Laryngoscope 2023-02-03

Differentiation of Bolus Texture During Deglutition via High‐Density Surface Electromyography: A Pilot Study

Gladys Ornelas, Hassler Bueno Garcia, David J. Bracken, Kristen Linnemeyer‐Risser, Todd P. Coleman, Philip A. Weissbrod

Publication date 03-02-2023


This pilot study evaluated high-density surface electromyography (HDsEMG) during pharyngeal swallows of five different bolus textures from eight healthy human subjects. Results indicate HDsEMG can differentiate swallows of varying consistencies through analysis of EMG signal features such as power and peak counts while maintaining a spatial orientation. This may prove useful in both future diagnostic and behavioral swallow applications.
Objective Swallowing is a complex neuromuscular task. There is limited spatiotemporal data on normative surface electromyographic signal during swallow, particularly across standard textures. We hypothesize the pattern of electromyographic signal of the anterior neck varies cranio-caudally, that laterality can be evaluated, and categorization of bolus texture can be differentiated by high-density surface electromyography (HDsEMG) through signal analysis.
Methods An HDsEMG grid of 20 electrodes captured electromyographic activity in eight healthy adult subjects across 240 total swallows.
Participants swallowed five standard textures: saliva, thin liquid, puree, mixed consistency, and dry solid. Data were bandpass filtered, underwent functional alignment of signal, and then placed into binary classifier receiver operating characteristic (ROC) curves. Muscular activity was visualized by creating two-dimensional EMG heat maps.
Results Signal analysis results demonstrated a positive correlation between signal amplitude and bolus texture. Greater differences of amplitude in the cranial most region of the array when compared to the caudal most region were noted in all subjects. Lateral comparison of the array revealed symmetric power levels across all subjects and textures. ROC curves demonstrated the ability to correctly classify textures within subjects in 6 of 10 texture comparisons.
Conclusion This pilot study suggests that utilizing HDsEMG during deglutition can noninvasively differentiate swallows of varying texture noninvasively. This may prove useful in future diagnostic and behavioral swallow applications.
Level of Evidence Level 4 Laryngoscope, 2023

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Analysis of the Quality of Parotidectomy Videos on YouTube Using the IVORY‐Grading‐System

Marcel Mayer, Tarik B. Isik, Lisa Nachtsheim, Philipp Wolber, Kevin K. Hansen, Maria Grosheva, Jens P. Klussmann, Sami Shabli

Publication date 03-02-2023


Our original article aims to introduce a new score, the so-called “Instructional Videos in Otorhinolaryngology by YO-IFOS (IVORY)-grading-system (GS)” derived from the IVORY Guidelines, which pose established consensus recommendations for the production of educational surgical videos in otolaryngology. We further statistically evaluate the new score and conclude that it is suitable for evaluation of educational videos showing parotidectomy in order to improve quality of these videos.
Objective The aim of this study was to evaluate the quality and the educational content of You Tube videos showing parotidectomy.
Methods We searched for videos displaying parotidectomy on You Tube. To rate parotidectomy videos, we introduced the “Instructional Videos in Otorhinolaryngology by YO-IFOS (IVORY)-grading-system (GS)” derived from the IVORY Guidelines, which pose established consensus recommendations for the production of educational surgical videos in otolaryngology. The videos were rated using the IVORY-GS, and the total score was tested for statistical association with views, likes, likes/dislikes-ratio, age, and length of the videos for validation of the IVORY-GS.
Results Overall, 50 parotidectomy videos were identified. Sixty-eight (68%) of the videos showed a superficial parotidectomy. The mean IVORY-GS total score was 24.9 (out of a maximum of 44 points). Video education quality was rated as moderate in 22% and high in 4%. There was a statistically significant correlation between the total score and the number of views (p = 0.03), the total score and the number of likes (p < 0.01), and the total score and the likes/dislikes ratio (p < 0.01). A higher total score was a significant predictor of more likes (p = 0.01) and a higher likes/dislikes ratio (p < 0.01).
Conclusion Our modification of the IVORY Guidelines is otolaryngology-specific, suitable, and recommended to evaluate parotidectomy videos. To date, most videos are of poor educational quality. Future efforts in otolaryngology surgical video education could focus on the establishment of an online video platform.
Level of EvidenceN/A Laryngoscope, 2023

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Characteristics of Adults Undergoing Soft Tissue and Orthognathic Surgery for Obstructive Sleep Apnea

Megan Durr, Jeanne Darbinian, Kimberly Ramirez, Austin R. Swisher, Nikolas R. Block‐Wheeler

Publication date 02-02-2023


Of those with obstructive sleep apnea, unique clinical and demographic characteristics were identified in those who underwent soft tissue and orthognathic sleep surgery. Trends in palate-related surgery, as well as the proportion that was female, were examined over time.
Objective To identify clinical and demographic characteristics of adults with obstructive sleep apnea (OSA) undergoing soft tissue and orthognathic sleep surgery, assess temporal trends in surgery type and proportion of women undergoing surgery, and provide clinical perspective before wide-spread implementation of hypoglossal nerve stimulation (HGNS).
Methods In a retrospective cohort study, adults diagnosed with OSA from 2009 to 2016 were identified in a large integrated healthcare system. Characteristics between cohort members who did and did not undergo sleep surgeries were compared. Multivariable logistic regression models examined associations of different characteristics with whether surgery was performed.
Results Of 172,216 adults with OSA, 2,262 (1.3%) underwent sleep surgery during 2009–2017. The most common sleep surgery was palate surgery (56.9%), which decreased proportionately over time. In multivariable analysis, older age and obesity were associated with lower odds of undergoing surgery. Those who underwent tonsillectomy and adenoidectomy were more likely to have larger tonsils and not require additional surgery, whereas tongue reduction recipients were more likely to have severe OSA and require multiple surgery types. The proportion of women undergoing surgery increased over time (p < 0.001 from trend test).
Conclusion Clinical and demographic characteristics associated with soft tissue and orthognathic sleep surgery were identified in a large adult cohort prior to widespread implementation of HGNS. An increase in sleep surgery among women and a decrease in palate surgery over time were observed. The findings provide clinical perspective on sleep surgery performed prior to implementation of HGNS and may inform future studies examining its associations with patient characteristics.
Level of Evidence3 Laryngoscope, 2023

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Human Leukocyte Antigen Genotyping of Idiopathic Subglottic Stenosis

Matthew L. Rohlfing, Alexander T. Hillel, Elizabeth Wohler, Nara Sobreira, Elizabeth J Phillips, Simon A. Mallal, Alexander Gelbard

Publication date 02-02-2023


Idiopathic subglottic stenosis is a rare disease with incompletely understood pathophysiology. This study investigated for association with human leukocyte antigen allele variations, which have important contributions to other airway disease including granulomatosis with polyangiitis. There was no specific HLA association identified for idiopathic subglottic stenosis.
Objective Despite recent scientific inquiry, idiopathic subglottic stenosis (iSGS) remains an enigmatic disease. The consistent demographics of the affected population suggest genetic factors may contribute to disease susceptibility. Given the inflammation observed in the affected proximal airway mucosa, we interrogated disease association with human leukocyte antigen (HLA) polymorphisms. Polymorphisms in the HLA locus have previously been shown to influence individuals susceptibility to distinct inflammatory diseases.
Methods High-resolution HLA typing of 37 iSGS patients was compared with 1,242,890 healthy Caucasian controls of European ancestry from the USA National Marrow Donor Program and 281 patients with granulomatosis with polyangiitis (GPA).
Results Complete HLA genotyping of an iSGS population showed no significant associations when compared to a North American Caucasian control population. Unlike GPA patients, iSGS was not associated with allele DPB1*04:01 nor did allele homozygosity correlate with disease severity.
Conclusions There was not a detectable HLA association observed in iSGS. These results support the concept that iSGS possesses a distinct genetic architecture from GPA. If genetic susceptibility exists in iSGS, it likely lies outside the HLA locus.
Level of EvidenceN/A, basic science Laryngoscope, 2023

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Ultrasonic Pin Placement for Resorbable Rigid Fixation of a Thyroid Cartilage Fracture

Claudia Gutierrez, Andrew Zaninovich, Rebecca Vozzo, James Daniero

Publication date 01-02-2023


This case presents the first use of an ultrasonic pin placement system for resorbable rigid fixation of a thyroid cartilage fracture. The patient incurred a right paramedian laryngeal cartilage fracture following a high velocity injury to his left anterior neck from a lacrosse ball. A tracheostomy was avoided and post-operatively he had complete return to his vocal baseline.
Objective To present the first use of an ultrasonic pin resorbable plate fixation system for rigid fixation of a laryngeal fracture.
Methods Presentation of a 20-year-old male with a high velocity injury to his neck, via a lacrosse ball, resulting in a displaced laryngeal cartilage fracture.
Results Intraoperatively, a Poly-D, L-Lactic Acid (PDLLA) polymer plate was contoured in-situ, bridging the fracture, and secured with ultrasonically placed resorbable pins. He was extubated on post-op day one and had return to vocal baseline one-month post-op.
Conclusion Ultrasonic pin placement systems for resorbable rigid fixation of a thyroid cartilage fracture optimizes recovery of respiratory and phonatory functions. Laryngoscope, 2023

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Intracapsular Dissection Approaches (Enucleation) in Surgical Resection of Carotid Body Tumors

Seyed Mohammadmehdi Samimi Ardestani, Farrokh Heidari, Mehraveh Sadeghi Ivraghi, Niloufar Saeedi, Ali Bagheri‐Hagh, Saeed Sohrabpour, Seyed Hadi Samimi Ardestani, Nasrin Yazdani, Ebrahim Karimi

Publication date 01-02-2023


Intracapsular dissection approaches in surgical resection of carotid body tumors. Laryngoscope, 2023

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The Best Modality to Assess Vocal Fold Mobility in Children: Flexible Fiberoptic Laryngoscopy or Ultrasound?

Claire M. Lawlor, Sukgi S. Choi

Publication date 30-01-2023


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Automated Creak Differentiates Adductor Laryngeal Dystonia and Muscle Tension Dysphonia

Katherine L. Marks, Manuel E. Díaz Cádiz, Laura E. Toles, Daniel P. Buckley, Lauren F. Tracy, J. Pieter Noordzji, Gregory A. Grillone, Cara E. Stepp

Publication date 30-01-2023


Objective The purpose of this study was to determine whether automated estimates of vocal creak would differentiate speakers with adductor laryngeal dystonia (AdLD) from speakers with muscle tension dysphonia (MTD) and speakers without voice disorders.
Methods Sixteen speakers with AdLD, sixteen speakers with MTD, and sixteen speakers without voice disorders were recorded in a quiet environment reading aloud a standard paragraph. An open-source creak detector was used to calculate the percentage of creak (% creak) in each of the speakers six recorded sentences.
ResultsA Kruskal-Wallis one-way analysis of variance revealed a statistically significant effect of group on the % creak with a large effect size. Pairwise Wilcoxon tests revealed a statistically significant difference in % creak between speakers with AdLD and controls as well as between speakers with AdLD and MTD. Receiver operating characteristic curve analyses indicated that % creak differentiated AdLD from both controls and speakers with MTD with high sensitivity and specificity (area under the curve statistics of 0.94 and 0.86, respectively).
Conclusion Percentage of creak as calculated by an automated creak detector may be useful as a quantitative indicator of AdLD, demonstrating the potential for use as a screening tool or to aid in a differential diagnosis.
Level of Evidence3 Laryngoscope, 2023

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Paralysis Versus Non‐Paralysis Anesthesia for Operative Laryngoscopy: A Randomized Controlled Trial

Jackie Yang, Tyler Crosby, Sophia Chen, Uche C. Ezeh, Sachi Patil, Paul E. Kwak, Wanda A. Chin, Milan R. Amin

Publication date 30-01-2023


We conducted a prospective, single-blinded randomized controlled trial at an ambulatory surgery center comparing two standard-of-care anesthesia regimens for laryngeal surgeries using a direct laryngoscopy approach: anesthesia with paralysis using rocuronium and anesthesia without paralysis using a continuous remifentanil/propofol infusion. Intraoperative impressions, anesthesia data, and post-operative patient surveys were collected. Anesthesia with paralysis during direct laryngoscopy was associated with more favorable surgical conditions and post-op pain compared to anesthesia with propofol and remifentanil.
Objective To compare outcomes between two standard-of-care anesthesia regimens for operative laryngoscopy: general anesthesia with a neuromuscular blocking agent (NMBA) versus remifentanil and propofol (non-NMBA).
Methods This was a prospective, single-blinded, randomized controlled trial at a tertiary care center. Patients were randomized to either anesthesia using rocuronium (NMBA) or with remifentanil/propofol infusion alone (non-NMBA). Intraoperative impressions, anesthesia data, and post-operative patient surveys were collected.
Results Sixty-one patients who underwent suspension laryngoscopy from 2020 to 2022 were included (25 female, 36 male, ranging 20–81 years). Thirty patients were enrolled in the NMBA arm and 31 patients in the non-NMBA arm. Heart rate and mean arterial pressure were higher in the NMBA (p < 0.01). Patients in the non-NMBA group were more likely to require vasopressors (p = 0.04, RR = 3.08 0.86–11.05). Surgeons were more frequently satisfied with conditions in the NMBA group (86.7%) compared to the non-NMBA group (58.1%, p < 0.01). Procedures were more likely to be paused due to movement in the non-NMBA group (45.1%) compared to the NMBA group (16.6%, p < 0.03, RR = 2.26 1.02–4.99). Patients in the non-NMBA group were more likely to endorse myalgia the week after surgery (44%) compared to the NMBA group (8.3%, p < 0.01) and reported higher average pain levels on a 0–10 pain scale (3.7) compared to the paralysis group (2.0).
Conclusions Anesthesia with rocuronium was associated with better intraoperative conditions and postoperative pain compared to anesthesia with remifentanil/propofol. Remifentanil/propofol were associated with lower blood pressure and suppression of laryngoscopy-associated tachycardia.
Level of Evidence Level 2 Laryngoscope, 2023

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Sphincter Pharyngoplasty for Velopharyngeal Dysfunction: Impact of 22q11.2 Deletion Syndrome

Prasanth Pattisapu, Sara Kinter, Randall A. Bly, John P. Dahl, Jonathan A. Perkins, Xing Wang, Kathleen C. Y. Sie

Publication date 25-01-2023


Objective Patients with 22q11.2 deletion syndrome (22q11DelS) often present with velopharyngeal dysfunction (VPD). VPD in patients with 22q11DelS is multifactorial beyond velopharyngeal insufficiency (VPI) alone, and differences in surgical outcomes are poorly understood. Our objective was to determine whether patients with 22q11DelS have an increased risk for persistent VPI after sphincter pharyngoplasty compared to patients without 22q11DelS.
Methods We completed a retrospective cohort study of patients with 22q11DelS undergoing sphincter pharyngoplasty between 1995 and 2019 using a VPD clinic database. Patients with 22q11DelS were compared to a cohort of 2:1 frequency-matched (age, degree of velopharyngeal closure) patients without 22q11DelS. Variables included patient characteristics, surgical history, perceptual speech evaluation, and degree of closure on nasopharyngoscopic evaluations. Primary outcomes included postoperative VPI severity and hypernasality. Speech and nasopharyngoscopic characteristics were compared using Fishers exact test. Postoperative VPI severity and hypernasality were compared between groups via relative risks (RR) from mixed effects Poisson regression models, with random effects of age and velopharyngeal closure.
Results134 patients (51 22q11DelS, 83 matched) were included, with mean age of 7.3 years (standard deviation 3.0) and 50% male. Cohorts had similar preoperative speech characteristics and nasopharyngoscopic findings. Patients with 22q11DelS had similar postoperative VP function as patients without 22q11DelS (RR 0.85, CI 0.46–1.57 for VPI severity, RR 0.83, CI 0.45–1.53 for hypernasality). Even after adjusting by preoperative variables, no differences were seen between both groups.
Conclusion Matched for age and pre-operative velopharyngeal closure, patients with and without 22q11DelS and VPI had similar benefits after sphincter pharyngoplasty.
Level of Evidence Non-randomized controlled cohort study, level 3 Laryngoscope, 2023

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Fatigue in Long‐Term Head and Neck Cancer Survivors From Diagnosis Until Five Years After Treatment

Malin Berg, Ewa Silander, Mogens Bove, Leif Johansson, Jan Nyman, Eva Hammerlid

Publication date 25-01-2023


Fatigue in head and neck cancer patients was studied, longitudinally, for up to 5 years after treatment, with the EORTC QLQ-FA12. Physical-, emotional-, and cognitive fatigue were stable after one year. Few predictors for chronic fatigue were found.
Objectives Fatigue due to cancer is a challenging symptom that might be long-lasting after cancer treatment. The aim of this study was to follow the development of fatigue among head and neck cancer (HNC) patients prospectively and longitudinally and to analyze predictors for acute and chronic fatigue.
MethodsHNC patients treated with curative intent were included at diagnosis and completed the following questionnaires multiple times, up to 5 years after treatment: the EORTC QLQ-FA12 for fatigue, EORTC QLQ-C30, and HNC-specific EORTC QLQ-H&N35 together with an anxiety and depression questionnaire. Predictors of fatigue were evaluated at 3 months and 5 years after treatment.
Results Of the 311 study participants, 74% responded at the 5-year follow-up. Physical fatigue was significantly worse 3 months after treatment, while emotional and cognitive fatigue were the worst at diagnosis and at 3 months. All fatigue domains were significantly better after 1 year, and the fatigue scores remained stable from 1 until 5 years after treatment. Three months after chemoradiotherapy, physical fatigue was more significant, but no long-term differences due to treatment modalities were found. Depression and anxiety were predictors for chronic emotional fatigue, and local HN pain and swallowing problems were predictors for chronic physical fatigue. Better global quality of life at diagnosis was associated with less physical and emotional fatigue.
Conclusion Fatigue was worst in the short term for HNC patients and improved after 1 year, and long-term fatigue remained stable up to 5 years after treatment. A few predictors for chronic fatigue were found.
Level of Evidence3 Laryngoscope, 2023

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Relationship of Lesion Location to Postoperative Steroid Use in Eosinophilic Chronic Rhinosinusitis

K. Miyamura, E. Mori, D. Nakashima, M. Miura, S. Chiba, N. Otori

Publication date 24-01-2023


The relationship between steroid use and endoscopic lesion location in the postoperative course of ECRS patients was examined, and sphenoethmoidal recess lesions were a risk factor for the need for postoperative steroids. These findings call for more appropriate use of steroids in the postoperative management of ECRS.
Objectives Eosinophilic chronic rhinosinusitis (ECRS) is known to recur after surgery. The treatment choice for recurrent ECRS, such as oral steroids or biological agents, must be chosen carefully, and identifying the lesion location may be useful. This study aimed to evaluate the postoperative course of ECRS patients and assess the relationship between endoscopic lesion location and postoperative oral steroid use.
Methods Patients with chronic rhinosinusitis who underwent bilateral endoscopic sinus surgery from April 2018 to March 2020 were divided into two groups based on the presence or absence of oral steroid use after surgery.
The primary endpoint was the lesion location on endoscopic findings during surgery: middle turbinate, middle meatus, superior turbinate, superior meatus, nasal septum, and sphenoethmoidal recess. Subjective symptoms, blood tests, and computerized tomography (CT) findings (Lund-Mackay score) were evaluated as secondary endpoints.
Results Among 264 patients, 88 were diagnosed histologically with ECRS (mean 48.98 ± 1.40 years, 67 males/21 females). Twenty-three patients were steroid-using, 65 were steroid-free, and six stopped attending their appointments. Patients with sphenoethmoidal recess lesions were significantly more likely to require steroids (p = 0.019). There was a significant association between steroid use and younger age (p = 0.041), olfactory dysfunction (p = 0.021), and all sinuses (Frontal sinus: p < 0.001, Anterior ethmoid sinus: p = 0.002, Posterior ethmoid sinus: p = 0.011, Maxillary sinus: p = 0.018, Sphenoid sinus: p = 0.034, Total score: p < 0.001).
ConclusionA sphenoethmoidal recess lesion was a risk factor for requiring postoperative steroids. Young age, olfactory dysfunction, and preoperative severe CT findings were also significant risk factors.
Level of Evidence3 Laryngoscope, 2023

