Laryngoscope 2022-12-02

In Response to Documentation in Pediatric Microlaryngoscopy/Bronchoscopy

Penelope Neocleous, Julie E. Strychowsky, Peng You, Murad Husein, Lily H. P. Nguyen, Evan Propst, Nikolaus Wolter, M. Elise Graham, on behalf of the primary authors of the Pediatric Bronchoscopy Working Group

Publication date 02-12-2022


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In Reference to Documentation in Pediatric Microlaryngoscopy/Bronchoscopy

Seamus Boyle, Michael Fitzsimons, Colleen Heffernan

Publication date 02-12-2022


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Social Perception of External Laryngeal Anatomy Related to Gender Expression in a Web‐based Survey

Patrick Kiessling, Karthik Balakrishnan, Alex Fauer, Akshay Sanan, Daniella McDonald, James Thomas, Elizabeth Erickson‐Direnzo, C. Kwang Sung, Brian Nuyen

Publication date 01-12-2022


Here we detail an original study examining the social perception of laryngeal contour, specifically as it relates to chondrolaryngoplasty and providing gender-affirming care to transgender patients. Over 1,000 study participants were divided into five cohorts, ranking their perceptions of images of graded laryngeal prominence sizes associated with perceived gender expression. This study provides new insights into maximizing ideal social perception of laryngeal contour as it relates to gender perception, while also balancing the essential consideration of preserving necessary thyroid cartilage to maintain laryngeal function.
Objective(s)To quantify the effect of laryngeal prominence size on socially perceived attributes relating to gender expression. Chondrolaryngoplasty (“tracheal shave”) is a common procedure performed for transgender women to feminize neck appearance. The extent of thyroid cartilage resection needed to convey socially-perceived feminine gender expression without destabilizing the voice is incompletely understood.
Methods Cross-sectional evaluation of a randomized allocation of images of varying laryngeal prominence to a non-repeated, random sample from November 2021 to December 2021. Photos of laryngeal prominence were isolated against a constant neck baseline with lateral, oblique, and frontal views. The images were embedded into a web-based survey with visual analog scales to capture perceived scaled gender expression (masculinity, femininity) and social traits (e.g., attractiveness, friendliness, leadership). We performed bivariate and multivariate analyses relating the laryngeal prominence to perceived gender expression and social traits.
Results The analytic sample included 1,026 respondents. Laryngeal grades similar to the demonstrated “grade M” in this study and smaller demonstrated similar perceptions of increased femininity and decreased masculinity. Grades larger than M demonstrate significantly increased perceived masculinity and significantly decreased perceived femininity. The lateral and oblique views of the neck appear to be the most gender-informative.
Conclusion This crowd-sourced analysis of external laryngeal anatomy by a large population of observers provides clear, reproducible insights into social perceptions of gender identity and specifically femininity. These data will meaningfully inform patient counseling and surgical planning for gender-affirming interventions by establishing normative data representing the general publics perceptions.
Level of EvidenceN/A Laryngoscope, 2022

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Comparison of Reflux Symptom Score versus Reflux Symptom Index in screening laryngopharyngeal reflux

Chun Zhang, Zhi Liu, Jinhong Zhang, Xiaoyu Wang, Jiasen Wang, Jing Zhao, Jinrang Li, LianLian Liu

Publication date 01-12-2022


Reflux Symptom Index (RSI) is the easiest tool that universally used for screening LPR. However, in recent years, the effectiveness of RSI has been questioned by many scholars. The Reflux Symptom Score (RSS), a new questionnaire, is more comprehensive and less straightforward than the RSI. This study compares the consistency of RSS and RSI for the screening diagnosis of LPR, and RSS showed a better screening value than RSI.
Objectives To compare the screening value of the Reflux Symptom Score (RSS) and the Reflux Symptom Index (RSI) for laryngopharyngeal reflux (LPR).
Methods All included patients attending the Department of Otolaryngology at the Sixth Medical Center of the PLA General Hospital from February 2022 to August 2022, completed the RSS and the RSI and underwent 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH (24 h HEMII-pH) monitoring. The results of 24 h HEMII-pH were used as a diagnostic criterion for LPR, consistency between two questionnaires (RSS, RSI) and 24 h HEMII-pH was compared by the weighted Cohens kappa statistic and the screening value of RSS and RSI for LPR was compared by receiver operating characteristics analysis.
ResultsA total of 77 patients, 58 males, and 19 females, were included. The Kappa values of between RSS, RSI, and 24 h HEMII-pH were 0.663 (p < 0.001) and 0.213 (p < 0.05), respectively. The sensitivity of RSS and RSI were 92.8% and 48.2%, respectively, the specificity was 71.4% and 80.9%. The negative predictive value and positive predictive value of RSI were 36.9%, 87.1%, and that of RSS were 78.9%, 89.6%. The area under curve of the RSS (0.783; 95% CI = 0.53, 0.75) is significantly higher than RSI (0.633; 95% CI = 0.72, 0.90).
Conclusion The RSS has a higher consistency and better screening value for LPR compared to RSI. In addition, the RSS includes more reflux symptoms, which may reduce the number of missed diagnoses in patients with LPR to some extent.
Level of Evidence3 Laryngoscope, 2022

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Killian Jamieson Diverticulum, the Great Mimicker: A Case Series and Contemporary Review

Rebecca Howell, Alice Tang, Jacqui Allen, Mekibib Altaye, Milan Amin, Semirra Bayan, Peter Belafsky, Brian Cervenka, Brad deSilva, Greg Dion, Dale Ekbom, Aaron Friedman, Mark Fritz, John Paul Giliberto, Elizabeth Guardiani, Jeffrey Harmon, Jan L. Kasperbauer, Sid Khosla, Brandon Kim, Maggie Kuhn, Paul Kwak, Yue Ma, Lyndsay Madden, Laura Matrka, Ross Mayerhoff, Cyrus Piraka, Clark Rosen, Meredith E. Tabangin, Shaun A. Wahab, Keith Wilson, S. Carter Wright, Vyvy Young, Sonia Yuen, Gregory N. Postma

