ConclusionsIn the long term, the vast majority of children needing unilateral sialendoscopy do not require similar treatment of the CL parotid gland. However, a history of bilateral swellings along with U/S findings of parenchymal disorganization on the CL side significantly increases the risk of needing further sialendoscopy at a later time.Level of Evidence4 Laryngoscope, 2020

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A National Evaluation of Food Insecurity in a Head and Neck Cancer Population

\nMichael H. Berger, \nHarrison W. Lin, \nNeil Bhattacharyya\n

Publicatie 24-10-2020


Objectives/HypothesisTo determine the food security status of patients with a history of head and neck cancer and compare to other types of cancer.Study DeignA retrospective analysis using the National Health Interview Series.MethodsThe National Health Interview Series (NHIS) for the calendar years 2014 to 18 was used to elicit food security status (secure, marginally secure/not secure) among adult patients with a history of throat/pharynx head and neck cancer (pHNC), thyroid cancer, and colon cancer. The relationship between food security and the primary site was compared and subanalyses were performed according to sex, race, and ethnicity.ResultsThe study population included 199.0 thousand patients with pHNC, with 17.7% (95% confidence interval, 10.5%–28.1%) of pHNC patients reporting their food security status as marginally secure or not secure. Food insecurity was significantly higher among pHNC patients when compared to thyroid cancer (insecurity 10.7%, 7.7%–14.7%) and colon cancer patients (10.1%, 7.8%–13.2%). Among pHNC patients, there was no significant difference in rates of food insecurity when stratified by gender, race, or ethnicity. However, black individuals were more likely to have food insecurity with a history of thyroid or colon cancer (P < .042) and Hispanics were more likely to have food insecurity with a history of thyroid cancer (P = .005).ConclusionsFood insecurity disproportionally affects patients with a history of pHNC, though there is less demographic variability when compared to other cancer primary sites. Food security assessments should be part of the tailored approach to survivorship management in head and neck cancer.Level of Evidence4 Laryngoscope, 2020

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National Analysis of 30‐Day Readmission Following Inpatient Sinus Surgery for Chronic Rhinosinusitis

\nHabib Khoury, \nNikhil Bellamkonda, \nPeyman Benharash, \nJivianne T. Lee, \nMarilene B. Wang, \nJeffrey D. Suh\n

Publicatie 24-10-2020


ObjectivesTo characterize the incidence, causes, risk factors, and costs of 30‐day readmission after inpatient functional endoscopic sinus surgery (FESS) for patients with chronic rhinosinusitis.Study DesignRetrospective cohort study.MethodsThe Nationwide Readmissions Database was used to characterize readmission after inpatient sinus surgery for chronic rhinosinusitis from 2015 to 2017. International Classification of Disease codes were used to identify the patient population, which included 5,644 patients. Incidence, causes, costs, and predictors of readmission were analyzed and determined.ResultsAmong 6,386 patients who underwent inpatient FESS, 742 (11.6%) were readmitted within 30 days of discharge. On univariate analysis, patients who were readmitted were more commonly older than 70 years (23.3% vs. 16.2%); had a higher burden of comorbidities including chronic kidney disease (15.0% vs. 7.8%), diabetes (25.6% vs. 20.4%), and hypertension (13.5% vs. 8.5%); had a greater rate of postoperative complications (20.7% vs. 12.2%); and had a longer length of stay (12.4 vs. 6.9 days) compared to patients who were not readmitted. Readmissions cost an additional $27,141 per patient. On multivariable analysis, age greater than 70 years, Medicaid insurance, several comorbidities, prolonged length of stay, postoperative neurologic complications, and lower hospital volume were independent predictors of 30‐day readmission. The most common cause for readmission was infection (36.3%).ConclusionReadmission following inpatient FESS is not uncommon. Identification and management of preoperative comorbidities, optimized patient selection for inpatient surgery, and thorough postoperative discharge care may improve patient outcomes and decrease healthcare expenditures.Level of Evidence3 Laryngoscope, 2020

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Prognostic Factors in Patients with Differentiated Thyroid Cancers Metastatic to the Cervical Spine

\nLinda X. Yin, \nCassandra L. Puccinelli, \nKathryn Van Abel, \nJan L. Kasperbauer, \nDaniel L. Price, \nJeffrey R. Janus, \nMabel Ryder, \nEric J. Moore\n

Publicatie 23-10-2020


ObjectivesThe spine is the most common site of bone metastases in differentiated thyroid cancer (DTC). The role of surgery in the management of cervical spine (C‐spine) metastases (CSpM) has not been adequately explored.MethodsThis is a retrospective cohort study at a tertiary referral center from 2002 to 2018. Inclusion criteria were pathologic diagnosis of DTC and imaging/pathologic diagnosis of CSpM. Statistical analysis utilized t tests for continuous variables and χ2 tests for categorical variables. Survival analysis was conducted using Kaplan–Meier curves with univariate and multivariate Cox regressions.ResultsFifty patients with DTC and CSpM were identified. Of those, 16 underwent surgical resection of the C‐spine, whereas 34 did not. The most common presenting symptom was neck pain (N = 37, 74%). Patients in the surgery group were more likely to report a subjective improvement of symptoms (P < .01) and to have local (P < .01) and systemic (P = .04) disease control. Five‐year overall survival was 44.7% for the surgery group (95% confidence interval CI: 17.1–69.3) and 11.1% (95% CI: 2.1–28.8) for the nonsurgery group (P = .01). The strongest risk factor for improved overall survival after C‐spine metastasis was local disease control at the C‐spine (multivariate hazard ratio HR = 0.32, 95% CI: 0.12–0.85, P = .02). Surgical intervention was significantly associated with improved survival on both univariate (HR = 0. 35, 95% CI: 0.15–0.82, P = .02) and multivariate (HR = 0.37, 95% CI: 0.14–0.98, P = .04) analysis.ConclusionSurgical management of CSpM in differentiated thyroid cancers is associated with significantly improved local disease control and overall survival. Referral to spine surgeons should be considered after diagnosis.Level of EvidenceIV. Laryngoscope, 2020

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SARS‐CoV‐2 presence in the saliva, tears and cerumen of COVID‐19 patients

\nFatih Mehmet Hanege, \nEsra Kocoglu, \nM Tayyar Kalcioglu, \nSerdal Celik, \nYasemin Cag, \nFehim Esen, \nEray Bayindir, \nSadrettin Pence, \nEmine Alp Mese, \nCanan Agalar\n

Publicatie 23-10-2020


ABSTRACTObjectivesThe emergence of a new coronavirus strain (SARS‐CoV‐2) in December 2019 from China led to a global pandemic. The lack of herd immunity against this virus and the possibility of viral spread from asymptomatic individuals is still a major challenge for the prevention of viral transmission. The aim of this study was to evaluate the presence of the virus in different bodily secretions as a potential source of viral spread among patients infected with SARS‐CoV‐2.MethodsThe study included 38 COVID‐19 patients with a positive real time polymerase chain reaction (RT‐PCR) test result for SARS‐CoV‐2, obtained from the combined nasopharyngeal–oropharyngeal swab samples. Saliva, tear and cerumen samples were taken from the patients within 72 hours of the first RT‐PCR test. SARS‐CoV‐2 N1 and N2 gene regions were studied with single‐step RT‐PCR in all samples.ResultsAmong the studied samples, the highest positivity rate was in saliva (76.3%) followed by tears (55.3%) and cerumen (39.5%). Viral load in saliva was also significantly higher compared to tears and cerumen (p<0.001), while there was no significant difference between tears and cerumen. Higher viral load in combined nasopharyngeal–oropharyngeal swab samples was associated with higher viral load in tears, but not in saliva or cerumen. Half of the saliva, tear and cerumen samples obtained from asymptomatic patients contained SARS‐CoV‐2 genome.ConclusionThe virus was detected in the saliva, tears and cerumen samples of both symptomatic and asymptomatic patients. The potential role of these bodily fluids on viral spread needs to be studied.

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Prevalence of Sensorineural Hearing Loss in Pediatric Patients with Sickle Cell Disease: A Meta‐analysis

\nDavid Strum, \nElina Kapoor, \nTimothy Shim, \nSunny Kim, \nParisa Sabetrasekh, \nAshkan Monfared\n

Publicatie 22-10-2020


ObjectivesTo determine the prevalence of Sensorineural Hearing Loss (SNHL) attributable to Sickle Cell Disease (SCD) in the global pediatric population and to identify factors contributing to its severity.Study DesignMeta‐analysis.MethodsWe performed a comprehensive literature search for scientific articles in PubMed, Scopus, CINAHL, Web of Science, and the Cochrane Library that reported the incidence of hearing loss in populations under 18 years of age with excluding studies analyzing patients on iron chelation therapy, adults, or those without objective audiological analysis.ResultsWe identified 138 initial studies with 17 selected for analysis after applying the exclusion criteria. A total of 1,282 SCD patients and 553 controls were included in the meta‐analysis. There was a statistically significant increase in the prevalence of SNHL in children with SCD compared to the general population with a cumulative risk ratio of 3.33.ConclusionThis is the first systematic investigation of the relationship between SCD and SNHL in pediatric patients across the globe. The increased prevalence of SNHL in the pediatric SCD population warrants future research into the predictors of SNHL severity and merits routine audiometric monitoring of SCD patients to reduce the social and developmental morbidity of hearing loss at a young age.PROSPERO Registration #: CRD42019132601. Laryngoscope, 2020

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Curbing the Cough: Multimodal Treatments for Neurogenic Cough: A Systematic Review and Meta‐Analysis

\nNneoma S. Wamkpah, \nAndrew M. Peterson, \nJake J. Lee, \nLena Jia, \nAngela Hardi, \nCarolyn Stoll, \nMolly Huston\n

Publicatie 21-10-2020


Objectives/HypothesisNeurogenic cough affects 11% of Americans and causes significant detriment to quality of life. With the advent of novel therapies, the objective of this review is to determine how procedural therapies (e.g., superior laryngeal nerve block) compare to other established pharmacologic and non‐pharmacologic treatments for neurogenic cough.MethodsWith the assistance of a medical librarian, a systematic review was performed using PICOS (patients, interventions, comparator, outcome, study design) format: adults with neurogenic cough receiving any pharmacologic or non‐pharmacologic treatment for neurogenic cough compared to adults with neurogenic cough receiving any other relevant interventions, or treated as single cohorts, assessed with cough‐specific quality of life outcomes, in all study designs and case series with ≥ 10 cases. Case reports, review articles, non‐human studies, non‐English language articles, and unavailable full‐text articles were excluded.ResultsThere were 2408 patients with neurogenic cough in this review, treated with medical therapy (77%), speech therapy (19%), both medical and speech therapy (1%), and procedural therapy (3%). The included studies ranged from low to intermediate quality. Overall, most interventions demonstrated successful improvement in cough. However, the heterogeneity of included study designs precluded direct comparisons between intervention types.ConclusionThis meta‐analysis compared various treatments for neurogenic cough. Procedural therapy should be considered in the armamentarium of neurogenic cough treatments, particularly in patients refractory to, or intolerant of, the side effects of medical therapy. Lastly, this review illuminates key areas for improving neurogenic cough diagnosis, such as strict adherence to diagnostic and treatment guidelines, sophisticated reflux testing, and standardized, consistent outcome reporting. Laryngoscope, 2020

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Real‐Time, Intraoperative, Ultrasound‐Assisted Transoral Robotic Surgery for Obstructive Sleep Apnea

\nChan‐Chi Chang, \nJiunn‐Liang Wu, \nJenn‐Ren Hsiao, \nCheng‐Yu Lin\n

Publicatie 21-10-2020


Objectives/HypothesisTo investigate the lingual artery (LA) position in the tongue base through intraoperative ultrasound (IOU) imaging during transoral robotic surgery (TORS) and evaluate bleeding complications with or without the assistance of IOU.Study DesignCohort study with historical control.MethodsPatients with obstructive sleep apnea (OSA) who underwent TORS for tongue base resection were recruited since 2016. During surgery, ultrasound imaging was employed to identify anatomic parameters of the LA in the tongue base, including distance to the midline and arterial depth and diameter.ResultsNinety‐three OSA patients (82 men, 88.2%) were analyzed. Mean age was 42.2 ± 10.0 years and body mass index was 29.2 ± 4.5 kg/m2. Average apnea–hypopnea index (AHI) was 58.1 ± 21.4 events/hour. Overall, 70 patients who underwent TORS with IOU had a shorter operation time (191.7 ± 3.8 vs. 220.1 ± 6.6 minutes), lower total blood loss (11.3 ± 10.8 vs. 19.6 ± 26.7 mL), and higher tongue base reduction volume (7.1 ± 2.5 vs. 3.9 ± 1.6 mL) than 23 patients who underwent TORS without IOU. Significant predictors of arterial depth included higher AHI level during the rapid eye movement sleep (P = .038), larger tonsil size (P = .034), and more elevated Friedman tongue position (P = .012). Postoperative complications associated with LA injury were not found in patients subjected to IOU.ConclusionsWith the assistance of IOU, surgeons can confidently determine LA position. The use of IOU can maximize efficiency and minimize catastrophic bleeding complications when OSA patients undergo TORS for tongue base resection.Level of Evidence4 Laryngoscope, 2020

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Does Drug‐Induced Sleep Endoscopy Improve Sleep Surgery Outcomes?

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

Publicatie 21-10-2020


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Surgical intervention for exercise‐induced laryngeal obstruction: A UK perspective

\nBamidele Famokunwa, \nGuri Sandhu, \nJames H. Hull\n

Publicatie 21-10-2020


ObjectivesExercise‐induced laryngeal obstruction (EILO) is a prevalent cause of exertional breathlessness and wheeze in young individuals. Typically diagnosed using the continuous laryngoscopy during exercise (CLE) test, treatment is largely based on breathing retraining promoting improved laryngeal function. In some cases, these techniques fail to alleviate symptoms, and surgical intervention with supraglottoplasty can be valuable in the supraglottic form of EILO. Globally, there is currently limited experience utilizing a surgical approach to EILO, and data regarding the optimum surgical technique and published outcomes and complication rates are thus limited.Study DesignRetrospective observational case series.MethodsIn this report, we describe our experience as the only UK center undertaking supraglottoplasty for EILO. We report the surgical outcome of 19 patients (n = 16 female), mean age, 29.6 ± 13.1 years, referred for surgery with moderate to severe supraglottic EILO. Follow‐up clinic ± CLE was performed within 4 months (median = 6 weeks), and CLE scores were evaluated before and following surgery.ResultsWe found a beneficial effect of surgery on supraglottic CLE scores (median score reducing from 3/3 to 1/3 postoperatively P < .05 overall) with 79% (n = 15) of patients reporting an improvement in their exercise capacity. One patient developed an apparent increased tendency for glottic‐level EILO following surgery; however, no voice‐ or swallowing‐related complications were encountered.ConclusionsThis study is the first to report the UK experience, surgical technique, and outcome for EILO surgery. The findings indicate that EILO surgery appears to be a safe and effective option for individuals with moderate to severe supraglottic‐type EILO who have failed initial conservative treatment.Level of Evidence5 Laryngoscope, 130:E667–E673, 2020

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The Therapeutic Effects of Straw Phonation on Vocal Fatigue

\nJing Kang, \nChao Xue, \nZhewei Lou, \nAustin Scholp, \nYi Zhang, \nJack J. Jiang\n

Publicatie 21-10-2020


ObjectivesStraw phonation has been investigated for its vocal warm‐up effects on healthy populations and therapeutic effects on voice patients. The purpose of this article was to determine whether it is beneficial for vocal fatigue.Study DesignProspective cohort studyMethodsTwenty‐five healthy participants were recruited into 1‐hour vocal loading tasks followed by 10‐minute vocal rest or straw phonation on 2 different days. Various parameters including phonation threshold pressure (PTP), mean airflow, closed quotient (CQ), current speaking effort level (EFFT), and laryngeal discomfort (DISC) were acquired at baseline, after vocal load, and after the intervention.ResultsIncreased PTP, EFFT, and DISC were observed after vocal load. Decreased PTP, EFFT, and DISC were then acquired after both vocal rest or straw phonation. More significant improvements were obtained in straw phonation when compared with vocal rest. Additionally, significantly increased mean flow and decreased CQ were obtained after straw phonation when compared to vocal rest.ConclusionsStraw phonation has the potential to adjust aerodynamics within the vocal tract leading to improved vocal efficiency, optimized vibration mode, and attenuated vocal fatigue. This study provided a promising treatment for vocal fatigue that could have wide clinical relevance to voice users with high voice demands.Level of Evidence4 Laryngoscope, 130:E674–E679, 2020

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Passy muir valve tolerance in medically complex infants and children: Are there predictors for success?

\nLaura Brooks, \nJanet Figueroa, \nTracy Edwards, \nWalter Reeder, \nSheila McBrayer, \nApril Landry\n

Publicatie 21-10-2020


ObjectiveThe aim of this study was to investigate if there are predictors for success with Passy Muir Valve (PMV) placement for medically complex pediatric patients.MethodsRetrospective chart review of 52 pediatric patients with a tracheostomy with or without ventilator dependence who received PMV assessments from October 2017 through October 2018 in intensive care units and acute care units within Childrens Healthcare of Atlanta (Atlanta, GA). Univariate analysis and logistic regression modeling were used to identify factors associated with a successful PMV trial.ResultsFactors found to be associated with a successful PMV trial were as follows: transtracheal pressure measurement, presence of voicing, age of patient >2 years, weight of patient, and ventilator rate.ConclusionMedically complex infants and children in the intensive care units and acute care units on or off the ventilator can be considered candidates for PMV use; several factors can be predictive of a successful trial.Level of Evidence2C Laryngoscope, 130:E632–E639, 2020

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Inhibitory Effects of Glucosylceramide on Tumorigenesis Induced by a Carcinogen in Mice

\nKazunori Fujiwara, \nHiroaki Yazama, \nRyouhei Donishi, \nSatoshi Koyama, \nTakahiro Fukuhara, \nHiromi Takeuchi\n

Publicatie 21-10-2020


ObjectiveGlucosylceramide (Glu‐Cer), a glycosylated form of ceramide, has been reported to have cytotoxic effects in the cells of various cancers. We previously reported that dietary Glu‐Cer from rice bran had inhibitory effects on human head and neck squamous cell carcinoma (HNSCC) in nonobese diabetes (NOD)/severe combined immunodeficiency (SCID) mice. In HNSCC, preventing recurrence and second primary cancer is required to improve prognosis. The purpose of the present study was to determine whether dietary Glu‐Cer had anticarcinogenic and antitumorigenic effects in a mouse model of HNSCC.MethodsA total of 40 CB6F1‐Tg rasH2@Jcl mice were divided into two groups: control and Glu‐Cer. All mice were given 4‐nitroquinoline 1‐oxide for 24 weeks. Control group mice were fed the normal diet without Glu‐Cer. The Glu‐Cer group mice were given a mixture of the normal diet plus 0.25% Glu‐Cer for 24 weeks. Microscopic examination was performed to identify grossly visible preneoplasms and neoplasms in the mouth, pharynx, and esophagus. Epithelial regions were classified as normal tissue, carcinoma in situ (CIS), or SCC; and the number of each type of region was counted.ResultsCompared with the Glu‐Cer group mice, control group mice more frequently developed individual and multiple tumors of each type, including CIS and SCC, in the mouth, pharynx, or esophagus.ConclusionTumor development was effectively inhibited by dietary Glu‐Cer derived from rice bran, indicating that this and related compounds show promise as prophylactic agents for human HNSCC.Level of EvidenceNA Laryngoscope, 130:E593–E597, 2020

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Review of Pediatric Otolaryngology Clinical Trials: Past Trends and Future Opportunities

\nKunal R. Shetty, \nSevan R. Komshian, \nAnand Devaiah, \nJessica R. Levi\n

Publicatie 21-10-2020


Objectives/HypothesisPediatric otolaryngologic conditions are highly prevalent in the United States. Although data gathered from clinical trials drive therapeutic strategies, the trends of research in pediatric otolaryngology remain unclear. The objective of this study was to characterize recent trials in pediatric otolaryngology to better understand current directions of study and to identify opportunities for future research.Study DesignRetrospective analysis.MethodsA retrospective analysis of United States pediatric clinical trials in otolaryngology between 2001 and 2017 was conducted on ClinicalTrials.gov. Criteria for inclusion included otolaryngologic trials with at least one trial arm of participants <18 years of age, interventional design that was closed, and conducted in the United States. We assessed the information available to us on ClinicalTrials.gov to identify recent trends in pediatric otolaryngology interventional research. We used PubMed to examine publication rates and National Institutes of Health RePORTER to characterize funding patterns for these trials.ResultsOf the 122 trials analyzed, 25% investigated treatments for rhinitis, 25% for acute otitis media, and 50% for all other conditions. Drug studies comprised 72% of all trials. Overall, 65% had their results published in a peer‐reviewed journal. Industry funding accounted for 73% of financial support.ConclusionsContinued focus on the development of pediatric otolaryngologic clinical trials allows an opportunity to better represent the wide spectrum of disease and therapy in the specialty. Increasing the rates of results publication and federal funding may spearhead a more balanced landscape of clinical trials and further advance the care of children with otolaryngologic disease.Level of EvidenceNA Laryngoscope, 130:2719–2724, 2020

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Optimizing Settings for Office‐Based Endoscopic CO2 Laser Surgery Using an Experimental Vocal Cord Model

\nAnouk S. Schimberg, \nTim M. Klabbers, \nDavid J. Wellenstein, \nFloris Heutink, \nJimmie Honings, \nIlse Engen‐Van Grunsven, \nRudolf M. Verdaasdonk, \nRobert P. Takes, \nGuido B. Broek\n

Publicatie 21-10-2020


Objectives/HypothesisTo provide insight in the thermal effects of individual laser settings in target tissues to optimize flexible endoscopic CO2 laser surgery treatment.Study DesignExperimental laboratory study.MethodsThermal effects of the CO2 laser using a fiber delivery system were visualized using the color Schlieren technique in combination with a polyacrylamide gel tissue model. Variable settings were used for emission mode, power, laser fiber distance, and laser duration, which were evaluated in every possible combination. Collateral thermal expansion and incision depth were measured. To validate the model, the results were compared to histology after CO2 laser irradiation of ex vivo human vocal cords, and the intraclass correlation coefficient was calculated. Thermal damage and incision depth were measured by a blinded pathologist.ResultsOf all parameters studied, duration of laser irradiation had the greatest effect on thermal expansion. Increased distance between laser tip and target tissue resulted in significantly reduced incision depth and increased thermal expansion. Pulsed emission modes led to increased incision depths. The intraclass correlation coefficient for consistency between the model setup and the ex vivo human vocal cords was classified as “fair.”ConclusionsBy using high‐intensity pulsed lasers at minimal distance to the target tissue, exposure times and subsequent damage to surrounding tissue can be reduced. If an evaporation technique is used, lower power in continuous wave at a larger distance to the target tissue will lead to superficial but broader thermal effects. The model setup used in this study is a valid model to investigate laser‐induced thermal effects in vocal cord tissue.Level of EvidenceNA Laryngoscope, 130:E680–E685, 2020

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Improving thyroid function monitoring in head and neck cancer patients: A quality improvement study