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Compression of the Vertebral Artery by the Thyroid Cartilage Causing Vertebrobasilar Insufficiency

Ryland N. Spence, Christopher Shumrick, John Tarro

Publication date 24-01-2023


Mechanical compression of the vertebral artery during mouth opening by the thyroid cartilage. Successfully resolved by resection of the thyroid cartilage.
Background This retrospective case report describes a rare presentation of VBI in a young male patient.
Aims Share a rare cause of VBI in a young patient.
Materials & Methods The patient presented with recurrent episodes of dizziness and a history of several cerebellar infarcts. Imaging revealed the right vertebral artery was being mechanically compressed by the right superior cornu of the thyroid cartilage during mouth opening. Surgical resection of the right superior cornu of the thyroid cartilage was performed.
Results Intraoperative angiography revealed a right vertebral artery without compression during mouth opening.
Discussion Clinicians should consider the thyroid cartilage as a potential source of recurrent VBI due to mechanical compression of the VA.
Conclusion Resection of the causative portion of the thyroid cartilage resolved the compression in this case, and should be employed in similar cases. Laryngoscope, 2023

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Serial In‐Office Steroid Injections for Airway Stenosis: Long‐Term Benefit and Cost Analysis

"Karla ODell, Valerie Huang, Joseph Acevedo, Lindsay Reder, Michael Johns, Li Ding"

Publication date 24-01-2023


Serial in office steroid injection help avoid operative intervention regardless of stenosis etiology. Follow up of at least 2 years suggest that serial in office steroid injection can avoid operative intervention long term. There is potential cost savings associated with serial steroid injection over traditional endoscopic dilation.
Objectives To evaluate the long-term benefit of serial in-office steroid injections (SISI) in the treatment of subglottic and proximal tracheal stenosis (SG/PTS). Evaluate cost of SISI compared to endoscopic dilation (ED).
Study Design Retrospective study and cost analysis.
Methods All patients with SGS/PTS with at least two consecutive in-office steroid injections between 2013 and 2021 were evaluated. Patients with less than 2 years of follow-up data after the initial SISI series were excluded. Demographics, etiology of stenosis, total injections performed, time between steroid series, surgery-free interval (SFI) and adverse events were collected. For patients with known surgical history before SISI, pre-SISI SFI was compared. Institutional billing records and the national CMS average reimbursement were evaluated. Total charges for three treatment strategies (ED alone, ED with post-operative SISI and primary intervention with SISI) were also compared.
Results Forty-nine patients were included; 29 (59%) idiopathic, 11 (22%) traumatic and 9 (18%) rheumatologic. Mean (SD) follow-up time after the first SISI was 3.41 years (1.5), range (2.08–7.25 years). 79% (39/49) did not require additional surgery during the entire follow-up period. The SFI improved from a mean 13.5 months (SD 12.6; range 2–42 months) pre-SISI to a mean (SD) of 42 months (SD 20.2; range 10–87 months) (p < 0.0001) after SISI. Annual average charges for ED alone in our cohort was $15,383.28, compared to $7,070.04 for SISI.
ConclusionsSISI are an effective treatment for patients with SG/PTS. In-office steroid injections could offer cost savings for the patient.
Level of Evidence4 Laryngoscope, 2023

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Myer‐Cotton Grade of Subglottic Stenosis Depends on Style of Endotracheal Tube Used

Evan Jon Propst, Nikolaus Ernst Wolter

Publication date 23-01-2023


The Myer-Cotton grade of subglottic stenosis depends on the style of endotracheal tube used. Using updated values from currently available endotracheal tubes aims to keep this grading system valid with respect to surgical approach and outcomes following surgery.
Objectives Determine percentage of subglottic stenosis using current endotracheal tube (ETT) cross-sectional areas as actual, compared with previously published ETT cross-sectional areas as expected, and determine if style of ETT could result in a change in percentage of stenosis or Myer-Cotton grade.
Study Type Cross-sectional study.
Design Prospective analysis.
Methods Eight styles of uncuffed pediatric ETT from four manufacturers ranging from 2.0 to 6.0 inner diameter (ID) were evaluated. ID and outer diameter (OD) measurements were obtained from each companys specification sheets. Cross-sectional area was calculated for each ETT using the formula (Area = πr 2). The cross-sectional areas of each current ETT (actual) were compared with those of previously published ETTs (expected) based on age, and the degree of stenosis was calculated using the formula 1- (Area actual/Area expected) × 100%. Ranges of percentage for each style of ETT were calculated.
Results There was an increase in range of OD and area with increasing size of ETT ID, with the largest range in OD being 0.8 mm, and the largest range in area being 10.55 mm2. The median interquartile range (IQR), range of percentage stenoses was 11 (5%), ranging from 0% to 21%. Seven of 28 (25%) ranges were found to span two Myer-Cotton grades.
Conclusions The Myer-Cotton grade of subglottic stenosis depends on the style of ETT used. Using updated values from currently available ETTs aims to keep this grading system valid with respect to surgical approach and outcomes following surgery.
Level of EvidenceNA Laryngoscope, 2023

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Characteristics of Nasal Foreign Bodies and Equipment on Complications During Removal Procedures

Kosuke Tochigi, Keisuke Miyashita, Satoshi Aoki, Hikaru Sakamoto, Kazuhiro Omura, Yasuhiro Tanaka

Publication date 23-01-2023


This study aimed to clarify the equipment for the safe removal of nasal foreign bodies. Suction, paper clips, and cotton swabs were considered beneficial equipment for the safe removal of nasal foreign bodies because of minimizing complications and their high versatility.
Objective The treatment of nasal foreign bodies involves safe and reliable removal. Few reports have investigated the relationship between equipment and the incidence of complications.
Methods This retrospective study included 300 patients with nasal foreign bodies (average: 3.28 years, interquartile range: 2–4 years). Patients background, characteristics of nasal foreign body, equipment to remove the nasal foreign body, and complications were obtained from medical records. Statistical analysis was performed using Pearsons chi-square test for associated factors and the incidence of epistaxis among the complications.
Results Nasal foreign bodies were found and removed in 256 patients. Forceps, hooks, suction, modified paper clips, and cotton swabs were mainly used to remove the nasal foreign bodies. Epistaxis due to the removal procedure was observed in 26 patients. The occurrence of epistaxis differed depending on the equipment (p = 0.077) and was less frequent in suction and paper clips than in forceps (p < 0.05 and p = 0.077). Epistaxis was not observed when a cotton swab was used. Aspiration and septal perforation were not observed. A statistical relationship was not detected between the hardness of foreign bodies and the occurrence of epistaxis (p = 0.251). The incidence of epistaxis was higher in cases nasal foreign bodies remained for 1 day and over than in cases foreign bodies were removed within 1 day (p < 0.05).
Conclusions This study revealed that suction, modified paper clips, and cotton swabs could be beneficial options for minimizing complications in the removal of nasal foreign bodies.
Level of Evidence Level 4 Laryngoscope, 2023

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Extended External Rhinoplasty Approach For Nasal Dermoids With Intracranial Extension

Dayton Rand, Brian J. Dlouhy, Sohit Paul Kanotra

Publication date 23-01-2023


We present an extended external rhinoplasty approach with bilateral marginal and alar base incisions for removal of a nasal dermoid cyst with intracranial extension in a 3-year-old patient. This approach provides adequate exposure, enables nasal bone osteotomies, and allows access to the skull base while achieving a cosmetically acceptable scar. Laryngoscope, 2023

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Superior Laryngeal Nerve Block Response Rates in 54 Neurogenic Cough Patients

Nicholas Talbot, Margaret Heller, Sarah Nyirjesy, Brandon Kim, Brad DeSilva, Laura Matrka

Publication date 23-01-2023


Superior laryngeal nerve block with steroid and local anesthetic is an emerging therapy for neurogenic cough secondary to hypersensitivity of the superior laryngeal nerve. Over 70% of patients endorsed subjective improvement after injection and 40% of patients endorsed benefit after initial nonresponse. No localizing symptoms, specific cough features, or aspects of the medical history helped predict response, suggesting that a broader range of patients may be offered the intervention.
Objective Neurogenic cough related to hypersensitivity of the internal branch of the superior laryngeal nerve (SLN) is often treated with neuromodulating medications, which can cause considerable side effects. An alternative therapy is steroid and local anesthetic injection of the SLN (“SLN block”), initially proposed to benefit those with lateralizing symptoms (tenderness over the thyrohyoid membrane or unilateral cough source). Our objectives are to determine if SLN block produces subjective symptomatic improvements and if repeat injections further improve symptoms, and evaluate clinical factors potentially predictive of response.
Methods Retrospective chart review of 54 patients receiving SLN blocks at a tertiary medical academic center from January 2010 to June 2020. Medical history and anticipated predictors of positive response, including stigmata of laryngeal hypersensitivity, were recorded. Outcomes included symptomatic response, number of injections required, and side effects. Response was defined subjectively by asking patients whether the injection was beneficial and objectively by using CSI scores.
Results Fifty-four patients met the inclusion criteria. Thirty-eight patients (70.4%) endorsed improvement. No variables were identified as positive predictors of response. Thirty-two of the 38 (84.2%) endorsed improvement after one injection. Six of 15 (40%) patients who failed the first injection had positive response to the second. No significant side effects were reported.
Conclusion No localizing symptoms, specific cough features, or aspects of the medical history helped predict response, suggesting that a broader range of patients may be offered the intervention. The majority of patients reported symptomatic improvement and repeat injections may benefit patients with initial nonresponse.
Level of Evidence4 Laryngoscope, 2023

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Preoperative Prediction of Sinonasal Inverted Papilloma‐associated Squamous Cell Carcinoma (IP‐SCC)

Marn Joon Park, Wonki Cho, Ji Heui Kim, Yoo‐Sam Chung, Yong Ju Jang, Myeong Sang Yu

Publication date 23-01-2023


The relatively low diagnostic sensitivity of in-office punch biopsy to detect inverted papilloma associated squamous cell carcinoma (IP-SCC) indicates the need to identify other clinical and radiological features associated with IP-SCC. IP patients with chronic systemic diseases, a history of tobacco smoking, facial pain, or epistaxis, and those with bony destruction, remodeling, or invasion of adjacent structures on preoperative radiologic imaging may be at higher risk of IP-SCC, suggesting the need for more aggressive surgical strategies.
Introduction Sinonasal inverted papillomas (IP) can undergo transformation into IP-squamous cell carcinomas (IP-SCC). More aggressive treatment plan should be established when IP-SCC is suspected. Nevertheless, inaccuracy of the preoperative punch biopsy results to detect IP-SCC from IP raises the need for an additional strategy. The present study aimed to investigate significant clinicoradiological remarks associated with IP-SCC than IP.
Material and Methods Postoperative surgical specimens obtained from patients with confirmed IP or IP-SCC at a single tertiary medical center from 1997 to 2018 were retrospectively evaluated. Patients demographic and clinical characteristics, preoperative in-office punch biopsy results, and preoperative computed tomography (CT) or magnetic resonance images were reviewed. Univariate and multivariate analyses were performed to assess the odds ratio (OR) associated with IP-SCC. The area under the curve (AUC) in the receiver Operating Characteristic (ROC) curve was calculated in the prediction model to discriminate IP-SCC from IP.
Results The study included 44 IP-SCC and 301 patients with IP. The diagnostic sensitivity of in-office punch biopsy to detect IP-SCC was 70.7%. Multivariate analysis showed that factors significantly associated with IP-SCC included tobacco smoking >10PY (adjusted-OR aOR: 4.1), epistaxis (aOR: 3.4), facial pain (aOR: 4.2), bony destruction (aOR: 37.6), bony remodeling (aOR: 36.3), and invasion of adjacent structures (aOR: 31.6) (all p < 0.05). Combining all significantly related clinicoradiological features, the ability to discriminate IP-SCC from IP reached an AUC of 0.974.
ConclusionIP patients with a history of tobacco smoking, facial pain, epistaxis, and bony destruction, remodeling, or invasion of an adjacent structure on preoperative images may be at higher risk for IP-SCC.
Level of Evidence3 Laryngoscope, 2023

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Extranodal Extension Improves AJCC‐8 Accuracy in HPV+ Oropharyngeal Cancer in a High‐Risk Population

Clayton Prakash Burruss, Christine Sharrer, James Zachary Porterfield, Alexandra Eva Kejner

Publication date 19-01-2023


Although American Joint Committee on Cancers 8th edition (AJCC-8) has demonstrated an improved ability to stratify OPSCCs into stages that predict overall survival, high-risk populations may be predisposed to worse outcomes. The goal of this manuscript is to validate the AJCC-8 as a better metric of survivability over AJCC-7 in a historically under-served rural population with confounding variables such as tobacco use, alcohol consumption, and poor healthcare access, and to analyze the role of extranodal extension in this population.
Objectives The American Joint Committee on Cancers 8th edition (AJCC-8) separates oropharyngeal squamous cell carcinomas (OPSCCs) into human papillomavirus-positive (HPV+) tumors and HPV-negative tumors. Although AJCC-8 improves prognostic prediction for survival for the majority of HPV+ OPSCC, outliers are still encountered. The goal of this manuscript is to validate the AJCC-8 as a better metric of survivability than the AJCC-7 in an historically under-served rural population with confounding variables, such as tobacco use, alcohol consumption, and poor health care access and to analyze the role of extranodal extension (ENE) in this population.
Design Retrospective cohort study.
Results Compared to AJCC-7, AJCC-8 had a higher odds ratio (OR) for predicting mortality of stage IV HPV+ OPSCCs versus stages I–III. On multivariate analysis, HPV+ OPSCCs with ENE had a higher OR of mortality compared to ENE- OPSCCs. In addition, HPV+ OPSCC patients with a Charlson Comorbidity Index (CCI) > 3 had a higher OR of mortality compared to those with a CCI ≤ 3. Patients with Medicaid/self-pay status had a higher OR of mortality compared to those with private insurance/Medicare. Finally, patients from rural populations had a higher OR of presenting with stage IV disease, a CCI > 3, and Medicaid/self-pay status.
Conclusions Despite not being a discrete part of the AJCC-8 staging rubric, ENE was found to have a significant impact on mortality among this population, whereas tobacco use had no effect. Rural patients were more likely to present with stage IV disease, CCI > 3, and Medicaid/self-pay status. Stage IV disease was also associated with a higher OR of mortality.
Level of Evidence4 Laryngoscope, 2023

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Functional Rhinoplasty—What Really Works?

Jeffrey Mella, Samuel Oyer, Stephen Park

Publication date 19-01-2023


Throughout the evolution of functional rhinoplasty, numerous techniques have been described and shown to be successful. Controversy exists regarding which techniques are most effective to address various deformities. The goal of this article is to review the available literature to examine the question, which surgical techniques within functional rhinoplasty are most successful in treating nasal airway obstruction. Based on the available data, it is not currently possible to draw conclusions about the superiority of a single graft or technique in functional rhinoplasty. Laryngoscope, 2023

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Prognostic Value of Controlling Nutritional Status Score in Advanced Hypopharyngeal Cancer

Qin Lin, Chen Li, Xiaoxia Lin, Shuchun Lin, Wei Chen, Xiaoqiang Chen, Xiaoting Huang, Desheng Wang

Publication date 18-01-2023


The CONUT score is a prognostic marker for patients with resectable advanced hypopharyngeal cancer Objective The purpose of this study was to investigate the prognostic significance of the preoperative controlling nutritional status (CONUT) score in patients with resectable advanced hypopharyngeal cancer.
Methods This retrospective study included 113 advanced hypopharyngeal cancer patients who underwent curative resection in our hospital from 2013 to 2017. The association between the CONUT score and clinicopathological variables was evaluated. The association between CONUT score and survival was analyzed using Kaplan–Meier survival curves and Cox regression. The efficacy of the CONUT score and other immune-nutritional markers to predict prognosis was compared using a time-dependent receiver operating characteristic (ROC).
Results Patients were divided into the high-CONUT score group (≥3) and the low-CONUT score group (≤2) according to ROC analysis. The CONUT score was associated with body mass index (p = 0.047), monocyte (p = 0.021), pharyngocutaneous fistula (p = 0.045), flap repairment (p = 0.034), tumor (T) classification (p = 0.034), node (N) classification (p = 0.036), subsite of tumor (p = 0.035), and negative pathologic factors (p < 0.001). Tumor, node, metastasis (TNM) stage, negative pathologic factors, adjuvant radiotherapy, postoperative chemoradiotherapy, and CONUT score were independent prognostic factors for survival. Patients with a higher CONUT score had worse overall survival (OS) (hazard ratio: 2.76, 95% confidence interval CI: 1.44–5.29, p = 0.002) and disease-free survival (hazard ratio: 2.51, 95% CI: 1.28–4.91, p = 0.007). The area under the curve of the CONUT score (0.799) to predict 5-year OS was greater than those of Preoperative Nutritional Index (0.769), platelet-to-lymphocyte ratio (0.643), neutrophil-to-lymphocyte ratio (0.565), and lymphocyte-to-monocyte ratio (0.577).
Conclusion The CONUT score is a prognostic marker for patients with resectable advanced hypopharyngeal cancer.
Level of Evidence3 Laryngoscope, 2023

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"Carolyns Window Approach to Unilateral Frontal Sinus Surgery"

Kachorn Seresirikachorn, Andrea Sit, Lu Hui Png, Larry Kalish, Raewyn G. Campbell, Raquel Alvarado, Richard J. Harvey

Publication date 18-01-2023


Carolyns window approach aims to remove the limitation created by the anterior-posterior depth to make a Draft 2a frontal sinusotomy easier for the surgeon. The approach is a 0° endoscope technique and provides an excellent view of the frontal sinus and recess.
Objectives Due to the complexity and variety of the frontal recess and sinus anatomy, traditional Draf 2a frontal sinus surgery is challenging. The thickness of the nasofrontal beak and anterior–posterior dimensions of the frontal recess contribute to this complexity. Carolyns window technique eliminates the limitation of anterior–posterior depth to facilitate a Draf 2a frontal sinusotomy. The approach is a 0° endoscope technique and provides an excellent view of the frontal sinus and recess. We describe Carolyns window approach to frontal sinus surgery and the perioperative outcomes.
Methods Consecutive adult patients in whom Carolyns window technique was applied for frontal sinus dissection as part of the endoscopic management of both inflammatory and neoplastic disease were assessed. The primary outcome was frontal sinus patency. Secondary outcomes were surgical morbidity, defined as early (<90 days) or late (>90 days).
Results Forty-five patients (49.1 ± 17.9 years, 48.9% Female) were assessed. All patients had successful frontal sinus patency (100% 95CI: 92.1%–100%). Morbidities were adhesion (4.8%), crusting (2.4%), pain (1.2%), and bleeding (1.2%) in the early postoperative period. There were no other morbidities in the early and late postoperative periods.
Conclusion Carolyns window approach to frontal sinusotomy is a technique that evolves from previously described approaches. Successful frontal sinus patency with very low morbidities is achieved while still working with a 0° endoscope. The “axillectomy” performed simplifies frontal recess surgery by removing the anteroposterior diameter limitation and the dexterity required in angled endoscopy and instrumentation. The inferior-based lateral wall mucosal flap and free mucosal grafting expedite the mucosal healing process. Laryngoscope, 2023

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Evaluation of Mobile and Digital Single‐Lens Reflex Photography for Facial Surgical Analysis

Neal Deot, Aleksandar Kiprovski, Adam Hatala, Ade Obayemi, Amar Suryadevara, Richard O. Davila