Publication date 01-12-2022


Prospective, multicenter cohort study of individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative. Killian Jamieson diverticula (KJD) are rare and represent 5% of hypopharyngeal diverticula undergoing surgical intervention. Open transcervical surgery significantly improves symptoms of dysphagia and reflux. Barium esophagram has high specificity but low sensitivity in detecting KJD. The interpretation of barium fluoroscopy is likely another limitation to not only this study, but our overall understanding of KJD, the great mimicker.
Objective To assess barium esophagram (BAS) as a diagnostic marker for patients with Killian Jamieson diverticula (KJD).
Methods Prospective, multicenter cohort study of individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative. Patient demographics, comorbidities, radiographic imaging reports, laryngoscopy findings, patient-reported outcome measures (PROM), and operative reporting were abstracted from a REDCap database and summarized using means, medians, percentages, frequencies. Paired t-tests and Wilcoxon Signed Rank test were used to test pre- to post-operative differences in RSI, EAT-10, and VHI-10 scores. Diagnostic test evaluation including sensitivity, specificity, positive, and negative predictive value with 95% confidence intervals were calculated comparing BAS findings to operative report.
ResultsA total of 287 persons were enrolled; 13 (4%) patients were identified with confirmed KJD on operative reports. 100% underwent open transcervical excision. BAS has a 46.2% (95% confidence interval CI: 23.2, 70.9) sensitivity and 97.8% (95% CI: 95.3, 99.0) specificity in detecting a KJD and 50% (95% CI: 25.4, 74.6) positive predictive value but 97.4% (95%CI: 94.8, 98.7) negative predictive value. Preoperatively, patients reported mean (SD) RSI and EAT-10 of 19.4 (9) and 8.3 (7.5) accordingly. Postoperatively, patients reported mean (SD) RSI and EAT-10 as 5.4 (6.2) and 2.3 (3.3). Both changes in RSI and EAT-10 were statistically significant (p = 0.008, p = 0.03).
ConclusionKJD are rare and represent <5% of hypopharyngeal diverticula undergoing surgical intervention. Open transcervical surgery significantly improves symptoms of dysphagia. BAS has high specificity but low sensitivity in detecting KJD.
Level of Evidence Level 4 Laryngoscope, 2022

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Use of Convolutional Neural Networks to Evaluate Auricular Reconstruction Outcomes for Microtia

Mariam Tolba, Z. Jason Qian, Hung‐Fu Lin, Kristen W. Yeom, Mai Thy Truong

Publication date 29-11-2022


We use convolutional neural networks to objectively assess aesthetic outcomes following ear reconstruction for microtia. This proof of concept paves the way for computer vision to be more broadly applied for us clinically and in outcomes research for reconstructive surgery.
Objectives The objective of this study is to determine whether machine learning may be used for objective assessment of aesthetic outcomes of auricular reconstructive surgery.
Methods Images of normal and reconstructed auricles were obtained from internet image search engines. Convolutional neural networks were constructed to identify auricles in 2D images in an auto-segmentation task and to evaluate whether an ear was normal versus reconstructed in a binary classification task. Images were then assigned a percent score for “normal” ear appearance based on confidence of the classification.
Results Images of 1115 ears (600 normal and 515 reconstructed) were obtained. The auto-segmentation task identified auricles with 95.30% accuracy compared to manually segmented auricles. The binary classification task achieved 89.22% accuracy in identifying reconstructed ears. When the confidence of the classification was used to assign percent scores to “normal” appearance, the reconstructed ears were classified to a range of 2% (least like normal ears) to 98% (most like normal ears).
Conclusion Image-based analysis using machine learning can offer objective assessment without the bias of the patient or the surgeon. This methodology could be adapted to be used by surgeons to assess quality of operative outcome in clinical and research settings.
Level of Evidence4 Laryngoscope, 2022

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Peer Review 2023

Samuel H. Selesnick

Publication date 29-11-2022


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Nasal mucociliary clearance after extremely low frequency by scintigraphic and histopathologic evaluation

Nur Aydinbelge‐Dizdar, Aylin Akbulut, Gokhan Koca, Nihat Yumusak, Ayse Gulnihal Canseven Kursun, Deniz Billur, Meliha Korkmaz

Publication date 29-11-2022


To investigate effect of exposure to extremely low-frequency magnetic fields (ELF-MFs) on nasal mucociliary clearance in a rat model by rhinoscintigraphy and histopathology assessment. Our rat model has shown the nasal mucosa damage and decreased nasal mucociliary clearance rates and nasal mucociliary transport rate by rhinoscintigraphy as ELF-MFs intensity increases. It may be detrimental to mucociliary function depending on the ELF-MFs intensity.
Objective To investigate the effect of exposure to extremely low-frequency magnetic fields (ELF-MFs) on nasal mucociliary clearance (MCC) by rhinosintigrapic and histopathological evaluation.
Materials and Methods The rats were separated into three groups according to ELF-MFs intensity and control group. The exposure groups were standardized for the ELF-MFs of 1, 1.5, and 2 mT emitted by 3 Helmholtz coils for 4 h/day for 30 days. Rhinoscintigraphy was performed to measure nasal MCC. The nasal tissues were examined for edema, inflammation, hyperemia, necrosis, ciliary loss, goblet cell density, and fibroblast proliferation. The data were evaluated statistically (p < 0.05).
Results Nasal mucociliary clearance rates (NMCR) were calculated as 33.13 ± 5.91% in control, 27.78 ± 4.7% in 1 mT, 22.67 ± 5.43% in 1.5 mT, and 18.11 ± 6.33% in 2 mT. NMCR were decreased with increasing ELF-MFs, in 1.5 and 2 mT groups (p < 0.05) compared to control. Nasal mucociliary transport rate (NMTR) values were found to be 2.17 ± 0.33 mm/min in control, 1.82 ± 0.32 mm/min in 1 mT, 1.46 ± 0.34 mm/min in 1.5 mT and 1.24 ± 0.29 mm/min in 2 mT. NMTR was decreased in the groups exposed to 1.5 and 2 mT (p < 0.05) compared to control. The edema, hyperemia, inflammation, ciliary loss, and goblet cell density were statistically significant differences between control and groups exposed to 1.5 and 2 mT (p < 0.05).
Conclusion Our rat model has shown nasal mucosa damage and decreased NMCR and NMTR by rhinoscintigraphy as ELF-MFs intensity increases. It may be detrimental to nasal mucosa mucociliary function depending on the ELF-MFs intensity.
Level of EvidenceN/A Laryngoscope, 2022

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Determining Invasion Depth in Superficial Pharyngeal Carcinoma by Transoral Ultrasonography

Kouhei Yumii, Tsutomu Ueda, Yuji Urabe, Motomitsu Fukuhara, Nobuyuki Chikuie, Takayuki Taruya, Takashi Kono, Takao Hamamoto, Minoru Hattori, Masaya Takumida, Takashi Ishino, Sachio Takeno

Publication date 28-11-2022


Classification for transoral US findings. (A) US-EP. (B) US-SEP slight. (C) US-SEP deep.
White arrow: Tumor. EP, epithelium; SEP, subepithelial propria; US, ultrasonography.
Objectives To examine the clinical usefulness of transoral ultrasonography (US) in determining the invasion depth of superficial pharyngeal carcinoma (SPC). Determining the invasion depth of SPC is crucial for transoral surgery including determining treatment strategy. This study aimed to examine the usefulness of transoral US in determining the invasion depth of SPC.
Methods Forty-six patients with 51 lesions who underwent both magnifying endoscopy with narrow-band imaging (ME-NBI) and transoral US were included. The primary outcomes were the sensitivity, specificity, positive (PPV), and negative predictive values (NPV) of ME-NBI and transoral US findings for pathological tumor depth in SPCs.
Results The accuracy (82.4%), sensitivity (85.2%), PPV (82.1%), and NPV (82.6%) rates of US for subepithelial propria (SEP) were higher than those of ME-NBI and macroscopic classification, indicating that transoral US is superior to ME-NBI in determining the invasion depth. All cases where the SEP was clearly invaded (SEP deep) could be diagnosed as SEP by transoral US.
Conclusions Transoral US may be useful in determining the invasion depth of SPCs.
Level of Evidence3 Laryngoscope, 2022