\nNupur Bhatt, \nZahrah Taufique, \nEmily Kamen, \nBinhuan Wang, \nCatherine Concert, \nZujun Li, \nKenneth Hu, \nBabak Givi\n

Publicatie 21-10-2020


ObjectiveTo investigate and improve compliance of thyroid function monitoring in head and neck cancer patients who received radiotherapy to the cervical region before and after instituting quality improvement interventions.MethodsUsing the Plan, Do, Study, Act (PDSA) methodology, patients with head and neck malignancies who received radiotherapy to the cervical region from 2013–2015 were identified at a tertiary medical center. The status of the patients’ thyroid monitoring and related characteristics were recorded. A quality improvement project was subsequently implemented by data sharing and providing feedback to practitioners involved in head and neck cancer care and creating a tracking database for all patients who received radiotherapy to the neck. After implementation of these interventions, data was collected on patients meeting the inclusion criteria from 2015–2017.ResultsOne hundred fifty‐six patients met criteria pre‐intervention and ninety‐eight patients met criteria post‐intervention. Compliance of thyroid monitoring went up from 34% to 80% after interventions (P < .0001). There was a significant increase in thyroid testing performed by radiation oncologists after interventions from 2% to 21%, while medical oncologists and otolaryngologists remained consistent in their compliance rates.ConclusionIt is possible to improve compliance with evidence‐based recommendations and improve the quality‐of‐care for head and neck cancer survivors through simple, cost effective interventions.Level of Evidence2 Laryngoscope, 130:E573–E579, 2020

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Tracheostomy in bilateral neck dissection: Comparison of three tracheostomy scoring systems

\nStefan Janik, \nFaris F. Brkic, \nStefan Grasl, \nMeinhard Königswieser, \nPeter Franz, \nBoban M. Erovic\n

Publicatie 21-10-2020


ObjectivesTo evaluate whether elective tracheostomy is justified after tumor resection and bilateral neck dissection (ND) and whether application of tracheostomy scoring systems is reliable for planning of postoperative airway management.Study DesignRetrospective cohort study.MethodsWe retrospectively assessed airway management in 160 patients with head and neck squamous cell carcinomas. Additionally, we applied and analyzed the 1) Cameron, 2) TRACHY, and 3) CASST tracheostomy scoring systems on the tracheostomy recommendations.ResultsElective tracheostomies were performed in 51.3% of our patients, particularly in T3 to T4 tumors, cases with free flap reconstruction, and concurrent procedures. Among patients undergoing concurrent procedures, those who received tracheostomy showed significantly longer inpatient stays (27.8 ± 30.0 days vs. 13.3 ± 6.6 days; P < 0.001). Tracheostomy recommendation coincides with the performance of bilateral ND in 28.6% (CASST), 60.0% (Cameron), and 75.0% (TRACHY) of the cases, respectively. By applying corresponding criteria, tracheostomy would be recommended in 2.5% (CASST), 76.9% (Cameron), and 84.4% (TRACHY) of our cases. Bleeding episodes were the most common complication occurring in 10 patients (6.3%), but tracheostomy scores did not significantly differ between bleeders and nonbleeders.ConclusionBilateral ND on its own is not a reliable predictor for elective tracheostomy. Furthermore, given the significant heterogeneity of currently available scoring systems, they prove inadequate for decision making and predictive modeling of tracheostomy placement.Level of Evidence4 Laryngoscope, 130:E580–E586, 2020

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Facial Nerve Branching Patterns Vary With Vascular Anomalies

\nLingga Adidharma, \nRandall A. Bly, \nHailey A. Theeuwen, \nRobert N. Holdefer, \nJefferson Slimp, \nGreg A. Kinney, \nVicente Martinez, \nKathryn B. Whitlock, \nJonathan A. Perkins\n

Publicatie 21-10-2020


ObjectivesAt our institution, in vivo facial nerve mapping (FNM) is used during vascular anomaly (VAN) surgeries involving the facial nerve (FN) to create an FN map and prevent injury. During mapping, FN anatomy seemed to vary with VAN type. This study aimed to characterize FN branching patterns compared to published FN anatomy and VAN type.Study DesignRetrospective study of surgically relevant facial nerve anatomy.MethodsVAN patients (n = 67) with FN mapping between 2005 and 2018 were identified. Results included VAN type, FN relationship to VAN, FNM image with branch pattern, and surgical approach. A Fisher exact test compared FN relationships and surgical approach between VAN pathology, and FN branching types to published anatomical studies. MATLAB quantified FN branching with Euclidean distances and angles. Principal component analysis (PCA) and hierarchical cluster analysis (HCA) analyzed quantitative FN patterns amongst VAN types.ResultsVANs included were hemangioma, venous malformation, lymphatic malformation, and arteriovenous malformation (n = 17, 13, 25, and 3, respectively). VAN FN patterns differed from described FN anatomy (P < .001). PCA and HCA in MATLAB‐quantified FN branching demonstrated no patterns associated with VAN pathology (P = .80 and P = .91, one‐way analysis of variance for principle component 1 (PC1) and priniciple component 2 (PC2), respectively). FN branches were usually adherent to hemangioma or venous malformation as compared to coursing through lymphatic malformation (both P = .01, Fisher exact).ConclusionsFN branching patterns identified through electrical stimulation differ from cadaveric dissection determined FN anatomy. This reflects the high sensitivity of neurophysiologic testing in detecting small distal FN branches. Elongated FN branches traveling through lymphatic malformation may be related to abnormal nerve patterning in these malformations.Level of EvidenceNA Laryngoscope, 130:2708–2713, 2020

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Recommended Personal Protective Equipment for Cochlear Implant and Other Mastoid Surgery During the COVID‐19 Era

"\nRachael J. Lawrence, \nGerard ODonoghue, \nPádraig Kitterick, \nKevin ODonoghue, \nRichard Hague, \nLaura Mitchell, \nZoe Lycett‐Ranson, \nDouglas E.H. Hartley\n"

Publicatie 21-10-2020


Objectives/HypothesisThe overall aim of this study was to evaluate personal protective equipment (PPE) that may facilitate the safe recommencement of cochlear implantation in the COVID‐19 era, with the broader goal of minimizing the period of auditory deprivation in prelingually deaf children and reducing the risk of cochlear ossification in individuals following meningitis.MethodsThe study design comprised 1) an objective assessment of mastoid drilling‐induced droplet spread conducted during simulated cochlear implant (CI) surgery and its mitigation via the use of a protective drape tent and 2) an evaluation of three PPE configurations by otologists while performing mastoid drilling on ex vivo temporal bones. The various PPE solutions were assessed in terms of their impact on communication, vital physiological parameters, visual acuity and fields, and acceptability to surgeons using a systematic risk‐based approach.ResultsDroplet spread during simulated CI surgery extended over 2 m, a distance greater than previously reported. A drape tent significantly reduced droplet spread. The ensemble of a half‐face mask and safety spoggles (foam lined safety goggles) had consistently superior performance across all aspects of clinical usability. All other PPE options were found to substantially restrict the visual field, making them unsafe for microsurgery.ConclusionsThe results of this preclinical study indicate that the most viable solution to enable the safe conduct of CI and other mastoid surgery is a combination of a filtering facepiece (FFP3) mask or half‐face respirator with safety spoggles as PPE. Prescription spoggles are an option for surgeons who need to wear corrective glasses to operate. A drape tent reduces droplet spread. A multicenter clinical trial to evaluate the effectiveness of PPE should be the next step toward safely performing CI surgery during the COVID‐19 era.Level of Evidence4 Laryngoscope, 130:2693–2699, 2020

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Clinical predictors of descending necrotizing mediastinitis after deep neck infections

\nAkari Kimura, \nShunsuke Miyamoto, \nTaku Yamashita\n

Publicatie 21-10-2020


Objectives/HypothesisTo identify the clinical predictors of descending necrotizing mediastinitis (DNM) secondary to deep neck infections (DNIs) before treatment.Study DesignRetrospective case series.MethodsWe reviewed 73 patients with DNIs who had been treated with external drainage at our institute between April 2009 and March 2019. We divided these patients into either a DNI group without mediastinitis (n = 55) or a DNM group secondary to DNI (n = 18). We collected clinical data and compared them between the groups, conducting univariate and multiple logistic regression analysis to identify the predictors of DNM.ResultsWe identified age, C‐reactive protein (CRP), neutrophil percentage, lymphocyte percentage, neutrophil to lymphocyte ratio (NLR), presence of comorbidities, presence of gas, and abscess extension below the hyoid bone as statistically significant by univariate analysis. Moreover, multiple logistic regression analysis showed that age ≥55 years, NLR ≥13, and CRP ≥30 mg/dL were statistically significant.ConclusionsWe identified age ≥55, NLR ≥13, and CRP ≥30 before DNI treatment as clinical predictors of a DNM complication.Level of Evidence4 Laryngoscope, 130:E567–E572, 2020

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Telemedicine in Otolaryngology in the COVID‐19 Era: Initial Lessons Learned

\nJason F. Ohlstein, \nJordan Garner, \nMasayoshi Takashima\n

Publicatie 21-10-2020


Objectives/HypothesisThe COVID‐19 pandemic has led to unprecedented global changes in the delivery of healthcare over a short period of time. With the implementation of shelter‐in‐place orders, otolaryngology clinic visits at our institution were transitioned to telemedicine. This change enabled the rapid characterization of the patients who accepted and declined telemedicine.Study DesignCross‐sectional analysis.MethodsA review was conducted of 525 otolaryngology patients at a tertiary‐care referral center with scheduled visits requiring rescheduling to a future date or a telemedicine visit. Visit, demographic information, and reason for deferring telemedicine were collected for analysis.ResultsSeventy‐two percent of patients declined a telemedicine visit, with the most common reason being the lack of a physical exam (97%). There was an even distribution of demographics between those who accepted and declined visits. There was an association between declining telemedicine with older age (P = .0004) and otology visits (P = .0003), whereas facial plastics patients were more likely to accept (P < .0001). Patients scheduled earlier during the pandemic were more likely to accept a visit with a median of 28 days from onset of shelter‐in‐place orders versus 35 for those who declined (P < .0001).ConclusionsWe describe our initial experience with a transition to telemedicine, where the majority of patients would decline a virtual visit due to the lack of a physical exam. Although the future remains uncertain, telemedicine will continue to play a vital role in healthcare delivery. We believe that understanding our patient base gives critical insights that will help guide and improve virtual care to meet patients needs.Level of Evidence4 Laryngoscope, 130:2568–2573, 2020

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A Novel Classification: Anomalous Routes of the Facial Nerve in Relation to Inner Ear Malformations

\nLevent Sennaroğlu, \nEmel Tahir\n

Publicatie 21-10-2020


Objectives/HypothesisThe objective of this study was to classify anomalous facial nerve (FN) routes and to determine their association with inner ear malformations (IEMs).Study DesignRetrospective cross sectional study.MethodsThe computed tomography images of 519 patients (796 ears) with IEMs were retrospectively evaluated, and the abnormal routes of the FN were classified as: Meatal segment: type 1, normal internal auditory canal (IAC); type 2, narrow IAC; type 3, facial canal (FC) only; type 4: separate FC/duplicated IAC. Labyrinthine segment (LS): type 1, normal; type 2a/b/c, mild/moderate/severe anterior displacement; type 3, superior displacement; type 4: straight LS. Tympanic segment (TS): type 1, normal; type 2, superiorly displaced TS; type 3, TS at the oval window; type 4: TS inferior to the oval window; type 5: unclassified. Mastoid segment: type 1, normal facial recess (FR)/normal mastoid segment; type 2: narrow FR; type 3, unclassified.ResultsIn meatal segment classification, a narrow IAC was common in ears with cochlear hypoplasia (CH) (76.1%), and only FC was common in ears with severe IEMs (62.7%) such as Michel deformity, common cavity, and cochlear aplasia. Incomplete partition‐III has its unique superiorly displaced LS (100%). CH‐IV also has its unique mild anterosuperior displacement. Ears with a superiorly displaced TS usually (93.1%) had aplastic or hypoplastic semicircular canals. The FR is likely to be narrow in CH and severe IEMs.ConclusionsThe FN route is affected in IEMs, which must be kept in mind when operating on ears with IEMs. Especially in CH cases, all segments of the FN can be abnormal.Level of Evidence4 Laryngoscope, 130:E696–E703, 2020

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Angular Vessels for Free‐Tissue Transfer in Head and Neck Reconstruction: Clinical Outcomes

\nAndrea Hanick, \nPeter Ciolek, \nMichael Fritz\n

Publicatie 21-10-2020


Objectives/HypothesisTo evaluate the efficacy and reconstructive applications of angular vessel microvascular anastomosis in free‐tissue transfer.Study DesignRetrospective cohort study.MethodsA study of patients treated from January 2010 to July 2017 was performed. Four hundred thirty patients undergoing free‐tissue transfer at the Cleveland Clinic by a single reconstructive surgeon were reviewed. Patients in whom free‐tissue transfer was performed using angular vessels were included. Patients in whom free‐tissue transfer was performed using another vascular supply of the head and neck were excluded. Primary outcome was free‐flap failure. Secondary outcomes included other postoperative complications and hospital length of stay.ResultsThirty‐one patients underwent free‐tissue transfer with microvascular anastomosis to the angular vessels during the study period. Seventy‐one percent of patients underwent reconstruction immediately following tumor ablation. A variety of primary subsites were reconstructed; 58% underwent nasal reconstruction, 16% orbit/skull base reconstruction, 13% palatal reconstruction, 6% maxillary reconstruction, and 6% mandible reconstruction. Eighty‐seven percent of patients underwent free‐tissue transfer from an anterolateral thigh donor site. Ninety‐seven percent of patients had successful free‐tissue transfer with a viable flap during the follow‐up period; only one patient experienced flap failure attributed to vascular insufficiency. Average length of stay was 4.7 days, and the most common length of stay was 3 days.ConclusionsThe angular vessels provide excellent arterial supply and venous drainage to serve as a viable option for microvascular anastomosis during free‐tissue transfer for head and neck reconstructive surgery. They are an ideal vascular source for central face and skull base reconstruction.Level of EvidenceNA Laryngoscope, 130:2589–2592, 2020

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Association of insurance type with time course of care in head and neck cancer management

\nKyohei Itamura, \nNiels Kokot, \nUttam Sinha, \nMark Swanson\n

Publicatie 21-10-2020


Objectives/HypothesisTo determine differences in time course of care based on major insurance types for patients with head and neck squamous cell carcinoma (HNSCC).Study DesignRetrospective cohort study.MethodsRetrospective study of Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Medicare patients with biopsy‐proven diagnosis of HNSCC referred to an academic tertiary center for tumor resection and adjuvant therapy. In addition to patient demographic information and tumor characteristics, duration of chief complaint and the following time points were collected: biopsy by referring physician, first specialty surgeon clinic appointment, surgery, and adjuvant radiation start and stop dates.ResultsThere was a statistically significant increase in time interval for HMO (n = 32) patients from chief complaint to biopsy (P = .003), biopsy to first specialty surgeon clinic appointment (P < .001), and surgery to start of adjuvant radiation (P < .001) compared to that of Medicare (n = 31) and PPO (n = 41) patients. Adjuvant radiation was initiated ≤6 weeks after surgery in 22% of HMO (mean duration of 59 ± 17 days), 48% of Medicare (44 ± 13 days), and 61% of PPO (41 ± 12 days) patients.ConclusionsCompared to PPO and Medicare patients, HMO patients begin adjuvant radiation after surgery later and experience treatment delays in transitions of care between provider types and with referrals to specialists. Delaying radiation after 6 weeks of surgery is a known prognostic factor, with insurance type playing a possible role. Further investigation is required to identify insurance type as an independent risk factor of delayed access to care for HNSCC.Level of Evidence4 Laryngoscope, 130:E587–E592, 2020

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What is the Best Test for Diagnosis and Monitoring Treatment Response in Malignant Otitis Externa?

\nJoshua J. Sturm, \nSagit Stern Shavit, \nAnil K. Lalwani\n

Publicatie 21-10-2020


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COVID‐19 Viral Load in the Severity of and Recovery From Olfactory and Gustatory Dysfunction

\nRyan H. W. Cho, \nZion W. H. To, \nZenon W.C. Yeung, \nEugene Y. K. Tso, \nKitty S. C. Fung, \nSandy K. Y. Chau, \nErica Y. L. Leung, \nThomas S. C. Hui, \nSteven W. C. Tsang, \nK. N. Kung, \nEudora Y. D. Chow, \nVictor Abdullah, \nAndrew Hasselt, \nMichael C. F. Tong, \nPeter K. M. Ku\n

Publicatie 21-10-2020


Objectives/HypothesisThis study investigated olfactory and gustatory dysfunction in the 2020 novel coronavirus disease (COVID‐19) patients, and their correlations with viral load evaluation.Study DesignProspective cross‐sectional cohort study.MethodsOne hundred forty‐three symptomatic patients being screened for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) were invited to participate. The clinical data of 83 confirmed COVID‐19 subjects were collected, with 60 patients who were symptomatic but negative for COVID‐19 recruited as controls. The prevalence and severity of and recovery time for olfactory and gustatory dysfunction, and cycle threshold (Ct) values from a SARS‐CoV‐2 polymerase chain reaction assay of nasopharyngeal and deep throat swabs were collected. Their correlations with Ct values were reported.ResultsThirty‐nine (47.0%) and 36 (43.4%) COVID‐19 patients reported olfactory and gustatory dysfunction, respectively. The results of one‐way analysis of variance did not show statistically significant relationships between the Ct values and severity of olfactory and gustatory dysfunction (P = .780 and P = .121, respectively). Among the COVID‐19 patients who reported smell and taste loss, 28/39 (71.8%) and 30/36 (83.3%) experienced complete recovery, respectively. The mean recovery time was 10.3 ± 8.1 days for olfactory dysfunction and 9.5 ± 6.8 days for gustatory dysfunction. The recovery time was not correlated with the Ct values (Pearson correlation coefficient, smell: −0.008, P = .968; taste: −0.015, P = .940).ConclusionsThere is a high prevalence of olfactory and gustatory dysfunction in COVID‐19. However, the severity of and recovery from these symptoms have no correlations with the viral load of SARS‐CoV‐2.Level of Evidence4 Laryngoscope, 130:2680–2685, 2020

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Clinical and Radiological Evaluations of COVID‐19 Patients With Anosmia: Preliminary Report

\nJerome R. Lechien, \nJustin Michel, \nThomas Radulesco, \nCarlos M. Chiesa‐Estomba, \nLuigi A. Vaira, \nGiacomo De Riu, \nLeigh Sowerby, \nClaire Hopkins, \nSven Saussez\n

Publicatie 21-10-2020


Objectives/HypothesisTo investigate clinical and radiological features of olfactory clefts of patients with mild coronavirus disease 2019 (COVID‐19).Study DesignProspective non controlled study.MethodsSixteen COVID‐19 patients were recruited. The epidemiological and clinical data were extracted. Nasal complaints were assessed through the 22‐item Sino‐Nasal Outcome Test. Patients underwent psychophysical olfactory testing, olfactory cleft examination, and computed tomography (CT) scans.ResultsSixteen anosmic patients were included. The mean Sniffin Sticks score was 4.6 ± 1.7. The majority of patients had no endoscopical abnormality, with a mean olfactory cleft endoscopy score of 0.6 ± 0.9. The olfactory clefts were opacified in three patients on the CT scan. The mean radiological olfactory cleft score was 0.7 ± 0.8. There were no significant correlations between clinical, radiological, and psychophysical olfactory testing.ConclusionsThe olfactory cleft of anosmic COVID‐19 patients is free regarding endoscopic examination and imaging. The anosmia etiology is not related to edema of the olfactory cleft.Level of Evidence4 Laryngoscope, 130:2526–2531, 2020

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Prospective Study in 355 Patients With Suspected COVID‐19 Infection: Value of Cough, Subjective Hyposmia, and Hypogeusia

\nEduardo Martin‐Sanz, \nJuan Riestra, \nLaura Yebra, \nAlba Larran, \nFiorella Mancino, \nJoaquin Yanes‐Diaz, \nMaria Garrote, \nMarta Colmenero, \nEsther Montiel, \nCristina Molina, \nDaniel Moreno, \nAntonio Rodriguez, \nGerardo Monedero, \nRicardo Sanz‐Fernández, \nRocio Gonzalez, \nJonathan Esteban‐Sanchez\n

Publicatie 21-10-2020


ObjectiveTo evaluate the incidence of certain symptoms in a population of health workers exposed to coronavirus disease 2019 patients.Study DesignCase‐control study.MethodsThe study was conducted at a tertiary care hospital from March 1 to April 7, 2020. Health workers with suspected coronavirus disease 2019 (COVID‐19) infection were included. The presence of COVID‐19 was detected by using real‐time polymerase chain reaction (RT‐PCR) methods. Positive and negative RT‐PCR patients were used as case and control groups, respectively.This study analyzed the incidence of COVID‐19 symptoms in both patient groups. Visual analog scales were used for self‐assessment of smell and taste disorders, ranging from 0 (no perception) to 10 (excellent perception).ResultsThere were 215 (60.6%) patients with positive RT‐PCR and 140 (39.4%) patients with negative RT‐PCR. The presence of symptoms such as hyposmia hypogeusia, dysthermia, and cough were strongly associated with a positive RT‐PCR. The association of cough and subjective hyposmia had 5.46 times higher odds of having a positive test. The receiver operating characteristic (ROC) analysis showed that a fever higher than 37.45°C resulted in sensitivity and specificity of 0.65 and 0.61, respectively. A total of 138 cases (64.1%) and 114 cases (53%) had subjective hyposmia and hypogeusia, respectively. The 85.4% of these patients recovered olfactory function within the first 14 days of the onset of the symptoms.ConclusionThere is a significant association between positive RT‐PCR and subjective hyposmia. The association of subjective hyposmia and cough increase significantly the odds of having a positive RT‐PCR. The measurement of fever as the only method for screening of COVID‐19 infection resulted in a poor association.Level of Evidence3 Laryngoscope, 130:2674–2679, 2020

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Competency‐Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus

\nEvan J. Propst, \nNikolaus E. Wolter, \nStacey L. Ishman, \nKarthik Balakrishnan, \nAshley R. Deonarain, \nDeepak Mehta, \nGeorge Zalzal, \nSeth M. Pransky, \nSoham Roy, \nCharles M. Myer, \nMichele Torre, \nRomaine F. Johnson, \nJeffrey P. Ludemann, \nCraig S. Derkay, \nRobert H. Chun, \nPaul Hong, \nDavid W. Molter, \nJeremy D. Prager, \nLily H. P. Nguyen, \nMichael J. Rutter, \nCharles M. Myer, \nKaren B. Zur, \nDouglas R. Sidell, \nLiane B. Johnson, \nRobin T. Cotton, \nCatherine K. Hart, \nJ. Paul Willging, \nCarlton J. Zdanski, \nJohn J. Manoukian, \nDerek J. Lam, \nNancy M. Bauman, \nEric A. Gantwerker, \nMurad Husein, \nAndrew F. Inglis, \nGlenn E. Green, \nLuv Ram Javia, \nScott Schraff, \nMarlene A. Soma, \nEllen S. Deutsch, \nSteven E. Sobol, \nJonathan B. Ida, \nSukgi Choi, \nTrina C. Uwiera, \nUdayan K. Shah, \nDavid R. White, \nChristopher T. Wootten, \nHamdy El‐Hakim, \nMatthew A. Bromwich, \nGresham T. Richter, \nShyan Vijayasekaran, \nMarshall E. Smith, \nJean‐Philippe Vaccani, \nChristopher J. Hartnick, \nErynne A. Faucett\n

Publicatie 21-10-2020


Objectives/HypothesisCreate a competency‐based assessment tool for pediatric tracheotomy.Study DesignBlinded, modified, Delphi consensus process.MethodsUsing the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as “keep” or “remove,” and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven‐point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items.ResultsThe first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as “keep,” and 137 comments were incorporated. In the second round, 30 task‐specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task‐Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus.ConclusionsIt is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency‐based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure.Level of Evidence5 Laryngoscope, 130:2700–2707, 2020

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Role of epstein‐barr virus in the severity of recurrent respiratory papillomatosis

\nVictor Costa, \nVivian Narana El‐Achkar, \nPatrícia Pimentel Barros, \nJorge Esquiche León, \nAlfredo Ribeiro‐Silva, \nRomán Carlos, \nShirley Shizue Nagata Pignatari, \nSilvaneide Ferreira, \nBarbara Pereira Mello, \nLaura Sichero, \nLuisa Lina Villa, \nEstela Kaminagakura\n

Publicatie 21-10-2020


ObjectiveThe objective was to investigate the prevalence of the Epstein‐Barr virus (EBV) and its association with human papilloma virus (HPV) detection, clinicopathological features, and the severity of recurrent respiratory papillomatosis (RRP).MethodsCases of juvenile recurrent respiratory papillomatosis (JRRP) (n = 36) and adult recurrent respiratory papillomatosis (ARRP) (n = 44) were collected retrospectively and subdivided into low‐ and high‐risk severity groups based on the Derkay score. We performed HPV detection and genotyping using a reverse hybridization protocol and investigated the presence of EBV by polymerase chain reaction (PCR) and in situ hybridization. CD21 levels were accessed by immunohistochemistry.ResultsAll samples were HPV‐positive, including 49 cases of HPV 6, 26 cases of HPV 11, four cases of HPV 6 and 11 coinfections, and one case of HPV 16. EBV‐DNA was detected in nine samples by PCR, although none of the cases were positive by means of in situ hybridization. CD21 immunoexpression was not statistically associated with any of the variables analyzed. HPV 6 detection was significantly higher in ARRP cases (P = 0.03), whereas HPV 11 was more prevalent in JRRP cases (P = 0.02) and was even more prevalent in JRRP cases of greater severity (Derkay laryngoscopic scale ≥20) (P = 0.04).ConclusionThe presence of EBV does not seem to play an important role in the progression/severity of RRP.Level of Evidence4 Laryngoscope, 130:E611–E618, 2020

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Mood, Anxiety and Olfactory Dysfunction in COVID‐19: Evidence of Central Nervous System Involvement?