Publication date 18-01-2023


High quality perioperative photography is imperative to good surgical planning and analysis in facial reconstructive and aesthetic surgery. In this article, we explored the utility of an add-on smartphone telephoto lens for facial photography using anthropometric measurements and a survey administered to facial plastic surgeons.
Objectives High-quality perioperative photography is imperative to good surgical planning in facial reconstructive and aesthetic surgery. We explore the utility of an add-on smartphone telephoto lens to avoid the distortions noted in prior studies using smartphone cameras.
Methods Standard perioperative photographs of the same subject were taken with three distinct cameras using a dual-ring light setup. The three camera setups i Phone 11 alone, i Phone 11 with the 58 Moment telephoto lens attachment, and a D3300 Nikon DSLR APS-C sensor camera with a 60 mm NIKKOR F2.8G ED macro lens were compared using a 47-question online survey consisting of demographic and image-specific questions sent to plastic surgeons.
Results Forty-nine facial plastic surgeons completed the survey. The i Phone 11 alone was identified as having the lowest quality for central/peripheral distortion (83%), columella/caudal septum/alar anatomy (58.3%), and skin quality (38.3%). With the addition of the telephoto lens, the ability to assess all categories was significantly improved. 53.1% (n = 26) of respondents found the i Phone 11 + 58 mm telephoto lens setup to be the most useful for perioperative surgical planning.
Conclusions Smartphone photography with the addition of a telephoto lens can offer a comparable option to the DSLR with regard to photo quality and detail.
SummaryA telephoto add-on lens is an effective solution to overcome the central distortion seen in images taken by the i Phone for perioperative photography. This photo quality was found to be comparable to that of traditional DSLR cameras in our survey study.
Level of EvidenceIII Laryngoscope, 2023

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The Efficacy of Human Papillomavirus Vaccination as an Adjuvant Therapy in Recurrent Respiratory Papillomatosis

Anusha Ponduri, Monica C. Azmy, Eden Axler, Juan Lin, Rachel Schwartz, Magdalena Chirilă, Frederik G. Dikkers, Christina J. Yang, Vikas Mehta, Mona Gangar

Publication date 18-01-2023


A systematic review and meta-analysis was done to characterize the efficacy of human papillomavirus (HPV) vaccination as an adjuvant therapy in recurrent respiratory papillomatosis (RRP). The addition of HPV vaccination was associated with an increase in time between surgeries, and reduced the number of surgical procedures required for patients with RRP. HPV vaccination may be a beneficial adjuvant treatment for RRP.
Objective To characterize the efficacy of human papillomavirus (HPV) vaccination as an adjuvant therapy in recurrent respiratory papillomatosis (RRP).
Data Sources Pub Med, Embase, Cochrane, Google Scholar, Clinical Trials.gov, and Web of Science databases were queried for articles published before April 2021.
Review Methods All retrieved studies (n = 870) were independently analyzed by two reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement using predefined inclusion and exclusion criteria. 13 studies met inclusion criteria. A random-effects meta-analysis was performed to study intersurgical interval (ISI) and number of surgical procedures per year before and after vaccination.
Results The systematic review included 13 studies, comprising 243 patients. All studies utilized the Gardasil® quadrivalent vaccine, and one study (Yiu et al. 2019) utilized both the quadrivalent and Gardasil® 9-valent vaccines. Our meta-analysis included 62 patients with ISI data across 4 studies, and 111 patients with data on the number of surgical procedures per month across 7 studies. The mean number of surgical procedures decreased by 4.43 per year after vaccination (95% CI, −7.48 to −1.37). Mean ISI increased after vaccination, with a mean difference of 15.73 months (95% CI, 1.46–29.99). Two studies reported on HPV sero-conversion, with HPV seropositivity of 100% prior to vaccination and 25.93% after vaccination.
Conclusion The addition of HPV vaccination was associated with an increase in time between surgeries and reduction in the number of surgical procedures required. HPV vaccination may be a beneficial adjuvant treatment for RRP.
Level of EvidenceN/A Laryngoscope, 2023

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Osseointegration and Bone Resorption of Scapula Tip Free Flaps in Mandibular Reconstruction

Blair M. Barton, Mohammed Mamdani, Catherine Lumley, Jeffrey Blumberg, Benjamin Y. Huang, Samip N. Patel

Publication date 18-01-2023


Few studies have shown significant bone resorption over time in scapula free flaps for mandibulectomy defects. Our series show high rates of osseous union and limited bone resorption that is equivalent to other vascularized osseous flaps.
Objectives Bone resorption of more conventional vascularized bone grafts have been well described showing minimal resorption over time. Few studies have evaluated osseous union and bone resorption in scapula tip free flaps (STFF) in the reconstruction of mandibulectomy defects. We aimed to describe our series on STFF with respect to osseous union and bone resorption over time.
Methods Retrospective chart review of patients receiving STFF from January 2014–January 2017 (n = 25). A neuroradiologist analyzed follow-up CT scans to assess (1) STFF complete, partial, or no osseous union with native mandible and (2) STFF volume change over time in a subset with multiple follow-up scans (n = 18).
Results Twenty-three of 25 patients (92%) showed complete or partial STFF osseous union with native mandible either distally or proximally. STFF volume change ranged from +4.8 to −54% (median −0.5%) over median follow-up interval of 23 months. History of chemoradiation therapy, bisphophonate use, sex, age, or smoking history did not correlate with bone resorption.
ConclusionsSTFFs shows high rates of osseous union and limited bone resorption that is equivalent to, or less than, vascularized fibular and iliac crest flaps. Clinically, this translates into both optimal healing and functional and cosmetic outcomes, especially in the setting of prior therapies.
Level of Evidence4 Laryngoscope, 2023

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Fiberoptic Endoscopic Evaluation of Swallowing in the Breastfeeding Infant

James W. Schroeder

Publication date 18-01-2023


Objective To demonstrate the importance of utilizing fiberoptic endoscopic evaluation of swallowing (FEES) when evaluating breastfeeding infants with suspected dysphagia. Failure to recognize and account for the fundamentally different physiology of the primarily breastfed infant can lead to false assumptions about the safety of breastfeeding in this understudied patient population.
Methods Case-series. The medical records of patients referred to an urban, university-based, pediatric hospital for FEES from February 2017 to October 2020 were reviewed. Their presenting symptoms, dysphagia severity, comorbidity, dysphagia workup, and management were analyzed. The standardized Dysphagia Outcome and Severity Scale was used to appraise dysphagia severity.
Results204 FEES exams were reviewed. 35 were conducted on breastfed infants. 34 of the 35 infants calmed for the FEES exam while breastfeeding. Cohorts were defined by a particular presenting sign (cough, laryngeal congestion, choking, and respiratory illness) and anatomical characteristic (laryngomalacia, vocal cord paralysis, aspiration, penetration, etc.) and then compared to all other exams. The average dysphagia score for all the exams was 2.37. Patients presenting with laryngeal congestion had an average dysphagia score of 2.81. There was no difference in dysphagia score based on comorbidities or anatomy.
ConclusionsFEES is the instrumental exam of choice when evaluating a primarily breastfed infant who has suspected dysphagia. The exam is well tolerated and provides accurate, objective information while accounting for this populations unique swallowing physiology. Primarily breastfed infants presenting with laryngeal congestion are more likely to have clinically worse dysphagia than those presenting with other clinical symptoms.
Level of Evidence Level 4 Laryngoscope, 2023

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"Office‐Based Treatment of Vocal Fold Polyps and Reinkes Edema: A Rational Comparison With Suspension Laryngoscopy"

Marta Filauro, Alessandro Ioppi, Alberto Vallin, Claudio Sampieri, Marta De Vecchi, Giulia Gabella, Pietro Benzi, Francesco Mora, Giorgio Peretti

Publication date 17-01-2023


Benign laryngeal lesions have traditionally been treated surgically through suspension laryngoscopy. In the present study, we report comparable vocal results with an office-based transnasal endoscopic approach with a fiber laser capable of providing favorable morbidity and reduced operation times.
Objective Benign laryngeal lesions have traditionally been treated through suspension laryngoscopy under general anesthesia (GA). Recently, the development of operative videoendoscopes coupled with photoangiolytic lasers has allowed clinicians to treat these conditions in the outpatient clinic. We report our experience in the office-based (OB) setting for the treatment of patients affected by vocal fold polyps (VFPs) and Reinkes edema (RE), comparing it to patients treated under GA.
MethodsA retrospective analysis was conducted on patients affected by VFP or RE. A 445 nm diode blue laser was used through the operative channel of a flexible video-endoscope for OB procedures, while GA surgeries were carried out with cold steel instrumentation. The Voice Handicap Index-10 (VHI-10) represented the primary outcome. Endoscopic outcomes, duration, and morbidity of the procedures were investigated as secondary outcomes.
ResultsA total of 153 patients were retrospectively enrolled. 52 were treated in an OB setting, while 91 underwent GA. Regarding patients with RE, both the OB and GA cohorts showed a significant improvement in VHI-10 (from 12.7 to 2.6 and 19.5 to 5.1, respectively; p < 0.001), as did those with VFPs (from 11.8 to 2.3 and 15.9 to 2.9 respectively; p < 0.001). No differences were found when comparing VHI-10 in the OB and GA cohorts. The mean procedural time of OB treatment (4.9 min) was significantly shorter than GA (37.1 min). No adverse events were reported.
Conclusion Our data demonstrate the efficacy and safety of the OB setting. For selected patients, OB treatments offer comparable vocal outcomes, favorable morbidity, and reduced operation times, making them an appealing alternative to the traditional approach.
Level of Evidence3Laryngoscope, 2023

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Is Percutaneous Tracheostomy Safe?

Sena Turkdogan, Catherine F. Roy, Jennifer A. Silver, Karen M Kost

Publication date 17-01-2023


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Endonasal Acoustic Doppler Sonography in Predicting the Survival of Nasoseptal Flap Following Previous Irradiation

Calvin Chee‐Fung Lai, Samuel Man‐Wai Chow, Michael Chi‐Fai Tong

Publication date 17-01-2023


Objective Blood supply to the nasoseptal flap may be compromised in patients who had previous irradiation to the head and neck region, hence, affecting its viability. Here, we evaluate the role of an endonasal acoustic Doppler sonography in predicting the survival of the nasoseptal flap in this group of patients.
Study Design Retrospective cohort.
Methods Retrospective review of patients with previous irradiation to the head and neck region who had undergone endoscopic endonasal surgeries requiring nasoseptal flap as reconstruction. Survival rates of nasoseptal flap were compared between groups where endonasal Doppler was used.
ResultsA total of 28 patients were identified with previous irradiation to the head and neck region who had undergone endoscopic endonasal surgeries requiring nasoseptal flap as reconstruction. The overall survival rate of nasoseptal flap is 67.8% (19 out of 28). Endonasal acoustic Doppler was used in 17 of these patients, of which 13 patients had a positive signal. The flap survival rate in the Doppler-positive group compared to the non-Doppler group was significantly better at 100% vs 45.4% (P = .003). Among those where the endonasal Doppler was used, the flap survival rate with a negative doppler signal was significantly worse at 25%, compared with 100% flap survival in those with positive doppler signal (P = .006). The positive predictive value of a positive endonasal Doppler signal with flap survival is 100%.
Conclusion The use of endonasal acoustic Doppler may be useful in predicting the viability of nasoseptal flap in postirradiated patients who need a local mucosal flap coverage.
Level of Evidence3 Laryngoscope, 133:244–247, 2023

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Epithelial response to vocal fold microflap injury in a preclinical model

Lea Sayce, Zachary Zimmerman, Gary Gartling, Bernard Rousseau, Ryan C. Branski

Publication date 17-01-2023


Transepithelial resistance quantification following bilatieral microflap injury.
Objectives Functional outcomes following microflap surgery for vocal fold pathology are favorable. Although the stratified squamous epithelium appears to heal rapidly, persistent physiologic tissue alterations are likely. We sought to elucidate key biochemical processes including recruitment of immune cells, regulation of cellular junction proteins, and long-term alterations to epithelial tissue permeability following microflap with an eye toward enhanced clinical outcomes.
Methods Forty New Zealand rabbits were assigned to eight groups (n = 5/group): no-injury control or bilateral microflap with survival for 0 h, 12 h, 1 day, 3 days, 7 days, 30 days, and 60 days post-microflap. The epithelium was dissected from one vocal fold and transepithelial resistance was quantified. The contralateral fold was subjected to transmission electron microscopy. Images were evaluated by a blinded rater and paracellular space dilation was quantified using ImageJ. Immune cell infiltration was evaluated and recorded qualitatively.
Results Increased innate immune response was observed 12 h as well as 7 and 30 days after microflap. At 60 days following injury, decreased epithelial resistance was observed. Paracellular spaces were dilated at all time-points following injury.
Conclusions The vocal fold epithelium was significantly altered at 60 days following microflap. The implications for this tissue phenotype are unclear. However, compromised epithelial barrier function is implicated in various diseases and may increase the risk of subsequent injury.
Level of EvidenceNA Laryngoscope, 133:350–356, 2023

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Dynamic Volumetric Computed Tomography Angiography is an Effective Method to Evaluate Tracheomalacia in Children

Maria Koenigs, Cody Young, Anna Lillis, Jessica Morrison, Natalie Kelly, Charles Elmaraghy, Rajesh Krishnamurthy, Tendy Chiang

Publication date 17-01-2023


Objective Standard methods to evaluate tracheal pathology in children, including bronchoscopy, may require general anesthesia. Conventional dynamic proximal airway imaging in noncooperative children requires endotracheal intubation and/or medically induced apnea, which may affect airway mechanics and diagnostic performance. We describe a technique for unsedated dynamic volumetric computed tomography angiography (DV-CTA) of the proximal airway and surrounding vasculature in children and evaluate its performance compared to the reference-standard of rigid bronchoscopy.
Methods Children who had undergone DV-CTA and bronchoscopy in one-year were retrospectively identified. Imaging studies were reviewed by an expert reader blinded to the bronchoscopy findings of primary or secondary tracheomalacia. Airway narrowing, if present, was characterized as static and/or dynamic, with tracheomalacia defined as >50% collapse of the tracheal cross-sectional area in exhalation. Pearson correlation was used for comparison.
Results Over a 19-month period, we identified 32 children (median age 8 months, range 3–14 months) who had undergone DV-CTA and bronchoscopy within a 90-day period of each other. All studies were unsedated and free-breathing. The primary reasons for evaluation included noisy breathing, stridor, and screening for tracheomalacia. There was excellent agreement between DV-CTA and bronchoscopy for diagnosis of tracheomalacia (κ = 0.81, p < 0.001), which improved if children (n = 25) had the studies within 30 days of each other (κ = 0.91, p < 0.001). CTA provided incremental information on severity, and cause of secondary tracheomalacia.
Conclusion For most children, DV-CTA requires no sedation or respiratory manipulation and correlates strongly with bronchoscopy for the diagnosis of tracheomalacia.
Level of Evidence3 Laryngoscope, 133:410–416, 2023

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Mortality Among Children with a Tracheostomy

Taylor B. Teplitzky, Ashley F. Brown, Rebecca L. Brooks, Candice H. Bailey, Cindy Whitney, Ashley Sewell, Yann‐Fuu Kou, Romaine F. Johnson, Stephen R. Chorney

Publication date 17-01-2023


Objectives To characterize the cause of death among children with a tracheostomy.
Study Design Prospective cohort.
Methods All pediatric patients (<18 years) who had a tracheostomy placed at a tertiary care institution between 2015 and 2020 were included. The location and cause of death were recorded along with patient demographics and age.
ResultsA total of 271 tracheostomies were placed with 46 mortalities reviewed for a mortality rate of 16.8%. Mean age at placement was 1.7 years (SD: 3.4) and mean age at death was 2.9 years (SD: 3.5). Most tracheostomies were placed for respiratory failure (N = 33, 72%). The mean time to death after tracheostomy was 1.2 years (SD: 1.2) and 28% (N = 13) occurred during the same admission as placement. Mean time to death after hospital discharge was 1.3 years (SD: 1.3). Etiology of death was respiratory failure (33%, N = 15), cardiopulmonary arrest (15%, N = 7), unknown (43%, N = 20), or secondary to a tracheostomy-related complication for 9% (N = 4). Location of death was in intensive care units for 41% (N = 19) and 30% died at home (N = 14). Comfort care measures were taken for 37% (N = 17). Severe neurological disability (HR: 4.06, p = 0.003, 95% CI: 1.59–10.34) and congenital heart disease (HR: 2.36, p = 0.009, 95% CI: 1.24–4.48) correlated with time to death on Cox proportional hazard modeling.
Conclusions Nearly one-third of children with a tracheostomy who expire will do so during the same admission as tracheostomy placement. Although progression of underlying disease will lead to most deaths, 9% will be a result of a tracheostomy-related complication, which represents a meaningful target for quality improvement initiatives.
Level of Evidence3 Laryngoscope, 133:403–409, 2023

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Impact of Age on Surgical Outcomes Following Mandible Fracture Repair

Ryan Jin, Kirolos Georges, Shravya Jasti, Salma Ahsanuddin, Joshua B. Cadwell, Boris Paskhover

Publication date 17-01-2023


Current literature on postoperative complications following repair of mandible fracture is limited. This study of a national database seeks to characterize the relationship between advanced age and postoperative complications following open repair of mandible fractures.
Objectives Open repair of mandibular fractures are frequently performed surgical procedures. Increasing rates of such fractures are seen in older adults following falls. This study assesses the impact of older age on early complications following mandible fracture repair.
Study Design Retrospective analysis of national registry.
Methods The 2013–2018 National Surgical Quality Improvement Program database was queried for all cases of open mandible fracture repair and cases were categorized into younger (18–40), middle (41–65), and older (>65) age cohorts. Demographics and comorbidities were compared between the age groups. Rates of surgical, medical, and wound complications within 30-days of surgery were determined. Multivariable logistic analyses were performed to assess the relationship between age and complications.
Results Altogether, 1818 cases were included for analysis, of which 1269 (69.8%) were younger, 459 (25.2%) were middle, and 90 (5.0%) were older age. Increased rates of complications were seen in the older groups, including unplanned reoperation, unplanned readmission, wound disruption, and medical complications (p < 0.01). On unadjusted analysis, the older (>65) age group had an increased odds of experiencing a complication compared to the younger (18–40) group (OR: 4.19, p < 0.001). The older age group continued to have a significantly increased odds of medical complications after multivariable adjustment (adjusted OR: 8.64, p < 0.001).
Conclusions On this analysis of a national database, advanced age was associated with an increased frequency of early postoperative complications following open mandibular fracture repair. Following multivariable adjustment, advanced age continued to be associated with increased odds of postoperative medical complications within 30 days of surgery.
Level of Evidence3 Laryngoscope, 133:287–293, 2023

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Incidence of Persistent Tracheocutaneous Fistula After Pediatric Tracheostomy Decannulation

Taylor B. Teplitzky, Yann‐Fuu Kou, Dylan R. Beams, Romaine F. Johnson, Stephen R. Chorney

Publication date 17-01-2023


Two-thirds of children will develop a persistent tracheocutaneous fistula (TCF) after tracheostomy decannulation. Persistent TCF is correlated with longer duration of tracheostomy and congenital malformations.
Objectives To determine the incidence of tracheocutaneous fistula (TCF) and identify characteristics associated with persistence.
Study Design Prospective cohort.
Methods All successfully decannulated children (<18 years) between 2014 and 2020 at a tertiary childrens hospital were included. Revision tracheostomies, concomitant major neck surgery, or single-stage laryngotracheal reconstructions were excluded. A persistent TCF was defined as a patent fistula at 6 weeks after decannulation.
ResultsA total of 77 children met inclusion criteria with a persistent TCF incidence of 65% (50/77). Children with a persistent TCF were younger at placement (1.4 years (SD: 3.3) vs. 8.5 years (SD: 6.5), p < 0.001) and tracheostomy-dependent longer (2.8 years (SD: 1.3) vs. 0.9 years (SD: 0.7), p < 0.001). On univariate analysis, placement under 12 months of age (86% vs. 26% p < 0.001), duration of tracheostomy more than 2 years (76% vs. 11% p < 0.001), short gestation (64% vs. 26%, p = 0.002), congenital malformations (64% vs. 33%, p = 0.02), newborn complications (58% vs. 26%, p = 0.009), maternal complications (40% vs. 11%, p = 0.009) and chronic respiratory failure (72% vs. 41%, p = 0.01) were associated with persistent TCF. Logistic regression analysis associated duration of tracheostomy (OR: 0.14, 95% CI: 0.05–0.35, p < 0.001) and congenital malformations (OR: 0.25, 95% CI: 0.06–0.99, p = 0.049) with failure to spontaneously close.
Conclusions Two-thirds of children will develop a persistent TCF after tracheostomy decannulation. Persistent TCF is correlated with a longer duration of tracheostomy and congenital malformations. Anticipation of this event in higher-risk children is necessary when caring for pediatric tracheostomy patients.
Level of Evidence3 Laryngoscope, 133:417–422, 2023