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Tympanostomy Tube Placement in Children with Autism Spectrum Disorder

Flora Yan, Arnav Shah, Glenn Isaacson

Publication date 25-11-2022


Objective The frequency of tympanostomy tube (TT) placement among United States children with autism spectrum disorder (ASD) is not known. We explored the rate of TT placement in children with ASD in the United States and compared this to children without ASD. We further examined demographic and behavioral factors that might vary between the two groups.
Methods We utilized data from the National Health Interview Survey (NHIS) administered in 2014. This survey samples a representative population of patients across the United States and includes children under 18 years of age. The 2014 version of the NHIS survey was chosen as it identifies both autism and TT placement among sampled patients. Descriptive statistics and univariable and multivariable logistic regression analyses were performed.
Results In total, 11,730 children (239 2.0% with ASD) were included. Overall, 34 (14.2%) children with ASD underwent TT placement versus 987 (8.6%) in children without ASD (p = 0.002) ASD diagnosis was associated with increased odds of TT placement (1.52 OR, 95% CI 1.04–2.22). Male sex, white race, and non-Hispanic ethnicity were also associated with increased odds of TT placement. Age at the time of TT surgery was not different between those with versus without ASD.
Conclusion Children with ASD have an increased rate of TT placement compared to children without ASD. The reason(s) for this increased rate might include the following: higher rates of infection in ASD, over-diagnosis of ear infection or hearing disability in a difficult-to-examine population, and/or a predilection toward aggressive treatment in this at-risk group.
Level of Evidence3-National database study Laryngoscope, 2022

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The Treatment Effect of Non‐Surgical Ear Molding Correction in Children with Mild Cryptotia Deformity

Huijuan Xu, Shaoguang Ding, Haitao Yang, Litao Qin, Cuncun Xie, Xiaodong Jia, Yanzi Zang, Wenfeng Yao, Qian Li, Guangke Wang, Hongjian Liu

Publication date 25-11-2022


The nonsurgical ear molding correction has a high success rate and a low complication rate in children with mild cryptotia deformity. We first propose and recommend that the treatment time window for non-surgical ear molding correction be maximally extended to 6 years old in children with mild cryptotia deformity.
Objective To investigate the treatment effect of non-surgical ear molding correction in children with mild cryptotia deformity.
Methods51 cases were collected from 2016 to 2021. They were divided into four groups (6 months–1 year group, 1–3 years group, 3–6 years group, and ≥6 years group). The effective rate, recurrence rate, complication rate, and treatment duration of non-surgical ear molding correction were analyzed among the four groups.
Results3 months after the end of corrective treatment, the overall effective rate was 92.2% (47/51), the overall recurrence rate was 7.8% (4/51), and there was statistical significance among the four groups (p = 0.001). The overall complication rate was 2.0% (1/51), and there was no statistical significance among the four groups (p = 1.000). There was statistical significance in the treatment duration among the four groups (p < 0.001), and the mean duration of treatment was positively correlated with the age at treatment (p < 0.001, R = 0.614).
Conclusions We first propose and recommend that the treatment time window for non-surgical ear molding correction be maximally extended to 6 years old in children with mild cryptotia deformity. There is a high success rate of non-surgical ear molding correction in children with mild cryptotia deformity. The complication rate is low. There is a positive correlation between the mean treatment duration and the age at treatment, and the treatment duration increases with the growth of months.
Level of Evidence4 Laryngoscope, 2022

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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 24-11-2022


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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Hajek and Hirsch: Otolaryngology Pioneers of Endonasal Transsphenoidal Pituitary Surgery

Nir Ben‐Shlomo, Albert Mudry, James Naples, Jarrett Walsh, Timothy R. Smith, Edward R. Laws, C. Eduardo Corrales

Publication date 24-11-2022


In the current era, the most common approach to pathology affecting the sellar and parasellar region involves an exclusively endonasal (extracranial) transnasal transsphenoidal approach using either microscopic or endoscopic techniques. Two pioneering Viennese otolaryngologists, building on each others expertise, were instrumental in the development of the exclusively extracranial transnasal transsphenoidal approach to the pituitary gland: Markus Hajek and Oskar Hirsch.
Objective To evaluate the historical descriptive origins of the extracranial transnasal transsphenoidal route to the sphenoid sinus and sella turcica focusing on the works of two otolaryngologists: Markus Hajek (1861–1941) and Oskar Hirsch (1877–1965).
Data SourcesA collection of primary references of author publications, and contemporary references and textbooks.
Review Methods Primary references were reviewed with specific focus on surgical routes to the sphenoid sinus and sella turcica. Chronology was cross-referenced with contemporary publications by contemporaries. Translations from German were conducted by author AM when necessary.
Results Markus Hajek elegantly described the surgical approach to the posterior ethmoids and sphenoid sinus in 1904 using a transnasal route. Building on this foundation, Oskar Hirsch described the fully extracranial endonasal transethmoid transsphenoidal approach in 1909. He was first to describe surgical entrance to the sella using this exclusively unilateral endonasal route, which he demonstrated on a cadaver. He reports performing this procedure on a live patient in April, 1910, under local anesthesia in stages over 5 weeks. For better exposure, Hirsch consolidated his method with Killians submucosal window resection of the posterior nasal septum allowing for bilateral access to the sphenoid sinus and sella, and completed a single stage procedure on a patient in June 1910.
Conclusion Oskar Hirsch was the first to describe and perform a stepwise surgical approach to the sella using an exclusively extracranial, endonasal, transethmoid, and transsphenoidal approach. He built upon his mentor Markus Hajeks approaches to the posterior ethmoid cells and sphenoid sinus.
Level of EvidenceN/A: Background information, synthesis from multiple sources emphasizing factual information Laryngoscope, 2022

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Does Surgery for Nasal Obstruction Improve Eustachian Tube Dysfunction?