\nMarlene M. Speth, \nThirza Singer‐Cornelius, \nMichael Oberle, \nIsabelle Gengler, \nSteffi J. Brockmeier, \nAhmad R. Sedaghat\n

Publicatie 21-10-2020


ObjectiveThe objective of this study was to determine the burden of depressed mood and anxiety in COVID‐19, and associated disease characteristics.Materials and MethodsThis is a prospective, cross‐sectional study of 114 COVID‐19 positive patients diagnosed using RT‐PCR‐based testing over a 6‐week period. The two‐item Patient Health Questionnaire (PHQ‐2) and the two‐item Generalized Anxiety Disorder questionnaire (GAD‐2) were used to measure depressed mood and anxiety level, respectively, at enrollment and for participants baseline, pre‐COVID‐19 state. Severity of smell loss, loss of taste, nasal obstruction, rhinorrhea/mucus production, fever, cough, and shortness of breath (SOB) during COVID‐19 were assessed.ResultsPHQ‐2 and GAD‐2 significantly (P < .001) increased from baseline to enrollment. PHQ‐2 was associated with smell loss (adjusted incidence rate ratio aIRR = 1.40, 95% CI, 1.10–1.78, P = .006), age (aIRR = 1.02, 95% CI, 1.01–1.04, P = .006), and baseline PHQ‐2 score (aIRR = 1.39, 95% CI, 1.09–1.76, P = .007). GAD‐2 score was associated with smell loss (aIRR = 1.29, 95% CI, 1.02–1.62, P = .035), age (aIRR = 1.02, 95% CI, 1.01–1.04, P = .025) and baseline GAD‐2 score (aIRR = 1.55, 95% CI, 1.24–1.93, P < .001). Loss of taste also exhibited similar associations with PHQ‐2 and GAD‐2. PHQ‐2 and GAD‐2 scores were not associated with severities of any other symptoms during the COVID‐19 course.ConclusionsDespite the occurrence of symptoms—such as SOB—associated with severe manifestations of COVID‐19, only the severities of smell and taste loss were associated with depressed mood and anxiety. These results may raise the novel possibility of emotional disturbance as a CNS manifestation of COVID‐19 given trans‐olfactory tract penetration of the central nervous system (CNS) by coronaviruses.Level of Evidence3 Laryngoscope, 130:2520–2525, 2020

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Genetic Testing for Congenital Bilateral Hearing Loss in the Context of Targeted Cytomegalovirus Screening

\nJoseph Peterson, \nCarla Nishimura, \nRichard J. H. Smith\n

Publicatie 21-10-2020


Objectives/HypothesisTo determine the prevalence of children with genetic hearing loss who are cytomegalovirus (CMV) positive at birth and the relative proportion of genetic and CMV etiology among children with congenital bilateral hearing loss.Study DesignDatabase review.MethodsWe performed a review of clinical test results for patients undergoing comprehensive genetic testing for all known hearing loss–associated genes from January 2012 to January 2019. This population was reviewed for reported CMV status and genetic causes of congenital bilateral hearing loss.ResultsIn the OtoSCOPE database, 61/4,282 patients were found to have a documented CMV status, and 661/4282 had documented bilateral congenital hearing loss. Two patients were identified who had both a positive CMV result and a genetic cause for their hearing loss. Forty‐eight percent of patients with bilateral congenital hearing loss (320/661) were found to have a genetic etiology. In 62% (198/320), the hearing loss was associated with pathogenic variants in GJB2, STRC, SLC26A4 or an Usher syndrome–associated gene.ConclusionsWe estimate that ~2% of CMV‐positive newborns with hearing loss have a known genetic variant as a cause. The subcohort of CMV‐positive newborns with symmetric mild‐to‐moderate bilateral hearing loss will have at least a 7% chance of having pathogenic gene variants associated with hearing loss. In a CMV‐positive neonate who failed their newborn hearing screen bilaterally, genetic screening needs to be considered for accurate diagnosis and possible deferment of antiviral treatment.Level of Evidence4 Laryngoscope, 130:2714–2718, 2020

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COVID‐19 and the Otolaryngologist: Preliminary Evidence‐Based Review

\nNeelaysh Vukkadala, \nZ. Jason Qian, \nF. Christopher Holsinger, \nZara M. Patel, \nEben Rosenthal\n

Publicatie 21-10-2020


The SARS‐CoV‐2 virus, which causes coronavirus disease 2019 (COVID‐19), has rapidly swept across the world since its identification in December 2019. Otolaryngologists are at unique risk due to the close contact with mucus membranes of the upper respiratory tract and have been among the most affected healthcare workers in Wuhan, China. We present information on COVID‐19 management relevant to otolaryngologists on the frontlines of this pandemic and provide preliminary guidance based on practices implemented in China and other countries and practical strategies deployed at Stanford University. Laryngoscope, 130:2537–2543, 2020

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Patterns of Dysphagia and Airway Protection in Infants with 22q11.2‐Deletion Syndrome

\nNicole S. Wong, \nZipei Feng, \nChristina Rappazzo, \nCatherine Turk, \nChelsea Randall, \nJulina Ongkasuwan\n

Publicatie 21-10-2020


Objective22q11.2‐deletion syndrome is a genetic condition that affects 1:3000 births. In addition to cardiac anomalies and immunosuppression, individuals with 22q11.2‐deletion syndrome can have feeding difficulties from birth resulting in failure to thrive and infections. This study aims to characterize the dysphagia seen in infants with 22q11.2‐deletion syndrome.MethodsThis is a retrospective chart review of infants with 22q11.2‐deletion syndrome who underwent videofluoroscopic swallow studies (VFSS) from June 1, 2008 to January 1, 2018 at a tertiary childrens hospital. Demographic data and VFSS findings were collected.ResultsForty‐four patients were identified, 52% were females, and mean age at VFSS was 71 days. In their lifetime, 30% of the patients had at least 1 episode of pneumonia, 66% had NG‐tube placement and 41% required G‐tube placement. 93% had oral‐phase dysphagia, and 89% had pharyngeal‐phase dysphagia. Twenty‐two patients (50%) demonstrated evidence of penetration. Eighteen patients (41%) showed tracheal aspiration. Of the patients that showed tracheal aspiration, 83% of them aspirated “silently.” Three patients (7%) had upper esophageal sphincter (UES) opening dysfunction.ConclusionVast majority of the infants with 22q11.2‐deletion syndrome referred for swallow studies demonstrated evidence of dysphagia in both oral and pharyngeal phases with deficits in swallow physiology not yet documented in other studies. Importantly, more than 80% of these infants showed evidence of “silent” tracheal aspiration, which can lead to recurrent pneumonia and significant morbidity if overlooked. Prompt recognition is paramount in these infants to intervene early and reduce long‐term complications and also develop targeted interventions.Level of Evidence4 Laryngoscope, 130:2532–2536, 2020

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The Reflux Symptom Index and Symptom Overlap in Dysphonic Patients

\nHannah Kavookjian, \nThomas Irwin, \nJames D. Garnett, \nShannon Kraft\n

Publicatie 21-10-2020


Objectives/HypothesisThe Reflux Symptom Index (RSI) is a validated quality‐of‐life instrument that quantifies symptoms associated with laryngopharyngeal reflux (LPR). Many dysphonic patients are managed empirically for reflux. In this study, we examine responses to the RSI in patients with dysphonia attributable to a variety of pathologies.Study DesignRetrospective cohort study.MethodsThis is an institutional review board–approved study. All patients presented to a tertiary care voice center January 2011 to June 2016 with the chief complaint of dysphonia. Patients were analyzed by 1) diagnosis and 2) treatment modality: surgery, medicine, or voice therapy (VT). Data collected included pre‐ and postintervention RSI and Voice Handicap Index, demographic, and clinical information. Statistical analysis was performed using SPSS.ResultsFive hundred forty‐six dysphonic patients were included. One hundred forty required surgery, 155 were treated with VT alone, and 251 were medically managed (MM). Prior to therapy, 63.4% of surgery patients, 62.5% of VT patients, and 74.6% of MM patients had an abnormal RSI with a score greater than 13. The most common diagnosis for each group was vocal cord paresis/paralysis (surgery), vocal fold atrophy (VT), and LPR (MM). There was a statistically significant improvement in RSI after treatment for each group.ConclusionsIn patients with dysphonia, pretreatment RSI scores were elevated for a variety of laryngeal pathologies. Scores often improved with directed treatment, regardless of etiology. This highlights the symptom overlap between reflux and nonreflux causes of dysphonia, and the importance of a comprehensive workup for patients with voice complaints.Level of Evidence4 Laryngoscope, 130:2631–2636, 2020

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Oral Squamous Cell Carcinoma as a Complication of Treatment for Recurrent High‐Grade Serous Cancer

\nLindsey E. Moses, \nJanine M. Rotsides, \nFiyinfolu O. Balogun, \nMark S. Persky, \nFranco M. Muggia, \nMichael J. Persky\n

Publicatie 21-10-2020


Objectives/HypothesisAdvances in cancer treatment have increased survival for many patients, prompting a need for greater recognition of the long‐term complications of treatment. Chemotherapy agents have the potential to induce carcinogenesis and can increase the risk of secondary malignancy. Pegylated liposomal doxorubicin (PLD) used for maintenance treatment of recurrent high‐grade serous cancers has been associated with the development of oral cavity squamous cell carcinoma (SCC).Study DesignRetrospective review.MethodsCases of oral cavity SCC in patients with recurrent high‐grade serous cancer treated with PLD between 1997 and 2017 at a single institution were reviewed.ResultsEight of 16 patients treated with PLD developed oral cavity SCC. The duration of PLD use ranged from 1.3 to 15 years (mean = 5.8 years) and cumulative dose ranged from 405 to 3,000 mg/m2 (mean = 1,542 mg/m2). Seven patients tested positive for BRCA mutations (four BRCA 1+, three BRCA 2+). No patients had a history of alcohol or tobacco use. All had early‐stage oral cavity disease; five were T1N0, two were T2N0, and one had carcinoma in situ. All patients underwent surgery, and two received adjuvant radiation. Four developed locoregional recurrence requiring additional treatment. Of these, one patient died from complications of oral SCC, one developed recurrent ovarian cancer, and two had no evidence of disease of the oral cavity or ovarian cancer at the last follow‐up.ConclusionsLong‐term PLD therapy may be associated with the development of oral cavity SCC. A high index of suspicion and routine head and neck examination should be included in follow‐up for exposed patients.Level of Evidence4 Laryngoscope, 130:2607–2610, 2020

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Autologous fibroblasts for vocal scars and age‐related atrophy: A randomized clinical trial

\nYue Ma, \nJennifer Long, \nMilan R. Amin, \nRyan C. Branski, \nEdward J. Damrose, \nChih‐Kwang Sung, \nStratos Achlatis, \nAnn Kearney, \nDinesh K. Chhetri\n

Publicatie 21-10-2020


Objectives/HypothesisTo assess the safety and efficacy of autologous cultured fibroblasts (ACFs) to treat dysphonia related to vocal fold scar and age‐related vocal atrophy (ARVA).Study DesignRandomized, double‐blinded, placebo‐controlled, multi‐institutional, phase II trial.MethodsACFs were expanded from punch biopsies of the postauricular skin in each subject; randomization was 2:1 (treatment vs. placebo). Three injections of 1–2 × 107 cells or placebo saline was performed at 4‐week intervals for each vocal fold. Follow‐up was performed at 4, 8, and 12 months. The primary outcome was improved mucosal waves. Secondary outcomes included Voice Handicap Index (VHI)‐30, patient reported voice quality outcomes, and perceptual analysis of voice.ResultsFifteen subjects received ACF and six received saline injections. At 4, 8, and 12 months after ACF treatments, a significant improvement in mucosal wave grade relative to baseline was observed in both vocal scar and ARVA groups. Relative to control group, mucosal waves were significantly improved in the ARVA group at 4 and 8 months. Perceptual analysis significantly improved in the vocal scar group 12 months after ACF treatments compared to controls. Vocal scar group reported significantly improved vocal quality from baseline. VHI and expert rater voice grade improved in both groups, but did not achieve significance. No adverse events related to fibroblast injections were observed.ConclusionsIn this cohort, injection of ACFs into the vocal fold lamina propria (LP) was safe and significantly improved mucosal waves in patients with vocal scar and ARVA. ACF may hold promise to reconstruct the LP.Level of Evidence1 Laryngoscope, 130:2650–2658, 2020

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Unilateral versus bilateral botulinum toxin injections in adductor spasmodic dysphonia in a large cohort

\nIshaan Dharia, \nSteven Bielamowicz\n

Publicatie 21-10-2020


Objectives/HypothesisThe primary treatment of adductor spasmodic dysphonia is repeated injections of botulinum toxin type A (Botox) into the thyroarytenoid muscles. Dosing can be performed into either one or both thyroarytenoid muscles. The objective of this study was to evaluate the treatment effect and side effect profile across a large number of injections. This study was performed previously in 2002 on 45 patients.Study DesignIndividual cohort study.MethodsThis is retrospective study of all patients with adductor spasmodic dysphonia with and without tremor treated by the senior laryngologist at George Washington University. In the current study, 272 patients (214 females and 58 males) were included in the current analysis. Duration of effects and side effects (vocal weakness and liquid dysphagia) were recorded into a database for each patient after each injection. These data were analyzed using χ2 analysis.ResultsA total of 4,023 injections (2,708 bilateral and 1,315 unilateral) were evaluated in this study. Optimal effect duration (≥3 months) was more commonly seen in the bilaterally injected patients (55%) compared to the unilaterally injected patients (47%) (P = .0001). Optimal side effect duration (≤2 weeks) was better for the unilaterally injected patients (77%) compared to the bilaterally injected patients (73%) (P = .023). Having both optimal effect and side effect in the same injection was more commonly seen in the bilaterally injected patients (36%) compared to the unilaterally injected patients (33%) (P = .0228).ConclusionsThis study shows that bilateral injections of Botox are more effective in producing optimal effect/side effect profiles.Level of Evidence2b Laryngoscope, 130:2659–2662, 2020

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Proton radiotherapy and treatment delay in head and neck squamous cell carcinoma

\nMichael C. Jin, \nJeremy P. Harris, \nAaron N. Sabolch, \nMichael Gensheimer, \nQuynh‐Thu Le, \nBeth M. Beadle, \nErqi L. Pollom\n

Publicatie 21-10-2020


ObjectiveFor patients with head and neck squamous cell carcinoma (HNSCC), delays in the initiation of radiotherapy (RT) have been closely associated with worse outcomes. We sought to investigate whether RT modality (proton vs. photon) is associated with differences in the time to initiation of RT.MethodsThe National Cancer Database was queried for patients diagnosed with nonmetastatic HNSCC between 2004 and 2015 who received either proton or photon RT as part of their initial treatment. Wilcoxon rank‐sum and chi‐square tests were used to compare continuous and categorical variables, respectively. Multivariable logistic regression was used to determine the association between use of proton RT and delayed RT initiation.ResultsA total of 175,088 patients with HNSCC receiving either photon or proton RT were identified. Patients receiving proton RT were more likely to be white, reside in higher income areas, and have private insurance. Proton RT was associated with delayed RT initiation compared to photon RT (median 59 days vs. 45, P < 0.001). Receipt of proton therapy was independently associated with RT initiation beyond 6 weeks after diagnosis (adjusted OR aOR, definitive RT = 1.69; 95% confidence interval CI 1.26–2.30) or surgery (aOR adjuvant RT = 4.08; 95% CI 2.64–6.62). In the context of adjuvant proton RT, increases in treatment delay were associated with worse overall survival (weeks, adjusted hazard ratio = 1.099, 95% CI 1.011–1.194).ConclusionUse of proton therapy is associated with delayed RT in both the definitive and adjuvant settings for patients with HNSCC and could be associated with poorer outcomes.Level of Evidence2bLaryngoscope, 122:0000–0000, 2019 Laryngoscope, 130:E598–E604, 2020

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Prognostic Value of a Family History of Oral Tongue Squamous Cell Carcinoma: A Matched‐Pair Study

\nMeng Cui, \nWei Du, \nQigen Fang, \nLiyuan Dai, \nJinxing Qi, \nRuihua Luo\n

Publicatie 21-10-2020


Objectives/HypothesisTo analyze the prognostic value of a family cancer history for predicting survival in patients with oral tongue squamous cell carcinoma (SCC).Study DesignRetrospective case series.MethodsEach patient with a family history was paired with one patient with sporadic oral tongue SCC without a family history. The primary endpoint was disease‐specific survival (DSS).ResultsIn total, 124 patients were enrolled as participants with a family cancer history, and the 5‐year DSS rate was 51%. In the matched group, the 5‐year DSS rate was 40%. The difference was significant (P = .032). In the smoking patients with a family history, the 5‐year DSS rate was 43%. In the smoking patients from the matched group, the 5‐year DSS rate was 17%; the difference was significant (P = .028). In nonsmoking patients with a history of cancer, the 5‐year DSS rate was 51%; in nonsmoking patients in the matched group, the 5‐year DSS rate was 40%; the difference was not significant (P = .141).ConclusionsA family cancer history is associated with improved DSS in surgically treated oral tongue SCC patients.Level of Evidence4 Laryngoscope, 130:E605–E610, 2020

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Predicting the Number of Fibular Segments to Reconstruct Mandibular Defects

\nYotam Shkedy, \nJoel Howlett, \nEdward Wang, \nJennifer Ongko, \nJ. Scott Durham, \nEitan Prisman\n

Publicatie 21-10-2020


ObjectivesSeveral classification schemes have been proposed to categorize mandibular defects following surgical resection; however, there is a paucity of data to guide an optimal reconstruction. This study examines the feasibility of using a geometric algorithm to simplify and determine the optimal reconstruction for a given mandibular defect. This algorithm is then applied to three different mandible defect classification schemes to correlate the defect type and number of bony segments required for reconstruction.MethodsComputed tomography (CT) scans of 48 mandibles were decomposed into curvilinear representations and analyzed using the Ramer‐Douglas‐Peucker algorithm. In total, 720 mandibular defects were created and subsequently analyzed utilizing three commonly referenced classification systems. For each defect, the number of bony segments required to reconstruct each defect was computed.ResultsA wide variance in the number of segments needed for optimal reconstruction was observed across existing classifications. A six‐segment total mandible reconstruction best reconstituted mandibular form in all 48 mandibles.ConclusionDefect classification schemes are not adaptable to predicting the number of fibula segments required for a given defect. Additionally, cephalometric templates may not be applicable in all clinical settings. The Ramer‐Douglas‐Peucker algorithm is well suited for providing case‐specific predictions of reconstruction plans in a reproducible manner.Level of EvidenceIV Laryngoscope, 130:E619–E624, 2020

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LncRNA miR143HG suppresses miR‐21 through methylation to inhibit cell invasion and migration

\nWu Xun, \nWei Cen, \nYu Dahai, \nWei Huaqing, \nSu Jiping, \nGuo Mengzhu, \nMeng Ning\n

Publicatie 21-10-2020


ObjectiveThis study aimed to investigate the role of lncRNA miR143HG in laryngeal squamous cell carcinoma (LSCC).MethodsQuantitative polymerase chain reaction (PCR) and paired t test were used to measure and compare expression levels of miR143HG and miR‐21 in LSCC and nontumor tissues. To analyze the interactions between miR143HG and miR‐21, UM‐SCC‐17A cells were transfected miR143HG expression vector or miR‐21 mimic. The effects of miR143HG and miR‐21 overexpression on UM‐SCC‐17A cell invasion and migration were analyzed by transwell assays.ResultsWe found that miR143HG was downregulated in LSCC and inversely correlated with miR‐21. In LSCC cells, miR143HG overexpression led to the downregulated expression of miR‐21, whereas miR‐21 overexpression failed to affect miR143HG. Methylation‐specific PCR results showed that miR143HG overexpression led to increased methylation of miR‐21. Low expression levels of miR143HG were correlated with poor survival. Overexpression of miR143HG led to decreased, whereas miR‐21 overexpression resulted in increased rate of LSCC cell migration and invasion. In addition, miR‐21 overexpression led to reduced effects of miR143HG on cell invasion and migration.ConclusionTherefore, miR143HG suppresses miR‐21 via methylation to regulate cell behaviors in LSCC.Level of EvidenceNA Laryngoscope, 130:E640–E645, 2020

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Manifestations of Skull Base IgG4‐Related Disease: A Multi‐Institutional Study

\nJohn P. Marinelli, \nChiara Marvisi, \nAugusto Vaglio, \nPierce A. Peters, \nEric M. Dowling, \nAlessandro A. Palumbo, \nJohn I. Lane, \nEric N. Appelbaum, \nAlex D. Sweeney, \nMatthew L. Carlson\n

Publicatie 21-10-2020


ObjectiveIgG4‐related disease (IgG4‐RD) is a recently recognized disease characterized by fibroinflammatory infiltrates rich in IgG4+ plasma cells that can present as isolated tumor‐like lesions of the head and neck. The objective of the current study was to describe the cranial base manifestations of IgG4‐RD.MethodsReview of all cases at three tertiary‐referral centers since disease description in 2003.ResultsEleven patients were identified at a median age at presentation of 58 years (IQR, 38–65; 55% male). Ten (91%) patients had isolated skull base masses without systemic disease. Cranial neuropathies were commonly observed in the abducens (45%), trigeminal (18%), and facial nerves (18%). Lesions frequently involved the cavernous sinus (55%; 6/11) with extension to the petroclival junction in 50% (3/6). Infiltration of the internal auditory canal was present in 27% (3/11) with one case demonstrating erosion of the bony labyrinth. Preliminary clinical diagnoses commonly included nasopharyngeal cancer, pituitary macroadenoma, cholesteatoma, and meningioma / multiple meningioma syndrome. Local biopsy demonstrated >30 IgG4‐positive plasma cells per high‐powered field or an IgG4:IgG ratio greater than 40% in all cases. Rapid and durable clinical improvement was seen in 91% following corticosteroid and rituximab therapy.ConclusionsIgG4‐RD nonspecifically presents as a rare cause of the skull base mass. Often presenting without concomitant systemic disease, local diagnostic biopsies are required. Obtaining adequate tissue specimen is complicated by densely fibrotic cranial base lesions that are frequently in close proximity to critical neurovascular structures. Primary medical therapy with corticosteroids and rituximab is effective in most patients.Level of Evidence4 Laryngoscope, 130:2574–2580, 2020

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Is Office Laryngoscopy an Aerosol‐Generating Procedure?