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The Optimized Protocol of Hyperbaric Oxygen Therapy For Sudden Sensorineural Hearing Loss

Hwabin Kim, Soo‐Keun Kong, Jia Kim, Hyun‐Min Lee, Sung‐Won Choi, Il‐Woo Lee, Se‐Joon Oh

Publication date 17-01-2023


When HBOT (10 sessions) was combined with corticosteroids as the initial therapy for SSNHL, a higher pressure (1.5 ATA vs. 2.5 ATA) provided better treatment result; however, increasing the duration (1 h vs. 2 h) did not result in a significant difference. The addition of 1.5 ATA HBOT showed similar results to the treatment without HBOT in our previous study.
Objective This study aimed to determine the optimal protocol of hyperbaric oxygen therapy (HBOT) according to various treatment settings for sudden sensorineural hearing loss (SSNHL).
MethodsA 112 patients with SSNHL were enrolled in this prospective study. All patients were treated with systemic steroid therapy, intratympanic steroid therapy, and HBOT. According to the pressure and duration of HBOT (10 sessions in total), the patients were divided into three groups: group 1, 2.5 atmospheres absolute (ATA) for 1 h; group 2, 2.5 ATA for 2 h; and group 3, 1.5 ATA for 1 h. The pure-tone average (PTA), word discrimination score (WDS), and mean gain were compared.
ResultsA total of 105 patients completed the 3-month follow-up, and 6 patients were excluded. Differences among groups were found in PTA, WDS, and mean gain. In the post-hoc analysis, group 3 had significantly lower WDS and mean gain than groups 1 and 2; however, group 2 showed no significant differences from group 1. The proportion of patients with hearing recovery after treatment was significantly higher in group 1 (57.6%) and group 2 (58.8%) than in group 3 (31.3%).
Conclusions When HBOT (10 sessions) was combined with corticosteroids as the initial therapy for SSNHL, a higher pressure (1.5 ATA vs. 2.5 ATA) provided better treatment results; however, increasing the duration (1 h vs. 2 h) under 2.5 ATA did not result in a significant difference. Therefore, HBOT for SSNHL may be performed at 2.5 ATA for 1 h in 10 sessions. Laryngoscope, 133:383–388, 2023

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Factors Shifting Preference Toward Telemedicine in the Delivery of Skin Cancer Reconstruction Care

Eric Y. Du, Rylee A. Moody, Matthew C. Simpson, Aditya Nellore, Joseph G. Sinnwell, Luke D. Heiland, Shane A. Grace, Collin L. Chen

Publication date 17-01-2023


Telemedicine is here to stay; we aimed to identify which delivery modality for skin reconstruction care is patient preferred and influences of this preference. In-person visits are preferred but this shifts toward virtual care with a cost and wait time in spite of perceived quality of care or age. Individuals with socioeconomic barriers to access prefer telemedicine.
Objectives Identify which delivery modality for skin reconstruction care, face-to-face (FTF) in-person versus two telemedicine modalities, store-and-forward (S&F) and live video chat (LVC), is patient preferred and how cost, access, wait time, and demographics influence this preference.
Study Design Cross-sectional survey.
MethodsA 16-question survey querying demographics and five scenario-specific preferences questions for the delivery of skin cancer reconstruction care was created and distributed via Amazon Mechanical Turk (MTurk), a crowdsourcing online marketplace, and in-person to Mohs micrographic surgery patients.
Results1394 MTurk and 55 in-person responses were included. While 82.1% of online respondents prefer FTF clinic visits, this decreases to 58.3% with an in-person visit cost (p < 0.01) and furthermore to a minority 43.5% with both an in-person visit cost and wait time (p < 0.01) despite 77.8% believing that usefulness to the surgeon would improve FTF. Both the MTurk and in-person cohorts demonstrated similar response patterns despite considerable demographic differences. Multivariable analyses revealed that telemedicine was preferred by MTurk respondents with Medicaid (adjusted OR 95% CI: 1.97 1.18–3.31) or Medicare (1.69 1.10–2.59) versus private insurance, and prior skin cancer (2.01 1.18–3.42) and less preferred by those earning $140,000+ per year (0.49 0.29–0.82) compared to those earning <$20,000 per year.
ConclusionsFTF visits are preferred for skin cancer reconstruction care; this shifts toward virtual care with a cost and wait time in spite of the perceived quality of care. Individuals with socioeconomic barriers to access prefer telemedicine. MTurk can be a valuable tool for behavioral research in FPRS.
Level of EvidenceNA Laryngoscope, 133:294–301, 2023

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Measurements of The Pediatric Cartilaginous Eustachian Tube: Implications for Balloon Dilation

Yuan Yu, Brent Geffen, Hilary McCrary, Gabriel Dunya, John Rampton, Chong Zhang, Angela P. Presson, Dennis Poe, Albert H. Park

Publication date 17-01-2023


Objectives(1) Measure the cartilaginous Eustachian tube (ET) length using a computed tomography (CT) scan and (2) develop a prediction model to measure this length without the need of a CT scan.
Study DesignCT measurements in children.
Setting Childrens Hospital.
MethodsCT scans were reformatted to project the cranial and caudal limits of the cartilaginous ET. The length was measured in 193 children who underwent a neck CT scan for nonotologic indications. Five physicians independently reviewed all or some of these measures. Four different models based on age, age ranges, weight, and height were created and compared to predict ET length.
Results The cartilaginous ET length was 25.3 ± 3.1 mm for the right and for the left ear. The mean ET length for the females was statistically significantly less than the length in males. The lower ET lengths in children as old as 5 years of age were less than the 2 cm adult criteria used for catheter insertion. All 4 models performed equally well in predicting ET length. Model number 4, which is based on height, was the easiest to calculate ET length.
Conclusion The cartilaginous portion of the pediatric ET can be measured with good precision using reformatted CT images. We caution against using the “adult” criteria of 2 cm for catheter insertion in children, especially those younger than 5 years of age. We recommend using a model utilizing height measures to estimate ET length or direct measurements from a reformatted CT scan.
Level of EvidenceNA Laryngoscope, 133:396–402, 2023

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Chronic Rhinosinusitis: T2r38 Genotyping and Nasal Cytology in Primary Ciliary Dyskinesia

Gioia Piatti, Umberto Ambrosetti, Mirko Aldè, Giorgia Girotto, Maria P. Concas, Sara Torretta

Publication date 17-01-2023


Objectives Chronic rhinosinusitis (CRS) is a major hallmark of primary ciliary dyskinesia (PCD). We investigated the possible correlation between some severity markers of CRS and several clinical features of the disease. We further studied the bitter taste receptor TAS2R38 polymorphisms to identify the genotypes associated with more severe disease.
Methods We included 39 adult PCD patients with (CRSwNP) and without nasal polyposis (CRSsNP); a sample for nasal cytology was obtained and clinical cytological grading (CCG) was determined. The SNOT-22 and Lund-Mackay scores were recorded. A sample of DNA was extracted from peripheral blood to investigate TAS2R38 polymorphisms.
ResultsCRSwNP patients had features of more severe disease: indeed, they had statistically significantly higher frequency of previous sinus surgery, higher SNOT-22, LM scores, and CCG than CRSsNP patients. Upon genotyping of TAS2R38 polymorphisms, we observed that the AVI–AVI genotype, associated to homozygous nonfunctional bitter TAS2R38 receptor, was more prevalent among CRSwNP (100%) than in CRSsNP patients (0%); furthermore, AVI–AVI subjects showed statistically significantly worse SNOT-22 and CCG scores than PAV–PAV and PAV–AVI subjects. The group of AVI–AVI patients also had more frequent respiratory exacerbations, Gram-negative infections, and Pseudomonas aeruginosa colonization than PAV–PAV and PAV–AVI patients.
Conclusion Our findings indicate for the first time that PCD patients with CRSwNP display a more severe disease than those with CRSsNP. Genotyping of TAS2R38 polymorphisms demonstrated that in PCD patients, the AVI–AVI genotype is strikingly more prevalent among CRSwNP than in CRSsNP, while the PAV–PAV genotype might be protective against Gram-negative infections and respiratory exacerbations.
Level of Evidence3 Laryngoscope, 133:248–254, 2023

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Association of APACHE‐II Scores With 30‐Day Mortality After Tracheostomy: A Retrospective Study

Matthew J. Marget, Raven Dunn, Christie L. Morgan

Publication date 17-01-2023


An APACHE-II score of 30 and above is a potentially useful clinical indicator of increased risk of mortality within 30 days of tracheostomy in patients with ventilator-dependent respiratory failure (VDRF). This tool may prove a valuable resource for ICU physicians, surgeons, and families who are considering tracheostomy for patients with VDRF.
Objective The objective of this study was to assess whether the Acute Physiology, Age, Chronic Health Evaluation II (APACHE-II) score is a reliable predictor of 30-day mortality in the setting of adult patients with ventilator-dependent respiratory failure (VDRF) who undergo tracheostomy.
Methods This is a retrospective, single-institution study. Potential subjects were identified using the current procedural terminology codes for the tracheostomy procedure and International Classification of Diseases, 10th Revision, codes for VDRF. APACHE-II scores were retrospectively calculated. Tracheostomies were performed in our population over an 18-month period (November 2018 through April 2020). Our study population did not include patients with novel coronavirus. The primary outcome was mortality at 30 days after tracheostomy.
ResultsA total of 238 patients with VDRF who had a tracheostomy were included in this study. Twenty-eight (11.8%) patients died within 30 days of tracheostomy. The mean (standard deviation) APACHE-II score was 22.5 (10.2) for patients who died within 30 days of tracheostomy and 19.8 (7.4) for patients living within 30 days of tracheostomy (p = 0.30). Patients with APACHE-II scores greater than or equal to 30 showed higher odds of death within 30 days of tracheostomy (odds ratio, 3.0; 95% CI, 1.14–7.89, p = 0.03).
Conclusion An APACHE-II score of 30 and above is associated with mortality within 30 days of tracheostomy in patients with VDRF. APACHE-II scores may be a promising tool for assessing risk of mortality in patients with VDRF after tracheostomy.
Level of Evidence3 Laryngoscope, 133:273–278, 2023

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Tumor Satellites Are Associated With Poor Outcome in Patients With Oral Cancer

Eyal Yosefof, Sharon Tzelnick, Leemor Wallach, Yuval Miller, Yulia Strenov, Gideon Bachar, Thomas Shpitzer, Aviram Mizrachi

Publication date 17-01-2023


Tumor satellites in oral cavity cancer are believed to be a sign of aggressive disease. our study demonstrates a correlation between tumor satellites and worse disease-specific survival and overall survival. Patients with oral cavity cancer and tumor satellites should be treated aggressively and followed up closely.
Objectives Tumor satellites are defined as islands of tumor cells completely separated from the border of the main tumor. They are believed to be a sign of aggressive disease. Our goal was to investigate the association between tumor satellites and outcome in patients with oral squamous cell carcinoma.
Materials and MethodsA retrospective analysis of all patients treated for oral squamous cell carcinoma at a university-affiliated tertiary care center between 2010 and 2018 was performed. Data collected included demographics, clinical and pathological features including tumor satellites, staging, treatment modalities, and outcomes.
ResultsA total of 144 patients were included. The mean age of all patients was 63.5 and 50.7% were males. The mean follow-up time was 40.5 months. Seventeen patients (11.8%) had tumor satellites. These patients had a higher rate of involved margins, peri-neural invasion, lympho-vascular invasion, and extra-nodal extension. Tumor, nodal and overall classification were significantly more advanced in patients with satellites. Disease-specific and overall survival rates were significantly lower among satellites patients (28.7% vs. 59.7% and 28.7% vs. 54.9%, respectively).
Conclusions Tumor satellites are associated with several adverse features and advanced locoregional disease. Patients with satellites should be treated aggressively with a combination of surgery aimed at achieving free surgical margins and adjuvant treatment, as they have a worse prognosis compared with patients without satellites. Further prospective studies are mandatory to consolidate the importance of adjuvant treatment in these patients.
Level of Evidence3 Laryngoscope, 133:336–343, 2023

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A Deep Learning Model for Classification of Parotid Neoplasms Based on Multimodal Magnetic Resonance Image Sequences

Xu Liu, Yucheng Pan, Xin Zhang, Yongfang Sha, Shihui Wang, Hongzhe Li, Jianping Liu

Publication date 17-01-2023


An accurate and efficient artificial intelligence-based classification model was produced to classify parotid neoplasms, resulting from the fusion of multimodal magnetic resonance image (MRI) sequences. The effectiveness certainly outperformed the model with single MRI images or single MRI sequences as input, and potentially, experienced radiologists.
Objective To design a deep learning model based on multimodal magnetic resonance image (MRI) sequences for automatic parotid neoplasm classification, and to improve the diagnostic decision-making in clinical settings.
Methods First, multimodal MRI sequences were collected from 266 patients with parotid neoplasms, and an artificial intelligence (AI)-based deep learning model was designed from scratch, combining the image classification network of Resnet and the Transformer network of Natural language processing. Second, the effectiveness of the deep learning model was improved through the multi-modality fusion of MRI sequences, and the fusion strategy of various MRI sequences was optimized. In addition, we compared the effectiveness of the model in the parotid neoplasm classification with experienced radiologists.
Results The deep learning model delivered reliable outcomes in differentiating benign and malignant parotid neoplasms. The model, which was trained by the fusion of T2-weighted, postcontrast T1-weighted, and diffusion-weighted imaging (b = 1000 s/mm2), produced the best result, with an accuracy score of 0.85, an area under the receiver operator characteristic (ROC) curve of 0.96, a sensitivity score of 0.90, and a specificity score of 0.84. In addition, the multi-modal paradigm exhibited reliable outcomes in diagnosing the pleomorphic adenoma and the Warthin tumor, but not in the identification of the basal cell adenoma.
Conclusion An accurate and efficient AI based classification model was produced to classify parotid neoplasms, resulting from the fusion of multimodal MRI sequences. The effectiveness certainly outperformed the model with single MRI images or single MRI sequences as input, and potentially, experienced radiologists.
Level of Evidence3 Laryngoscope, 133:327–335, 2023

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Post‐operative Outcomes in Pediatric Patients Following Facial Reconstruction With Fibula Free Flaps

Allison A. Slijepcevic, Mark K. Wax, Matthew Hanasono, Yadranko Ducic, Daniel Petrisor, Carissa M. Thomas, Yelizaveta Shnayder, Kiran Kakarala, Patrik Pipkorn, Sidharth V. Puram, Jason Rich, Rod Rezaee, Amy Pittman, Scott Troob, Head and Neck Reconstruction Group

Publication date 17-01-2023


Educational Objective Assess outcomes of pediatric facial reconstruction with fibula free flaps.
Objectives Free flap reconstruction of complex maxillofacial defects in pediatric patients is rare. Post-operative complications, donor site morbidity, impact on craniofacial growth, and oro-dental rehabilitation are unknown. Our study assesses the outcomes of pediatric maxillofacial reconstruction with composite fibula free flaps.
Study Design Retrospective chart review.
Methods Multi-institutional retrospective chart review from 2000 to 2020 on pediatric patients undergoing maxillomandibular reconstruction with fibula free flaps.
Results Eighty-seven patients underwent 89 surgeries; 5 maxillary and 84 mandibular defects.
Median age: 12 years. Defects were acquired following resection of sarcoma/carcinoma 44% or benign tumors 50%. 73% of cases had immediate free flap reconstruction. Closing osteotomies were reported in 74%; 1 in 40%, 2 in 27%, and more than 2 in 6.7%. Hardware was used in 98% and removed in 25%. 9.2% demonstrated long-term hardware exposure, greater than 3 months following reconstruction. Short-term complications: wound infection 6.7%, flap salvage/failure 2.2%, fistula 1.1%, and compromised craniofacial growth: 23%. Two patients developed trismus. Long-term fibula donor site complications: hypertrophic scarring: 3.4%, dysesthesia: 1.1%, and long-term gait abnormality: 1.1%. Dental rehabilitation was performed in 33%. Post-operative speech outcomes showed 94% with fully intelligible speech.
Conclusion Pediatric maxillary and mandible defects repaired with fibula free flaps demonstrated complication rates comparable to the adult free flap population. Long-term follow-up did not demonstrate adverse outcomes for craniofacial growth. Hardware for flap retention was utilized and remained in place with minimal exposure. Post-operative gait abnormality is rare.
Level of Evidence3 Laryngoscope, 133:302–306, 2023

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Mucosal Melanoma of the Oral Cavity: What is the Role of Elective Neck Dissection?

Sean Haimowitz, David A. Cohen, Aatin Dhanda, Kendyl Barron, Roman Povolotskiy, Dylan Roden

Publication date 17-01-2023


This study uses the National Cancer Database to analyze factors associated with survival in oral cavity mucosal melanoma, as well as the role of elective neck dissections. Lymph node involvement, distant metastasis, age, race, and male sex were associated with worse outcomes. While elective neck dissections did not improve overall survival, they may have a prognostic role and help select patients for treatment intensification.
Objectives Mucosal melanoma (MM) is a rare malignancy that can present in the head and neck (H&N). The Oral cavity is the second most common primary site in the H&N after sinonasal mucosa. This study investigates the impact of demographic and clinical factors on survival in oral cavity MM. Further, it investigates the outcomes and utility of elective neck dissections (END) in the management of oral MM.
Methods The National Cancer Database was used to evaluate 432 patients with oral cavity MM from 2004 to 2016. Kaplan-Meir and Cox regression analyses were used to determine variables associated with survival.
Results The mean age was 64.0 ± 16.0 years. Most patients were white (85.1%) and male (60.0%). Gingiva (37.6%) and hard palate (36.1%) were the most common primary subsites in the oral cavity. Five-year overall survival was 31.0%. Age (Hazards Ratio 95% Confidence Interval, 1.03 1.01–1.06), N-stage (1.94 1.10–3.42), M-stage (10.13 3.33–30.86), male sex (1.79 1.06–3.03), and African-American race (2.63 1.14–6.11) were significantly associated with worse survival. 199 patients (46.9%) underwent neck dissection including 118 with lymph node yield (LNY) ≥ 18. The rate of occult nodal positivity was 45.4% for LNY ≥ 18 and 28.3% for LNY ≥ 1. ENDs were not associated with improved outcomes. However, occult lymph node involvement was associated with worse overall survival (p = 0.004).
Conclusions Oral cavity MM has a poor prognosis. Lymph node involvement, distant metastasis, age, race, and male sex are associated with worse outcomes. Performing an END did not improve survival. However, END may have a prognostic role and help select patients for treatment intensification.
Level of Evidence4 Laryngoscope, 133:317–326, 2023

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"Correlations of MR Sialographic Gradings with the Clinical Measures of Sjögrens Syndrome"

Ara Cho, Ye Rin Lee, Yu Tae Jeon, Seung‐Hyun Chang, Young Min Park, Sung Jun Ahn, Jae‐Yol Lim

Publication date 17-01-2023


PG sialectasis and the fat deposition stage in SMGs on MR sialography reflect the structural deformity-related disease status in SS. MR sialography is a reliable, adjunctive anatomical and functional study to assess SS.
Objectives Sjögren syndrome (SS) features salivary gland architectural changes such as ductal deformities and fat deposition secondary to inflammatory cell infiltrates; however, the anatomical and pathophysiological correlations of SS remain to be determined. This study aimed to determine the correlations of imaging findings based on the magnetic resonance (MR) sialography with the clinical and laboratory aspects of SS patients.
Methods We evaluated the MR sialographic findings of two pairs of parotid glands (PGs) and submandibular glands (SMGs) from 41 SS patients. The distinct MR sialographic features were then compared with the clinical symptoms, biological (anti-SSA/Ro antibody positivity), histological (labial gland focus score), and functional (salivary flow and scintigraphy) data.
Results Ductal deformities such as sialectasis in the PG ducts were exclusively observed in SS, and fat replacement in SMGs was more distinct in patients with SS than in non-SS sicca patients. Of the 82 PGs and SMGs from 41 SS patients, the grade of sialectasis in PGs on MR sialographic images and fat stage in SMGs showed strong correlations with anti-SSA/Ro-positivity. PG sialectasis was found more frequently in patients with dry mouth and decreased salivary gland function. A significant correlation was found between fat deposition in PGs and SMGs and decreased salivary gland function.
Conclusion These results suggest that MR sialography is a reliable, adjunctive anatomical and functional study to assess SS. Detail aspects of sialectasis and fat accumulation encountered on MR sialography in SS patients can help physicians assume the disease status in SS.
Level of Evidence3 Laryngoscope, 133:307–316, 2023