Celina Virgen, Tuleen Sawaf, Bryan Renslo, Alexander G. Chiu

Publication date 23-11-2022


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Simple Means to Prevent Cuff Rupture During Nasotracheal Intubation

Justin P. Benoit, John Flynn, Nate Jowett, Fred E. Shapiro

Publication date 17-11-2022


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In Response to Predicting Pathologic Lymph Node Positivity in cN0 Pharynx and Larynx Cancers

Eric Anderson, Michael Luu, Allen S. Ho, Zachary S. Zumsteg

Publication date 17-11-2022


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In Reference to Predicting Pathologic Lymph Node Positivity in cN0 Pharynx and Larynx Cancers

Suresh Mani, Smriti Panda, Rajeev Kumar, Chirom A Singh

Publication date 17-11-2022


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Gender and Ethnic Diversity in Academic Facial Plastic Surgery

David W. Chou, Eleanor Layfield, Karthik Prasad, Charles Shih, Kathleyn Brandstetter

Publication date 16-11-2022


This study characterizes academic facial plastic surgeons by demographics and time in practice and correlates these factors with academic productivity and faculty position. Representation of Hispanic/Latinx and Black surgeons was low, and the majority of the cohort was male. Research productivity and academic advancement was similar between race and gender groups, and diversity was greater among early-career faculty.
Objective Characterize academic facial plastic surgeons by demographics, time in practice, academic productivity, and faculty position.
Study Type Cross-sectional study.
Methods Facial plastic surgery faculty in US otolaryngology residencies with a title of assistant professor, associate professor, or professor were identified. Demographics and academic data were obtained from public profiles and Scopus.
Results One hundred sixty-eight surgeons were identified. Females comprised 25.6%. Most surgeons were White (69.6%), followed by Asian (25%), Hispanic (3.6%), and Black (1.8%). Mean h-index was similar between sexes when controlling for years in practice (1.13 vs. 1.14, p = 0.575). Female representation was greater among early-career surgeons (41%) than among mid- or late-career surgeons (24% and 13%, respectively) (p = 0.006). The correlation of years in practice with academic title was similar between sexes. There was no difference in h-index (p = 0.384) or distribution of academic positions (p = 0.658) between White and non-White surgeons. There was no statistical difference in full professorship (p = 1.0) or research productivity (p = 0.974) between late-career White and non-White academic facial plastic surgeons. There was no statistical difference in promotion from assistant professorship (p = 0.506) or research productivity (p = 0.857) between White and non-White surgeons in practice for over 5 years.
Conclusion Female representation in academic facial plastic surgery is low, though greater gender parity among younger surgeons suggests an improving trend. Hispanic and Black surgeons remain significantly underrepresented in the field. Although increased diversity is needed in academic facial plastic surgery, established minority surgeons have experienced similar research productivity and advancement through academic ranks as their majority counterparts.
Level of EvidenceN/A Laryngoscope, 2022

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The Arterial Pattern of the Upper Nasal Septum (S‐Point) and Potential Role in Severe Epistaxis

Natália Cerqueira Rezende, Luciano C.P.C. Leonel, Eduardo Macoto Kosugi, Carlos Diógenes Pinheiro‐Neto, Maria Peris‐Celda

Publication date 16-11-2022


The previously described S-point, corresponds to the medial projection of the middle turbinate axilla in the superior nasal septum and has been identified as a common source of severe epistaxis. The rich anatomical patterns of vascularization of the S-point area could explain why this area is a common site of severe epistaxis and guide its surgical cauterization when an obvious vascular ectasia is not visualized.
Objectives The previously described S-point, corresponds to the medial projection of the middle turbinate axilla in the superior nasal septum and has been identified as a common source of severe epistaxis. The objective is to define the anatomical patterns of vascularization of the S-point area that could explain its clinical relevance.
Methods Thirty-three nasal septums of latex-injected formalin-embalmed and fresh human cadaveric heads were dissected to analyze the arterial arrangement of the S-point area. Measurements and patterns of vascularization were described.
Results The S-point area, was consistently surrounded by a single or multiple arterial anastomotic arches consistently formed superiorly by the anterior ethmoidal and posterior ethmoidal artery branches, and inferiorly by the posterior septal artery. The caliber of the arterial arches was typically larger than the caliber of the arterial branches supplying them. A single arch was present in 36.3% of septums, and multiple arches in 63.6%. The mean distance from the S-point to the anterior limit of the arch was 9 mm, to the posterior arch when the present was 3 mm, to the superior limit 6 mm, to the inferior limit 6 mm, and to the nasal roof was 10 mm.
Conclusion This study demonstrates the dense arterial configuration of the S point area, which is characterized by a single or multiple vascular arches of greater caliber than the branches of origin. This finding could explain why the S-point area is a frequent source of epistaxis, and guide its surgical cauterization when an obvious vascular ectasia is not visualized.
Level of EvidenceN/A Laryngoscope, 2022

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Surveying the Landscape of Social Media Usage for Health Care by Otolaryngology Patients

Sameer D. Kini, Firas A. Houssein, Armo Derbarsegian, Sarah M. Adams, Katie M. Phillips, Ahmad R. Sedaghat

Publication date 14-11-2022


The objective of this study was to determine the extent of social media usage for finding a doctor or seeking medical advice among otolaryngology patients, and to identify factors associated with this social media usage. We found that a majority of otolaryngology patients may be aware of healthcare applications of social media, with Facebook being the dominant platform, and Medicare insurance identifying patients who may most use social media in this manner. There is also indication that social determinants of health, as reflected by Medicaid insurance, may be associated with using social media to seek medical advice.
Objective To determine factors associated with social media usage for finding a doctor or seeking medical advice among otolaryngology patients.
Methods Cross-sectional study of 361 patients visiting our clinics. All participants were asked if they were aware social media may be used to find doctors and if they had ever done so, and also if they were aware social media could be used to get advice about a medical condition or its treatment and if they had ever done so. Demographic characteristics were examined for association with affirmative answers to these questions.
Results Facebook was the most used social media platform with 50.7% using Facebook daily. Over 50% of participants were aware social media could be used to find a doctor or seek medical advice. Daily use of Facebook was associated with using social media for finding a doctor (OR = 2.57, 95%CI: 1.41–4.67, p = 0.002) and seeking medical advice (OR = 1.72, 95%CI: 1.09–2.71, p = 0.020). Having Medicare was associated with using social media to find a doctor (OR = 2.20, 95%CI: 1.15–4.21, p = 0.017), whereas Medicaid was associated with using social media for medical advice (OR = 1.99, 95%CI: 1.08–3.67, p = 0.027).
ConclusionA majority of otolaryngology patients may be aware of health care applications of social media, with Facebook being the dominant platform, and Medicare insurance identifying patients who may most use social media in this manner. There is also an indication that social determinants of health, as reflected by Medicaid insurance, may be associated with using social media to seek medical advice.
Level of EvidenceNA Laryngoscope, 2022

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"Abnormal TSH Prior to Surgery in Children with Graves Disease Predicts Abnormal TSH Following Thyroidectomy"

Inbal Hazkani, Eli Stein, Evan Edwards, John Maddalozzo, Douglas Johnston, Jill Samis, Jami Josefson, Jeffrey Rastatter

Publication date 12-11-2022


Objective To identify variables that are associated with poor compliance to thyroid hormone replacement therapy in children after total thyroidectomy.
MethodA retrospective cohort study of children who underwent total thyroidectomy by high-volume pediatric otolaryngologists between 1/2014 and 9/2021. Postoperative poor compliance was characterized by at least three separate measurements of high TSH levels not associated with radioactive iodine treatment.
Results There were 100 patients, ages 3–20 years old who met inclusion criteria; 44 patients underwent thyroidectomy for cancer diagnosis, and 56 for Graves disease. The mean follow-up time was 36.5 months (range 3.0–95.6 months). Overall, 42 patients (42%) were found to have at least three measurements of high TSH during follow-up, and 29 patients (29%) were diagnosed with clinical hypothyroidism. Sex, race, income, insurance type, and benign versus malignant etiology for thyroidectomy were not associated with adherence to therapy. Multivariate regression analysis identified patients with Graves disease and hyperthyroidism at the time of surgery and Hispanic ethnicity to be associated with postoperative clinical hypothyroidism (OR 9.38, 95% CI 2.16–49.2, p = 0.004 and OR 6.15, 95% CI 1.21–36.0, p = 0.033, respectively).
Conclusions Preoperative hyperthyroidism in patients with Graves disease and Hispanic ethnicity were predictors of postoperative TSH abnormalities. Preoperative counseling for patients and their families on the implications of total thyroidectomy and the need for life-long medications postoperatively is necessary. Efforts should be made to evaluate and improve adherence to therapy pre-and postoperatively in patients with Graves disease.
Level of Evidence4 Laryngoscope, 2022

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Can electrocautery replace the scalpel for surgical skin incision?