\nAnaïs Rameau, \nMark Lee, \nNecati Enver, \nLucian Sulica\n

Publicatie 21-10-2020


Objectives/HypothesisThe aims of this work were 1) to investigate whether office laryngoscopy is an aerosol‐generating procedure with an optical particle sizer (OPS) during clinical simulation on healthy volunteers, and 2) to critically discuss methods for assessment of aerosolizing potentials in invasive interventions.Study DesignProspective quantification of aerosol and droplet generation during clinical simulation of rigid and flexible laryngoscopy.MethodsTwo healthy volunteers were recruited to undergo both flexible and rigid laryngoscopy. An OPS was used to quantify aerosols and droplets generated for four positive controls relative to ambient particles (speech, breathing, /e/ phonation, and /æ/ phonation) and for five test interventions relative to breathing and phonation (flexible laryngoscopy, flexible laryngoscopy with humming, flexible laryngoscopy with /e/ phonation, rigid laryngoscopy, and rigid laryngoscopy with /æ/ phonation). Particle counts in mean diameter size range from 0.3 to >10 μm were measured with OPS placed at 12 cm from the subjects nose/mouth.ResultsNone of the laryngoscopy interventions (n = 10 each) generated aerosols above that produced by breathing or phonation. Breathing (n = 40, 1–3 μm, P = .016) and /æ/ phonation (n = 10, 1–3 μm, P = .022; 3–5 μm. P = .083; >5 μm, P = .012) were statistically significant producers of aerosols and droplets. Neither speech nor /e/ phonation (n = 10 each) were associated with statistically significant aerosols and droplet generation.ConclusionsUsing OPS to detect droplets and aerosols, we found that office laryngoscopy is likely not an aerosol‐generating procedure. Despite its prior use in otolaryngological literature, an OPS has intrinsic limitations. Our study should be complemented with more sophisticated methods of droplet distribution measurement.Level of Evidence3 Laryngoscope, 130:2637–2642, 2020

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Utility of Tracheostomy in Patients With COVID‐19 and Other Special Considerations

\nJeffrey C. Mecham, \nOlivia J. Thomas, \nPhillip Pirgousis, \nJeffrey R. Janus\n

Publicatie 21-10-2020


IntroductionPatients who become severely ill from coronavirus disease 2019 (COVID‐19) have a high likelihood of needing prolonged intubation, making tracheostomy a likely consideration. The infectious nature of COVID‐19 poses an additional risk of transmission to healthcare workers that should be taken into consideration.MethodsWe explore current literature and recommendations for tracheostomy in patients with COVID‐19 and look back at previous data from severe acute respiratory syndrome coronavirus 1 (SARS‐CoV‐1), the virus responsible for the SARS outbreak of 2003.ResultsGiven the severity and clinical uncertainty of patients with COVID‐19 and the increased risk of transmission to clinicians, careful consideration should be taken prior to performing tracheostomy. If tracheostomy is performed, we recommend a bedside approach to limit exposure time and number of exposed personnel. Bronchoscopy use with a percutaneous approach should be limited in order to decrease viral exposure.ConclusionThorough preprocedural planning, use of experienced personnel, enhanced personal protective equipment where available, and a thoughtful anesthesia approach are instrumental in maximizing positive patient outcomes while successfully protecting the safety of healthcare personnel. Laryngoscope, 130:2546–2549, 2020

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Nasal Endoscopy During the COVID‐19 Pandemic: Mitigating Risk with 3D Printed Masks

\nJoel C. Davies, \nHarley H. L. Chan, \nRalph W. Gilbert, \nJonathan C. Irish\n

Publicatie 21-10-2020


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Closed Total Laryngectomy During the COVID‐19 Pandemic Disease

\nDaniele De Seta, \nValeria Marrosu, \nFrancesca Y. Russo, \nFilippo Carta, \nRoberto Puxeddu\n

Publicatie 21-10-2020


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Optimum Naso‐oropharyngeal Swab Procedure for COVID‐19: Step‐by‐Step Preparation and Technical Hints

\nElisa Coden, \nFederico Russo, \nAlberto D. Arosio, \nPaolo Castelnuovo, \nApostolos Karligkiotis, \nLuca Volpi\n

Publicatie 21-10-2020


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Flexible versus rigid laryngoscopy: A randomized crossover study comparing patient experience

"\nBhavishya S. Clark, \nWilliam Z. Gao, \nCaitlin Bertelsen, \nJanet S. Choi, \nHagit Shoffel‐Havakuk, \nLindsay S. Reder, \nEdie R. Hapner, \nMichael M. Johns, \nKarla ODell\n"

Publicatie 21-10-2020


ObjectivesTo compare flexible distal‐chip laryngoscopy (FDL) versus rigid telescopic laryngoscopy (RTL) in regard to examinees pain level, comfort, satisfaction, and preference, and to evaluate the clinicians assessment of the examinees experience with both exam types.Study DesignRandomized crossover study.MethodsTwenty‐three normal adult subjects were recruited to undergo both FDL and RTL; the initial exam type was randomized. Subjects and clinicians completed corresponding questionnaires after each exam. Differences in participant characteristics and questionnaire scores between the two exam types were assessed via Pearson χ2 and paired t tests, respectively.ResultsOverall, participants reported that FDL was more uncomfortable than RTL (4.22 vs. 2.91, P = .003) and scored higher on the pain scale for FDL compared to RTL (2.91 vs. 1.70, P = .006). However, there was no significant difference in number of participants who preferred FDL versus RTL (10 43% vs. 13 57%). Poor correlation was seen between clinicians assessment of participants discomfort and actual reported discomfort for FDL (2.70 vs. 4.22, P = .001).ConclusionsSubjects undergoing FDL experience greater discomfort and pain compared to RTL, but do not demonstrate a differential preference of exam. Overall, clinicians underestimate the discomfort of patients undergoing FDL, but participants maintain high satisfaction with both exams nonetheless.Level of Evidence1 Laryngoscope, 130:2663–2666, 2020

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Dissemination of Information During Public Health Crises: Early COVID‐19 Data From The Laryngoscope

\nAlexander Chern, \nSamuel H. Selesnick\n

Publicatie 21-10-2020


ObjectivesDuring a public health crisis, it is important for medical journals to share information in a timely manner while maintaining a robust peer‐review process. This review reports and analyzes The Laryngoscopes publication trends and practices during the COVID‐19 pandemic, before the COVID‐19 pandemic, and during previous pandemics.MethodsComprehensive review of two databases (PubMed and The Laryngoscope) was performed. COVID‐19 manuscripts (published in The Laryngoscope during the first 4 months of the pandemic) were identified and compared to manuscripts pertaining to historic pandemics (published in The Laryngoscope during the first 2 years of each outbreak). Keywords included “Laryngoscope”, “flu”, “pandemic”, “influenza”, “SARS”, “severe acute respiratory syndrome”, “coronavirus”, “COVID‐19”, and “SARS‐CoV‐2”. Data were obtained from The Laryngoscope to characterize publication trends during and before the COVID‐19 pandemic.ResultsFrom March 1, 2020 to June 30, 2020, The Laryngoscope had 203 COVID‐19 submissions. As of July 8, 2020, 20 (9.9%) were accepted, 117 (57.6%) under review, and 66 (32.5%) rejected. During the first 4 months of the pandemic, 18 COVID‐19 manuscripts were published. The mean number of days from submission to online publication was 45, compared to 170 in 2018 and 196 in 2019. A total of 4 manuscripts concerning previous pandemics were published during the initial 2 years of each outbreak.ConclusionsThe Laryngoscope rapidly disseminated quality publications during the COVID‐19 pandemic by upholding a robust peer‐review process while expediting editorial steps, highlighting relevant articles online, and providing open access to make COVID‐19‐related publications available as quickly as possible. Laryngoscope, 130:2508–2515, 2020

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Efficacy of pentoxifylline–tocopherol–clodronate in mandibular osteoradionecrosis

\nAlexis Dissard, \nNathalie P. Dang, \nIsabelle Barthelemy, \nCandice Delbet, \nMathilde Puechmaille, \nArnaud Depeyre, \nBruno Pereira, \nFanny Martin, \nFlorent Guillemin, \nJulian Biau, \nSonia Mirafzal, \nThierry Mom, \nLaurent Gilain, \nNicolas Saroul\n

Publicatie 21-10-2020


Objectives/HypothesisPENTOCLO treatment, associating pentoxifylline, tocopherol, and clodronate, resolves radiation‐induced fibrosis. The main aim of the present study was to prospectively assess efficacy in mandibular osteoradionecrosis (ORN).Study DesignProspective cohort study.MethodsTwenty‐seven patients with mandibular ORN were included in the Pentoclauvergne Study between January 2014 and February 2016. After an initial 28‐day phase of antibiotic, antifungal, and corticosteroid therapy, they received the PENTOCLO association daily until cure or a maximum of 24 months. The main assessment criterion was exposed bone area (EBA); secondary criteria comprised the Subjective, objective, management, and analytic (SOMA) score.ResultsUnder PENTOCLO, EBA decreased by 28% at 2 months, 55% at 6 months, and 92% at 24 months; the SOMA score decreased by 23%, 38%, and 50%, respectively. A complete treatment course cured 76.5% of patients at a mean 9.6 months.ConclusionsPENTOCLO is a simple, well‐tolerated, and effective treatment for mandibular ORN.Level of Evidence4 Laryngoscope, 130:E559–E566, 2020

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The miniature lateral crural strut graft: Efficacy of a novel technique in tip plasty

\nMohamed Abdelwahab, \nSam P. Most\n

Publicatie 21-10-2020


Objectives/HypothesisTo describe a novel technique for tip plasty and determine its efficacy using validated patient‐reported outcome measures and objective measures.Study DesignRetrospective cohort study.MethodsThis study was carried out at a tertiary center. Patients undergoing tip plasty using the miniature lateral crural strut grafts (mini‐LCSG) in cosmetic/combined rhinoplasty between January 2016 and August 2019 with available outcome measures were included. We used the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS), Nasal Obstruction Symptom Evaluation (NOSE) scores, visual analog scale: functional and cosmetic, and lateral wall insufficiency (LWI) grades.ResultsAmong 52 patients, 33 were included; 26 had cosmetic whereas seven had combined functional and cosmetic rhinoplasty, with a follow‐up up to 3 years. Both cosmetic and combined subjects showed significant improvement in SCHNOS‐Cosmesis (C) scores (−57.31 ± 1.79, P < .001 and − 53.57 ± 8.39, P < .001, respectively) and zone 1 LWI (P < .05, both sides). SCHNOS‐Obstruction (O) and NOSE scores showed significant decrease among subjects undergoing combined rhinoplasty only (−55.36 ± 18.58, P < .004, and − 53.93 ± 15.99, P < .003, respectively). With specific regard to tip cosmesis, the mean SCHNOS‐6 (item 6 of the SCHNOS questionnaire for tip cosmesis) showed significant improvement (−2.61, P < .001).ConclusionsThe mini‐LCSG is a novel modification for tip plasty that improves tip cosmesis and symmetry, both subjectively and objectively without compromising nasal function.Level of Evidence4 Laryngoscope, 130:2581–2588, 2020

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Functional Electrical Stimulation for Presbyphonia: A Prospective Randomized Trial

\nMarkus Gugatschka, \nMarlies Feiner, \nWinfried Mayr, \nAndrea Groselj‐Strele, \nKatharina Eberhard, \nClaus Gerstenberger\n

Publicatie 21-10-2020


ObjectivesThe aim of this prospective study was to examine the effects of transcutaneous functional electrical stimulation (FES) in a group of elderly women with presbyphonia.Study DesignProspective randomized study.MethodsFourteen participants were enrolled prospectively and attributed randomly to two different treatment groups, where one group (n = 7) received 8 weeks of training (5 days a week), whereas the other group (n = 7) received 4 weeks of ineffective stimulation, followed by 4 weeks of effective training. Stimulation protocols were established during baseline examination and confirmed with endoscopy to ensure a glottal reaction. Numerous acoustical, vocal, patient‐centered, and respiratory parameters were obtained at several time points.ResultsNeither 4 weeks nor 8 weeks of functional electrical transcutaneous stimulation led to changes of vocal, acoustical, or respiratory parameters, apart from patient‐centered items (Voice Handicap Index 12, Voice‐Related Quality of Life), which improved over time. However, there were no differences between the two arms for both items.ConclusionsTranscutaneous FES over 4 weeks and 8 weeks did not lead to significantly improved objective voice and acoustical parameters, which could be caused by the fact that the muscles of interest cannot be targeted specifically enough. However, we found a significant improvement of subjective voice perception and voice‐related quality of life in both groups. We explain this finding with an observer‐expectancy effect secondary to the very time‐consuming and elaborate study procedures.Level of Evidence1b Laryngoscope, 130:E662–E666, 2020

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Trust as a Predictor of Patient Perceptions Regarding Overlapping Surgery and Trainee Independence

\nAlexander Langerman, \nKathleen M. Brelsford, \nCarolyn J. Diehl, \nColeman R. Harris, \nThomas G. Stewart\n

Publicatie 21-10-2020


ObjectivesTo examine opinions on trainee independence and attending presence among a cross‐section of the general population and explore how perceptions of trust, past experiences, and demographics interacted with comfort consenting to these surgical scenarios.Study DesignMixed‐methodsMethodsBased on prior qualitative analysis, we designed a survey of patient preferences and values that focused on trust in healthcare practitioners and processes, which also included comfort ratings of three surgical scenarios (including overlapping surgery). The survey was administered to a sample from the general public using Mechanical Turk. We identified discreet domains of trust and examined the association of responses to these domains with comfort ratings, prior healthcare experiences, and demographics.ResultsWe analyzed 225 surveys and identified four patient subgroups based on responses to the surgical scenarios. Subjects that were more comfortable with overlapping surgery were more trusting of trainees and delegation by the attending. Past experiences in healthcare (positive and negative) were associated with multiple domains of trust (in trainees, surgeons, and the healthcare system). Demographics were not predictive of trust responses or comfort ratings.ConclusionPatients express varying degrees of comfort with overlapping surgery, and this is not associated with demographics. Past negative experiences have an impact on trust in the healthcare system overall, and trust in trainees specifically predicts comfort with attending absence from the operating room. Efforts to increase patient comfort with overlapping surgery and surgical training should include strategies to address past negative experiences and foster trust in trainees and the delegation process.Level of EvidenceIV Laryngoscope, 130:2728–2735, 2020

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Evolution of Olfactory Disorders in COVID‐19 Patients

\nVictor Gorzkowski, \nSibylle Bevilacqua, \nAlexandre Charmillon, \nRoger Jankowski, \nPatrice Gallet, \nCécile Rumeau, \nDuc Trung Nguyen\n

Publicatie 21-10-2020


ObjectivesA high frequency and a strong association of olfactory/gustatory impairment with COVID‐19 were reported. Its spontaneous evolution remains unknown. The aim of this study was to investigate the spontaneous evolution of olfactory disorders in COVID‐19 patients.Study DesignCross‐sectional study.MethodsA total of 229 patients with laboratory‐confirmed COVID‐19 from March 1 through 31, 2020 in our institution were included. Among them, 140 patients (mean age, 38.5 years, 89 women) reported sudden olfactory/gustatory disorders during COVID‐19. All patients were interviewed by phone based on a questionnaire with 16 questions at time of survey. The primary end point was olfactory recovery rate at time of survey.ResultsThe frequency of patients with olfactory disorders was higher before March 20, 2020 than since (70.3% vs. 53.9%, respectively) (P = .016). At time of survey (26 days of the mean time from anosmia onset), 95.71% reported to start an olfactory recovery. The mean time from olfactory loss onset to recovery onset was 11.6 days. Recovery started between the fourth and the fifteenth day after olfactory loss onset in 78.4% of patients. Complete olfactory recovery happened for 51.43% of patients. There was a significant relationship between the complete olfactory recovery and a short time from olfactory loss onset to recovery onset (P = .0004), absence of nasal obstruction (P = .023) and absence of sore/dry/tingling feeling in the nose (P = .007) in COVID‐19 patients.ConclusionKnowledge of spontaneous evolution of olfactory disorders allows reassuring patients and planning therapeutic strategies for persistent olfactory dysfunction after having definitely recovered from COVID‐19.Level of Evidence4 Laryngoscope, 130:2667–2673, 2020

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The COVID‐19 Airway Management Isolation Chamber (CAMIC) for Ears

\nAnthony M. Tolisano, \nTimothy C. Blood, \nCharles A. Riley, \nDouglas S. Ruhl, \nSteven S. Hong\n

Publicatie 21-10-2020


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Apoptosis signaling molecules as treatment targets in head and neck squamous cell carcinoma

\nThomas J. Ow, \nCarlos Thomas, \nCory D. Fulcher, \nJianhong Chen, \nAndrea López, \nDenis E. Reyna, \nMichael B. Prystowsky, \nRichard V. Smith, \nBradley A. Schiff, \nGregory Rosenblatt, \nThomas J. Belbin, \nThomas M. Harris, \nGeoffrey C. Childs, \nNicole Kawachi, \nNicolas F. Schlecht, \nEvripidis Gavathiotis\n

Publicatie 21-10-2020


ObjectivesTo evaluate BCL‐2 family signaling molecules in head and neck squamous cell carcinoma (HNSCC) and examine the ability of therapeutic agents with variable mechanisms of action to induce apoptosis in HNSCC cells.Methodsmessenger ribonculeic acid (mRNA) expression of BAK, BAX, B‐cell lymphoma (Bcl‐2), BCL2 Like 1 (BCL2L1), and MCL1 were measured in The Cancer Genome Atlas (TCGA) head and neck cancer dataset, as well as in a dataset from a cohort at Montefiore Medical Center (MMC). Protein expression was similarly evaluated in a panel of HNSCC cell lines (HN30, HN31, HN5, MDA686LN, UMSCC47). Cell viability and Annexin V assays were used to assess the efficacy and apoptotic potential of a variety of agents (ABT‐263 navitoclax, A‐1210477, and bortezomib.ResultsExpression of BAK, BAX, BCL2L1, and MCL1 were each significantly higher than expression of BCL2 in the TCGA and MMC datasets. Protein expression demonstrated the same pattern of expression when examined in HNSCC cell lines. Treatment with combined ABT‐263 (navitoclax)/A‐1210477 or with bortezomib demonstrated apoptosis responses that approached or exceeded treatment with staurospaurine control.ConclusionHNSCC cells rely on inhibition of apoptosis via BCL‐xL and MCL‐1 overexpression, and induction of apoptosis remains a potential therapeutic option as long as strategies overcome redundant anti‐apoptotic signals.Level of EvidenceNA Laryngoscope, 130:2643–2649, 2020

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Spatial Motion of Arytenoid Cartilage Using Dynamic Computed Tomography Combined with Euler Angles

\nYanli Ma, \nHuijing Bao, \nXi Wang, \nXi Chen, \nZheyi Zhang, \nJinan Wang, \nPeiyun Zhuang, \nJack J. Jiang, \nAzure Wilson, \nChenxu Wu\n

Publicatie 21-10-2020


ObjectiveTo investigate the feasibility of dynamic computed tomography in recording and describing the spatial motion characteristics of the arytenoid cartilage.MethodsDynamic computed tomography recorded the real‐time motion trajectory of the arytenoid cartilage during inspiration and phonation. A stationary coordinate system was established with the cricoid cartilage as a reference and a motion coordinate system was established using the movement of the arytenoid cartilage. The Euler angles of the arytenoid cartilage movement were calculated by transformation of the two coordinate systems, and the spatial motion characteristics of the arytenoid cartilage were quantitatively studied.ResultsDisplacement of the cricoid cartilage was primarily inferior during inspiration. During phonation, the displacement was mainly superior. When the glottis closed, the superior displacement was about 5–8 mm within 0.56 s. During inspiration, the arytenoid cartilage was displaced superiorly approximately 1–2 mm each 0.56 s. The rotation angle was subtle with slight rotation around the XYZ axis, with a range of 5–10 degrees. During phonation, the displacement of the arytenoid cartilage was mainly inferior (about 4–6 mm), anterior (about 2–4 mm) and medial (about 1–2 mm). The motion of the arytenoid cartilage mainly consisted of medial rolling, and there was an alternating movement of anterior‐posterior tilting. The arytenoid cartilage rolled medially (about 20–40 degrees within 0.56 s), accompanied by anterior‐posterior tilting (about 15–20 degrees within 0.56 s).ConclusionDynamic computed tomography recordings of arytenoid cartilage movement can be combined with Euler transformations as a tool to study the spatial characteristics of laryngeal structures during phonation.Level of Evidence4 Laryngoscope, 130:E646–E653, 2020

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Automatic Recognition of Laryngoscopic Images Using a Deep‐Learning Technique

\nJianjun Ren, \nXueping Jing, \nJing Wang, \nXue Ren, \nYang Xu, \nQiuyun Yang, \nLanzhi Ma, \nYi Sun, \nWei Xu, \nNing Yang, \nJian Zou, \nYongbo Zheng, \nMin Chen, \nWeigang Gan, \nTing Xiang, \nJunnan An, \nRuiqing Liu, \nCao Lv, \nKen Lin, \nXianfeng Zheng, \nFan Lou, \nYufang Rao, \nHui Yang, \nKai Liu, \nGeoffrey Liu, \nTao Lu, \nXiujuan Zheng, \nYu Zhao\n