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Features of Odontogenic Sinusitis Associated With Dental Implants

Marn Joon Park, Han Ick Park, Kang‐Min Ahn, Ji Heui Kim, Yoo‐Sam Chung, Yong Ju Jang, Myeong Sang Yu

Publication date 17-01-2023


Objectives With the increase in dental implants for tooth loss, odontogenic sinusitis following maxillary dental implants is frequently encountered in otorhinolaryngology practice. The authors aimed to reveal the association between implant extrusion into maxillary sinus, along with implant-related complications in patients diagnosed with implant-related odontogenic sinusitis (IR-ODS).
Study Design Case–control study.
Methods This study enrolled 60 patients who received functional endoscopic sinus surgery due to IR-ODS. The preoperative sinus computed tomography was retrospectively reviewed. Among the 120 maxillary sinuses of the 60 patients, 68 sides were diagnosed with IR-ODS sides, whereas 27 sides showed no clinical or radiological evidence of this condition after the implant insertion and were defined as the control sides. Statistical analysis between these two groups was conducted, in addition to odds ratio (OR) calculations for associations with IR-ODS.
Results The mean age of the IR-ODS subjects was 59.5 ± 19.1, with a male to female ratio of 32/28 (53.3%/46.7%). Implants extruding by more than 4 mm into the maxillary sinus, peri-implantitis, bone graft disruption–extrusion were associated with a significantly higher incidence in the IR-ODS (p = 0.035, p = 0.003, p = 0.011, respectively). The IR-ODS sides showed an adjusted-OR (95% confidence interval) of 27.4 (2.7–276.5) for extrusion length >4 mm, 11.8 (3.0–46.5) for peri-implantitis, and 34.1 (3.3–347.8) for bone graft disruption (p = 0.005, p < 0.001, and p = 0.003, respectively).
Conclusion Maxillary dental implants extruding more than 4 mm into the maxillary sinus, peri-implantitis, and disrupted–extruded bone grafts show significant association with IR-ODS.
Level of Evidence4 Laryngoscope, 133:237–243, 2023

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Risk Factors For Hearing Decline From Childhood To Early Adolescence

Danique E. Paping, Berthe C. Oosterloo, Hanan El Marroun, Nienke C. Homans, Rob J. Baatenburg de Jong, Marc P. Schroeff, Jantien L. Vroegop

Publication date 17-01-2023


The aim of the present study was to identify risk factors for hearing decline between 9 and 13 years of age. Lower educational level and risky behavior were significantly associated with hearing decline.
Objective To identify risk factors of hearing decline between 9 and 13 years of age. The risk factors examined included sociodemographic, health, and lifestyle-related factors.
Methods This study was embedded within a population-based prospective cohort study from fetal life onwards in the Netherlands. Pure-tone audiometry and tympanometry were performed at the age of 9 and 13 years. The hearing decline was defined as an increase in low-frequency or high-frequency pure-tone average of at least 5 dB in one of both ears. Multivariable logistic regression was performed to examine the association of possible risk factors with hearing decline. The study was conducted from April 2012 to October 2015, and from April 2016 to September 2019.
Results Of the 3,508 participants included, 7.8% demonstrated a hearing decline in the low frequencies, and 11.3% in the high frequencies. Participants who reported alcohol consumption were more likely to have a hearing decline in the low frequencies (OR 1.5, 95% CI 1.1; 2.0). Moreover, a lower educational level was associated with an increased odds of having a hearing decline in the high frequencies (OR 1.4, 95% CI 1.0; 1.8). Age, sex, household income, personal music player use, and body mass index were not associated with hearing decline.
Conclusion Educational level and risky behavior were significantly associated with hearing decline from childhood to early adolescence. The findings of the present study can help in the design of public health interventions to prevent hearing loss at a young age.
Level of Evidence2 (prospective cohort study) Laryngoscope, 133:389–395, 2023

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Expanded transcanal transpromontorial approach for acoustic neuroma removal

Giulia Molinari, Francesco Chiari, Livio Presutti, Matteo Fermi, Ignacio Javier Fernandez, Matteo Alicandri‐Ciufelli

Publication date 17-01-2023


Axial sections from preoperative magnetic resonance imaging without contrast, showing a cone-shaped lesion of the internal auditory canal, extending toward the most lateral part of the cerebello-pontine angle. (A) T1-weighted high-resolution isotropic volume excitation (THRIVE) sequence; (B) T1-weighted sequence; (C) Fluid attenuated inversion recovery (FLAIR) sequence. Laryngoscope, 133:282–286, 2023

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Facility Volume as a Prognosticator of Survival in Locally Advanced Papillary Thyroid Cancer

Arash Abiri, Jonathan C. Pang, Kelsey Roman, Khodayar Goshtasbi, Jack L. Birkenbeuel, Edward C. Kuan, Tjoson Tjoa, Yarah M. Haidar

Publication date 17-01-2023


The influence of facility case-volume on survival was evaluated in patients with locally advanced papillary thyroid cancer. Facility case-volume was an independent predictor of improved overall survival. Facilities that treated ≥27 cases per year were associated with increased overall survival, indicating a possible survival benefit at high-volume medical centers.
Objectives To evaluate the influence of facility case-volume on survival in patients with locally advanced papillary thyroid cancer (PTC), and to identify prognostic case-volume thresholds for facilities managing this patient population.
Study Design Retrospective database study.
Methods The 2004–2017 National Cancer Database was queried for patients receiving definitive surgery for locally advanced PTC. Using K-means clustering and multivariable Cox proportional-hazards (CPH) regression, two groups with distinct spectrums of facility case-volumes were generated. Multivariable CPH regression and Kaplan–Meier analysis assessed for the influence of facility case-volume and the prognostic value of its stratification on overall survival (OS).
Results Of 48,899 patients treated at 1304 facilities, there were 34,312 (70.2%) females and the mean age was 48.0 ± 16.0 years. Increased facility volume was significantly associated with reduced all-cause mortality (HR 0.996; 95% CI, 0.992–0.999; p = 0.008). Five facility clusters were generated, from which two distinct cohorts were identified: low (LVF; <27 cases/year) and high (HVF; ≥27 cases/year) facility case-volume. Patients at HVFs were associated with reduced mortality compared to those at LVFs (HR 0.791; 95% CI, 0.678–0.923, p = 0.003). Kaplan–Meier analysis of propensity score-matched N0 and N1 patients demonstrated higher OS in HVF cohorts (all p < 0.001).
Conclusions Facility case-volume was an independent predictor of improved OS in locally advanced PTC, indicating a possible survival benefit at high-volume medical centers. Specifically, independent of a number of sociodemographic and clinical factors, facilities that treated ≥27 cases per year were associated with increased OS. Patients with locally advanced PTC may, therefore, benefit from referrals to higher-volume facilities.
Level of Evidence4 Laryngoscope, 133:443–450, 2023

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Comparison of Inhaled Drug Delivery in Patients With One‐ and Two‐level Laryngotracheal Stenosis

Raluca E. Gosman, Ryan M. Sicard, Seth M. Cohen, Dennis O. Frank‐Ito

Publication date 17-01-2023


In seven patients with either one- and two-level stenosis, we used CFD modeling of upper airway airflow and drug delivery to mimic DPI and MDI use at varying initial release velocities. Results show increased airflow resistance and drug delivery within stenotic regions in subjects with two-level stenosis. Drug particles between 6-10microns had greater deposition at most stenotic sites, and lower initial release velocities produced greater drug deposition than higher initial velocities from MDIs. These particle characteristics may not be comparable to typical particle sizes released from commonly used inhalers.
Objectives/Hypothesis Laryngotracheal stenosis (LTS) is a functionally devastating condition with high respiratory morbidity and mortality. This preliminary study investigates airflow dynamics and stenotic drug delivery in patients with one- and two-level LTS.
Study DesignA Computational Modeling Restropective Cohort Study.
Methods Computed tomography scans from seven LTS patients, five with one-level (three subglottic, two tracheal), and two with two-level (glottis + trachea, glottis + subglottis) were used to reconstruct patient-specific three-dimensional upper airway models. Airflow and orally inhaled drug particle transport were simulated using computational fluid dynamics modeling. Drug particle transport was simulated for 1–20 μm particles released into the mouth at velocities of 0 m/s, 1 m/s, 3 m/s, and 10 m/s for metered dose inhaler (MDI) and 0 m/s for dry powder inhaler (DPI) simulations. Airflow resistance and stenotic drug deposition in the patients airway models were compared.
Results Overall, there was increased airflow resistance at stenotic sites in subjects with two-level versus one-level stenosis (0.136 Pa s/ml vs. 0.069 Pa s/ml averages). Subjects with two-level stenosis had greater particle deposition at sites of stenosis compared to subjects with one-level stenosis (average deposition 2.31% vs. 0.96%). One-level stenosis subjects, as well as one two-level stenosis subject, had the greatest deposition using MDI with a spacer (0 m/s): 2.59% and 4.34%, respectively. The second two-level stenosis subject had the greatest deposition using DPI (3.45%). Maximum deposition across all stenotic subtypes except one-level tracheal stenosis was achieved with particle sizes of 6–10 μm.
Conclusions Our results suggest that patients with two-level LTS may experience a more constricted laryngotracheal airflow profile compared to patients with one-level LTS, which may enhance overall stenotic drug deposition.
Level of EvidenceNA Laryngoscope, 133:366–374, 2023

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3D Reconstruction of Phonatory Glottal Shape and Volume: Effects of Neuromuscular Activation

Neha K. Reddy, Patrick Schlegel, Yoonjeong Lee, Dinesh K. Chhetri

Publication date 17-01-2023


In this study, we utilized a 3D reconstruction approach to visualize the vocal fold medial surface during phonation in an in vivo canine hemilarynx, and we obtained direct measurements of glottal movement, and glottal volume waveform, and resulting voice quality. We present the glottal volume waveform as a correlate of laryngeal vibratory dynamics and highlight the importance of intrinsic laryngeal muscles in modulating medial surface dynamics to achieve improved voice quality.
Introduction Although phonatory glottal posture and airflow pulse shape affect voice quality, studies to date have been limited by visualization of vocal fold (VF) vibration from a superior view. We performed a 3D reconstruction of VF vibratory motion during phonation from a medial view and assessed the glottal volume waveform and resulting acoustics as a function of neuromuscular stimulation.
Study Design In vivo canine hemilarynx phonation.
Methods Across 121 unique combinations of the superior laryngeal nerve (SLN) and recurrent laryngeal nerve (RLN) stimulation, the hemilarynx was excited to the oscillation with airflow. VF medial surface reference points were tracked on high-speed video, mapped into 3D space, and surface shape was restored using cubic spline interpolation. Glottal surface shape, reconstruction-based parameters, and glottal volume waveform were calculated. Fundamental frequency (F0), cepstral peak prominence (CPP), and harmonic amplitude (H1-H2) were measured from high-quality audio samples.
Results The glottis was convergent during opening and divergent during closing. Neuromuscular activation changed phonatory glottal shape and reduced glottal volume. Significant reduction in glottal volume and closing quotient were present with SLN stimulation. RLN stimulation significantly increased F0 and CPP and decreased H1-H2 (constricted glottis), while SLN effects were similar and synergistic with concurrent RLN stimulation.
Conclusion3D reconstruction of in vivo medial surface vibration revealed effects of laryngeal nerve stimulation on glottal vibratory pattern and acoustic correlates of voice quality. SLN activation resulted in significantly quicker glottal closure per cycle, decreased glottal volume, and higher-pitched, less breathy, and less noisy voice. RLN had a similar effect on acoustic measures.
Level of EvidenceNA, Basic Science Laryngoscope, 133:357–365, 2023

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Anaplastic Transformation of Differentiated Thyroid Carcinoma

Alice C. Yu, Albert Y. Han, David Alex Cronkite, Dipti Sajed, Maie A. St. John

Publication date 17-01-2023


In this study, we found that foci of differentiation within anaplastic thyroid carcinoma do not affect prognosis and should not be taken as a guarantee of more benign tumor biology. The malignant anaplastic component of these tumors does not appear to be tempered by the presence of well-differentiated thyroid carcinoma. Instead, improved survival was associated with smaller tumor size and use of chemotherapy.
Objectives Anaplastic thyroid carcinoma (ATC) is a rare but highly aggressive form of thyroid cancer. Increasingly, patients with ATC present with concurrent foci of well-differentiated thyroid carcinoma (WDTC); however, the significance of these pathologic findings remains unclear. The objective of this study is to determine whether the presence of WDTC within anaplastic tumors is a prognosticator of survival.
MethodsA retrospective cohort study of all cases of biopsy-proven ATC managed at a tertiary care academic medical center from 2002 to 2020 was performed. Mean age at diagnosis, median survival time, and locations of distant metastases were assessed. The impact of clinical markers such as presence of differentiation, demographic variables, and oncologic information on overall survival was also determined via univariate and multivariate analysis.
Results Forty-five patients were included in this study. The mean age at diagnosis was 69.1 years. Median survival time was 6.1 months after diagnosis. The most common location of distant metastases was the lung (40%). The presence of limited areas of WDTC in patients with predominantly anaplastic thyroid tumors was not significantly associated with improved outcomes (p = 0.509). Smaller tumor size and use of chemotherapy in ATC patients were significantly associated with prolonged survival (p = 0.026 and 0.010, respectively).
Conclusions Clinical outcomes for ATC remain poor. The presence of foci of differentiation within anaplastic thyroid tumors does not appear to improve overall survival—the anaplastic component evidently drives outcomes. Further studies into novel therapies are needed to improve survival in ATC.
Level of Evidence4 Laryngoscope, 133:437–442, 2023

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Association Between Systemic Corticosteroid Use and Mortality in Patients with Epiglottitis

Yuya Kimura, Taisuke Jo, Norihiko Inoue, Maho Suzukawa, Goh Tanaka, Hidenori Kage, Ryosuke Kumazawa, Hiroki Matsui, Kiyohide Fushimi, Hideo Yasunaga, Hirotoshi Matsui

Publication date 17-01-2023


Objectives To clarify whether treatment with systemic corticosteroids at a certain dose was associated with better outcomes in patients with epiglottitis requiring airway management (tracheotomy or airway intubation).
Methods This was a retrospective cohort study on patients hospitalized for epiglottitis requiring airway management from a nationwide inpatient database (between July 2010 and March 2019). Patients treated with systemic corticosteroids equivalent to methylprednisolone ≥40 mg/d within 2 days of admission and patients who were not treated with corticosteroids within 2 days of admission were compared after inverse probability of treatment weighting using covariate balancing propensity score. The primary outcome was all-cause 30-day in-hospital mortality, and secondary outcomes included all-cause 7-day in-hospital mortality, length of hospital stay, and total medical cost.
Results There were 1986 and 1771 patients in the corticosteroid and control groups, respectively. A total of 72 of 3757 (1.9%) patients died within 30 days of admission, including 17 of 1986 (0.9%) patients in the corticosteroid group and 55 of 1771 (3.1%) in the control group (weighted odds ratio, 0.28 95% confidence interval, 0.11–0.70; weighted risk difference, −2.2% −3.2% to −1.3%). Treatment with corticosteroids was associated with lower total medical costs (weighted median, $6,187 vs. $6,587; weighted difference, $-1,123 −2,238 to −8) but not all-cause 7-day in-hospital mortality (weighted odds ratio, 0.63 0.22–1.82; weighted risk difference, −0.3% −0.9 to 0.2) and length of hospital stay (weighted median, 13 vs. 13 days; weighted difference, −0.2 days −2.1 to 1.8).
Conclusions Systemic corticosteroids may be beneficial to patients with epiglottitis requiring airway management.
Level of Evidence3 Laryngoscope, 133:344–349, 2023

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The Role of Sialendoscopy in Parotid Duct Stenosis in Graft‐Versus‐Host Disease

Elisabeth E. Hansen, Margaret B. Mitchell, Rahmatullah W. Rahmati

Publication date 17-01-2023


A 58-year-old man with chronic graft-versus host disease underwent left parotid duct sialendoscopy for parotid swelling and dry mouth. An area of ductal obstruction was dilated. Three-and-a-half months after the procedure, the patient had no recurrence of parotid gland symptoms.
Sialendoscopy, a minimally invasive procedure for concurrent diagnosis and treatment of salivary gland ductal pathologies, was used to alleviate recurrent left parotid gland swelling and dry mouth in a 58-year-old man with chronic graft-versus-host disease. Laryngoscope, 133:279–281, 2023

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Endoscopic Posterior Costochondral Graft with Cricoid Sutures for a Recurrent Type 3 Laryngeal Cleft

Clare Richardson, Vanessa Masco, Kaalan Johnson

Publication date 17-01-2023


A patient with a multiply recurrent tracheoesophageal fistula (TEF) after type III laryngotracheoesophageal cleft (LTEC) repair underwent endoscopic repair with a posterior costochondral graft (PCCG). The graft was parachuted into place via two sutures placed through the postero-lateral cricoid cartilage, providing a layered, rigid, and secure repair. This represents the first description of an all endoscopic revision LTEC/TEF repair with PCCG.
A patient with a recurrent connection between their trachea and esophagus underwent an endoscopic repair (through the mouth with no incisions) with a graft secured via sutures, which is the first description of fully endoscopic graft placement for this pathology. Laryngoscope, 133:269–272, 2023

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In Reference to Predictors of Postoperative Nausea and Vomiting After Endoscopic Skull Base Surgery

Ozkan Onal, Merih Onal

Publication date 17-01-2023


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In Response to Predictors of Postoperative Nausea and Vomiting After Endoscopic Skull Base Surgery

Arash Abiri, Jack L. Birkenbeuel, Edward C. Kuan

Publication date 17-01-2023


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New Facial Plastics/Reconstructive Surgery Associate Editor for the Laryngoscope

Samuel H. Selesnick

Publication date 17-01-2023


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Masthead

Publication date 17-01-2023


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Table of contents

Publication date 17-01-2023


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Physician Turnover Among Otolaryngologists in the United States, 2014–2021

Amar H. Sheth, Vinay K. Rathi, George A. Scangas, Lucy Xu, Mark A. Varvares, Matthew R. Naunheim

Publication date 17-01-2023


Using publicly available Medicare data, we performed a retrospective cross-sectional analysis of separation between otolaryngologists and affiliated medical groups between 2014 and 2021. During this period, the cumulative turnover rate among otolaryngologists was 36.4%, with annual turnover rates ranging between 6.2%–10.2%. Otolaryngologist turnover rates varied by career stage and group size.