Jobran Mansour, Ameya Asarkar, John Pang, Cherie‐Ann O. Nathan

Publication date 12-11-2022


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Is Posterior Nasal Nerve Ablation Effective in Treating Symptoms of Allergic Rhinitis?

Camron Davies, Daniel Gorelik, Andrew P. Lane, Masayoshi Takashima, Omar G. Ahmed

Publication date 12-11-2022


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Development of Artificial Intelligence for Parathyroid Recognition During Endoscopic Thyroid Surgery

Bo Wang, Jing Zheng, Jia‐Fan Yu, Si‐Ying Lin, Shou‐Yi Yan, Li‐Yong Zhang, Si‐Si Wang, Shao‐Jun Cai, Amr H. Abdelhamid Ahmed, Lan‐Qin Lin, Fei Chen, Gregory W. Randolph, Wen‐Xin Zhao

Publication date 12-11-2022


PTAIR is an artificial intelligence algorithm to identify parathyroid glands in the endoscopic thyroid. Artificial intelligence biopsies are on the horizon for us.
Objective We aimed to establish an artificial intelligence (AI) model to identify parathyroid glands during endoscopic approaches and compare it with senior and junior surgeons visual estimation.
MethodsA total of 1,700 images of parathyroid glands from 166 endoscopic thyroidectomy videos were labeled. Data from 20 additional full-length videos were used as an independent external cohort. The YOLO V3, Faster R-CNN, and Cascade algorithms were used for deep learning, and the optimal algorithm was selected for independent external cohort analysis. Finally, the identification rate, initial recognition time, and tracking periods of PTAIR (Artificial Intelligence model for Parathyroid gland Recognition), junior surgeons, and senior surgeons were compared.
Results The Faster R-CNN algorithm showed the best balance after optimizing the hyperparameters of each algorithm and was updated as PTAIR. The precision, recall rate, and F1 score of the PTAIR were 88.7%, 92.3%, and 90.5%, respectively. In the independent external cohort, the parathyroid identification rates of PTAIR, senior surgeons, and junior surgeons were 96.9%, 87.5%, and 71.9%, respectively. In addition, PTAIR recognized parathyroid glands 3.83 s ahead of the senior surgeons (p = 0.008), with a tracking period 62.82 s longer than the senior surgeons (p = 0.006).
ConclusionsPTAIR can achieve earlier identification and full-time tracing under a particular training strategy. The identification rate of PTAIR is higher than that of junior surgeons and similar to that of senior surgeons. Such systems may have utility in improving surgical outcomes and also in accelerating the education of junior surgeons.
Level of Evidence3 Laryngoscope, 132:2516–2523, 2022

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Advanced Bionics HiRes Ultra and Ultra 3D Series Cochlear Implant Recall: Time Course of Anomalies

Lutz Gärtner, Thomas Lenarz

Publication date 12-11-2022


The initial version of Advanced Bionics Hi Res Ultra and Hi Res Ultra 3D cochlear implants (CIs) showed anomalies within a median survival time of 1062 days. Continuous testing at follow-up visits is needed for patients with CIs to monitor the full functionality of their devices.
Objectives To estimate median survival time until the appearance of anomalies indicating a potential implant failure associated with fluid ingress in implanted cochlear implant (CI) devices of the initial version of Advanced Bionics Hi Res Ultra and Hi Res Ultra 3D series.
Study Design Retrospective review.
Methods Cochlear implantation was performed in a standard fashion. Implant integrity was tested at follow-up visits by measuring impedance and electrically evoked compound action potential (ECAP). Additional tests such as electrical field imaging (EFI) were conducted by the manufacturer. Based on these tests, the presence or absence of an anomaly was classified.
Results Of the 349 devices implanted at this institution, 181 showed anomalies in accordance with the special failure mode and for this reason, 120 implants were already explanted. The median survival time without anomalies was 1062 days. So far, the suspicion of device failures has been confirmed in all cases in which a post-implantation analysis was already available.
Conclusions Regular tests at the follow-up visits are necessary to monitor the integrity of CIs.
Level of Evidence3 Laryngoscope, 132:2484–2490, 2022

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"Performers Perceptions of Vocal Function During Oral Steroid Treatment of Vocal Fold Edema"

Christine Murphy Estes, Keith Chadwick, Babak Sadoughi, Katerina Andreadis, Scott Sussman, Lucian Sulica

Publication date 12-11-2022


Objectives Acute vocal fold edema (VFE) is often a consequence of illness, allergy, or voice overuse, causing dysphonia. Although VFE typically resolves with voice rest and treatment of predisposing causes, oral glucocorticoids are often considered for performers with imminent performance demands. There are limited data about performers perceptions of vocal change during treatment and how this relates to their ability to perform. This study aims to examine performers self-perceptions of vocal function with steroid treatment.
Methods Fifty-five performers (34 F; 21 M) diagnosed with VFE who chose treatment with a 6-day methylprednisolone taper were prospectively assessed. They completed the Evaluation of the Ability to Sing Easily (EASE) and reported on their voice use, regimen, performance obligations, and ability to perform. Findings were compared between Day 1 and Day 6 using paired t-tests and nonparametric Wilcoxon signed-rank tests.
Results Nearly all subjects completed scheduled performances without interruption. Following treatment, all subscales of the EASE were decreased at Day 6 (Vocal Function 29.78–20.59; Pathologic Risk Indicator 26.60–17.33; Vocal Concerns 6.10–4.20). These differences were statistically significant (p < 0.0001) and greater in subjects with performances scheduled and subjects who consistently completed vocal warmups. These findings demonstrate significant improvement in several facets of performers self-perception of function.
Conclusion Subjects reported significant improvement in vocal function with oral steroid treatment and were able to meet performance obligations. It remains important that steroids are not prescribed without laryngeal examination. Examination should be repeated when dysphonia persists, recurs swiftly, or when patients seek repeated treatment, as there may be increased risk of adverse outcomes, and continued steroid use may mask underlying chronic pathology that is best treated by other means.
Level of Evidence4 Laryngoscope, 132:2434–2441, 2022