Publicatie 21-10-2020


Objectives/HypothesisTo develop a deep‐learning–based computer‐aided diagnosis system for distinguishing laryngeal neoplasms (benign, precancerous lesions, and cancer) and improve the clinician‐based accuracy of diagnostic assessments of laryngoscopy findings.Study DesignRetrospective study.MethodsA total of 24,667 laryngoscopy images (normal, vocal nodule, polyps, leukoplakia and malignancy) were collected to develop and test a convolutional neural network (CNN)‐based classifier. A comparison between the proposed CNN‐based classifier and the clinical visual assessments (CVAs) by 12 otolaryngologists was conducted.ResultsIn the independent testing dataset, an overall accuracy of 96.24% was achieved; for leukoplakia, benign, malignancy, normal, and vocal nodule, the sensitivity and specificity were 92.8% vs. 98.9%, 97% vs. 99.7%, 89% vs. 99.3%, 99.0% vs. 99.4%, and 97.2% vs. 99.1%, respectively. Furthermore, when compared with CVAs on the randomly selected test dataset, the CNN‐based classifier outperformed physicians for most laryngeal conditions, with striking improvements in the ability to distinguish nodules (98% vs. 45%, P < .001), polyps (91% vs. 86%, P < .001), leukoplakia (91% vs. 65%, P < .001), and malignancy (90% vs. 54%, P < .001).ConclusionsThe CNN‐based classifier can provide a valuable reference for the diagnosis of laryngeal neoplasms during laryngoscopy, especially for distinguishing benign, precancerous, and cancer lesions.Level of EvidenceNA Laryngoscope, 130:E686–E693, 2020

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Type I Thyroplasty Using a Titanium Implant Combined With Modified Arytenoid Adduction

\nKoji Matsushima\n

Publicatie 21-10-2020


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Treatment sequence and survival in locoregionally advanced hypopharyngeal cancer: A surveillance, epidemiology, and end results–based study

\nColleen G. Hochfelder, \nAileen P. McGinn, \nVikas Mehta, \nEnrico Castellucci, \nRafi Kabarriti, \nThomas J. Ow\n

Publicatie 21-10-2020


Objectives/HypothesisThe objective of this study was to examine the association between modality of primary treatment and survival among patients with locoregionally advanced hypopharyngeal cancer.Study DesignRetrospective cohort.MethodsThere were 2,328 adult patients diagnosed with stage III or IV, M0, hypopharyngeal squamous cell carcinoma identified within the Surveillance, Epidemiology and End Results (SEER) registry (years 2004–2015). Patients who received primary chemoradiation (CRT) were compared to those who received surgery with either adjuvant radiation therapy (S + RT), or surgery with adjuvant CRT (S + CRT). The latter primary surgery group (S + Adj) was also analyzed collectively. Overall survival (OS) and disease‐specific survival (DSS) were assessed using Kaplan‐Meier analyses and Cox regression models using a propensity score to adjust for factors associated with treatment allocation.ResultsMedian survival was 20 months (interquartile range IQR = 10–45) with CRT and 25 months (IQR = 10–47) with S + Adj (P < .001). S + Adj had higher‐grade cancers and more advanced T staging (P < .001). S + CRT was associated with longer OS (hazard ratio HR = 0.70, 95% confidence interval CI: 0.59‐0.84) and DSS (HR = 0.66, 95% CI: 0.54‐0.82) after adjusting for age, gender, race, subsite, grade, and stage. S + RT was associated with longer DSS than CRT (HR = 0.75, 95% CI: 0.57‐0.99) but not OS (HR = 0.82, 95% CI: 0.66‐1.04). S + Adj was associated with longer DSS in T1/T2 disease (P = .04) and T4 disease (P = .0003), but did not reach significance among patients with T3 disease (P = .06).ConclusionsAmong patients with advanced hypopharyngeal cancer reported in the SEER database, treatment with S + Adj was associated with longer DSS and OS compared to those treated with primary CRT.Level of Evidence2b Laryngoscope, 130:2611–2621, 2020

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Intersegmenter Variability in High‐Speed Laryngoscopy‐Based Glottal Area Waveform Measures

\nYouri Maryn, \nMonique Verguts, \nHannelore Demarsin, \nJoost Dinther, \nPablo Gomez, \nPatrick Schlegel, \nMichael Döllinger\n

Publicatie 21-10-2020


Objectives/HypothesisHigh‐speed videoendoscopy (HSV) has potential to objectively quantify vibratory vocal fold characteristics during phonation. Glottal Analysis Tools (GAT) version 2018, developed in Erlangen, Germany, is software for determining various glottal area waveform (GAW) quantities. Before having GAT analyze HSV videos, segmenters have to define glottis manually across videos in a semiautomatic segmentation protocol. Such interventions are hypothesized to induce variability of subsequent GAW measure computation across segmenters and may attenuate GAT measures’ reliability to a certain point. This study explored intersegmenter variability in GATs GAW measures based on semiautomatic image processing.Study DesignCohort study of rater reliability.MethodsIn total, 20 HSV videos from normophonic and dysphonic subjects with various laryngeal disorders were selected for this study and segmented by three trained segmenters. They separately segmented glottis areas in the same frame sets of the videos. Upon analysis of GAW, GAT offers 46 measures related to topologic GAW dynamic characteristics, GAW periodicity and perturbation characteristics, and GAW harmonic components. To address GATs reliability, intersegmenter‐based variability in these measures was examined with intraclass correlation coefficient (ICC).ResultsIn general, ICC behavior of the 46 GAW measures across three raters was highly acceptable. ICC of one parameter was moderate (0.5 < ICC < 0.75), good for seven parameters (0.75 < ICC < 0.9), and excellent for 38 parameters (0.9 < ICC).ConclusionsOverall, high ICC values confirm clinical applicability of GAT for objective and quantitative assessment of HSV. Small intersegmenter differences with actual small parameter differences suggest that manual or semiautomatic segmentation in GAT does not noticeably influence clinical assessment outcome. To guarantee the softwares performance, we suggest segmentation training before clinical application.Level of Evidence2b Laryngoscope, 130:E654–E661, 2020

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Otolaryngology Resident Practices and Perceptions in the Initial Phase of the U.S. COVID‐19 Pandemic

\nYi Cai, \nNicole T. Jiam, \nKatherine C. Wai, \nElizabeth A. Shuman, \nLauren T. Roland, \nJolie L. Chang\n

Publicatie 21-10-2020


ObjectiveThe coronavirus 2019 (COVID‐19) pandemic has had widespread implications on clinical practice at U.S. hospitals. These changes are particularly relevant to otolaryngology–head and neck surgery (OHNS) residents because reports suggest an increased risk of contracting COVID‐19 for otolaryngologists. The objectives of this study were to evaluate OHNS residency program practice changes and characterize resident perceptions during the initial phase of the pandemic.Study DesignA cross‐sectional survey of U.S. OHNS residents at 81 programs was conducted between March 23, 2020, and March 29, 2020.ResultsEighty‐two residents from 51 institutions (63% of invited programs) responded. At the time of survey, 98% of programs had enacted policy changes to minimize COVID‐19 spread. These included filtered respirator use for aerosol‐generating procedures even in COVID‐19‐negative patients (85%), decreased resident staffing of surgeries (70%), and reduced frequency of tracheotomy care (61%). The majority of residents (66%) perceived that residents were at higher risk of contracting COVID‐19 compared to attendings. Residents were most concerned about protective equipment shortage (93%) and transmitting COVID‐19 to patients (90%). The majority of residents (73%) were satisfied with their departments COVID‐19 response. Resident satisfaction correlated with comfort level in discussing concerns with attendings (r = 0.72, P < .00001) and inversely correlated with perceptions of increased risk compared to attendings (r = −0.52, P < .00001).ConclusionU.S. OHNS residency programs implemented policy changes quickly in response to the COVID‐19 pandemic. Sources of resident anxieties demonstrate the importance of open communication and an integrated team approach to facilitate optimal patient and provider care during this unprecedented crisis.Level of Evidence4. Laryngoscope, 130:2550–2557, 2020

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An Example of Employing the Principles of Bioethics to Medical Decision Making in the COVID‐19 Era

\nDouglas S. Ruhl, \nMarc H. Hohman\n

Publicatie 21-10-2020


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Acute airway compromise after recombinant human TSH administration: A case report and review of the literature

\nEric Dowling, \nJan Kasperbauer, \nJohn Morris, \nSemirra Bayan\n

Publicatie 21-10-2020


Radioiodine ablation is a commonly utilized treatment for differentiated thyroid carcinoma. Uptake of radioiodine can be enhanced by pretreatment with thyroid hormone withdrawal or administration of recombinant human thyroid‐stimulating hormone (rhTSH). rhTSH is generally well‐tolerated with minimal adverse effects. However, in patients with extensive tumor burden in confined anatomic spaces, rapid enlargement of normal or neoplastic thyroid tissue secondary to rhTSH administration can result in significant compressive effects. In this report, we describe a case of rapid airway deterioration requiring intubation in a patient with involvement of the thyroid cartilage by papillary thyroid carcinoma.Laryngoscope, 122:0000–0000, 2019 Laryngoscope, 130:2725–2727, 2020

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Sialadenitis: A Possible Early Manifestation of COVID‐19

\nAlexander Chern, \nAkinrinola O. Famuyide, \nGul Moonis, \nAnil K. Lalwani\n

Publicatie 21-10-2020


Acute sialadenitis may be caused by viruses, including coronaviruses. Although there are anecdotal reports of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) salivary gland infections, there have been no well‐documented cases of sialadenitis in patients with COVID‐19 described in the literature. We report a case of parotitis and submandibular gland sialadenitis, as well as an isolated case of parotitis, in two patients with concurrent SARS‐CoV‐2 infections. Computed tomography imaging demonstrated parotid and submandibular gland enlargement with heterogenous enhancement and attenuation, consistent with sialadenitis. Medical management was sufficient for successful resolution of the acute sialadenitis. Laryngoscope, 130:2595–2597, 2020

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Laryngeal adductor reflex hyperexcitability may predict permanent vocal fold paralysis

\nCatherine F. Sinclair, \nMaria J. Téllez, \nM. Angeles Sánchez Roldán, \nSedat Ulkatan\n

Publicatie 21-10-2020


Laryngeal adductor reflex–continuous intraoperative neuromonitoring (LAR‐CIONM) is a novel method of continuous intraoperative neuromonitoring. In contrast to other vagal nerve monitoring techniques, which elicit a laryngeal compound muscle action potential, LAR‐CIONM elicits a laryngeal reflex response (LAR). In 300 nerves at risk monitored with LAR‐CIONM, two patients have had postoperative permanent vocal fold immobility (VFI). Both patients exhibited a significant LAR amplitude increase prior to complete loss of signal. No other patients have exhibited LAR hyperexcitability. If confirmed in a larger sample, this represents the first time that a vagal intraoperative neuromonitoring technique can distinguish transient from permanent VFI, which could improve patient outcomes. Laryngoscope, 2019 Laryngoscope, 130:E625–E627, 2020

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Thyroid Cartilage Cysts, A Rare Entity Causing Dysphonia

\nFroukje J. Verdam, \nHans Mahieu\n

Publicatie 21-10-2020


Five cases are presented with a strained voice quality due to a unique underlying cause: thyroid cartilage cysts. Laryngoscopy and radiological images show antero‐medial displacement of both vestibular and vocal fold(s). Swelling in the ala of the thyroid cartilage results in a pear‐shaped lumen. These cysts were marsupialized with CO2 laser, fluid emerged, and histological biopsies confirmed cartilaginous cysts. Postoperatively, all cases report largely reduced or completely resolved vocal complaints, with a consistent follow‐up of 2 years. Together with previous publications, an overview of 17 cases is presented, to enhance awareness that thyroid cartilage cysts can cause a strained voice quality. Laryngoscope, 130:E628–E631, 2020

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Management of Upper Airway Bleeding in COVID‐19 Patients on Extracorporeal Membrane Oxygenation

\nPhillip S. LoSavio, \nTirth Patel, \nMatthew J. Urban, \nBobby Tajudeen, \nPeter Papagiannopoulos, \nPeter C. Revenaugh, \nInna Husain, \nPete S. Batra\n

Publicatie 21-10-2020


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In Response to Anosmia and Ageusia: Common Findings in COVID‐19 Patients

\nLuigi A. Vaira, \nGiovanni Salzano, \nGiovanna Deiana, \nGiacomo De Riu\n

Publicatie 21-10-2020


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In Reference to Anosmia and Ageusia: Common Findings in COVID‐19 Patients

\nYang‐Pei Chang, \nChih‐Jen Yang, \nYen‐Hsu Chen\n

Publicatie 21-10-2020


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In Response to Regarding Surgical Impact of a Dedicated Endocrine Surgeon on an Academic Otolaryngology Department

\nAyaka J. Iwata, \nSteven S. Chang, \nTamer A. Ghanem, \nMichael C. Singer\n

Publicatie 21-10-2020


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In Reference to: Surgical Impact of a Dedicated Endocrine Surgeon on an Academic Otolaryngology Department

\nAshish Luthra, \nDeepak Kumar Kisku, \nRajat Kumar Patra, \nSanjay Kumar Yadav\n

Publicatie 21-10-2020


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Editorial: Laryngoscope addresses COVID‐19

\nSamuel H. Selesnick\n

Publicatie 21-10-2020


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Masthead

Publicatie 21-10-2020


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Table of contents

Publicatie 21-10-2020


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The Prognostic Role of Programmed Death‐Ligand 1 in Nasopharyngeal Carcinoma

\nMichael Wotman, \nSaori W. Herman, \nPeter Costantino, \nTristan Tham\n

Publicatie 21-10-2020


ObjectivesProgrammed death‐ligand 1 (PD‐L1) is an immune checkpoint protein that may be a useful prognostic biomarker in nasopharyngeal cancer (NPC). The purpose of this systematic review and meta‐analysis was to investigate the relationship between PD‐L1 expression and survival in NPC.MethodsPubMed, Cochrane, Embase, Scopus, and Web of Science were searched from inception to present. A predefined inclusion and exclusion criteria were used to select articles. Hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled for overall survival (OS), disease‐free survival (DFS), and disease metastasis‐free survival (DMFS).ResultsEleven studies published from 2014 to 2018 were included, with 1,356 total participants. PD‐L1 expression was not associated with OS (HR = 1.10, 95% CI: 0.79‐1.55), DFS (HR = 1.66, 95% CI: 0.68‐4.03), or DMFS (HR = 1.18, 95% CI: 0.44‐3.20).ConclusionsThe prognostic role of PD‐L1 in NPC remains unsubstantiated. Future research is needed. Laryngoscope, 130:2598–2606, 2020

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Minimizing Contagion Risks of COVID‐19 During Transoral Robotic Surgery

\nGiuseppe Meccariello, \nGiovanni Cammaroto, \nGiannicola Iannella, \nPasquale Capaccio, \nStefano Pelucchi, \nClaudio Vicini\n

Publicatie 21-10-2020


In this communication, we would like to share our experience in managing TORS patients during COVID‐19 pandemic. Laryngoscope, 130:2593–2594, 2020

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Editorial Comment on How COVID‐19 is Affecting Otolaryngology–Head and Neck Surgery

\nJohn S. Oghalai\n

Publicatie 21-10-2020


Level of Evidence5 Laryngoscope, 130:2686–2687, 2020

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How to Reorganize an Ear, Nose, and Throat Outpatient Service During the COVID‐19 Outbreak: Report From Northern Italy

\nFrancesca De Bernardi, \nMario Turri‐Zanoni, \nPaolo Battaglia, \nPaolo Castelnuovo\n

Publicatie 21-10-2020


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Evaluating Patient Benefit From Laryngochondroplasty

\nChristopher G. Tang\n

Publicatie 20-10-2020


Objectives/HypothesisTo elucidate and review current literature on the surgical technique for laryngochondroplasty in male‐to‐female transgender patients. To determine the degree of benefit afforded to male‐to‐female transgender patients by laryngochondroplasty using the Glasgow Benefit Inventory (GBI).Study DesignRetrospective case series.MethodsAfter institutional review board approval was obtained, the GBI survey was given to patients who underwent laryngochondroplasty by the author. Demographic information was analyzed including age, race, wait time to surgery, distance traveled, median zip code income, and concomitant gender‐affirming surgeries such as vaginoplasty, breast augmentation, or facial feminization.ResultsFrom April 2016 to April 2020, 209 patients received laryngochondroplasty within the Kaiser Permanente Northern California Medical System. Of those, 91 received laryngochondroplasty with the author and were given the GBI, with 73 patients (80%) responding. Patients were on average 31.4 years old, traveled 45.4 miles to the surgical site, lived in a zip code with a median income of $86,793.61, and waited 95.7 days for surgery. Patients had a statistically significant improvement in all three subscores (general, social, and physical) of the GBI as well as in their overall score.ConclusionsLaryngochondroplasty is a safe and effective procedure to reduce thyroid cartilage prominence (Adams apple) in male‐to‐female transgender patients. There was a statistically significant improvement in the overall score and all subscores of the GBI after laryngochondroplastyLevel of Evidence4 Laryngoscope, 130:S1–S14, 2020

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Table of contents

Publicatie 20-10-2020


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Masthead

Publicatie 20-10-2020


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Expression of ACE2 and TMPRSS2 Proteins in the Upper and Lower Aerodigestive Tracts of Rats: Implications on COVID 19 Infections

\nTaku Sato, \nRumi Ueha, \nTakao Goto, \nAkihito Yamauchi, \nKenji Kondo, \nTatsuya Yamasoba\n

Publicatie 19-10-2020


ObjectivePatients with coronavirus disease 2019 (COVID‐19), caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), exhibit not only respiratory symptoms but also symptoms of chemo‐sensitive disorders. Cellular entry of SARS‐CoV‐2 depends on the binding of its spike protein to a cellular receptor named angiotensin‐converting enzyme 2 (ACE2), and the subsequent spike protein‐priming by host cell proteases, including transmembrane protease serine 2 (TMPRSS2). Thus, high expression of ACE2 and TMPRSS2 is considered to enhance the invading capacity of SARS‐CoV‐2.MethodsTo elucidate the underlying histological mechanisms of the aerodigestive disorders caused by SARS‐CoV‐2, we investigated the expression of ACE2 and TMPRSS2 proteins using immunohistochemistry, in the aerodigestive tracts of the tongue, hard palate with partial nasal tissue, larynx with hypopharynx, trachea, esophagus, and lung of rats.ResultsCo‐expression of ACE2 and TMPRSS2 proteins was observed in the taste buds of the tongue, nasal epithelium, trachea, bronchioles, and alveoli with varying degrees of expression. Remarkably, TMPRSS2 expression was more distinct in the peripheral alveoli than in the central alveoli. These results coincide with the reported clinical symptoms of COVID‐19, such as the loss of taste, loss of olfaction, and respiratory dysfunction.ConclusionsA wide range of organs have been speculated to be affected by SARS‐CoV‐2 depending on the expression levels of ACE2 and TMPRSS2. Differential distribution of TMPRSS2 in the lung indicated the COVID‐19 symptoms to possibly be exacerbated by TMPRSS2 expression. This study might provide potential clues for further investigation of the pathogenesis of COVID‐19.Level of EvidenceNA Laryngoscope, 2020

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Outcomes of Venous End‐to‐Side Microvascular Anastomoses of the Head and Neck

\nMatthew Stewart, \nPerry Hammond, \nIshani Khatiwala, \nBrian Swendseid, \nFarshid Taghizadeh, \nDaniel Petrisor, \nTingting Zhan, \nRichard Goldman, \nAdam Luginbuhl, \nRyan Heffelfinger, \nLarissa Sweeny, \nMark K. Wax, \nJoseph M. Curry\n

Publicatie 19-10-2020


Objectives/HypothesisThe literature on outcomes of end‐to‐side (ETS) anastomoses for microvascular reconstruction of the head and neck is limited. This series reviews ETS in free tissue transfer (FTT) across multiple institutions to better understand their usage and associated outcomes.Study DesignRetrospective review of 2482 consecutive patients across three tertiary institutions.MethodsAdult patients (> 18) who received a FTT from 2006 to 2019 were included.ResultsTwo hundred and twenty‐one FTT were identified as requiring at least one ETS anastomosis. These ETS cases had a failure rate of 11.2% in comparison to 3.8% in a cohort of end‐to‐end (ETE) cases (P < .001). ETS cases were significantly more likely to have a prior neck dissection (P < .001), suggesting the ETS method was utilized in select circumstances. A second ETS anastomosis improved survival of the FTT (P = .006), as did utilization of a coupler over suture (P = .002). Failure due to venous thrombosis was significantly more common with one ETS anastomosis instead of two ETS anastomoses (P = .042).ConclusionsETS is effective but is often used as a secondary technique when ETE is not feasible; as such, in this series, ETS was associated with higher failure. A second anastomosis and the use of the coupler for completing the anastomoses were associated with lower rates of failure.Level of Evidence3 Laryngoscope, 2020

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Catastrophic Hemorrhage After Chemoradiation for Advanced Stage Oropharyngeal Carcinoma: A Case Series

\nCourtney T. Chou, \nTanya J. Rath, \nJonas T. Johnson, \nLindsey K. Goyal\n

Publicatie 17-10-2020


Objectives/HypothesisWe have seen several incidences of catastrophic bleeding in patients with advanced oropharyngeal squamous cell carcinoma treated nonoperatively. Aside from advanced disease, these patients have not had traditional risk factors for major hemorrhage.Study DesignRetrospective chart review.MethodsPatients treated nonoperatively for oropharyngeal squamous cell carcinoma were compared to determine characteristics that may predisposed to bleeding. Five patients with bleeding were identified and compared with a cohort of stage‐ and treatment‐matched patients without bleeding. Blinded imaging review was performed to characterize the tumor site and its relationship to vasculature using standardized systems.ResultsComparing the bleeder versus nonbleeder groups pre‐treatment, the bleeder group had larger tumors (15.4 vs. 8.3 cm2), greater rates of parapharyngeal fat effacement (80% vs. 20%), and always involved the facial artery. Post‐treatment, endophytic ulcerated tumor beds occurred in 100% of bleeders versus 0% of nonbleeders.ConclusionsCatastrophic oropharyngeal bleeding may be encountered after cytoreductive therapy. Large deeply invasive tumors seem to set the necessary circumstances. Rapid vascular control with interventional radiology has been largely effective therapy.Level of Evidence3 Laryngoscope, 2020

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Polymeric Microspheres Containing Human Vocal Fold Fibroblasts for Vocal Fold Regeneration

\nAlicia Reyes Valenzuela, \nGuangyu Bao, \nAbigail Vikstrom, \nKaren M. Kost, \nSatya Prakash, \nLuc Mongeau\n

Publicatie 17-10-2020


ObjectiveMost acellular injectable biomaterials for vocal fold (VF) wound treatment have limited regenerative potential due to their fast enzymatic degradation and limited recruitment of native cells postinjection. The injection of cells as therapeutic treatment often results in apoptosis due to stresses within the needle and the immune response of the host. Degradable microspheres may improve treatment effectiveness by increasing cell residence time, shielding cells during injection, and offering early protection against the immune system response. The objective of the present study was to investigate the potential of human VF fibroblasts encapsulated in polymeric microspheres as an injectable therapeutic treatment in vitro.MethodsAlginate, alginate‐poly‐L‐lysine, and alginate‐chitosan microspheres were fabricated using electrospraying and characterized in terms of biocompatibility, swelling, and mechanical properties as well as cytokine production.ResultsAlginate microspheres were found to have the most desirable properties for VF regeneration. They were resistant to mechanical challenges. They were found to have a stiffness similar to that reported for native VF‐lamina propria. They were found to be biocompatible and increased the proliferation of fibroblasts. Human VF fibroblasts encapsulated in alginate microspheres induced the production of interleukin (IL)‐8 and IL‐4 at 24 hours.ConclusionThe alginate microspheres fabricated in this study were found to offer potential advantages, as cell delivery tool. This study highlights the importance of combining biomaterials and cells to expedite the wound‐healing process through cytokine production. Future work is aimed to further analysis of the wound‐healing properties the microspheres.Level of EvidenceNA Laryngoscope, 2020

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A meta‐analysis of 67 studies with presenting symptoms & laboratory tests of COVID‐19 patients

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

Publicatie 17-10-2020


AbstractObjectiveThe objective of this meta‐analysis was to look at the pooled prevalence of symptoms, Laboratory tests and imaging of all COVID‐19 infected patients. This will allow better identification of potential COVID‐19 patients and take appropriate precautions.MethodsWe searched three databases, PubMed, EMBASE and Ovid to identify studies published between Dec‐2019 and May‐2020. All studies reporting upper‐aerodigestive symptoms of COVID‐19 infection were included. The meta‐analysis was conducted following MOOSE guidelines which have evaluated the pooled prevalence of 14 symptoms and nine laboratory investigations.ResultsBased on inclusion criteria, 67 publications consisting of 8302 patients were included. Among adults, the pooled proportion of hypertensive and diabetic patients was 18% and 7%. Cough 53% (0.46–0.61), anosmia 38%(0.19–0.58), loss/distortion of taste 31%(0.17–0.45) and nasal obstruction 26%(0.12–0.39) were the most common ear nose throat (ENT) symptom. Fever 69% (0.62–0.76) and fatigue 31% (0.26–0.37) were the commonest generalized symptoms. C‐reactive protein(CRP) and erythrocyte sedimentation rate(ESR) was raised in 56% (0.41–0.71) and 49%(0.21–0.77) respectively. Interestingly, lymphopenia 41% (0.30–0.53) and leucopenia22%(0.16–0.29) were more common than lymphocytosis 33%(0.02–0.64) and leucocytosis 12%(0.09–0.16). Fever(69% vs, 44%), cough(53% vs. 33%) and dyspnea(20% vs 4%) were more common in adults as compared to paediatric population. Diarrhoea was more common among the paediatric cases 12%) vs. 9%). The pooled estimate of fatality was 4%.ConclusionsThe most commonly experienced ENT symptom was cough followed by anosmia and dysguesia. Raised ESR and CRP with leukopenia and lymphopenia are common laboratory findings. Majority of the infected patients had abnormal computed tomography findings. COVID infection is less severe in paediatric patients.This article is protected by copyright. All rights reserved.