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Comparison of Adult and Pediatric Cochlear Implant Wound Complications: A Meta‐Analysis

Brady Ekman, Jack Laureano, Beverly Balasuriya, Anthony Mahairas, Matthew L. Bush

Publication date 17-01-2023


The objective of this study is to compare age-related differences in wound complications following cochlear implantation (CI). CI wound complication rates reported in the literature are low; however, adults have a higher risk of these complications than pediatric patients. The reported complication rate in elderly adults is low.
Objective To compare age-related differences in wound complications following cochlear implantation (CI).
Methods We performed a systematic review of Pub Med, Cochrane Database, and Web of Science databases to identify original research evaluating the patient-level factors (demographics and medical history) associated with wound complications following CI. Outcomes were expressed as relative risk (RR) with 95% confidence intervals using the inverse variance method. Studies without comparison groups were described qualitatively.
Results Thirty-eight studies representing 21,838 cochlear implantations were included. The rate of wound complications ranges from 0% to 22%. Patient age (adult versus pediatric) was the only factor with comparison groups appropriate for meta-analysis. The 10 studies (n = 9547 CIs) included in the meta-analysis demonstrated that adults had a higher incidence of overall wound complications (2.94%) than in children (2.44%) (RR 1.31, 95% CI 1.01–1.69). Adults had a higher incidence of general/unclassified wound complications (2.07%) than in children (1.34%) (RR 1.68, 95% CI 1.12–2.52). There was no difference between adults and children for specific complications such as hematoma, infection, or seroma. Elderly patients (over age 75) have wound complication rates that range from 1% to 4%. No studies contained comparison groups regarding other patient-level factors and CI wound complications.
ConclusionCI wound complication rates reported in the literature are low; however, adults have a higher risk of these complications than pediatric patients. The reported complication rate in elderly adults is low. There is a gap in CI research in consistently reporting wound complications and rigorous research investigating the impact of patient-level factors and wound complications.
Level of EvidenceNA Laryngoscope, 133:218–226, 2023

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The American Broncho‐Esophagological Association Position Statement on Swallowing Fluoroscopy

"Shumon Ian Dhar, Nogah Nativ‐Zeltzer, Heather Starmer, Linda Nayeli Morimoto, Lisa Evangelista, Ashli ORourke, Mark Fritz, Anaïs Rameau, Derrick R. Randall, Daniel Cates, Jacqueline Allen, Gregory Postma, Maggie Kuhn, Peter Belafsky"

Publication date 17-01-2023


Objectives To develop an expert consensus statement on the clinical use of swallowing fluoroscopy in adults that reduces practice variation and identifies opportunities for quality improvement in the care of patients suffering from swallowing impairment.
MethodologyA search strategist reviewed data sources (Pub Med, Embase, Cochrane, Web of Science, Scopus) to use as evidence for an expert development group to compose statements focusing on areas of controversy regarding swallowing fluoroscopy. Candidate statements underwent two iterations of a modified Delphi protocol to reach consensus.
ResultsA total of 2184 publications were identified for title and abstract review with 211 publications meeting the criteria for full text review. Of these, 148 articles were included for review. An additional 116 publications were also included after reviewing the references of the full text publications from the initial search. These 264 references guided the authors to develop 41 candidate statements in various categories. Forty statements encompassing patient selection, fluoroscopic study choice, radiation safety, clinical team dynamics, training requirements, videofluoroscopic swallow study and esophagram techniques, and interpretation of swallowing fluoroscopy met criteria for consensus. One statement on esophagram technique reached near-consensus.
Conclusions These 40 statements pertaining to the comprehensive use of swallowing fluoroscopy in adults can guide the development of best practices, improve quality and safety of care, and influence policy in both the outpatient and inpatient settings. The lack of consensus on some aspects of esophagram technique likely reflects gaps in knowledge and clinical practice variation and should be a target for future research. Laryngoscope, 133:255–268, 2023

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What is the Current State of Extended Reality Use in Otolaryngology Training? A Scoping Review

Ivry Zagury‐Orly, Mark A. Solinski, Lily HP. Nguyen, Meredith Young, Veronica Drozdowski, Paul A. Bain, Eric A. Gantwerker

Publication date 17-01-2023


A scoping review was conducted to map current literature on the educational use of extended reality (XR) in Otolaryngology-Head and Neck Surgery (OHNS) Education. Based on 40 articles, eligible for inclusion, current educational applications of XR in OHNS are restricted to virtual reality, do not fully immerse participants nor assess higher-level learning outcomes, and are mostly limited to temporal bone surgery. The educational OHNS community would benefit from assessment of skills transfer, deliberate testing of augmented and mixed reality, and procedures beyond Otology training.
Objective To map current literature on the educational use of extended reality (XR) in Otolaryngology-Head and Neck Surgery (OHNS) to inform teaching and research.
Study Design Scoping Review.
MethodsA scoping review was conducted, identifying literature through MEDLINE, Ovid Embase, and Web of Science databases. Findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review checklist. Studies were included if they involved OHNS trainees or medical students who used XR for an educational purpose in OHNS.
XR was defined as: fully-immersive virtual reality (VR) using head-mounted displays (HMDs), non-immersive and semi-immersive VR, augmented reality (AR), or mixed reality (MR). Data on device use were extracted, and educational outcomes were analyzed according to Kirkpatricks evaluation framework.
Results Of the 1,434 unique abstracts identified, 40 articles were included. All articles reported on VR; none discussed AR or MR. Twenty-nine articles were categorized as semi-immersive, none used occlusive HMDs therefore, none met modern definitions of immersive VR. Most studies (29 of 40) targeted temporal bone surgery. Using the Kirkpatrick four-level evaluation model, all studies were limited to level-1 (learner reaction) or level-2 (knowledge or skill performance).
Conclusions Current educational applications of XR in OHNS are limited to VR, do not fully immerse participants and do not assess higher-level learning outcomes. The educational OHNS community would benefit from a shared definition for VR technology, assessment of skills transfer (level-3 and higher), and deliberate testing of AR, MR, and procedures beyond temporal bone surgery. Laryngoscope, 133:227–234, 2023

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Novel Outcome Analysis Tool for Hypoglossal Nerve Stimulator Sensor Lead Function and Comparison by Incision Type (2 Versus 3)

Mohamad Z. Saltagi, Kayla Powell, Abdul K. Saltagi, Stephanie Stahl, Shalini Manchanda, Noah P. Parker

Publication date 17-01-2023


This study demonstrates a method of sensor electrode outcome measurement that is reproducible for surgeons and sleep medicine specialists looking to evaluate intraoperative sensor function during hypoglossal nerve stimulator (HNS). The 2-incision technique for HNS placement demonstrates no reduction in quality, and even may provide some improvement in intraoperative sensory waveforms, supporting the transition to the 2-incision procedure among surgeons.
Objective No reported outcome measures have been established to evaluate sensor lead function in the hypoglossal nerve stimulator (HNS). This study describes the development of novel functional outcome measures for intraoperative sensor electrode function and compares 2-incision and 3-incision outcomes for HNS.
MethodsA retrospective cohort study of 100 consecutive patients who underwent HNS between June 2019 and September 2021. Demographic information, intraoperative findings, and immediate postoperative outcomes were recorded.
Structured parameters were developed to compare intraoperative waveforms with six outcome measures utilized: waveform syncing, waveform amplitude, sensory current leakage, shark-fin morphology, cardiac artifact, and overall impression. Two sleep surgeons and two sleep medicine specialists compared all waveforms in a blinded fashion and assigned scores on the Likert Scale.
Results The cohort included 50 three-incision and 50 two-incision patients. Age, gender, average body mass index, comorbidity profiles, and sleep endoscopy findings did not significantly differ between the two groups. No major complications occurred. The interclass-correlation-coefficient was greater than 0.7 for all comparisons (good to very good interrater reliability). There was no difference in waveform amplitude, cardiac artifact, sensory current leakage, or shark-fin morphology between the two groups. Waveform syncing and overall impression were statistically better in the 2-incision cohort.
Conclusions This study is the first to define a structured method of HNS sensor electrode outcome measurement and showed consistent measures by surgeons and sleep medicine specialists. This article supports the transition to the 2-incision technique among surgeons for placement of the sensor lead. Consideration should be given to utilizing this novel tool in the clinical/research setting and validating these measures moving forward.
Level of Evidence3 Laryngoscope, 133:423–430, 2023

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Chemosensory Functions After Glossectomy—A Cross‐Sectional Pilot Study

Stefan Grasl, Stefan Janik, Stephanie Wiederstein, Georg Haymerle, Bertold Renner, Christan A. Mueller

Publication date 17-01-2023


In this cross-sectional pilot study, chemosensory functions and potential interactions and compensatory mechanisms were assessed in 25 patients after glossectomy. The psychophysical chemosensory testing revealed a significant discrepancy between a normal self-perception in 80% and the assessed gustatory function with normal taste function in only 32% of our collective. A contribution of the intact retronasal olfactory system with a normal retronasal function in 84% of our patients could be a possible explanation of our results.
Objective To evaluate potential interactions and compensatory mechanisms of subjectively impaired taste function with ortho- and retronasal olfaction after glossectomy.
Study Design In this cross-sectional pilot study, chemosensory functions were assessed in 25 patients with tongue carcinomas after glossectomy. The orthonasal-, retronasal-, and gustatory functions were tested with a mean time of 25 months after surgery with the Sniffin’ Sticks odor identification test kit (ISST), the Candy Smell-27 test (CST-27) and the Taste strip test (TST). Visual analog scales (VAS) were additionally used for self-assessment of taste, flavor perception, and odor ranging from 0 (no perception) to 10 (excellent perception) and further correlated with our psychophysical evaluated outcome measures.
Results The TST, ISST, and CST-27 tests revealed that only eight (32%) and 13 (52%) glossectomy patients had normal taste and orthonasal function, e 21 (84%) patients showed normal retronasal function. Importantly, neither extent of resection and reconstruction nor prior radiotherapy affected chemosensory functions. Contrary, 20 (80%) patients rated their taste and flavor perception as acceptable (VAS >5). Results of the TST, ISST, and CST-27 tests did not correlate with the equivalent self-assessments of taste (p = 0.260, r = 0.234), odor (p = 0.588, r = −0.114), and flavor (p = 0.728, r = 0.073) perception.
Conclusion There was a significant discrepancy between self-perception of taste and flavor and assessed gustatory function after glossectomy. A contribution of the intact retronasal olfactory system could be a possible explanation of our results.
Level of Evidence4 Laryngoscope, 133:375–382, 2023

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Palatal Coupling Maneuvers Do Not Predict Hypoglossal Nerve Stimulator Treatment Efficacy

Bryan Renslo, Kealan Hobelmann, Emily S. Sagalow, Ashwin Ananth, Maurits Boon, Colin Huntley

Publication date 17-01-2023


Objective(s)Maneuvers during drug-induced sleep endoscopy (DISE), for patients with obstructive sleep apnea (OSA), have been used as predictors for success with oral appliances. Hypoglossal nerve stimulation (HGNS) promotes opening at the velum through palatoglossus coupling. In this study, we evaluate maneuvers during DISE as predictors for HGNS treatment efficacy.
Methods We evaluated patients undergoing HGNS between November, 2014 and February, 2021. We assessed maneuvers including jaw thrust and chin lift during preoperative DISE. The impact of tongue base and palatal opening during these maneuvers were rated from 1 to 4 (1: no improvement, 2: mild improvement, 3: moderate improvement, 4: significant improvement). Patients were grouped by a score of 1–2 (weak response) or 3–4 (strong response). Apnea hypopnea index (AHI) change was calculated from the difference between preoperative and postoperative sleep study.
Results One hundred and seventy one patients were included. With jaw thrust, there was no significant difference in AHI change between patients with weak or strong response at the palate (n = 68 vs. 94, 9.5 vs. 13.6, p = 0.21) or tongue base (n = 24 vs. 138, 16.6 vs. 11.3, p = 0.24). On chin lift, there was no significant difference at the palate (n = 82 vs. 18, 13.9 vs. 11.4, p = 0.63) or tongue base (n = 92 vs. 72, 10.8 vs. 14.6, p = 0.24). On multiple linear regression analysis, lower body mass index, higher preoperative AHI, and higher preoperative oxygen nadir were associated with a larger AHI change.
Conclusion Palatal coupling maneuvers during DISE are not predictive of AHI change with HGNS. Findings using these maneuvers should not preclude HGNS candidacy.
Level of Evidence3 Laryngoscope, 133:431–436, 2023

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What is the Role of Induction Chemotherapy in the Treatment of Locally Advanced Sinonasal Squamous Cell Carcinoma?

Arash Abiri, Maie A. St. John, Edward C. Kuan

Publication date 17-01-2023


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Functional and Symmetry Outcomes After Forehead Flap Reconstruction of Medial Peri‐Ocular Defects

Aarti Agarwal, Ramez Philips, Kathryn Landers, Samantha Savitch, Eric Barbarite, Howard Krein, Ryan Heffelfinger

Publication date 16-01-2023


Orbital defects have a profound impact on orbital function and symmetry of the face and are difficult to reconstruct given the complexity of this area. The paramedian forehead flap is feasible for medial periorbital reconstruction with acceptable functional and symmetrical outcomes and low morbidity.
Background Orbital defects have a profound impact on orbital function and symmetry of the face and are difficult to reconstruct given the complexity of this area. The paramedian forehead flap (PMFF) has not been well studied in reconstruction of orbital defects.
Methods Retrospective review of patients who underwent reconstruction of periorbital defects with PMFF between 2016 and 2021. Variables were ocular adnexal asymmetry, functional outcomes, and orbital complications.
Results Eighteen patients met inclusion criteria. Mean defect size was 11.1 ± 7.5 cm. The most common subsite involved was medial canthus in 88.9% of patients. There was no statistically significant difference between mean medial canthus to midline ratio and mean medial brow to midline ratio when compared to the assumed normal of 1. The medial canthus to pupil ratio and medial canthus to lateral canthus ratio had a statistically significant mean difference from 1.0 (p = 0.003 for both). In 22.2% of patients, the orbit was functional with impairment; the remaining had no impairment. Surgical sequelae occurred in 12/18 (66.7%) of patients, most commonly epiphora in 9/18 (50%) of patients, and ectropion in 5/18 (27.7%).
Conclusion The PMFF is feasible for medial periorbital reconstruction with acceptable functional and symmetrical outcomes and low morbidity.
Level of Evidence4 Laryngoscope, 2023

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In vitro Nasodine Can be an Effective Antibiofilm Agent for Biofilms that May Cause CRS

Samuel J M Hale, Christian A Lux, Raymond Kim, Kristi Biswas, Simon Tucker, Peter Friedland, Brett Wagner Mackenzie, Richard G Douglas

Publication date 16-01-2023


Nasodine nasal spray was applied to biofilms of Staphylococcus aureus grown in vitro to determine its antibiofilm efficacy. When Nasodine was applied to intact biofilm, near complete eradication was observed at 6 h exposure. When the bacterial cells were released from the biofilm prior to treatment, eradication was observed at 1 min. This shows that Nasodine is active against S. aureus biofilms in vitro and that biofilm eradication is slowed by the presence of the intact biofilm structure.
Objectives Bacterial biofilms on the sinonasal mucosa, especially biofilms of Staphylococcus aureus, are associated with greater severity and recalcitrance of chronic rhinosinusitis (CRS). There are few, if any, antibiofilm agents suitable for sinonasal application available for the management of this problem. Nasodine® Nasal Spray (Nasodine) is a 0.5% povidone-iodine-based formulation that has been developed for sinonasal application. We investigated the antibiofilm efficacy of Nasodine to determine whether it may be a candidate for the treatment of biofilm-associated CRS.
Methods Biofilms of S. aureus ATCC 6538 were grown in vitro using the Centers for Disease Control biofilm reactor. Intact biofilms were treated by immersion in 0.9% saline (control), half concentration Nasodine, or full concentration Nasodine for between 5 min and 6 h. Further biofilm cells were dispersed into suspension then treated for between 30 s and 5 min. Surviving bacteria were then enumerated by culture and counting colonies, and the log10 reduction in viable bacteria was compared with control.
Results Nasodine demonstrated time and concentration-dependent bacterial killing against intact biofilm. Statistically significant reductions in viable bacteria from intact biofilms were seen with exposures as brief as 5 min. Nasodine consistently eradicated dispersed biofilm within 1 min.
Conclusion Nasodine is highly active against biofilms of S. aureus ATCC 6538 in vitro. Biofilm killing is impeded by the presence of the intact biofilm structure.
Lay summary:In chronic rhinosinusitis (CRS), bacterial communities called biofilms are associated with more severe inflammation. An iodine-based nasal spray called Nasodine almost completely eradicates bacterial biofilms after 6 h of exposure. Nasodine may be useful for treating CRS. Laryngoscope, 2023

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Does Platelet‐Rich Plasma Have a Therapeutic Role in Hair Restoration?

Marc Levin, Jeffrey H. Spiegel

Publication date 13-01-2023


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Assessment of Laryngeal Sensory Function using a Tactile Aesthesiometer in Healthy Adults

Yue Ma, Joseph Kidane, Grant E. Gochman, David J. Bracken, Madeleine P. Strohl, Clark A. Rosen, VyVy N. Young

Publication date 13-01-2023


Thirty seven healthy adults recruited with 340 tactile stimuli analyzed to study laryngeal sensation. Laryngeal sensation decreases in aging, male sex, and a more lateral laryngeal subsite.
Introduction Laryngeal sensory function in healthy adults was assessed through the delivery of tactile stimuli using Cheung–Bearelly monofilaments.
Methods37 healthy adults were recruited with 340 tactile stimuli analyzed.
Four calibrated tactile stimuli were delivered to three laryngeal sites: false vocal fold (FVF), aryepiglottic fold (AEF), and lateral pyriform sinus (LPS). Primary outcome was the elicitation of laryngeal adductor reflex (LAR). Secondary outcomes were gag, patient-reported laryngeal sensation (PRLS), and perceptual strength. Analysis was performed with mixed effects logistic regression modeling.
Results Positive LAR was observed in 35.7%, 70.2%, and 91.2% of stimuli at LPS, AEF, and FVF respectively. LAR rates were significantly associated with laryngopharyngeal subsite (p < 0.001), tactile force (p = 0.001), age (p = 0.022) and sex (p = 0.022). LAR, gag, PRLS, and perceptual strength significantly increased as a more medial laryngeal subsite was stimulated and as stimulus force increased. Each of the ten years of age increase was associated with 19% reduction in odds of LAR (aOR = 0.81, 95% CI 0.68, 0.97; p = 0.022). Male gender was associated with a 55% reduction in odds of LAR (aOR = 0.45, 95% CI 0.23, 0.89; p = 0.022).
ConclusionLAR elicitation capability decreases in the male gender, aging, and a more lateral subsite. This study provides insight into the pathophysiology of hypo- and hyper-sensitive laryngeal disorders and is paramount to making accurate diagnostic assessments and finding novel treatment options for various laryngological disorders. Laryngoscope, 2023

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Myeloid Phenotypes in Tracheostomy‐Associated Granulation Tissue

Alexandra J. Berges, Rafael Ospino, Ioan A. Lina, Samuel Collins, Yee Chan‐Li, Alexander Gelbard, Alexander T. Hillel, Kevin M. Motz

Publication date 12-01-2023


In patients with indwelling tracheostomy, granulation tissue is a common, recurrent problem that may lead to multiple surgeries, difficulties with decannulation, and even wound contracture leading to stenosis at the site of prosthesis. This study demonstrates that alternatively activated M2 macrophages are increased in airway granulation tissue as determined by gene expression analysis of canonical biomarkers and cell surface antigens assessed by flow cytometry and immunohistochemistry. The monocyte cell populations associated with granulation tissue are predominantly classical subtype and the majority of macrophages were positive for pro-inflammatory marker S100A8/A9 with 36% of macrophages co-localizing the biomarker CD169+, highlighting these cell population as potential therapeutic targets for airway granulation tissue.
Objective(s)Tracheostomy-associated granulation tissue is a common, recurrent problem occurring secondary to chronic mucosal irritation. Although granulation tissue is composed of predominantly innate immune cells, the phenotype of monocytes and macrophages in tracheostomy-associated granulation tissue is unknown. This study aims to define the myeloid cell population in granulation tissue secondary to tracheostomy.
Methods Granulation tissue biopsies were obtained from 8 patients with tracheostomy secondary to laryngotracheal stenosis. Cell type analysis was performed by flow cytometry and gene expression was measured by quantitative real-time polymerase chain reaction. These methods and immunohistochemistry were used to define the monocyte/macrophage population in granulation tissue and were compared to tracheal autopsy control specimens.
Results Flow cytometry demonstrated macrophages (CD45+CD11b+) and monocytes (CD45+FSClowSSClow) represent 23.2 ± 6% of the granulation tissue cell population. The M2 phenotype (CD206) is present in 77 ± 11% of the macrophage population and increased compared to the M1 phenotype (p = 0.012). Classical monocytes (CD45+CD14highCD16low) were increased in granulation tissue compared to controls (61.2 ± 7% and 30 ± 8.5%, p = 0.038). Eighty-five percent of macrophages expressed pro-inflammatory S100A8/A9 and 36 ± 4% of macrophages co-localized CD169, associated with tissue-resident macrophages. M2 gene expression (Arg1/CD206) was increased in granulation tissue (3.7 ± 0.4, p = 0.035 and 3.5 ± 0.5, p = 0.047) whereas M1 gene expression (CD80/CD86) was similar to controls (p = 0.64, p = 0.3). Immunohistochemistry of granulation tissue demonstrated increased cells co-localizing CD11b and CD206.
ConclusionsM2 macrophages are the dominant macrophage phenotype in tracheostomy-associated granulation tissue. The role of this cell type in promoting ongoing inflammation warrants future investigation to identify potential treatments for granulation tissue secondary to tracheostomy.
Level of Evidence3 Laryngoscope, 2023