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Longitudinal Recovery of Speech Motor Function Following Facial Transplantation: A Prospective Observational Study

Bridget J. Perry, Marziye Eshghi, Kaila L. Stipancic, Brian Richburg, Hayden Ventresca, Bohdan Pomahac, Jordan R. Green

Publication date 12-11-2022


Objectives Although facial transplantation is considered effective for restoring facial appearance, research on speech outcomes following surgery is limited. More research is critically needed to inform patients of expected rates and extent of recovery, and to develop interventions aimed at improving speech outcomes.
Methods Four patients in early recovery (3 weeks–24 months postsurgery) and three patients in late recovery (36–60 months postsurgery) were included. Clinical measures of speech recovery, including speech intelligibility measured using the Sentence Intelligibility Test, a lip strength testing device (Iowa Oral Performance Instrument), and kinematic measures of lip and jaw function measured using high-resolution 3D optical motion capture were used to describe the rate and extent of functional speech and lip recovery, describe and compare the rate of functional speech recovery and kinematic lip and jaw changes in early and late stages of recovery, and explore the association between kinematic measures and functional speech.
Results Speech intelligibility, speaking rate, and lip strength were below normative values in the first 2 years of postsurgery. Participants in the first 2 years of recovery demonstrated steeper slopes of improvement in clinical and kinematic measures than participants in the later stages of recovery (36–64 months). Gains in jaw range of movement and gains in lip speed and range of movement were significantly correlated with rates of sentence intelligibility improvement. Gains in lip strength were not associated with functional speech improvement.
Conclusions These findings motivate ongoing work aimed at developing interventions for improving motor speech function in this population.
Level of Evidence3 Laryngoscope, 132:2359–2367, 2022

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Mucosal Epithelial Preservation of Free Nasal Grafts Depending on the Recipient Site

Kosuke Tochigi, Teru Ebihara, Kazuhiro Omura, Haw Torng, Satoshi Aoki, Teppei Takeda, Nobuyoshi Otori, Hiromi Kojima, Yasuhiro Tanaka

Publication date 12-11-2022


Objectives/Hypothesis Reconstruction of mucosal defects using free mucosal grafts has become a common procedure during endoscopic sinus surgery. Epithelialization of mucosal grafts affects postoperative complications and outcomes, which could be influenced by different recipient tissue. However, morphological changes occurring in the grafts transplanted over different tissues remain unexplored.
Study Design An animal study.
Methods Free mucoperichondrial grafts were prepared from the nasal septum of rabbits; the cartilage group had reconstruction on the nasal septal cartilage, and the perichondrium group had reconstruction on the contralateral perichondrium. The nasal septum was removed after 1 and 4 weeks of reconstruction, and the graft was histologically evaluated.
Results After 1 week of reconstruction, the mucosal epithelium of grafts in the cartilage group disappeared, whereas the columnar epithelium of grafts was preserved in the perichondrium group. After 4 weeks of reconstruction, the mucosal defect site was covered with mucosal epithelium in both groups. However, while squamous epithelium was mostly observed in the cartilage group, columnar epithelium containing the healthy ciliary and goblet cells was observed in the perichondrium group. Statistically significant differences were detected in the parameters of epithelial morphology between the two groups, which were higher in the perichondrium group.
Conclusions In the reconstruction of mucosal defects using free mucosal grafts, difference in recipient tissue affects the graft epithelial morphology.
Level of EvidenceNA Laryngoscope, 132:2301–2306, 2022

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Discriminant Ability of the Eating Assessment Tool‐10 to Detect Swallowing Safety and Efficiency Impairments

Cara Donohue, Lauren Tabor Gray, Amber Anderson, Lauren DiBiase, Jennifer Chapin, James P. Wymer, Emily K. Plowman

Publication date 12-11-2022


Objectives/Hypothesis Quick, sensitive dysphagia screening tools are necessary to identify high-risk patients for further evaluation in busy multidisciplinary amyotrophic lateral sclerosis (ALS) clinics. We examined the relationship between self-perceived dysphagia using the validated Eating Assessment Tool-10 (EAT-10) and videofluoroscopic analysis of swallowing safety and efficiency.
Study Design Prospective, observational, longitudinal study.
Methods Individuals with ALS completed the EAT-10 and a videofluoroscopic swallowing study. Duplicate, independent, blinded analyses of the validated Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale were performed to index swallowing safety and efficiency (mild dysphagia: DIGEST ≥ 1, moderate dysphagia: DIGEST ≥ 2). A between-groups analysis of variance with Games-Howell test for post-hoc pairwise comparisons was performed to examine EAT-10 scores across dysphagia severity levels. Receiver operator characteristic curve analysis, area under the curve (AUC), sensitivity, specificity, positive–negative predictive values (PPV, NPV), and odds ratios (OR) were derived.
Results Four hundred and thirty five paired EAT-10 and DIGEST scores were analyzed. Mean EAT-10 score was 8.48 (95% confidence interval CI: 7.63–9.33). Individuals with dysphagia demonstrated higher EAT-10 scores (mild: 4.1 vs. 11.3, moderate: 6.0 vs. 17.5, P < .001). Mean EAT-10 scores increased across DIGEST levels (D0: 4.1, D1: 7.9, D2: 15.1, D3: 20.4, D4: 39.0). For mild dysphagia, an EAT-10 cut score of 3 was optimal: AUC 0.74 (95% CI: 0.69–0.78; sensitivity: 77%; specificity: 53%; PPV: 71%; NPV: 60%; OR: 3.5). An EAT-10 cut score of 7 optimized detection of moderate dysphagia: AUC 0.83 (95% CI: 0.78–0.87; sensitivity: 81%; specificity: 66%; PPV: 39%; NPV: 93%; OR: 8.1).
Conclusion The EAT-10 is an easy-to-administer dysphagia screening tool with good discriminant ability for use in ALS clinics.
Level of Evidence2 Laryngoscope, 132:2319–2326, 2022

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Prospective, Multi‐Center Study of the Anatomic Distribution of Recurrent Respiratory Papillomatosis

Peter A. Benedict, Adam Kravietz, Efstratios Achlatis, Binhuan Wang, Yan Zhang, Joseph Kidane, Tina Harrison, Jonas Miller, Virginia E. Drake, Simon R. Best, Andrew J. McWhorter, R. Jun Lin, Clark A. Rosen, Libby J. Smith, Milan R. Amin