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In Response to Letter to the Editor Regarding In‐Office Tympanostomy Tube Placement in Children Using Iontophoresis and Automated Tube Delivery

\nLawrence R. Lustig, \nEli Grunstein, \nSusannah Hills, \nAmy Ingram, \nAndrew R. Gould, \nD. Macy Vidrine, \nRobert Puchalski, \nJacob W. Zeiders, \nRandall A. Ow, \nChristopher R. Thompson, \nJonathan R. Moss, \nRitvik Mehta, \nAudrey Calzada, \nJohn E. McClay, \nAmy Brenski, \nJohn Gavin, \nErik H. Waldman, \nJohn Ansley, \nDavid M. Yen, \nDavid M. Brown, \nNeil K. Chadha, \nFrederick K. Kozak, \nMichael T. Murray, \nChristopher York, \nRobert C. Sprecher, \nDenise A. Sherman, \nScott R. Schoem, \nDan Harfe, \nLaura J. England, \nCharles A. Syms\n

Publicatie 16-10-2020


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Regarding In‐Office Tympanostomy Tube Placement in Children Using Iontophoresis and Automated Tube Delivery

\nPadmanabhan Karthikeyan, \nParvathy Vidyan\n

Publicatie 16-10-2020


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Subglottic Stenosis Position Affects Work of Breathing

\nMax M. Yang, \nNara S. Higano, \nChamindu C. Gunatilaka, \nErik B. Hysinger, \nRaouf S. Amin, \nJason C. Woods, \nAlister J. Bates\n

Publicatie 14-10-2020


ObjectivesSubglottic stenosis (SGS) is the most common type of laryngeal stenosis in neonates. SGS severity is currently graded based on percent area of obstruction (%AO) via the Myer‐Cotton grading scale. However, patients with similar %AO can have widely different clinical courses. Computational fluid dynamics (CFD) based on patient‐specific imaging can quantify the relationship between airway geometry and flow dynamics. We investigated the effect of %AO and axial position of SGS on work of breathing (WOB) in neonates using magnetic resonance imaging.MethodsHigh‐resolution ultrashort echo‐time MRI of the chest and airway was obtained in three neonatal patients with no suspected airway abnormalities; images were segmented to construct three‐dimensional (3D) models of the neonatal airways. These models were then modified with virtual SGSs of varying %AO and axial positioning.CFD simulations of peak inspiratory flow were used to calculate patient‐specific WOB in nonstenotic and artificially stenosed airway models.ResultsCFD simulations demonstrated a relationship between stenosis geometry and WOB increase. WOB rapidly increased with %AO greater than about 70%. Changes in axial position could also increase WOB by approximately the same amount as a 10% increase in %AO. Increased WOB was particularly pronounced when the SGS lumen was misaligned with the glottic jet.ConclusionThe results indicate a strong, predictable relationship between WOB and axial position of the stenotic lumen relative to the glottis, which has not been previously reported. These findings may lead to precision diagnosis and treatment prediction tools in individual patients.Level of Evidence4 Laryngoscope, 2020

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In Response to “Factors Affecting Success of Laser Posterior Transverse Cordotomy”

\nTed Mau, \nKathleen M. Tibbetts\n

Publicatie 14-10-2020


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Factors Affecting Success of Laser Posterior Trasverse Cordotomy

\nPetros D. Karkos, \nMarios Stavrakas, \nIoannis Koskinas\n

Publicatie 14-10-2020


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Office‐Based Procedure Training in Laryngology Fellowship Programs

\nNecati Enver, \nApoorva Ramaswamy, \nLucian Sulica, \nMichael J. Pitman\n

Publicatie 12-10-2020


ObjectiveTo assess the current practices and challenges of training office‐based procedures to laryngology fellows in the United States.MethodsAn anonymous web‐based survey study was distributed to laryngology fellowship program directors, as listed by the American Laryngological Association. The survey was a 19‐item questionnaire with free‐text, Likert scale, and multiple‐choice answers.ResultsTwenty‐two of 27 program directors (81.4%) replied to the survey. Many programs (8/16) have three or more laryngologists and do more than 10 procedures each week (10/16). Sixty‐nine percent (11/16) of directors had not been trained for office procedures in their fellowship. The fellows are allowed to be primary surgeon on 68.75% and 75% of vocal fold augmentation and laser procedures, respectively. The expected competencies for these procedures on graduation are average‐moderate and moderate. When program directors asked about the methods used for training, a minority of them use simulators (2/16), procedural checklists (2/16), or structured debriefing (2/16). The most commonly used methods were case‐based troubleshooting (13/16) and unstructured debriefing (13/16). Patients being awake and patients expectations are seen as the most important obstacles. Most of the directors thought office‐based procedure training could be improved (14/16). The most common suggestions were using step‐wise checklists, simulator‐labs, and formal debriefings.ConclusionThis is the first study evaluating the training of office‐based laryngeal procedures during laryngology fellowship. Given the increasing importance of these procedures in practice and the herein identified barriers and need for improvement, fellowships should investigate the use of systematic training tools to improve fellow competency with office‐based procedures. Laryngoscope, 2020

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Treatment of Oligometastatic Disease in Squamous Cell Carcinoma of the Head and Neck

\nAurora G. Vincent, \nWeitao Wang, \nTom Shokri, \nYadranko Ducic\n

Publicatie 12-10-2020


ObjectiveNo surgical or radiotherapeutic treatment guidelines exist for oligometastatic head and neck squamous cell carcinoma (oHNSCC), and only recently have interventions with curative intent been studied. Herein, we sought to elucidate survival rates among patients with oHNSCC to determine if treatment with curative intent is warranted in this population.Study DesignRetrospective chart review.MethodsWe retrospectively reviewed cases of oHNSCC treated between March 1998 and March 2018. Fishers exact test was used to compare patients treated with radiotherapy (RT) to those who underwent surgical excision and to compare outcomes of patients with oligometastases at the time of initial presentation to those that developed oligometastatic disease after primary treatment.ResultsEighty one patients with metastases to the lungs, ribs, pelvis, vertebral column, liver, clavicle, and sternum were included. Overall, 32 patients (40%) were alive 5 years post‐treatment. The site of metastasis, the modality of treatment, and the time of development of oligometastatic disease did not significantly affect 5‐year survival.ConclusionHerein, we demonstrate that multi‐modality treatment of oHNSCC is warranted for some patients with an estimated 40% 5‐year survival. Aggressive treatment of the primary and regional sites is necessary in addition to treatment of the metastatic site and incurs a survival benefit compared to patients with metastatic HNSCC treated with systemic therapy alone. oHNSCC should be approached separately from polymetastatic disease. Patients should be counseled about the possibility for long‐term survival, and aggressive initial treatment with the intention for cure should be considered in this population.Level of Evidence4 Laryngoscope, 2020

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Prevalence of Voice Disorders in Healthcare Workers in the Universal Masking COVID‐19 Era

\nClaudia A. Heider, \nMatías L. Álvarez, \nEduardo Fuentes‐López, \nClaudia A. González, \nNorma I. León, \nDaniela C. Verástegui, \nPedro I. Badía, \nCarla A. Napolitano\n

Publicatie 12-10-2020


Objectives/HypothesisTo determine the prevalence and associated risk factors of voice disorders in healthcare workers of high‐risk hospital care units during the 2019 coronavirus disease (COVID‐19) pandemic.Study DesignCross‐sectional study.MethodsQuestionnaire survey to healthcare personnel of COVID‐19 high‐risk hospital units was conducted, regarding demographic data, clinical activity, the pattern of usage of personal protective equipment, medical and vocal history, vocal symptoms, and Spanish validated Voice Handicap Index (VHI)‐10 questionnaire.ResultsA total of 221 healthcare workers answered the survey. Nearly 33% of them reported having trouble with their voice during the last month, and 26.24% had an abnormal score in the Spanish validated VHI‐10 questionnaire. The mean VHI‐10 score was 7.92 (95% confidence interval 6.98–8.85). The number of working hours, the number of hours of mask daily use, simultaneous surgical and self‐filtering mask use, and working in intermediate or intensive care units were independent variables significantly associated with a higher VHI‐10 score.ConclusionsHealthcare workers of high‐risk hospital care units during the universal masking COVID‐19 pandemic are at risk of voice disorders.Level of Evidence3 Laryngoscope, 2020

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Septal Perforation Repair Using Bilateral Mucosal Flaps With a Temporalis Fascia Interposition Graft

\nAmar Miglani, \nCullen Taylor, \nStephen F. Bansberg\n

Publicatie 10-10-2020


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Peri‐procedural Anticoagulation in Patients with Head and Neck Versus Extremity Venous Malformations

\nHarish Dharmarajan, \nJennifer L. McCoy, \nNoel Jabbour, \nAndrew McCormick, \nFrederico Xavier, \nDebra Correa, \nReema Padia\n

Publicatie 10-10-2020


Objective(1) Review a multidisciplinary vascular anomalies centers practice regarding periprocedural anticoagulation for venous malformations (VM) and the associated risk of thromboembolic and disseminated intravascular coagulation (DIC) events. (2) Compare the risk of thromboembolic events and DIC post‐procedure between head and neck (H&N) and extremity VM patients.MethodsAn Institutional Review Board (IRB)‐approved, retrospective chart review was performed on 120 VM patients. A thromboembolic event was defined as a thrombus formation post‐sclerotherapy or post‐surgery within 2 months in a distant or local venous structure not directly addressed by the procedure.ResultsThere were 39 cases involving the H&N and 81 cases based at the extremities. There were eight cases of post‐procedure thrombus formation within the extremity VM group (8/71; 11.3%) as opposed to 0 cases in the H&N group (OR: 0, 95% CI .00–.09), p = .049. There was no difference in incidence of post‐procedure thromboembolic events between those with elevated D‐dimer (H&N: 0%, extremity: 22.7%, 5/22) and normal D‐dimer values (H&N: 0%, extremity: 6.3% 1/16, P = .370). There was no difference in incidence of post‐procedure thromboembolic events between those who received periprocedural anticoagulation (H&N: 0%, extremity: 21%, 4/19) and those who did not (H&N: 0%, extremity: 8.2%, 4/49), (Extremity: OR: 3.00, .67–13.50, P = .206).ConclusionPost‐procedure thromboembolism is rare in the treatment of venous malformations, especially in the head and neck subsite. Regardless of anticoagulation use, there were no thromboembolic events for H&N VM patients. Such events are rare, and the odds may approach zero, especially with small sample size.Level of Evidence4 Laryngoscope, 2020

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Neuromodulators for Atypical Facial Pain and Neuralgias: A Systematic Review and Meta‐Analysis

\nTriet M. Do, \nGraham D. Unis, \nNrusheel Kattar, \nAshwin Ananth, \nEdward D. McCoul\n

Publicatie 10-10-2020


ObjectiveTo evaluate the effectiveness of neuromodulating agents for the management of atypical facial pain and primary facial neuralgias.MethodsWe searched MEDLINE, Embase, CINAHL, and ClinicalTrials.gov databases for original research articles that examine the effectiveness and adverse reactions of pharmacologic therapy for the treatment of trigeminal neuralgia and atypical facial pain. Studies that included surgical interventions for atypical facial pain or facial pain secondary to other causes were excluded. Meta‐analysis was conducted for reductions in symptom scores and adverse effects.ResultsOf 3,409 articles screened, 73 full‐text articles were included, consisting of 45 observational studies and 29 randomized controlled trials. Twenty‐four different pharmacological agents were assessed; carbamazepine was the most frequently studied while botulinum toxin A demonstrated the highest consistency in reduction of symptom scores. Pooled estimate of three randomized controlled trials revealed that patients with trigeminal neuralgia who received botulinum toxin A had higher odds (odds ratio 7.46; 95% CI 3.53–15.78) of achieving a ≥50% reduction in visual analogue scale scores compared to controls. Pooled estimate of 15 observational studies showed that three‐fourths of patients with trigeminal neuralgia who received carbamazepine experienced clinically significant pain reduction (prevalence proportion 0.75; 95% CI 0.66–0.83).ConclusionsPatients receiving botulinum toxin A for trigeminal neuralgia had higher odds of achieving ≥50% reduction in pain scores. A significant proportion of patients with trigeminal neuralgia experienced positive response to carbamazepine. There was moderate evidence for amitriptyline in patients with atypical facial pain. Standardization of outcome reporting would facilitate future quantitative comparisons of therapeutic effectiveness. Laryngoscope, 2020

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Reconstructive Options During Nonfunctional Laryngectomy

\nDerek Escalante, \nAurora G. Vincent, \nWeitao Wang, \nTom Shokri, \nYadranko Ducic\n

Publicatie 10-10-2020


ObjectiveA paucity of data exists regarding surgical outcomes for patients undergoing total laryngectomy for a dysfunctional larynx. Herein, we present the largest study evaluating the method of closure on postoperative fistula rate and swallowing ability.MethodWe performed a retrospective review of patients undergoing total laryngectomy for a dysfunctional larynx after primary radiation or chemoradiation therapy for laryngeal carcinoma from 1998 to 2020. Demographic information, operative details, length of hospitalization, fistula formation, method of fistula treatment, and need for enteral feeding 6 months after surgery were analyzed.ResultsA total of 268 patients were included. Flaps were performed in 140 (52.2%) patients, including radial forearm free flaps (RFFF), pectoralis flaps, and supraclavicular flaps. Sixty‐four (23.9%) patients developed postoperative fistulas. There was no significant difference in the fistula rate between flap and primary closure methods (P = .06). However, among patients who had a flap, RFFF had a significantly lower fistula rate (P = .02). Significantly more patients who had initial closure with a pectoralis flap required an additional flap for fistula repair than those who underwent RFFF or primary closure (P < .05). Last, whereas 87 patients (32.5%) required an enteral feeding tube 6 months after surgery, significantly fewer patients who underwent RFFF were feeding tube‐dependent (P = < .0001).ConclusionHerein, we present the largest study of outcomes after total laryngectomy for dysfunctional larynx. Postoperative fistula rates are high, 23%; however, the majority of patients, 67%, will not require long‐term enteral support. The RFFF is an excellent option demonstrating the lowest rates of postoperative fistula and enteral feeding tube dependence.Level of Evidence4 Laryngoscope, 2020

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Competency‐Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus

\nErynne A. Faucett, \nNikolaus E. Wolter, \nKarthik Balakrishnan, \nStacey L. Ishman, \nDeepak Mehta, \nSanjay Parikh, \nLily H. P. Nguyen, \nDiego Preciado, \nMichael J. Rutter, \nJeremy D. Prager, \nGlenn E. Green, \nSeth M. Pransky, \nRavi Elluru, \nMurad Husein, \nSoham Roy, \nKaalan E. Johnson, \nJacob Friedberg, \nRomaine F. Johnson, \nNancy M. Bauman, \nCharles M. Myer, \nEllen S. Deutsch, \nEric A. Gantwerker, \nJ. Paul Willging, \nCatherine K. Hart, \nRobert H. Chun, \nDerek J. Lam, \nJonathan B. Ida, \nJohn J. Manoukian, \nDavid R. White, \nDouglas R. Sidell, \nChristopher T. Wootten, \nAndrew F. Inglis, \nCraig S. Derkay, \nGeorge Zalzal, \nDavid W. Molter, \nJeffrey P. Ludemann, \nSukgi Choi, \nScott Schraff, \nCharles M. Myer, \nRobin T. Cotton, \nShyan Vijayasekaran, \nCarlton J. Zdanski, \nHamdy El‐Hakim, \nUdayan K. Shah, \nMarlene A. Soma, \nMarshall E. Smith, \nDana M. Thompson, \nLuv Ram Javia, \nKaren B. Zur, \nSteven E. Sobol, \nChristopher J. Hartnick, \nReza Rahbar, \nJean‐Philippe Vaccani, \nBenjamin Hartley, \nSam J. Daniel, \nIan N. Jacobs, \nGresham T. Richter, \nAlessandro de Alarcon, \nMatthew A. Bromwich, \nEvan J. Propst\n

Publicatie 09-10-2020


Objectives/HypothesisCreate a competency‐based assessment tool for pediatric esophagoscopy with foreign body removal.Study DesignBlinded modified Delphi consensus process.SettingTertiary care center.MethodsA list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as “keep” or “remove” and comments were incorporated. In the second round, experts rated the importance of each item on a seven‐point Likert scale. Consensus was determined with a goal of 7 to 25 final items.ResultsThe response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to “keep” all items and 172 comments were incorporated. Twenty‐four task‐specific and 7 previously‐validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task‐specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus.ConclusionsIt is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated.Level of Evidence5. Laryngoscope, 2020

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Low Skeletal Muscle Mass Is a Risk Factor for Aspiration Pneumonia During Chemoradiotherapy

\nKazuhira Endo, \nTakayoshi Ueno, \nNobuyuki Hirai, \nTakeshi Komori, \nYosuke Nakanishi, \nSatoru Kondo, \nNaohiro Wakisaka, \nTomokazu Yoshizaki\n

Publicatie 08-10-2020


ObjectivesThis study aimed to investigate whether pretreatment skeletal muscle mass index (SMI) is a predictor for the risk of aspiration pneumonia and to explore the relationship between low SMI and overall survival (OS) in patients with head and neck squamous cell carcinoma (HNSCC) receiving chemoradiotherapy (CRT).MethodsWe retrospectively reviewed the data of patients with HNSCC who received CRT during 2010–2019. Patients received a combination of radiotherapy and cisplatin‐based chemotherapy (3 cycles of 80 mg/m2 cisplatin on days 1, 22, and 43). Aspiration pneumonia were defined as the presence of both subjective and objective symptoms. Kaplan–Meier curves were generated to analyze survival.ResultsAmong the 159 patients, 36 (22.6%) developed aspiration pneumonia during treatment. Median SMI in patients with and without pneumonia was 12.4 cm2/m2 (9.0–20.7) and 13.6 cm2/m2 (8.1–19.7), respectively (P < .01). Multivariate logistic regression revealed that SMI was the only independent predictor of aspiration pneumonia (P = .0026). Mean OS was significantly shorter for patients with low SMI than for patients with normal SMI (66.9 months vs. 92.7 months, P = .001).ConclusionPretreatment low SMI predicts development of aspiration pneumonia and is a strong negative prognostic predictor for OS in patients with HNSCC undergoing CRT. Supportive treatment can be provided to patients at high risk of a low SMI. This study is the first to report SMI as a prognostic predictor in HNSCC. Laryngoscope, 2020

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In Reference to Impact of Fiberoptic Endoscopic Evaluation of Swallowing Outcomes and Dysphagia Management in Neurodegenerative Diseases

\nJosef Finsterer, \nFulvio A. Scorza, \nCarla A. Scorza\n

Publicatie 08-10-2020


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In Response to Letter to the Editor Regarding Patients With Dysphagia Due to Neurodegenerative Disease May Profit From Early FEES

\nLaura M. Dominguez, \nGregory R. Dion\n

Publicatie 08-10-2020


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External Auditory Canal Cholesteatoma Causing Simultaneous Bezold Abscess and Sinus Thrombosis

\nGabor Polony, \nLászló Tamás, \nNóra Kecskeméti\n

Publicatie 08-10-2020


Extra‐ and intracranial complications of cholesteatoma are rare in the new era of antibiotics. The rarity of the severe complications and the atypical symptoms cause difficulties to set up proper diagnosis and treatment. We report about a 76‐year old patient with external auditory canal cholesteatoma causing Bezold abscess and sigmoid sinus thrombosis. The patient underwent canal wall up mastoidectomy and mastoid obliteration with abdominal fat and Bezold abscess drainage. Systemic antibiotic and anticoagulant therapy were applied. The treatment resulted in fast improvement in the general condition of the patient, and the control magnetic resonance imaging (MRI) showed no recurrence of the disease. Laryngoscope, 2020

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Clinical Characteristics of Patients With Papilloma in the External Auditory Canal

\nWenwei Luo, \nJingfang Wu, \nKevin A. Peng, \nQingzhong Li, \nQiang Du, \nJianghong Xu, \nChunfu Dai, \nFanglu Chi, \nYilai Shu\n