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Analysis of Otolaryngologic Readmissions at a High‐Volume Quaternary Referral Center

Neal R. Godse, Carl H. Snyderman

Publication date 12-01-2023


The study is a retrospective review of readmissions in a high-volume, quaternary care center. Post-operative neck infection and bleeding were the most common reasons for unplanned readmission and are high-value targets in ongoing efforts to mitigate hospital readmission.
Objectives To identify common reasons for readmission following otolaryngologic surgery at a high-volume center and identify possible risk factors for readmission.
Methods Retrospective chart review of readmissions identified by hospital-based electronic medical record reporting mechanism.
Results From January 2019 to September 2020, there were 87 readmissions following 808 index surgeries. The most common reason for readmission was for planned surgery (23%), followed by post-operative neck infection, bleeding, or pneumonia. Patients with unplanned readmissions had significantly longer index admission duration than patients who were not readmitted (median 7 days vs. median 5 days, resp.; p = 0.0056). Analysis of cases of unplanned readmission for neck infection and bleeding identified the oral cavity/pharynx as the most common site of initial surgery and that a majority of patients had a history of radiation therapy.
Conclusion Neck infection, bleeding, and pneumonia were the most common reasons for unplanned readmission following otolaryngologic surgery, and a large portion of patients required additional procedures during readmission. Unplanned readmissions for bleeding were significantly more costly than readmissions for neck infections. Long-index hospitalizations, index surgery involving the oral cavity and pharynx, and a history of radiation therapy may be useful clinical features that could stratify the risk of readmission.
Level of Evidence Level 4, retrospective chart review Laryngoscope, 2023

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Leadership of Black Women Faculty in Otolaryngology—More than A Rounding Error

Valerie Flanary, Gina D. Jefferson, David J. Brown, Oneida A. Arosarena, Michael J. Brenner, Cristina Cabrera‐Muffly, Trinitia Y. Cannon, Erynne A. Faucett, Carrie L. Francis, Erin Harvey, Romaine F. Johnson, Myriam Loyo, Melonie A. Nance, Kimberly N. Vinson, Dana M. Thompson

Publication date 10-01-2023


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In Response to Leadership of Black Women Faculty in Otolaryngology‐More than a Rounding Error

Melissa Mortensen

Publication date 10-01-2023


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In Response to Development and Implementation of the Cochlear Implant Quality of Life (CIQOL) Functional Staging System

Paul E. Hammerschlag, Daniel H. Coelho, Darius Kohan

Publication date 10-01-2023


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Age, ASA‐status, and Changes in NSQIP Comorbidity Indices Reporting in Facial Fracture Repair

Karl R. Khandalavala, Kieran Boochoon, Makayla Schissel, W Wesley Heckman, Katie Geelan‐Hansen

Publication date 10-01-2023


Objective To evaluate the impact of age and the American Society of Anesthesiologists (ASA) classification on post operative outcomes as well as the changes in the National Surgical Quality Improvement Program (NSQIP) database reporting of comorbidity index variables in patients with facial fractures.
Methods The NSQIP database was queried for facial fracture repair CPT codes between 2012 and 2019 and for modified Frailty Index (mFI) and modified Charlson Comorbidity Index (mCCI) variables between years 2006 and 2018.
The predominant question analyzed two preoperative risk factors: patient and ASA classification. Chi-square analysis, Kruskal-Wallis, Mann–Whitney, Spearman correlation, and multivariable logistic regression were used to evaluate age and ASA classification with wound dehiscence, superficial surgical site infection (SSSI), deep wound infection (DWI), readmission status, and return to the OR. The reporting of indices variables was evaluated with descriptive statistics.
Conclusion In this large database with univariate analysis, patients with a higher ASA classification and older patients experience significantly increased risks of readmission, return to the OR, and longer hospital stays. On multivariate analyses, ASA classes II, III, and IV are independently associated with increased risk of readmission and return to the OR, while controlling for patient age. The reporting of all mFI and mCCI variables were consistent from 2006 to 2010, but after 2011, there has been inconsistent or absent reporting of variables, therefore, conclusions on the impact of comorbidities on facial fracture repair are unreliable.
Level of Evidence4 Laryngoscope, 2023

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Deep Neuromuscular Block for Endolaryngeal Surgery: A Systematic Review and Meta‐Analysis

Jianqiao Zheng, Li Du, Lu Zhang, Bin Du, Weiyi Zhang, Guo Chen

Publication date 10-01-2023


Deep NMB provides better surgical conditions due to a higher incidence of clinically acceptable surgical conditions and a lower incidence of intraoperative complications without increasing the incidence of postoperative complications.
Objectives To determine the safety and efficacy of deep neuromuscular block (NMB) for endolaryngeal surgery.
Data Sources Pub Med, Web of Science, Cochrane Library, Ovid Medline, Embase, China National Knowledge Infrastructure, Wanfang, VIP databases, and trial registry database.
Methods Inclusion criteria followed the PICOS principles: Participants, adults undergoing endolaryngeal surgery; Intervention, deep NMB performed during the surgery; Control, no-deep NMB performed; Outcomes, primary outcome: the incidence of clinically acceptable surgical conditions.
Secondary outcome: the incidence of intraoperative complications (including vocal fold movement and coughing) and total incidence of postoperative complications including postoperative residual curarization (PORC), postoperative sore throat (POST), and postoperative nausea and vomiting (PONV). Study design, randomized controlled trials (RCTs). Duplicate publications, editorials, letters, abstracts, and reviews were excluded.
Results Four articles with 242 patients were identified for analysis. The results indicated that compared with no-deep NMB, deep NMB provides a higher incidence of clinically acceptable surgical conditions (98.36% vs. 76.67%; relative ratio RR = 1.29, 95% CI: 1.07–1.56), a lower incidence of intraoperative complications (10.83% versus 37.16%; RR = 0.32; 95% CI: 0.21–0.49) (lower incidence of vocal fold movement 1.85% vs. 34%; RR = 0.08, 95% CI: 0.02–0.41 and coughing 15.53% vs. 38.78%; RR = 0.42, 95% CI: 0.27–0.66). There were no differences in the overall incidence of postoperative complications (RR = 2.10, 95% CI: 0.12–36.40).
Conclusions Based on current published evidence, deep NMB provides better surgical conditions with a higher incidence of clinically acceptable surgical conditions and a lower incidence of intraoperative complications (lower incidence of vocal fold movement and coughing) without increasing the overall incidence of postoperative complications.
Level of EvidenceI Laryngoscope, 2023

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Outcomes of KTP Laser Ablation in Glottic Neoplasms: A Systematic Review and Meta‐Analysis

Mustafa Suppah, Abdallah Kamal, William E. Karle, Rakan Saadoun, David G. Lott

Publication date 06-01-2023


The aim of our review is to evaluate the safety and efficiency of transoral laser microsurgery (TLM) with potassium-titanyl-phosphate (KTP) laser ablation for glottic neoplasms. Eight studies were included. After an average follow-up of 3.3 years, the overall survival and disease-free survival for patients who underwent KTP. KTP is a safe and effective method for treating patients with early glottic neoplasms.
Objectives To evaluate the safety and clinical effectiveness of transoral laser microsurgery (TLM) with potassium-titanyl-phosphate (KTP) laser ablation for glottic neoplasms.
Data SourceMEDLINE via Pub Med, SCOPUS, Web of Science, and Cochrane Library.
Review MethodsA systematic review and meta-analysis of studies assessing the safety and efficacy of KTP laser therapy in patients with early-stage glottic neoplasms.
Results Eight studies were included. After an average follow-up of 3.3 years, the overall survival and disease-free survival for patients who underwent KTP were 90.7% (95% CI 85%–96.5%) and 98.5% (95% CI 97.3%–99.8%), respectively. In the single-arm meta-analysis, the pooled estimate of recurrence was 7.7% (95% CI 3.4%–12%). The overall voice handicap index (VHI) estimate attributed to KTP in the single-arm meta-analysis was 6.76 (95% CI 3.05, 10.48) and 5.21 (95% CI 2.86, 7.56) within 6 months and after a one-year follow-up, respectively.
ConclusionKTP laser ablation is a safe and effective method for treating patients with early glottic neoplasms. Laryngoscope, 2023

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Patient Reported Outcome Measures for Salivary Function: A Systematic Review

Arushi Gulati, Joseph Kidane, Jolie L. Chang

Publication date 06-01-2023


We conducted a systematic review to assess the quality and measurement properties of 16 identified patient-reported outcome measures (PROMs) assessing salivary gland disease. PROMs were evaluated for developmental methodology, structure, validity, and reliability using Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) criteria. We found that content validity was doubtful or inadequate for all included PROMs, and future instruments should include both provider and patient input in design.
ObjectiveA number of patient-reported outcome measures (PROMs) assess quality of life and symptom severity in patients with salivary gland dysfunction, but many vary in the extent of validation and domain types addressed. We identified PROMs validated to measure salivary gland function and analyzed key properties.
Data Sources Pub Med, Web of Science, Embase, Psyc Info, and CINAHL.
Review MethodsA systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Validated instruments with >1 item to assess salivary gland-related symptoms were included. PROMs were evaluated for developmental methodology, structure, validity, and reliability using Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) criteria.
ResultsA total of 2059 abstracts were retrieved, and 133 full-text articles were reviewed. Sixteen PROMs assessing xerostomia (n = 7), sialadenitis (n = 4), Sjogrens syndrome (n = 2), Parkinsons-associated sialorrhea (n = 2), and oral systemic sclerosis (n = 1) were identified. Most (n = 15) were developed de novo, one was adapted from a pre-existing questionnaire. Eleven PROMs demonstrated “very good” analysis of internal consistency per COSMIN criteria, and 10 included test–retest data. Regarding content validity, four PROMs were developed with both patient and physician input, but none were rated as “adequate.” All included comparisons against other questionnaires (n = 7), salivary flow rate (n = 9), and/or healthy controls (n = 3). The most rigorously developed PROM, the Xerostomia Inventory, was rated adequate in 6 out of 7 domains.
Conclusions Several PROMs evaluate salivary function. The abilties of these PROMs to meet design and validation standards were variable, with notable limitations in content validity for all tools. New and updated PROMs assessing obstructive and inflammatory salivary symptoms should  utilize patient and provider input.
Level of EvidenceN/A Laryngoscope, 2023

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Patient Satisfaction and Acoustic Changes in Trans Women after Gender Affirming Voice Training

Sarah K. Rapoport, Eleni A Varelas, Christopher Park, Sarah K. Brown, Leanne Goldberg, Mark S. Courey

Publication date 05-01-2023


Objectives Gains in pitch from gender affirming voice training (GVT) alone in trans women have historically been shown to decline after 1 year. Currently no standard exists for length and type of GVT that yields meaningful behavioral change and patient satisfaction with voice outcomes in trans women. This study aims to determine whether GVT alone leads to sustained pitch elevation and patient satisfaction in trans women.
Methods Retrospective review from 2016 to 2020 of trans women patients who underwent GVT alone for voice change. Charts were reviewed for acoustic analysis of pitch including sustained vowel fundamental frequency, speaking fundamental frequency, and quality of life data from the Trans Woman Voice Questionnaire at pre-therapy, immediate post-therapy, and extended post-therapy time intervals.
ResultsA total of 157 patients presented to our Voice Center, of which 34 participated in the full course of GVT. Patients underwent an average of six sessions of GVT (range 5–7) over an average of 13.14 weeks (range 6–16). Average time between completing GVT and presenting for extended follow-up was 11.37 months (range 6–31). Compared to initial presentation prior to therapy, at extended follow-up after completing GVT average change in F0/a/, SF0, and TWVQ were 64.6 Hz, 31.3 Hz, and 32.45. No significant change was noted between immediate post-therapy and extended post-therapy acoustic measures. TWVQ demonstrated continued improvement between immediate post-therapy and extended post-therapy.
Conclusions In self-selected patients who present for extended follow-up, GVT alone can result in sustained pitch elevation and voice-related quality life in trans women.
Level of Evidence4 Laryngoscope, 2023

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Team Consistency in Reducing Operative Time in Head and Neck Surgery with Microvascular Free Flap Reconstruction

"Tuleen Sawaf, Bryan Renslo, Celina Virgen, Nathan Farrokhian, Katherine M. Yu, Thomas G. Gessert, Cree Jackson, Katie ONeill, Bethany Sperry, Kiran Kakarala"

Publication date 05-01-2023


This study evaluated the effect of having a consistent team in the operating room, focusing on the surgeon, surgical technologist, and circulating nurse. Consistent teams were associated with improved procedure efficiency without compromise to patient safety.
Objective(s)To evaluate the impact of consistent surgical teams on procedure duration in head and neck free tissue transfer, and to evaluate the length of stay and readmission rates with consistent teams.
MethodsA retrospective chart review of head and neck microvascular reconstruction by a single surgeon between August 2017 and November 2021 was performed. Procedure duration, wound complications, length of stay, and 30-day readmissions were analyzed. One circulating nurse (CN) and surgical technologist (ST) were considered “consistent” due to their prior work with the primary surgeon. All others were considered “ad hoc.” Teams were “Consistent CN + ST,” “Consistent ST,” “Consistent CN,” or “Ad hoc.” Procedure duration between groups was compared via analysis of variance. Multivariate linear regression was performed to predict procedure duration.
ResultsA total of 135 patients were included. Age, sex, and American Society of Anesthesiologists status did not significantly differ across groups (p = 0.963; p = 0.467; p = 0.908, respectively). The mean procedure duration was 339.3 min and differed significantly across all groups (p = 0.006, Cohen d = 0.32). Compared to the Ad hoc group, consistent teams demonstrated significant reductions in mean procedure duration (Consistent CN + ST: 58.4 min, p = 0.001, Cohen d = 0.67; Consistent ST: 51.6 min, p = 0.013, Cohen d = 0.61; Consistent CN: 44.5 min, p = 0.031, Cohen d = 0.52). Controlling for other factors, the ad hoc team predicted increased procedure duration on multivariate analysis (β$$ \beta $$ 57.38, 19.92–94.85, p < 0.003). Wound complications, length of stay, and readmission rates did not differ significantly across groups (p = 0.940; p = 0.174; p = 0.935, respectively).
Conclusion Consistent CN and ST improve operative efficiency in head and neck-free tissue transfer. Future studies may evaluate the impact of team consistency on complications, physician burnout, and health systems costs.
Level of EvidenceIII Laryngoscope, 2023

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"Casual Observers Perception on the Aesthetics of the Butterfly Graft"

Mark M. Mims, William W. Shockley, Joseph Madison Clark

Publication date 05-01-2023


The butterfly graft is used to repair the internal nasal valve, but concerns remain regarding the postoperative appearance of the supra tip. This study finds casual observers do not view the supra tip region of a postoperative butterfly graft patient negatively.
Objective The butterfly graft is an effective technique for improving the internal nasal valve, however, there is hesitancy among surgeons due to possible aesthetic changes. This study aims to determine if average observers rated the post-operative appearance of the butterfly graft negatively.
Methods An online survey was distributed by social media to non-medical observers in which they rated either the pre-operative or post-operative appearance of 22 patients noses (11 butterfly graft, 11 spreader graft). A heat map was used to determine if the supratip region was rated as the least aesthetically appealing. Post-operative ratings and heat maps of the butterfly graft patients were compared to pre-operative ratings as well as ratings of the spreader graft group.
Results226 observers responded. There was no difference in the pre-operative and post-operative rating of the butterfly graft group (58.27 vs. 58.00, p = 0.88) or the number of supratip regions selected as least attractive (165 vs. 169, p = 0.60). Similarly, there was no difference in post-operative ratings between the butterfly graft group and spreader graft group (58.00 vs. 58.21, p = 0.63) or in selection of the supratip as the least attractive region (169 vs. 172, p = 0.74).
Conclusion The butterfly graft did not negatively affect observers opinion of patients noses.
Level of Evidence3 Laryngoscope, 2023

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In Reference to Robustness of the Clinical Benefit of Mastoid Obliteration Technique for Cholesteatoma Surgery

Luigi La Via, Antonino Maniaci, Gianluca Albanese, Ignazio La Mantia, Filippo Sanfilippo

Publication date 04-01-2023


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Voice Outcomes From Direct Vocal Fold Testosterone Injections, a Case Report

Andrew M. Vahabzadeh‐Hagh, Erin Walsh, Vala Hamidi, Karen McCowen

Publication date 03-01-2023


Here we provide the first demonstration of targeted vocal fold testosterone injection to achieve voice masculinization in 2 transgender male patients. Successful voice outcome was achieved in 2–3 weeks, without side effects, and continues to be durable. Laryngoscope, 2023

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Duration of Clinical Response After In‐Office Steroid Injection for Vocal Fold Scar

Lucas G. Axiotakis, Necati Enver, Evan L. Kennedy, Kimberly A. Duncan, Michael J. Pitman

Publication date 03-01-2023


The duration of clinical benefit after in-office vocal fold steroid injection (VFSI) for vocal fold scar remains unaddressed in the literature. In the present study using blinded expert ratings of voice and stroboscopy data, VFSI was associated with persistent improvement in voice in approximately half of patients.
Objective To assess the duration of clinical response after in-office vocal fold steroid injection (VFSI) for vocal fold (VF) scar.
Methods Demographic and clinical data for in-office VFSI occurring from 2017 to 2020 were collected. Two Speech-Language Pathologists (SLPs) used perceptual evaluation of voice and functional scales to evaluate blinded voice and laryngovideostroboscopy (LVS) samples collected pre- and post-injection across multiple timepoints.
Results Blinded SLP ratings were used for 30 individual VFs undergoing initial injection in 18 patients. Persistent improvement in voice past 6 months was seen in 57% of patients after VFSI. Multiple measures of voice and amplitude, percent vibrating tissue, and closed phase predominance significantly improved at various follow-up timepoints on average.
Conclusion Accounting for patient heterogeneity and disease progression, in-office VFSI for VF scar is associated with sustained improvement in a subset of patients. Approximately half of patients can expect to experience a lasting improvement in voice. Future studies of larger scale are required to identify patient factors associated with long-term benefit.
Level of Evidence4 Laryngoscope, 2023

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Tissue Eosinophilia is Superior to an Analysis by Polyp Status for the Chronic Rhinosinusitis Transcriptome: An RNA Study

Tripti Brar, Chantal McCabe, Amar Miglani, Michael Marino, Devyani Lal

Publication date 03-01-2023


Transcriptomic profiling using RNA-Sequencing (RNA-Seq) has enabled the study of differential expression of genes in diseased versus non-diseased tissue. In Chronic rhinosinusitis (CRS), RNA-Seq has been utilized to understand the mechanistic pathways underpinning the disease. While CRS is commonly sub-divided by phenotype into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP), sub-classification by endotype (tissue eosinophilia) has also been used, although less commonly, in understanding pathophysiology and guiding treatment. We used both metrics to compare CRS with controls using RNA-Seq and found that endotype classification by tissue eosinophilia, agnostic of nasal polyp status, offers superior insights into understanding the pathogenetics of CRS.
ObjectiveRNA sequencing (transcriptomics) is used to study biological pathways. However, the yield of data depends on comparing well-characterized cohorts. We compared tissue eosinophilia versus nasal polyp (NP) status as the metric to characterize transcriptomic mechanisms at play in eosinophilic and non-eosinophilic chronic rhinosinusitis (CRS) versus controls.
MethodsRNA sequencing was conducted on sinonasal tissue samples of CRS and controls. Analyses were conducted based on polyp status with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP) as well as tissue eosinophil levels per high power field (eos/hpf)non-eosinophilic (<10 eos/hpf, neCRS) or eosinophilic (≥10 eos/hpf, eCRS). The yield of differentially expressed genes (DEGs) and biological pathways through Ingenuity Pathway Analysis (IPA) were compared.
ResultsCRS tissue differed from controls by 736 statistically significant DEGs. Both NP status and tissue eosinophilia were effective in differentiating CRS from controls and into two distinct subgroups. Statistically significant DEGs identified when comparing CRS by NP status were 60, whereas 110 DEGs were identified using eosinophil cutoff ≥10 and <10 eos/hpf. Additionally, heatmaps showed greater homogeneity within each CRS subgroup when analyzed by tissue eosinophilia versus NP status. On IPA, the IL-17 signaling pathway was significantly different only by tissue eosinophilia status, not NP status, being higher in CRS <10 eos/hpf.
Conclusion Tissue eosinophilia is superior to an analysis by NP status for the study of CRS transcriptome by RNA sequencing in identifying DEGs. Classification of CRS samples by eosinophil counts agnostic of NP status may offer advantageous insights into CRS pathogenetic mechanisms.
Level of Evidence3 Laryngoscope, 2023