Publication date 12-11-2022


Objectives/Hypothesis To create a model of the anatomic distribution, recurrence, and growth patterns of recurrent respiratory papillomatosis (RRP).
Study Design Prospective, multi-institutional cohort study.
Methods Adult patients with a diagnosis of RRP evaluated between August 1, 2018 and February 1, 2021 at six participating centers were invited to enroll. At each office or operating room encounter, laryngologists recorded the location and size of RRP lesions using a 22-region schematic. A generalized linear mixed effects model was used to compare region variations in lesion prevalence and recurrence.
Results The cohort comprised 121 patients: 74% were male, 81% had been diagnosed with adult-onset RRP, and a plurality (34%) had undergone 0 to 3 RRP interventions prior to enrollment. Across the study period, the odds of a lesion occurring in the glottis was significantly higher (odds ratio OR: 26.51; 95% confidence interval CI: 11.76–59.75, P < .001) compared with all other areas of the larynx and trachea. Within the true vocal folds, the membranous vocal folds had significantly higher odds (OR: 6.16; 95% CI: 2.66–14.30, P < .001) of lesion occurrence compared to the cartilaginous vocal folds. Despite these strong trends in lesion distribution, there were no differences in the odds of lesion recurrence, growth, or in the time to recurrence, between anatomic subsites.
ConclusionsRRP lesions are most likely to occur in the glottis, particularly the membranous vocal folds, compared with other regions of the larynx or trachea. However, all lesions demonstrate similar behavior with respect to recurrence, growth, and time to recurrence regardless of anatomic location.
Level of Evidence3 Laryngoscope, 132:2403–2411, 2022

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Dupilumab Adverse Events in Nasal Polyp Treatment: Analysis of FDA Adverse Event Reporting System

Austin R. Swisher, Rijul S. Kshirsagar, Nithin D. Adappa, Jonathan Liang

Publication date 12-11-2022


Objectives Dupilumab was the first biologic approved to treat chronic rhinosinusitis with nasal polyps (CRSwNP). While the risk of adverse events in phase-III clinical trials was low, dupilumab-associated adverse reactions (DAR) with real-world use is unknown and potentially under-reported. We aimed to evaluate DAR for CRSwNP treatment (CRSwNP-tx) using the FDA Adverse Event Reporting System (FAERS).
Study Design Retrospective database study.
MethodsFAERS was queried for DAR from 2019Q1 to 2021Q2. Individual DAR (iDAR) were categorized and quantitatively compared between treatment groups (CRSwNP, asthma, atopic dermatitis). Zero-truncated Poisson regression was modeled to predict the number of iDAR, and logistic regression was modeled to predict serious DARs.
Results There were 15,411 DAR observations; 911 for CRSwNP-tx, of which 121 (13.3%) had serious reactions and 3 died. Common CRSwNP-tx iDAR were dermatologic (13.9%), generalized (13.3%), and injection-site (10.8%) symptoms. The number of CRSwNP-tx iDAR was 2.99 2.81, 3.17, compared to 3.44 3.32, 3.56 for asthma and 3.18 3.13, 3.24 for atopic dermatitis (Kruskal-Wallis test, P < .001). For CRSwNP-tx, iDAR reported-risk-ratio was 0.84 0.77, 0.92 among men and 1.12 1.04, 1.22 among older adults (>50). Serious DAR reported-odds-ratio was 1.37 0.91, 2.04 among men and 1.39 0.93, 2.08 among older adults.
Conclusions While there are limitations with FAERS, this analysis suggests CRSwNP-tx is associated with fewer iDAR compared with other treatment indications. More iDAR are experienced among women and older adults, but men tend to have more serious DAR.
Level of Evidence3 Laryngoscope, 132:2307–2313, 2022

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Long‐Term Improvement in Localization for Cochlear Implant Users with Single‐Sided Deafness

Nicholas J. Thompson, Margaret T. Dillon, Emily Buss, Meredith A. Rooth, Margaret E. Richter, Harold C. Pillsbury, Kevin D. Brown

Publication date 12-11-2022


Objectives/Hypothesis To assess whether early, significant improvements in sound source localization observed in cochlear implant (CI) recipients with normal hearing (NH) in the contralateral ear are maintained after 5 years of CI use.
Study Design Prospective, repeated measures study.
Methods Participants were recruited from a sample of CI + NH listeners (n = 20) who received their device as part of a prospective clinical trial investigating outcomes of CI use for adult cases of single-sided deafness. Sound source localization was assessed annually after the clinical trial endpoint (1-year post-activation). Listeners were asked to indicate the perceived sound source for a broadband noise burst presented randomly at varied intensity levels from one of 11 speakers along a 180° arc. Performance was quantified as root-mean-squared (RMS) error.
Results Linear mixed models showed superior post-activation performance was maintained with long-term CI use as compared to preoperative abilities (P < .001). Unexpectedly, a significant improvement (P = .009) in sound source localization was observed over the long-term post-activation period (1–5 years). To better understand these long-term findings, the response patterns for the 11 participants who were evaluated at the 1- and 5-year visits were reviewed. This subgroup demonstrated a significant improvement in RMS error (P = .020) and variable error (P = .031), indicating more consistent responses at the 5-year visit.
Conclusion Adult CI + NH listeners experience significant improvements in sound source localization within the initial weeks of listening experience, with additional improvements observed after long-term device use. The present sample demonstrated significant improvements between the 1-year and 5-year visits, with greater accuracy and consistency noted in their response patterns.
Level of Evidence3 Laryngoscope, 132:2453–2458, 2022

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Surgery and Adjuvant Therapy Improve Derkay Scores in Adult and Pediatric Respiratory Papillomatosis

Kiefer Hock, Aimee Kennedy, Rebecca Howell, Aaron Friedman, Alessandro Alarcon, Sid Khosla

Publication date 12-11-2022


Objectives/Hypothesis Comparing Derkay anatomical score at time of procedure, disease characteristics, and mean treatment interval among adult and pediatric patients with recurrent respiratory papillomatosis (RRP).
Study Design Restrospective study.
Methods Retrospective review of juvenile-onset (JO) and adult-onset (AO) RRP patients treated longitudinally at pediatric and adult institutions from 1999 to 2019. Patients were included if they had a tissue diagnosis of papilloma and had at least a 12-month follow-up.
Results One hundred and twelve patients met inclusion criteria (68 JO-RRP and 44 AO-RRP). All patients were stratified into either potassium titanyl phosphate (KTP) (n = 42), CO2 (n = 21), or microdebrider (n = 49) treatment groups. The Derkay score improved between first and last procedure in the KTP group (mean difference, 3.5; P < .001), CO2 group (mean difference, 4.4; P < .001), and microdebrider group (mean difference, 4.1; P < .001), but overall improvement did not differ across groups (P = .73). Baseline mean to last mean Derkay score improved for nine patients during bevacizumab treatments (mean difference, 3.0; P = .01) but did not improve for these same patients during an interval prior to receiving bevacizumab treatments. Baseline mean to last mean Derkay score improved for 19 patients during cidofovir treatments (mean difference, 3.84; P < .001) but did not improve for these same patients during the interval prior to receiving cidofovir treatments. The AO-RRP population had more patients with dysplasia (50%) compared to JO-RRP population (10%) (P < .001).
Conclusion Various surgical modalities appear to be equally effective treatments for RRP. Adult and pediatric patients have decreased recurrent disease burden when receiving bevacizumab or cidofovir. AO-RRP patients have more concomitant dysplasia.
Level of Evidence3 Laryngoscope, 132:2420–2426, 2022