Publicatie 08-10-2020


ObjectivesTo determine the clinical characteristics of papilloma involving the external auditory canal (PEAC) in a region of China.Study designA retrospective study.MethodsDemographics, manifestations, imaging results, histopathology, and treatment of 67 patients diagnosed with PEAC in a period of 6 years were analyzed at Shanghai Eye, Ear, Nose and Throat Hospital in China.ResultsPEAC were encountered in patients between the ages of 12 and 82 years (mean 53.8 years). It was more prevalent in men (82%) than in women (18%) (P < .05). The clinical presentation was usually a mass in EAC, aural fullness, and hearing loss. Otoscopic and radiological examination were used together for initial diagnosis and pretreatment planning. Unilateral involvement was more common than bilateral involvement (P < .05). The average time between onset of first symptom and surgical resection and/or biopsy was 6.5 months (range, 0.25–60 months). All patients underwent gross total resection. In 5 patients, (7.5%) carcinoma was detected in the specimen. Fifteen patients (22%) had recurrence; recurrent tumors were detected after an average period of 10 months after surgery (range, 4–24 months).ConclusionPEAC is largely a benign lesion with a low risk of malignancy. Optimal management is via gross total resection. However, the risk of recurrence is high, which motivates a need for long‐term monitoring.Level of Evidence4 Laryngoscope, 2020

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Voice‐Related Quality of Life Is Associated with Postoperative Change in Subglottic Stenosis

\nAri D. Schuman, \nAndrew Neevel, \nRobert J. Morrison, \nNorman D. Hogikyan, \nRobbi A. Kupfer\n

Publicatie 07-10-2020


ObjectivesTo characterize the impact of subglottic stenosis (SGS) on voice‐related quality of life (V‐RQOL) and quantify the effect of treatment on voice outcomes.Study DesignCase series.MethodsRetrospective review of SGS patients treated from 1996 to 2018 at a single institution to assess for 1) V‐RQOL association with individual patient cumulative treatment number and 2) V‐RQOL correlation with treatment type, time between treatments, and degree of stenosis. Analysis included both parametric and nonparametric statistical comparison across treatment types and multivariable and univariate linear regression.ResultsSixty‐one patients, predominantly white (93%) and female (93%), were included. Etiology of SGS included idiopathic (61%), iatrogenic (16%), granulomatosis with polyangiitis (16%), and other (7%). The plurality of patients had four or more treatments (44%), with the remainder having one (28%), two (13%), or three treatments (15%). Analysis of change between pre‐ and postoperative V‐RQOL scores was completed for 130 treatments. These included dilation with laser incision (52%), in‐office injection (34%), dilation without division (8%), cricotracheal resection (1%), and all other treatment (8%). For every 10% improvement in airway caliber postoperatively, there was a 1.3‐point improvement in calculated V‐RQOL (r = 0.27, P = .02). After adjustment for treatment type, age, sex, and SGS etiology, this association held (beta = 1.5, P = .02). Change in V‐RQOL was not associated with treatment type, treatment number, or time between treatments.ConclusionPatients with subglottic stenosis who have greater degree of change in airway caliber experience greater improvement in V‐RQOL scores following treatment. V‐RQOL scores are not associated with treatment type or time between individual treatments.Level of Evidence4 Laryngoscope, 2020

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Opioid Prescribing Patterns Following Pediatric Tonsillectomy in the United States, 2009–2017

\nZ. Jason Qian, \nJennifer C. Alyono, \nMichael C. Jin, \nShayna P. Cooperman, \nAlan G. Cheng, \nKarthik Balakrishnan\n

Publicatie 07-10-2020


ObjectivesAssess national trends in opioid prescription following pediatric tonsillectomy: 1) overall percentage receiving opioids and mean quantity, 2) changes during 2009–2017, and 3) determinants of prescription patterns.MethodsCross‐sectional analysis using 2009–2017 Optum claims data to identify opioid‐naïve children aged 1–18 with claims codes for tonsillectomy (n = 82,842). Quantities of opioids filled in outpatient pharmacies during the perioperative period were extracted and converted into milligram morphine equivalents (MMEs) for statistical comparison. Demographic, clinical, and socioeconomic predictors of opioid fill rate and quantity were determined using regression analyses.ResultsIn 2009, 83.3% of children received opioids, decreasing to 58.3% by 2017. Rates of all‐cause readmissions and post‐tonsillectomy hemorrhages were similar over time. Mean quantity received was 153.47MME (95% confidence intervals 95%CI: 151.19, 155.76) and did not significantly change during 2009–2017. Opioids were more likely in older children and those with higher household income, but less likely in children with obstructive sleep apnea, other comorbidities, and Hispanic race. Higher quantities of opioids were more likely in older children, while lower quantities were associated with female sex, Hispanic race, and higher household income. Outpatient steroids were prescribed to 8.04% of patients, who were less likely to receive opioids.ConclusionWhile the percentage of children receiving post‐tonsillectomy opioids decreased during 2009–2017, prescribed quantities remain high and have not decreased over time. Prescription practices were also influenced by clinical and sociodemographic factors. These results highlight the need for guidance, particularly with regard to opioid quantity, in children after tonsillectomy.Level of EvidenceN/A Laryngoscope, 2020

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Prognostic Value of Tumor Proportion Score in Salivary Gland Carcinoma

\nFumihiko Sato, \nTakeharu Ono, \nAkihiko Kawahara, \nKatsuhisa Matsuo, \nReiichiro Kondo, \nKiminobu Sato, \nJun Akiba, \nToshihiko Kawaguchi, \nTatsuyuki Kakuma, \nShun‐ichi Chitose, \nHirohito Umeno, \nHirohisa Yano\n

Publicatie 06-10-2020


ObjectiveLimited information is available regarding the role of programmed death ligand 1 (PD‐L1) expression and CD8+ tumor‐infiltrating lymphocyte (TIL) density in the tumor immune microenvironment (TIM) of patients with salivary gland carcinoma (SGC). This study aimed to assess the association between the prognosis of SGC patients and the probability of PD‐L1 expression in tumor and/or immune cells using the tumor proportion score (TPS), mononuclear immune cell density score (MIDS), combined positive score (CPS), and CD8+TIL density in the TIM.Study DesignRetrospective cohort study.MethodsWe retrospectively reviewed 73 SGC patients treated with definitive surgery between 2000 and 2015. Immunohistochemical analysis was used to assess TPS, MIDS, CPS, and CD8+TIL density, followed by prognostic evaluation of these immune‐related parameters.ResultsHistological grade was associated with TPS, MIDS, and CPS based on PD‐L1 expression, and these scores exhibited a significant association with CD8+TIL density. Patients with positive TPS had an unfavorable disease‐free survival and overall survival. Multivariate analyses indicated that the TPS was a significant and independent prognostic factor.ConclusionOur results suggest that TPS might be a useful prognostic biomarker in SGC patients receiving definitive surgery. Laryngoscope, 2020

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Hybrid Three‐Dimensional–Printed Ear Tissue Scaffold With Autologous Cartilage Mitigates Soft Tissue Complications

\nBrian Chang, \nAshley Cornett, \nZahra Nourmohammadi, \nJadan Law, \nBlaine Weld, \nSarah J. Crotts, \nScott J. Hollister, \nIsabelle M. A. Lombaert, \nDavid A. Zopf\n

Publicatie 06-10-2020


Objectives/HypothesisTo analyze the use of highly translatable three‐dimensional (3D)–printed auricular scaffolds with and without novel cartilage tissue inserts in a rodent model.Study DesignPreclinical rodent animal model.MethodsThis prospective study assessed a single‐stage 3D‐printed auricular bioscaffold with or without porcine cartilage tissue inserts in an athymic rodent model. Digital Imaging and Communications in Medicine computed tomography images of a human auricle were segmented to create an external anatomic envelope filled with orthogonally interconnected spherical pores. Scaffolds with and without tissue inset sites were 3D printed by laser sintering bioresorbable polycaprolactone, then implanted subcutaneously in five rats for each group.ResultsTen athymic rats were studied to a goal of 24 weeks postoperatively. Precise anatomic similarity and scaffold integrity were maintained in both scaffold conditions throughout experimentation with grossly visible tissue ingrowth and angiogenesis upon explantation. Cartilage‐seeded scaffolds had relatively lower rates of nonsurgical site complications compared to unseeded scaffolds with relatively increased surgical site ulceration, though neither met statistical significance. Histology revealed robust soft tissue infiltration and vascularization in both seeded and unseeded scaffolds, and demonstrated impressive maintenance of viable cartilage in cartilage‐seeded scaffolds. Radiology confirmed soft tissue infiltration in all scaffolds, and biomechanical modeling suggested amelioration of stress in scaffolds implanted with cartilage.ConclusionsA hybrid approach incorporating cartilage insets into 3D‐printed bioscaffolds suggests enhanced clinical and histological outcomes. These data demonstrate the potential to integrate point‐of‐care tissue engineering techniques into 3D printing to generate alternatives to current reconstructive surgery techniques and avoid the demands of traditional tissue engineering.Level of EvidenceNA Laryngoscope, 2020

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Pediatric Post‐Tonsillectomy Opioid Prescribing Practices

\nYusuf M. Agamawi, \nLauren M. Cass, \nMaggie Mouzourakis, \nJaibir S. Pannu, \nJennifer V. Brinkmeier\n

Publicatie 06-10-2020


ObjectiveTo evaluate the effect of discharge order sets on prescribing patterns of opioids after pediatric tonsillectomy. Secondary outcomes included encounters for postoperative pain, dehydration, and bleeding.MethodsRetrospective chart review of pre‐ and post‐intervention in pediatric post‐tonsillectomy patients, 0–18 years old (n = 1486). Order sets were installed with age‐specific analgesic medication defaults and recommendation of concurrent alternating scheduled ibuprofen and acetaminophen. Time‐balanced pre‐ and post‐intervention cohorts were established. Opioid outcomes calculated in morphine milligram equivalents per kilogram (MME/kg) per dosage and total prescribed.ResultsDischarge order set intervention resulted in 17% reduction of opioid dose prescribed (0.095 MME/kg 95% CI, 0.092–0.099 vs. 0.079 95% CI, 0.076–0.083, P < .001). Total number of opioid doses prescribed was reduced after order set implementation (46.4 95% CI, 43.6–49.1 to 20.3 95% CI, 19.1–21.5, P < .001). Patients <7 years old prescribed opioids remained rare in pre‐ and post‐intervention groups (1.6% and 1.8%, respectively, P = .86). Admissions and emergency department visits for postoperative dehydration and pain were significantly reduced. Post‐intervention group showed an increase in readmissions for post‐tonsillectomy hemorrhage (9.2% vs. 5.2%, P = .003) which was isolated to an increase in the older post‐intervention group after stratification by age.ConclusionUtilization of order sets with standardized analgesic medication regimen of acetaminophen, ibuprofen, and opioid helped effectively reduce opioid amount per dose, total opioid amount dispensed, and variability in the total opioid amount dispensed while maintaining pain control. An increase in post‐tonsillectomy hemorrhage was recognized following this implementation which did not persist after the study period despite continuation of intervention.Level of Evidence4 Laryngoscope, 2020

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Complications of Neck Drains in Thyroidectomies: A Systematic Review and Meta‐Analysis

\nTerrence Chi Fang Soh, \nQi Jia Ong, \nHao Meng Yip\n

Publicatie 06-10-2020


ObjectivesIntraoperative placement of neck drains in thyroidectomy patients remains a widespread practice, despite prevailing evidence discouraging this practice. This systematic review and meta‐analysis was conducted to update the currently available evidence base.MethodsTwo independent investigators performed a comprehensive literature search to identify randomized control trials that evaluated postoperative complications associated with neck drains. This was conducted using four databases: Medline, Web of Science, EMBASE, and Cochrane. Identified articles were then screened using a strict eligibility criterion. Sixteen studies were included in the final quantitative analysis and assessed for risk of bias. All methods were in accordance with recommendations from the Cochrane Review Group, U.K. National Health Service Centre for Reviews and Dissemination, and the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines.ResultsOur initial search yielded 743 articles. Of those, 16 were included for final quantitative synthesis. The overall analysis demonstrated that postoperative hematomas pooled odds ratio (OR) = 2.09 (1.04, 4.21); P = .04 and surgical site infections pooled OR = 3.85 (2.04, 7.28); P < .01 were significantly more likely in the drained group. Furthermore, hospital stays were longer in the drained group pooled mean difference = 0.88 days (0.56, 1.20); P < .01. There were no significant differences in fluid volumes within the thyroid bed between study groups pooled mean difference = −2.30 mL (−4.82, 0.21); P = .07.ConclusionThe drained patient group had overall higher odds of hematomas, surgical site infections, and longer hospital stays. Therefore, we recommend against this practice of neck drain insertions in patients who have undergone thyroidectomies. Laryngoscope, 2020

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Preference Signaling for the Otolaryngology Interview Market

\nC.W. David Chang, \nSteven D. Pletcher, \nMarc C. Thorne, \nSonya Malekzadeh\n

Publicatie 06-10-2020


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Quantification of Aerosol Concentrations During Endonasal Instrumentation in the Clinic Setting

\nAlexander T. Murr, \nNicholas R. Lenze, \nMark W. Gelpi, \nWilliam C. Brown, \nCharles S. Ebert, \nBrent A. Senior, \nBrian D. Thorp, \nAdam J. Kimple, \nAdam M. Zanation\n

Publicatie 05-10-2020


ObjectiveRecent anecdotal reports and cadaveric simulations have described aerosol generation during endonasal instrumentation, highlighting a possible risk for transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2) during endoscopic endonasal instrumentation. This study aims to provide a greater understanding of particle generation and exposure risk during endoscopic endonasal instrumentation.Study DesignProspective quantification of aerosol generation during office‐based nasal endoscopy procedures.MethodsUsing an optical particle sizer, airborne particles concentrations 0.3 to 10 microns in diameter, were measured during 30 nasal endoscopies in the clinic setting. Measurements were taken at time points throughout diagnostic and debridement endoscopies and compared to preprocedure and empty room particle concentrations.ResultsNo significant change in airborne particle concentrations was measured during diagnostic nasal endoscopies in patients without the need for debridement. However, significant increases in mean particle concentration compared to preprocedure levels were measured during cold instrumentation at 2,462 particles/foot3 (95% CI 837 to 4,088; P = .005) and during suction use at 2,973 particle/foot3 (95% CI 1,419 to 4,529; P = .001). In total, 99.2% of all measured particles were ≤1 μm in diameter.ConclusionWhen measured with an optical particle sizer, diagnostic nasal endoscopy with a rigid endoscope is not associated with increased particle aerosolization in patient for whom sinonasal debridement is not needed. In patients needing sinonasal debridement, endonasal cold and suction instrumentation were associated with increased particle aerosolization, with a trend observed during endoscope use prior to tissue manipulation. Endonasal debridement may potentially pose a higher risk for aerosolization and SARS‐CoV‐2 transmission. Appropriate personal protective equipment use and patient screening are recommended for all office‐based endonasal procedures.Level of Evidence3 Laryngoscope, 2020

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Equal Access to Telemedicine during COVID‐19 Pandemic: A Pediatric Otolaryngology Perspective

\nWen Jiang, \nAnthony E. Magit, \nDaniela Carvalho\n

Publicatie 05-10-2020


Objectives/HypothesisDuring the current COVID‐19 pandemic, the demand for direct‐to‐home telemedicine services has risen to an unprecedented level. Equal access to specialty care was assessed to identify potential barriers that may negatively impact telemedicine utilization.Study designRetrospective case series.MethodsWe examined the 6‐week period between March and May 2020 when the only access to nonurgent pediatric otolaryngology service was through telemedicine and compared it to in‐person visits during the same period in 2019. We compared patient demographics, including age, gender, preferred language, zip code of residence, and primary insurance plan.ResultsA total of 1,495 visits were conducted through telemedicine from March 23, 2020 to May 1, 2020, and 1983 in‐person visits were completed in 2019. There was no difference in patient age and gender. The proportions of Spanish‐speaking families were similar (15.8% in 2019 vs. 14.4% in 2020, P = .96). The percentage of Medi‐Cal‐insured patients (51.4% in 2019 vs. 49.8% in 2020, P = .73) and the mean poverty level (12.6% in 2019 vs. 12.2% in 2020, P = .38) also remained the same. Spanish‐speaking families were statistically more likely to require rescheduling of their telemedicine visits (17.2%) when compared to the overall rescheduling rate of 11.9% (P = .0083).ConclusionsWe were able to successfully provide access to telemedicine services to our vulnerable populations during the current COVID‐19 pandemic. Telemedicine is likely to remain an essential mode of delivering patient care going forward. It is important to evaluate and identify potential disparities to telemedicine access and proactively implement changes to address these barriers.Level of Evidence4. Laryngoscope, 2020

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Virtual Reality as Distraction Analgesia and Anxiolysis for Pediatric Otolaryngology Procedures

\nKatherine Y. Liu, \nSen J. Ninan, \nBenjamin M. Laitman, \nDavid Y. Goldrich, \nAlfred M. Iloreta, \nAldo V. Londino\n

Publicatie 05-10-2020


Objectives/HypothesisWhile virtual reality (VR) has been used as analgesia and anxiolysis for invasive procedures, no literature exists on the use of VR in the pediatric otolaryngology setting. The purpose of this study was to determine the efficacy of VR in reducing pain and anxiety for pediatric otolaryngology patients.MethodsA total of 53 patients aged 7–17 undergoing in‐office nasal endoscopies were included. Patients were randomized to receive VR or standard of care. Procedural pain, anxiety, and satisfaction scores were recorded from patients and caregivers. The physician filled out a childhood emotional manifestation scale (CEMS).Study DesignRandomized controlled trial.ResultsPatients in VR group reported a significant decrease in pain (0.80 ± 1.06 vs. 2.26 ± 2.38, P = .018) and anxiety (9.50 ± 12.48 vs. 38.48 ± 29.83, P = .0002) and increase in procedural satisfaction (6.40 ± 0.77 vs. 4.74 ± 1.74, P = .0002) compared to patients in control group. CEMS scores were significantly reduced in VR group (5.15 ± 0.46 vs. 9.64 ± 5.66, P = .0001) and caregiver anxiety levels were significantly reduced in VR group (11.50 ± 17.67 vs. 27.39 ± 30.48, P = .041) compared to control group. There were no reported side effects. Procedural time did not significantly differ between groups.ConclusionsFor pediatric otolaryngology patients undergoing in‐office nasal endoscopies, VR is a safe and effective form of distraction analgesia and anxiolysis, significantly reducing pain and increasing procedural satisfaction for patients. In addition, VR significantly reduces anxiety for both patients and caregivers without disrupting procedural efficiency and workflow.Level of Evidence2. Laryngoscope, 2020

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The Effect of Diathermy Power Settings on Oral Cavity Mucosal Contraction: A Rat Model

\nAnton Warshavsky, \nShaked Shivatzki, \nLiyona Kampel, \nLeonor Leider‐Trejo, \nUdi Shapira, \nNidal Muhanna, \nOmer J. Ungar, \nDan M. Fliss, \nIlana Kaplan, \nGilad Horowitz\n

Publicatie 05-10-2020


Objectives/HypothesisThe effects of different electrocautery power settings on mucosal contraction and margin status in the oral cavity have not been well established. The aim of this study was to examine how different levels of electrocautery energy outputs affect oral mucosal tissue margins.Study DesignAnimal model.MethodsA model of 23 adult rats was used (two specimens per rat). After anesthetizing the animals, a 6‐mm biopsy punch marked the resection margin on the buccal mucosa (one per cheek). The specimens were excised by means of three energy levels, a cold knife, and monopolar diathermy that was set on either 20 W or 30 W cut modes. The specimens were evaluated for extent of contraction.ResultsA total of 45 samples were obtained and measured, including 15 specimens in the cold‐knife group, 15 specimens in the 20 W group, and 15 specimens in the 30 W group. The median diameters of the specimens after resection were 4.5 mm for the cold‐knife group (interquartile range IQR = 4.0–5.0), 3.5 mm for the 20 W group (IQR = 3.5–4.0), and 2.8 mm for the 30 W group (IQR = 2.5–3.0). Specimen contraction was 25.0%, 41.7%, and 53.3%, respectively. The difference in shrinkage between each pair was statistically significant: cold knife versus 20 W, P = .001; cold knife versus 30 W, P < .0001; and 20 W versus 30 W, P < .001.ConclusionsDiathermy power settings result in a significant difference of mucosal tissue contraction, with higher outputs resulting in a narrower mucosal margin. It is imperative that the surgical team take into consideration the diathermy settings during initial resection planning. Laryngoscope, 2020

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Near‐Infrared Fluorescence Imaging in the Identification of Parathyroid Glands in Thyroidectomy

\nTakeshi Takahashi, \nKeisuke Yamazaki, \nHisayuki Ota, \nRyusuke Shodo, \nYushi Ueki, \nArata Horii\n

Publicatie 05-10-2020


Objectives/HypothesisTo assess the ability of near‐infrared fluorescence imaging (NIFI) to identify parathyroid glands (PGs) among histologically proven PG/non‐PG specimens compared with a surgeons visual acumen, and to determine NIFI sensitivity in detecting incidentally resected PGs from thyroidectomy specimens, compared to the surgeons visual inspection.Study DesignProspective study.MethodsWith mean age of 61 years, 36 patients with various thyroid diseases were enrolled. Possible PGs (n = 28) and lymph nodes (n = 32) were identified by the experienced surgeons visual inspection. Using NIFI, 15 PGs were further identified from thyroidectomy specimens. For these 75 specimens, the surgeons judgments (PG vs. non‐PG) were recorded. Histological evaluation was performed after examining the NIFI auto‐fluorescence of each specimen.ResultsThere were no significant differences in sensitivity, specificity, positive predictive value, and negative predictive value between the surgeons visual inspection and NIFI in identifying PGs, with values of 100%/97.1%, 85.0%/87.5%, 85.4%/87.2%, and 100%/97.2%, respectively. The sensitivity of NIFI (82.9%) for detection of PGs from thyroidectomy specimens was significantly higher than that of the surgeons visual inspection (61.0%). False negative specimens contained bleeding/congestion and/or encapsulation by thick tissues, whereas false positive specimens contained electrocoagulated tissues.ConclusionsNIFI showed results comparable to the experienced surgeons visual inspection in identifying PGs. This could benefit novice surgeons. NIFI may be useful for experienced surgeons to locate incidentally resected PGs within thyroidectomy specimens for auto‐transplantation. Prevention of intra‐gland bleeding and congestion, careful removal of thick capsules, and bloodless surgeries without electrocoagulation are important for reducing false positive and false negative results. Laryngoscope, 2020

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Predictive Nomogram for the Necessity of Tracheotomy During Oral and Oropharyngeal Cancer Surgery

\nSiyuan Xu, \nKai Wang, \nKan Liu, \nYang Liu, \nYing Huang, \nYe Zhang, \nXiaolei Wang, \nZhengang Xu, \nShaoyan Liu, \nJie Liu\n