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Audiometric and Otologic Findings in Children and Young Adults with Neurofibromatosis Type 1 and Plexiform Neurofibromas

Victoria Idowu, Julie Christensen, Andrea M. Gross, Eva Dombi, Jennifer R Miles, Kelly King, Jennifer Chisholm, Christopher Zalewski, Andrea Baldwin, Patricia Whitcomb, Crystal Burgess, Brigitte C Widemann, Carmen C Brewer, Hung Jeffrey Kim

Publication date 30-12-2022


Objectives To characterize otologic and audiologic manifestations in our NF1 cohort and explore the relationship between otologic and audiologic findings in a subset of patients with ear-related plexiform neurofibromas (PNs).
Methods Audiologic and otologic clinical evaluations were conducted on 102 patients with NF1 in a natural history study (5–45 years; M = 14.4 years; Mdn = 14). Testing included pure tone and speech audiometry, middle ear function, neurodiagnostic auditory brainstem response (ABR), auditory processing, and MRIs of the head and neck region. Patients referred to this study had an overall higher incidence and burden of PNs than the overall NF1 population.
Results The majority of subjects in this cohort had normal hearing sensitivity (81%) and normal middle ear function (78%). Nineteen participants had hearing loss that ranged in degree from mild to profound, with the majority in the mild range. Hearing loss was twice as likely to be conductive than sensorineural. In patients with ear-related PNs (n = 12), hearing loss was predominantly conductive (60%). Seventy-five percent of ears with PNs had atypical tympanometric tracings that could not be characterized by the classic categories. In all 20 patients with a PN in the temporal bone, the ear canal was affected, and the PNs often extended to the surrounding soft tissue regions.
Conclusions People with NF1-related PNs in the temporal bone and adjacent skull base should have audiometric and otologic monitoring. Addressing hearing concerns should be part of routine clinical evaluations in patients with NF1. Magnetic resonance imaging (MRI) should be performed in patients with NF1 who have hearing loss.
Level of Evidence3 Laryngoscope, 2022

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H‐Type Tracheoesophageal Fistula Cannulation for Rapid Intraoperative Localization

Soraya Abdul‐Hadi, Miguel A. Serpa Irizarry, Emanuel De‐Miranda, Gabriel Pujol‐Cuevas, Anwar Abdul‐Hadi

Publication date 30-12-2022


Various techniques for tracheoesophageal fistula cannulation have been reported. In this case, we created a loop using a plastic catheter. The loop allowed us to create traction for rapid intraoperative localization and to pull a difficult-to-reach fistula, superiorly into the neck, to be reached through a cervical approach. Laryngoscope, 2022

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T4b Sinonasal Squamous Cell Carcinoma: Surgery Plus Radiotherapy May Contribute to Prolonged Survival

Zekun Wang, Jianghu Zhang, Bining Yang, Ye Zhang, Xuesong Chen, Jingbo Wang, Runye Wu, Kai Wang, Yuan Qu, Xiaodong Huang, Jingwei Luo, Li Gao, Guozhen Xu, Ye‐Xiong Li, Junlin Yi

Publication date 30-12-2022


The optimal treatment strategy for T4b sinonasal squamous cell carcinoma (SNSCC) was unclear, we compared two treatment modalities: surgery plus radiotherapy and definitive radiotherapy. Our results demonstrated that patients treated with surgery plus radiotherapy had better cancer-specific survival and overall survival than with definitive radiotherapy before and after propensity score matching.
Purpose To determine oncologic outcomes for patients with T4b sinonasal squamous cell carcinoma (SNSCC) treated with either surgery plus radiotherapy or definitive radiotherapy.
Materials and Methods Between January 1999 and December 2016, 85 patients with T4b SNSCC were analyzed retrospectively, there were 54 who received surgery plus radiotherapy (S + RT group) ± chemotherapy and 31 with definitive radiotherapy (RT group) ± chemotherapy.
A 1: 2 propensity score matching (PSM) was performed to balance clinical factors and match patients. Kaplan–Meier method and Cox proportional hazard model were used to determine risk factors on survival outcomes.
Results The median follow-up time was 76.7 months. The cumulative rates of locoregional control (LRC), distant metastasis-free survival (DMFS), cancer-specific survival (CSS), and overall survival (OS) at 5 years for entire cohort were 44.6%, 33.1%, 38.8%, and 33.9% respectively. After PSM, a total of 50 patients in S + RT group and 25 patients in RT group were analyzed. The 5-year LRC, DMFS, CSS, and OS between S + RT and RT group were 58.6% versus 27.5% (p = 0.035), 42.8% versus 20.0% (p = 0.006), 50.3% versus 22.0% (p = 0.005), 44.5% veruss 20.0% (p = 0.004). The 5-year survival rates with orbital retention between groups were 32.7% and 15.0%, p = 0.080. Multivariate Cox analysis revealed non-surgical therapy (HR = 3.678, 95%CI 1.951–6.933) and invasion of cranial nerves (other than maxillary division of trigeminal nerves) (HR = 2.596, 95%CI 1.217–5.535) were associated with decreased OS.
Conclusion The inclusion of surgery in the multimodal management of T4b SNSCC might confer a survival benefit. Further prospective studies comparing the oncologic outcomes of S + RT with RT are warranted.
Level of EvidenceIII Laryngoscope, 2022

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Pediatric Bilateral Vocal Cord Immobility: New Treatment With Preservation of Voice

Marilena Trozzi, Miriam Torsello, Duino Meucci, Mariella Micardi, Maria L. Tropiano, Sara Balduzzi, Alejandra Ossandon Avetikian, Antonio Salvati, Sergio Bottero

Publication date 29-12-2022


Pediatric bilateral vocal cord immobility represents a severe life-threatening condition. Endoscopic arytenoid lateral abduction (EALA) is a new minimal-invasive surgical technique. The present study aims to evaluate the effects of EALA in terms of respiratory function, voice quality, and swallowing capabilities.
Objectives Pediatric bilateral vocal cord immobility (BVCI) represents a severe life-threatening condition that often causes severe dyspnea. Endoscopic arytenoid lateral abduction (EALA) is a relatively new, secure, minimal-invasive surgical technique. The present prospective observational study aims to evaluate the effects of EALA in terms of respiratory function, voice quality, and swallowing capabilities.
Methods Twenty-one pediatric patients with BVCI underwent EALA. Eleven out of 21 patients had tracheostomy at the time of surgery. Pre and postoperative functional assessments included endoscopic evaluation, maximum phonation time, pediatric Voice Handicap Index (pVHI), GIRBAS Scale criteria, and Montreal Childrens Hospital Feeding scale (MCH-Feeding scale). peak tidal inspiratory flow or peak inspiratory flow (PIF) and number of desaturations/hour (ODI/h) were evaluated in patients without tracheostomy.
Results Postoperative endoscopy showed glottic airway improvement in all patients. Average time for decannulation was 4.6 weeks. One patient has not yet been decannulated. No major complications occurred. In patients without tracheostomy, we observed a significant improvement of ODI/h and PIF after surgery (p < 0.05) as expected. PVHI, MCH-Feeding scale, and GIRBAS score significantly worsened 1 month after surgical intervention (p < 0.05). One year after surgery, however, all values, except for B and A parameters of the GIRBAS score, returned to levels comparable to those preoperative.
ConclusionsEALA represents a simple, safe and effective solution in pediatric patients with BVCI, avoiding tracheostomy, allowing early decannulation, preserving swallowing function, and maintaining good quality voice.
Level of Evidence4 Laryngoscope, 2022

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Diagnosis and Management of Vocal Complications after Chondrolaryngoplasty

Brian Nuyen, Z. Jason Qian, Meher Rakkar, James P. Thomas, Elizabeth Erickson‐DiRenzo, C. Kwang Sung

Publication date 28-12-2022


Anterior commissure dislocation should be suspected with signs of vocal impairment after chondrolaryngoplasty. Following proper diagnosis, resuspension of the anterior commissure via feminization laryngoplasty approach can be an effective reparative technique.
Objective Transfeminine patients (transwomen/feminine nonbinary folks assigned male at birth) can undergo chondrolaryngoplasty (“tracheal shave”) to feminize their neck appearance. While isolated cases of vocal complications have been reported following the procedure, aggregated outcomes have not been quantitatively studied. We present acoustic and stroboscopic data to describe a patient cohort with vocal complications after chondrolaryngoplasty and discuss reparative surgical technique.
Methods Subjective and objective data, including videostroboscopy, were collected from patients with voice complaints after chondrolaryngoplasty. Dislocated anterior commissures were reconstructed with feminization laryngoplasty. Postoperative voice data were recorded and statistically compared to preoperative data using paired t-tests.
Results On consecutive chart review, of the 94 transfeminine women with prior outside history of chondrolaryngoplasty, 27 (29%) reported chronic postoperative hoarseness, deepened pitch, or loss of upper register. On endoscopy, short, lax vocal folds with persistent anterior glottic gap and phase asymmetry were commonly noted; anterior commissure dislocation was confirmed in-office by using needle localization through absent thyroid cartilage. After open resuspension of the anterior commissure with feminization laryngoplasty, post-repair modal-speaking, minimum, and maximum fundamental frequencies (F0) increased on average by 7, 8, and 5 semitones, respectively (p < 0.01), when compared to pre-repair values. On average, perioperative maximum phonation time did not change significantly (p = 0.15). Average self-assessment of vocal femininity increased by 48% (p < 0.01).
Conclusion Anterior commissure dislocation should be suspected with signs of vocal impairment after chondrolaryngoplasty. Following proper diagnosis, resuspension of the anterior commissure via feminization laryngoplasty approach can be an effective reparative technique.
Level of Evidence This work represents a 2011 OCEBM Level 4 evidence as a case series Laryngoscope, 2022

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Topical Adenosine Inhibits Inflammation and Mucus Production in Viral Acute Rhinosinusitis

Kody A. Waldstein, Maria Ganama, Steven M. Varga, Stephen Tilley, Xiaoyang Hua

Publication date 28-12-2022


Topical adenosine treatment inhibits inflammation and mucus production in a mouse model of viral acute rhinosinusitis. It may be an effective treatment for viral ARS. Original work created with Biorender.com.
Objective Viral acute rhinosinusitis (ARS) is the leading cause of work and school absence and antibiotic over-prescription. There are limited treatment options available to ameliorate the symptoms caused by viral ARS. We have previously demonstrated that topical adenosine treatment enhances mucociliary clearance in the sino-nasal tract. Here, we assessed the therapeutic potential of topical adenosine in a mouse model of viral ARS.
Methods The effect of topical adenosine on inflammatory response and mucin gene expression was examined in a mouse model of viral ARS induced by respiratory syncytial virus (RSV) nasal-only infection. We also investigated the inflammatory effect of both endogenous and exogenous adenosine in the sino-nasal tract.
Results Topical adenosine significantly inhibited the expression of pro-inflammatory cytokines, goblet hyperplasia, mucin expression, and cell damage in the nose of mice with viral ARS. This treatment did not prolong virus clearance. This inhibitory effect was primarily mediated by the A2A adenosine receptor (AR). Although previous studies have shown that adenosine induces a robust inflammatory response in the lungs, neither endogenous nor exogenous adenosine produced inflammation in the sino-nasal tract. Instead, exogenous adenosine inhibited the baseline expression of TNF and IL-1β in the nose. Additionally, baseline expression of ARs was lower in the nose than that in the trachea and lungs.
Conclusion We demonstrated that intranasal adenosine administration effectively decreased inflammation and mucus production in a mouse model of viral ARS.
Level of EvidenceN/A Laryngoscope, 2022

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Pre‐resection Intraoperative Core Biopsies in Oral Tongue Cancer—A Pilot Study

Anton Warshavsky, Alexandra Dorman, Narin Nard Carmel‐Neiderman, Leonora Leider‐Trejo, Nidal Muhanna, Liyona Kampel, Clariel Ianculovici, Gilad Horowitz

Publication date 28-12-2022


A novel intraoperative technique that may detect unapparent tumor in glossectomies is presented. Pre-resection core biopsies taken midway between the mass and the planned margin may reveal occult malignant infiltration and guide the ablation.
Objective To assess a novel intraoperative core biopsy technique to provide enhanced guidance in partial glossectomies.
Methods All patients diagnosed with squamous cell carcinoma of the oral tongue were eligible for study participation. Following anesthesia, the planned resection and three points midway between the gross tumor and the intended ablation were marked. A core biopsy was performed with a needle spring on each point and sent for frozen sections. The initially planned resection was executed if the cores returned free of tumor. In case of a positive core biopsy, a new 1–1.5 cm margin was marked around that point. The main outcome measure was the closest final margin diameter, especially the deep ones. Other outcome measures were the core biopsies sensitivity, specificity, and negative predictive value. Complications were recorded.
Results The final margins of 10 patients undergoing intraoperative core biopsies and 20 matched controls were analyzed. One patient had two positive cores and final negative margins after modifying the resection accordingly. Another patient had a positive biopsy diagnosed only on final pathology, and one close final margin.
Patients that were operated with the new technique had larger margins compared to the controls: median (interquartile range) closest margin 5.95 (3.97; 9.63) mm versus 4 (2.25; 5) mm (p = 0.074) and median deep margin 8.6 (6.16; 10) mm versus 5 (3;10) mm (p = 0.411), respectively. There were no complications.
ConclusionA novel pre-resection intraoperative biopsy technique is presented. Core biopsies taken during glossectomies have the potential to prevent inadequate margins.
Level of Evidence3 Laryngoscope, 2022

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Should Injection Laryngoplasty Be Performed for Acute Unilateral Vocal Fold Paralysis to Improve Swallowing safety?

Yin Yiu, Daniel Gorelik, Anaïs Rameau

Publication date 27-12-2022


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Vocal Fold Pathologies Among Undergraduate Singing Students In Three Different Genres

Michelle M. Bretl, Julia Gerhard, David E. Rosow, Mursalin Anis, Mario A. Landera, Dana Libman, Judy Marchman, Frank Ragsdale, Stephannie Moore, Ruixuan Ma, Bari Hoffman, Chandra Ivey, Michael M. Johns, Stacey M. Menton, Adam T. Lloyd

Publication date 25-12-2022


Objective This study aimed to compare the prevalence and incidence of vocal fold pathologies among undergraduate classical, musical theatre, and contemporary commercial music (CCM) students over two-time points.
Methods This study is part of a longitudinal investigation. Videostroboscopic examinations were rated, with consensus among three of four expert blinded raters confirming the presence of pathology. Association between genre of singer and the presence of pathology, interrater reliability, and intra-rater reliability were calculated. Prevalence and incidence of pathologies were compared across genres.
Results During first-year evaluations, 32% of musical theatre, 18% of CCM, and 0% of classical students had vocal pathologies. The prevalence at third-year evaluations showed 22% of classical, 39% of musical theatre, and 27% of CCM participants having vocal fold pathologies. The incidence of pathologies was 67% of musical theatre students compared to 22% of classical students and 27% of CCM students. The four raters demonstrated fair to moderate interrater agreement. Singing Voice Handicap Index-10 scores were normal for CCM singers at both time points but elevated for musical theatre and classical singers.
Conclusion No classical singers were found to have pathology during first-year evaluations, although CCM and musical theatre singers showed evidence of vocal fold pathologies. At third-year evaluations, all three genres had an apparent increase in prevalence of pathologies. Implications of this study suggest that more time in the field and intense voice usage may lead to a greater risk of pathology for all singers, regardless of genre.
Level of Evidence2 Laryngoscope, 2023

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Total Thyroidectomy and Subsequent Weight Gain in Pediatric Populations

Evan R. Edwards, Inbal Hazkani, Eli Stein, Jami L. Josefson, Jill H. Samis, Jennifer L. Miller, Jeffrey Rastatter

Publication date 20-12-2022


Using CDC growth charts to control for expected growth in childhood, this study identified greater-than-expected weight gain in children in the first two years following thyroidectomy—especially in Hispanic and younger patients.
Objective To evaluate weight gain in children post-thyroidectomy and identify predictors.
Methods Charts from patients at a tertiary health care facility who underwent total thyroidectomy from 2014 to 2020 were reviewed for Body Mass Index z-scores (BMIz) at the time of thyroidectomy and at 1 and 2-year post-operation intervals. Patient demographic information, comorbidities, pre- and postoperative thyroid stimulating hormone, and postoperative free T4 levels were also extracted. Patients with other known endocrine abnormalities, chronic kidney disease, or without sufficient follow-up were excluded.
ResultsA total of 56 patients (ages 3–17 years old) met the inclusion criteria (n = 17 Graves disease; n = 39 presumed cancer). Over the first year, average BMIz significantly increased in patients with Graves disease (∆BMIz = 0.45 ± 0.77, p = 0.03), Hispanic ethnicity (∆BMIz = 0.43 ± 0.68, p = 0.004), Medicaid/no insurance coverage (∆BMIz = 0.33 ± 0.74, p = 0.038), age <13 years at thyroidectomy (∆BMIz = 0.35 ± 0.68, p = 0.016), and persistent postoperative hypothyroidism (∆BMIz = 0.41 ± 0.41, p = 0.012). These changes remained significant after the second year. Age at thyroidectomy correlated negatively with ∆BMIz only after the first year (r = −0.40, p = 0.002). Regression analysis, controlling for Graves status, persistent postoperative hypothyroidism, and insurance coverage, identified age at thyroidectomy as a significant predictor of ∆BMIz after the first year (b = −0.06, p = 0.004) and Hispanic ethnicity as a significant predictor after the second year (b = 0.60, p = 0.003).
ConclusionA small increase in BMIz post-thyroidectomy was observed across several patient subgroups. Younger age at thyroidectomy and Hispanic ethnicity were associated with increased BMIz in the first 2 years post-thyroidectomy.
Level of Evidence Level 4- Historically controlled cohort Laryngoscope, 2022

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A Two‐Stage Method for Adult Congenital Microtia: The Essentials of 15‐Year Experience

Hanbo Li, Yue Wang, Jin Qian, Bingqing Wang, Tun Liu, Qingguo Zhang

Publication date 20-12-2022


Hypothesis Treatment of congenital microtia in adults remains challenging due to the unique physiological characteristics of the costal cartilages and retroauricular skin, which interfere with obtaining a satisfactory aesthetic result; thus, different perspectives and technical modifications during treatment are warranted. This article aims to present complementary new information and essential tips to refine the surgical technique in adult microtia reconstruction.
MethodsA total of 346 adult microtia patients underwent surgical intervention at the Auricular Reconstruction Center of Plastic Surgery Hospital (Beijing, China) between 2006 and 2021. Each patient underwent a rigorous preoperative evaluation and stages one and two surgeries.
Results Patients were followed in our clinic for 6 months to 10 years (average: 15.3 months). The postoperative complication rate was 8.1%, which included cartilage exposure, broken helix, local hematoma, infection, poor skin graft survival, and scar hypertrophy.
Conclusions Our results showed that the two-stage treatment strategy for adults is versatile, reliable, and effective for the treatment of congenital microtia.
Level of EvidenceIV Laryngoscope, 2022

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In reference to Inflammation‐Based Score Predicts Pharyngocutaneous Fistula

Merih Onal, Ozkan Onal

Publication date 20-12-2022


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