Publicatie 05-10-2020


Objectives/HypothesisThe individualized risk of airway obstruction after head and neck cancer surgery is unclear, especially oral and oropharyngeal cancer. The study aimed to establish an individualized predictive model for the necessity of temporary tracheotomy in these patients.MethodsPatients who underwent oral and oropharyngeal cancer surgery from 1999 to 2019 were retrospectively reviewed. A nomogram was developed and validated in patients treated from 1999 to 2009 and 2010 to 2019, respectively.ResultsIn total, 1551 patients were included. Oropharyngeal cancer, large tumor, midline crossing, preoperative radiation, mandibulectomy, flap reconstruction, and neck dissection were independent risk factors of postoperative airway obstruction in the training group (n = 707). A nomogram incorporating these factors had a C‐index of 0.931 and was validated in the testing group (n = 844) (C‐index, 0.918). Good calibration curves were observed in both groups.ConclusionsThe nomogram successfully predicted the individual risk of postoperative airway obstruction for patients with oral and oropharyngeal cancer.Level of Evidence4. Laryngoscope, 2020

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Ability of Bedside Ultrasonography to Detect Pediatric Nasal Bone Fractures

\nEmre Gökçen, \nAtakan Savrun, \nMikail Kuşdoğan, \nİbrahim Çaltekin, \nLevent Albayrak, \nDilek Atik, \nSevilay Vural, \nŞeyda T. Savrun, \nGökhan Yıldırım\n

Publicatie 03-10-2020


Objectives/HypothesisThe aims of this study were to evaluate the diagnostic test features of bedside ultrasonography in pediatric patients with nasal trauma and to investigate whether it is a preferable alternative method to conventional radiography (CR).Study DesignCross‐sectional prospective study.MethodsThis prospective study was conducted from March 1, 2019, through November 1, 2019. Thirty‐one patients under the age of 18 years who had nasal trauma were consecutively included. CR and ultrasonographic imaging tests were investigated in patients with clinical indications for nasal bone fracture. The sensitivity, specificity, and accuracy of ultrasonography and CR were calculated with respect to detecting nasal fractures according to the gold standard method.ResultsParticipants were between 3 and 16 years old and the median age was 8 (5–13) years. Nasal bone fracture was clinically detected in 18 patients. While 13 of these fractures were detected with ultrasonography, only 11 were also detected with CR. The sensitivity and specificity of ultrasonography and CR in detecting nasal fractures were 72.2% (95% confidence interval CI: 46.5–90.3) and 76.9% (95% CI: 46.2–95.0) for ultrasonography and 61.1% (95% CI: 35.8–82.7) and 69.2% (95% CI: 38.6–90.9) for CR.ConclusionsAccording to the results of this study, ultrasonography may be used with confidence as a first imaging method in the investigation of nasal fractures, particularly with consideration for avoiding the effects of radiation as much as possible. Our findings point to the next step of conducting trials with a greater number of patients in order to define the diagnostic test features of ultrasonography in pediatric patients.Level of Evidence2 Laryngoscope, 2020

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Yield of Imaging to Evaluate Unilateral Vocal Fold Paralysis of Unknown Etiology

\nStephen Politano, \nFernando Morell, \nKevin Calamari, \nBrad DeSilva, \nLaura Matrka\n

Publicatie 03-10-2020


Objectives/HypothesisTo identify the incidence and nature of positive findings on imaging studies ordered for evaluation of unilateral vocal fold paralysis (UVFP) of unknown etiology, to analyze these findings based on laterality, and to examine the use of the expanded‐field computed tomography (CT) neck protocol in this evaluation.Study DesignRetrospective review.MethodsA total of 145 patients from 2000 to 2018 with UVFP of unknown etiology were studied. Data on imaging studies ordered, laterality of paralysis, and significant positive results were studied. An expanded‐field CT neck protocol that included the entire course of the vagus and recurrent laryngeal nerves was instituted during the study period.ResultsA total of 20.7% of patients had an etiology for paralysis identified on imaging. Malignancies comprised the majority of findings overall (19/30), whether in the chest (12/18) or the neck (7/12). Etiology was more often found in the chest for left‐sided paralysis (15/21) and in the neck for right‐sided paralysis (6/9). In 26 patients who underwent both expanded‐field CT neck and CT chest, no findings related to the UVFP were seen on CT chest that were not captured by expanded‐field CT neck.ConclusionsThis is one of the largest retrospective studies examining the incidence of positive findings on imaging studies for evaluation of UVFP of unknown etiology. Imaging in one of five patients with UVFP of unknown etiology will reveal a causative lesion, most often malignant. Left‐sided paralysis tends to localize to the chest, and right‐sided paralysis to the neck. Expanded‐field CT neck may allow practitioners to forego dedicated CT chest in evaluation of UVFP.Level of Evidence4 Laryngoscope, 2020

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Predictive Utility of the Penetration‐Aspiration Scale in Inter‐Arytenoid Injection Augmentation

\nMichael S. Weinstock, \nJennifer L. McCoy, \nKristin Cangilla, \nAmber D. Shaffer, \nRaymond C. Maguire, \nAllison B. J. Tobey, \nJeffrey P. Simons, \nReema K. Padia\n

Publicatie 03-10-2020


Objectives/HypothesisTo determine the utility of preoperative penetration‐aspiration scale (PAS) scores and clinical findings on modified barium swallow (MBS) in predicting advancement of diet after interarytenoid injection augmentation (IAIA).Study DesignRetrospective review.MethodsIn this retrospective cohort study, 372 consecutive patients who underwent IAIA for pharyngeal dysphagia between 2009 and 2019 were initially identified. Patients were excluded from the study if they had insufficient preop MBS, no postop MBS within 3 months of injection, supraglottoplasty, or underlying neurological condition. Ninety‐three patients were included in the study. Pre‐ and postoperative PAS scores were recorded, as were pre and postop diets. PAS scores were calculated by a single pediatric speech and language pathologist.ResultsAverage PAS score on MBS was 5.87 (standard deviation SD 2.74); median (range) = 8 (1–8). Postop average was 4.29 (SD 3.02); median (range) = 2 (1–8), P < .001. Those with worse preop PAS scores had increased odds of improvement in diet (odds ratio 1.24, 95% confidence interval CI 1.02–1.49, P = .029). An improvement in PAS score of 3.0 or greater predicted an improvement in diet with a sensitivity of 76.7% and a specificity of 85.7%.ConclusionsPAS score on MBS can be a useful tool when assessing pediatric patients who may be candidates for IAIA. Prospectively comparing PAS score in patients post‐IAIA to patients solely undergoing diet modification can help to better objectively assess differences in outcomes and understand the full utility of PAS score.Level of EvidenceLevel III (Individual Cohort Study) Laryngoscope, 2020

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Stridor Related to Vagus Nerve Stimulator: A Case Report

\nAbigail Tami, \nDaniel Gerges, \nHeather Herrington\n

Publicatie 03-10-2020


Implantation of a vagus nerve stimulator (VNS) can be an effective treatment for medically refractory seizures. Laryngeal side effects from a VNS can include hoarseness, cough, and shortness of breath. This report highlights a 5‐year‐old female who presented with stridor in the setting of acquired laryngomalacia, global developmental delay, and a VNS device. The case demonstrates that a VNS can exacerbate the symptoms of acquired laryngomalacia and that close monitoring of laryngeal side effects is crucial to optimizing care in this population. Laryngoscope, 2020

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Ocular Protection Not Used During Elective Cochlear Implant and Mastoid Surgery During Covid‐19 Era

\nVibha Jaiswal, \nLyndsay Fraser, \nPeter Wardrop\n

Publicatie 03-10-2020


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Long‐term Follow‐up After Radiation Therapy for Laryngeal Amyloidosis

\nCaitlin Bertelsen, \nKeith Chadwick, \nJohn Holland, \nPaul Flint, \nJoshua S. Schindler\n

Publicatie 03-10-2020


ObjectivesLaryngeal amyloidosis (LA) is a rare disease characterized by extracellular protein deposition within the larynx. Treatment is difficult due to the frequently submucosal and multifocal nature of disease. The mainstay of treatment is surgical resection; however, recurrence rates are high. Recently, use of radiotherapy (RT), either alone or postoperatively, for LA has been adapted from the management of extramedullary plasmacytoma and has been shown to provide local disease control. Here, we describe the experience with adjuvant RT for LA at our center.Study DesignRetrospective case series.MethodsRetrospective study of patients with amyloidosis of the larynx, with or without other disease sites, seen at a tertiary academic center between 2011 and 2019. Outcomes included disease characteristics, recurrence rates, treatment modalities, and pre‐ and posttreatment voice handicap index (VHI)‐10.ResultsTen patients met eligibility criteria. Mean follow‐up time for all patients was 62.0 ± 41.0 months; mean follow‐up time after last treatment was 51 ± 55 months. All but one patient underwent surgical resection of disease. Seven patients underwent subsequent RT. Of these seven, six underwent RT at our institution; five received a dose of 45 Gray (Gy); and one received a dose of 20 Gy. All seven completed RT without toxicity‐related interruption. Patients undergoing RT underwent 2.1 ± 1.3 surgical procedures prior to RT; no patients required surgery after RT. Mean pretreatment VHI‐10 was 22.9 ± 8.1; mean posttreatment VHI‐10 was 12.9 ± 13.3.ConclusionRT after surgery for LA can provide good local control without unacceptable toxicity and may decrease the need for further surgery.Level of EvidenceIV. Laryngoscope, 2020

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Transorbital Endoscopic Approach for Repair of Frontal Sinus Cerebrospinal Fluid Leaks: Case‐Series

\nRaywat Noiphithak, \nJuan C. Yanez‐Siller, \nPree Nimmannitya, \nPataravit Rukskul\n

Publicatie 03-10-2020


ObjectivesTo highlight the feasibility and evaluate the outcomes of the transorbital endoscopic approach (TOEA) in the management of frontal sinus cerebrospinal fluid (CSF) leaks.Study designRetrospective case series.MethodsThe database of patients with frontal sinus CSF leaks managed with TOEA from January 2017 through December 2019 at our institution was reviewed. Two videos of clinical case examples are presented.ResultsSixteen patients (10 males, 6 females, mean age 53; range 21–61 years) underwent TOEA through the superior eyelid corridor for the repair of frontal sinus CSF leak. The most common etiology of the CSF leak was trauma (nine cases; 56.3%), followed by injury from iatrogenic causes in six cases (37.5%), and spontaneous leak in one case (6.2%). Average defect size was 8.8 mm (range 2.0–20.8 mm). Ten patients were revision cases who had undergone prior nontransorbital CSF leak repair at outside institutions. All patients underwent successful repair via TOEA without postoperative complications. Complete resolution was maintained in all cases. Mean follow‐up period was 11 months (range 6–22 months).ConclusionsTOEA is a safe minimally disruptive alternative for definitive of frontal sinus CSF leak in well‐selected primary or revision cases. Further studies are necessary to define its indications and outcomes.Level of Evidence4 Laryngoscope, 2020

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Squamous Cell Carcinoma of Nasal Vestibule and Pyramid: Outcomes and Reconstructive Strategies

\nAlessia Lambertoni, \nMario Cherubino, \nPaolo Battaglia, \nAlessia De Col, \nMarta Giovannardi, \nPaolo Antognoni, \nLuigi Valdatta, \nApostolos Karligkiotis, \nMaurizio Bignami, \nPaolo Castelnuovo, \nMario Turri‐Zanoni\n

Publicatie 02-10-2020


ObjectivesSquamous cell carcinoma of nasal vestibule and pyramid is rare, thus classification, treatment protocol, and indications for elective neck treatment are still controversial. Nasal reconstruction is challenging, as well, and prosthesis is still used.Study DesignRetrospective cohort study.MethodsRetrospective review of patients surgically treated from 2010 to 2018 in a single Institution. Advanced tumors were further treated with adjuvant irradiation. Reconstruction strategy included grafts, locoregional and free flaps, and was customized on layers removed.ResultsForty‐five patients were enrolled. The 5‐year overall survival and disease‐free survival were 81.9% ± 7.45% and 61.9% ± 9.09%, respectively. Wangs classification, site of origin, extent of surgery and margins status significantly correlated with prognosis and recurrence rate. Regional recurrences occurred in patients affected by advanced tumors who did not receive any form of elective neck treatment.ConclusionMultidisciplinary management and a proper reconstructive algorithm are recommended. Adjuvant irradiation and elective neck treatment should be advocated for advanced stage high‐risk patients.Level of Evidence4. Laryngoscope, 2020

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Unbiased Measure of General Quality of Life in Chronic Rhinosinusitis Reveals Disease Modifiers

\nMadison V. Epperson, \nAdam C. McCann, \nKatie M. Phillips, \nDavid S. Caradonna, \nStacey T. Gray, \nAhmad R. Sedaghat\n

Publicatie 02-10-2020


IntroductionChronic rhinosinusitis (CRS) is associated with a significant decrease in general health‐related quality of life (QOL). The EuroQol 5‐dimensional questionnaire measures general health‐related quality of life through a health utility value (EQ‐5D HUV)—based on five domains reflecting mobility, self‐care, activities of daily life, pain/discomfort, and anxiety/depression—and an unbiased visual analog scale (EQ‐5D VAS). We sought to identify characteristics of CRS patients with a high EQ‐5D HUV but low EQ‐5D VAS score.Materials and MethodsRetrospective cross‐sectional study of 300 CRS patients with EQ‐5D HUV equal to 1.0 (reflecting perfect health). All patients completed a 22‐item Sinonasal Outcome Test (SNOT‐22)—from which nasal, sleep, ear/facial discomfort, and emotional subdomain scores were calculated, as well as the EQ‐5D. Low EQ‐5D VAS was defined as a score less than 80.ResultsOn multivariate analysis, low EQ‐5D VAS was associated with only the SNOT‐22 sleep subdomain score (odds ratio OR = 1.07, 95%CI: 1.02–1.12, P = .003). Comorbid asthma was also associated with lower EQ‐5D VAS (OR = 2.16, 95%CI: 1.02–4.59, P = .045). In contrast, polyps were negatively associated with having a lower EQ‐5D VAS (OR = 0.34, 95%CI: 0.17–0.69, P = .003).ConclusionThere are patients with perfect general health‐related QOL according to a health utility value‐based methodology (like the EQ‐5D HUV) who report low general health‐related QOL on an unbiased measure like the EQ‐5D VAS. In CRS patients with perfect EQ‐5D HUV, poor sleep and asthma were associated with low QOL on the EQ‐5D VAS, while polyps were negatively associated with low QOL.Level of Evidence3 Laryngoscope, 2020

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The Association of Vestibular Schwannoma Volume With Facial Nerve Outcomes After Surgical Resection

\nDaniel E. Killeen, \nSamuel L. Barnett, \nBruce E. Mickey, \nJacob B. Hunter, \nBrandon Isaacson, \nJoe Walter Kutz\n

Publicatie 02-10-2020


ObjectiveTo explore the relationship between tumor size and facial nerve outcomes following vestibular schwannoma (VS) resection.Study DesignSingle institutional retrospective chart review of all adult patients with untreated sporadic VS who underwent surgical resection from 2008 to 2018 with preoperative magnetic resonance imaging (MRI) and 1 year of follow‐up. The primary outcome measure was facial nerve outcome as assessed by the House‐Brackmann facial nerve grading system.ResultsOne hundred sixty‐seven patients, 54.5% female, with a median age of 49 years (20–76 years), were identified who underwent VS resection. Surgical resection was performed by translabyrinthine (76.7%), middle cranial fossa (14.4%), retrosigmoid (7.2%), and transpromontorial (1.8%) approaches. The median tumor diameter and volume were 25.3 mm (range: 4.1–47.1 mm) and 3.17 cm3 (range: 0.01–30.6 cm3), respectively. The median follow‐up was 24.2 months (range: 12–114.2 months). Gross total resection was performed in 79% of cases, with residual tumor identified on MRI in 17% of cases. For patients with tumors <3 cm3, 92.7% had grade 1 or 2 facial function after at least 1 year follow‐up, compared to 81.2% for those with tumors >3 cm3 (univariate logistic regression OR = 2.9, P = .03). Tumor volume >3 cm3 was predictive of facial weakness on multivariate regression analysis (OR = 7.4, P = .02) when controlling for surgical approach, internal auditory canal extension, anterior extension, age, gender, and extent of resection.ConclusionsTumor volume >3 cm3 is associated with worse facial nerve outcomes 12 months following surgical resection.Level of EvidenceIV Laryngoscope, 2020

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A Rare Cause of Extremely Loud Expiratory Stridor in a 11‐Year‐Old Patient

\nGiovanna Cantarella, \nAnna Clara Ciabatta\n

Publicatie 02-10-2020


Stridor can be a very alarming symptom in children, as it is typically caused by turbulent airflow through a partially obstructed airway, due to an organic cause. An abnormal respiratory sound can induce the suspicion of a life‐threatening clinical condition and requires an immediate diagnostic assessment. The aim of this article is to describe a very peculiar case of loud expiratory stridor, with an abrupt onset and no other associated symptoms, occurring in an 11‐year‐old girl. The stridor sounds ceased only during sleep at night. Videolaryngoscopy demonstrated that the anatomy and patency of the larynx were normal, and expiratory noise was generated by vibration of the supraglottic structures. Voice therapy led to remission of stridor within 3 weeks. To the best of our knowledge, this is the first reported case of expiratory stridor with such striking volume and characteristics related to psychological causes. This peculiar clinical condition needs to be taken into consideration in the differential diagnosis of pediatric stridor to avoid unnecessary and invasive procedures and treatments. Laryngoscope, 2020

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Upper Lip Tie: Anatomy, Effect on Breastfeeding, and Correlation With Ankyloglossia

\nShalini Shah, \nPaul Allen, \nRyan Walker, \nCasey Rosen‐Carole, \nMargo K. McKenna Benoit\n

Publicatie 02-10-2020


ObjectivesThere is debate among otolaryngologists and other practitioners about whether upper lip tie contributes to difficulty with breastfeeding and whether upper lip tie and ankyloglossia are linked. Our objectives were to evaluate the anatomy of the upper lip (maxillary) frenulum, to determine if the visual anatomy of the upper lip has an effect on breastfeeding, and to determine whether the occurrence of lip tie and tongue tie are correlated.MethodsA prospective cohort study of 100 healthy newborns was examined between day of life 3–7. Surveys were completed by the mother at the time of the initial exam and 2 weeks later. The maxillary frenulum was graded based on the Stanford and Kotlow classifications by two independent reviewers. Inter‐rater reliability and relationships between tongue tie, lip tie, and the infant breastfeeding assessment tool (IBFAT) were calculated.ResultsInter‐rater reliability showed fair agreement (κ = 0.302) using the Kotlow scale and better agreement using the Stanford classification (κ = 0.458). There was no correlation between the upper lip tie classification and breastfeeding success score. Lastly, there was a modest inverse correlation in the degree of tethering for the tongue and lip.ConclusionsThere was no correlation between maxillary frenulum grade and comfort with breastfeeding, pain scores, or latch. There was also no relationship between tip to frenulum length (tongue tie) and visualized lip anatomy, suggesting that tongue tie and lip tie may not cluster together in infants.Level of Evidence2 Laryngoscope, 2020

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Pre‐ and Post‐Radiotherapy Radiologic Nodal Features and Oropharyngeal Cancer Outcomes

"\nThiparom Sananmuang, \nEugene Yu, \nJie Su, \nBrian OSullivan, \nShrinivas Rathod, \nBiu Chan, \nEric Bartlett, \nJohn Waldron, \nJolie Ringash, \nJohn Kim, \nScott V. Bratman, \nAndrew Hope, \nAnna Spreafico, \nAaron R. Hansen, \nJohn Almeida, \nDavid P. Goldstein, \nIan Witterick, \nLi Tong, \nWei Xu, \nShao H. Huang\n"

Publicatie 01-10-2020


ObjectivesTo assess the prognostic value of pre‐/post‐radiotherapy (pre‐/post‐RT) radiologic lymph node (LN) features in human papillomavirus (HPV)‐positive and HPV‐negative oropharyngeal carcinoma (OPC) patients treated with definitive (chemo‐)RT.MethodsClinical node‐positive OPCs treated from 2011 to 2015 were reviewed. Nodal features were reviewed by a radiologist on pre‐/post‐RT computed tomography (CTs). Univariable analysis calculated hazard ratio (HR) for regional failure (RF), distant metastasis (DM), and deaths. Multivariable analysis estimated adjusted HR (aHR) of significant nodal features identified in univariable analysis adjusting for confounders.ResultsPre‐RT CT was undertaken in 344 HPV‐positive and 94 HPV‐negative OPC patients, of whom 242 (70%) HPV‐positive and 67 (71%) HPV‐negative also had a post‐RT CT. Median follow‐up was 4.9 years. Pre‐RT LN calcification (pre‐RT_LN‐cal) increased the risk of RF in HPV‐negative (aHR: 5.3, P = .007) but not HPV‐positive patients (P = .110). Pre‐RT radiologic extranodal extension (pre‐RT_rENE+) increased the risk of DM and death in both HPV‐negative (DM: aHR 6.6, P < .001; death: aHR 2.1, both P = .019) and HPV‐positive patients (DM: aHR 4.9; death: aHR 3.0, both P < .001). Increased risk of RF occured with < 20% post‐RT LN size reduction in both HPV‐negative (HR 6.0, P = .002) and HPV‐positive cases (HR 3.0, P = .049). Post‐RT_LN‐cal did not affect RF, DM, or death regardless of tumor HPV status (all P > .05).ConclusionPre‐RT_LN‐cal is associated with higher RF risk in HPV‐negative but not in HPV‐positive patients. Pre‐RT_rENE increases risk of DM and death regardless of tumor HPV status. Minimal post‐RT LN size reduction (< 20%) increases risk of RF in both diseases. Post‐RT_LN‐cal + has no apparent influence on outcomes in either disease.Level of Evidence4 (a single institution case–control series) Laryngoscope, 2020

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Efficacy of Ultrasound‐Guided Needle Biopsy in the Diagnosis of Kikuchi‐Fujimoto Disease

\nSang Gyu Park, \nHye Ryoung Koo, \nKiseok Jang, \nJae Kyung Myung, \nChang Myeon Song, \nYong Bae Ji, \nJeong Seon Park, \nKyung Tae\n

Publicatie 01-10-2020


Objectives/HypothesisUltrasound‐guided fine‐needle aspiration cytology (US‐FNAC) is a well‐established procedure performed to establish the diagnosis of Kikuchi‐Fujimoto disease (KFD). Ultrasound‐guided core needle biopsy (US‐CNB) is an alternative diagnostic tool for KFD. However, the efficacy of US‐CNB is not well evaluated. This study aimed to evaluate the efficacy of US‐CNB and compare it with that of US‐FNAC in the diagnosis of KFD.Study DesignRetrospective cohort study.MethodsWe analyzed 170 patients who were diagnosed with KFD between January 2009 and May 2019. US‐FNAC, US‐CNB, and excisional biopsy were performed in 47, 114, and 9 patients, respectively. Diagnostic accuracies of US‐FNAC and US‐CNB were analyzed and compared.ResultsOf the 170 patients, 45 and 125 were men and women, respectively. The mean age was 26.9 ± 9.1 years. The most common symptom was cervical lymphadenopathy, followed by fever, headache, and myalgia. The diagnosis of KFD was established primarily by US‐FNAC in 21 (44.7%) of the 47 patients, by US‐CNB in 109 (95.6%) of the 114 patients, and by excisional biopsy in all 9 patients. There was no specific major complication related to US‐FNAC and US‐CNB.ConclusionUS‐CNB can be considered safe and effective and used as the primary modality for the pathological diagnosis of KFD.Level of Evidence4. Laryngoscope, 2020

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