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Radiological Findings in Laryngeal Anterior Commissure Invasion: CT Scan Highlights

Giovanni Cristalli, Antonello Vidiri, Giuseppe Mercante, Fabio Ferreli, Armando De Virgilio, Filippo Donelli, Luigi Davì, Pierpaola Gasparin, Patrizia Cocco, Fabiola Giudici, Francesca Boscolo Nata

Publication date 12-11-2022


Objectives Preoperative anterior commissure (AC) evaluation in glottic cancer is crucial for therapeutic decisions. Endoscopy is often inadequate to precisely detect the presence of cancer in the AC; thus, computed tomography (CT) scan could help. We investigated the relation between AC thickness on CT scan (in mm), AC involvement by cancer at histology, and radiologic signs of anterior paraglottic space (PGS) infiltration.
Study Design Retrospective observational study.
Methods An experienced radiologist retrospectively measured AC thickness and identified signs of anterior PGS infiltration on pretreatment contrast-enhanced CT scans of 80 patients with primary glottic cancer. The gold standard to define the presence of cancer in the AC was histology. The receiver operating characteristic (ROC) curves were used to determine the potential cut-off values of AC thickness (Youden index method) able to maximize both sensitivity and specificity in identifying the presence of cancer in the AC at histology and PGS infiltration on CT scan.
ResultsAC was significantly thicker in patients with cancer in the AC at histology (P < .001) and in patients with PGS infiltration on CT scan (P < .001). The cut-off values to discriminate the presence of cancer at histology and PGS infiltration on CT scan were 3.62 and 2.6 mm, respectively. We found a substantial agreement between anterior PGS infiltration on CT scan and the presence of cancer in the AC at histology (Cohen Kappa: P = .70).
ConclusionAC thickness and radiologic signs of PGS infiltration on pretreatment CT scan could represent a method to predict the presence of cancer in the AC at histology.
Level of Evidence4 Laryngoscope, 132:2427–2433, 2022

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Superior Labial Frenulum Attachment Site and Correlation with Breastfeeding Outcomes

Gayle D. Haischer‐Rollo, Khang Lu, Caitlin Drumm, Angela Fagiana, Sarah N. Bowe, James Aden, Micheal Demarcantonio

Publication date 12-11-2022


Objectives Current literature suggests that infant oral anatomy may impact breastfeeding outcomes. Our research seeks to evaluate superior labial frenulum (SLF) attachment site grade utilizing a modified existing system and investigate the correlation with breastfeeding outcomes.
Methods Two hundred and eight dyads were recruited from the nursery at Brooke Army Medical Center. The neonates SLF and lingual frenulum were evaluated and photo-documented. Photos were assessed by blinded reviewers utilizing a modified Stanford SLF grade. Breastfeeding mothers completed surveys on attitudes and associated pain with feedings 24 h postdelivery, at 2 weeks and at 2 months. Categorical data were analyzed using chi-squared tests or Fishers exact tests. Means and standard deviations were analyzed using analysis of variance or Wilcoxons test.
Results At 2 weeks and 2 months, 86.8% and 72.8% were breastfeeding, respectively. At 2 months, SLF grade 1 newborn dyads had a significantly lower breastfeeding rate (50.0%) compared to SLF grade 2 (75.3%) and SLF grade 3 (85.7%) subjects (p = 0.0384). At 2 weeks and 2 months, there was no difference between SLF groups with regard to maternal breastfeeding attitudes or pain scores. There was no significant difference in terms of weight, referrals, or lingual–labial frenulectomy between SLF groups.
Conclusions Our study shows no correlation between SLF attachment grade and breastfeeding outcomes to include length of breastfeeding, maternally reported confidence, maternal pain, or infant weight. Our findings do not support labial frenulectomy based on SLF grade alone and highlight the need for a more robust functional grading system.
Level of Evidence2Oxford Center for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653Laryngoscope, 132:2498–2504, 2022

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Perceptions of Otolaryngology Residency Among Students Underrepresented in Medicine

Adam Thompson‐Harvey, Marc Drake, Valerie A. Flanary

Publication date 12-11-2022


Objective Otolaryngology-Head and Neck Surgery (OHNS) has historically been one of the least diverse surgical subspecialties. The objective of this study was to better understand perceptions of OHNS from underrepresented students in medicine (URiM) and identify factors affecting URiM application to the specialty.
Study Design Survey via electronic questionnaire.
Methods An anonymous, 22-question electronic survey was administered nationally to URiM medical students (N = 388) regarding factors that play a role in developing an interest in applying to OHNS. Responses to questions were compared between URi Ms applying to OHNS and those applying to other fields.
Results Thirty-six percent of respondents identified as African American and 26% as Latino. Students completed the survey in all years of medical school. Research opportunities (H(2) = 18.58, P < .001) and having a race-concordant role model were the most important factors for those pursing OHNS residency. Personality fit and interactions with OHNS faculty had the greatest influence on their decision to pursue OHNS residency. Board scores (e.g., USMLE Step 1/2CK Scores), competitiveness, lifestyle during residency, the influence of application costs, and racial/ethnic and gender distributions did not reach statistical significance or were noninfluential.
ConclusionURi Ms applying to OHNS value race-concordant mentorship, are involved in research, and have meaningful relationships with their respective OHNS department. We found that establishing meaningful connections with URiM mentors significantly impacts URiM students considering OHNS. While this cohort was not influenced by overemphasis of board scores within the OHNS match process, the COVID-19 pandemic negatively impacted this aspect of their application, along with away rotations.
Level of EvidenceNA Laryngoscope, 132:2335–2343, 2022

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Comparing the M.D. Anderson Symptom and Dysphagia Inventories for Head and Neck Cancer Patients

Adam H. Yarschenko, Demetra H. Yannitsos, Sarah Weppler, Lisa Barbera, Harvey Quon, Qiao Sun, Wendy Smith

Publication date 12-11-2022


Objectives Where patient-reported outcome measures (PROMs) may be administered at multiple patient visits, it is advantageous to capture these symptoms with as few questions as possible. In this study, the M.
D. Anderson Head and Neck Symptom Inventory (MDASI-HN), and the M.
D. Anderson Dysphagia Inventory (MDADI) is compared to determine if using the MDASI-HN alone would overlook symptoms identified with MDADI.
Methods The MDASI-HN and the MDADI were completed by 156 patients, postradiotherapy for head and neck cancer (HNC). Associations between the two instruments were analyzed using correlation analysis, unsupervised machine learning, and sensitivity analysis.
Results Little correlation was found between the two surveys; however, there was overlap between MDASI-HN dry mouth and many MDADI items, confirming that dry mouth is an important factor in difficulty swallowing, and patient QoL. Taking longer to eat (MDADI), was the most commonly reported item overall, with 85 (54%) patients rating it as moderate–severe. Dry mouth was the most endorsed MDASI-HN item (68, 44%). There were 51 patients missed by the MDASI-HN, reporting no moderate–severe symptoms, but reported one or more moderate–severe QoL impacts on MDADI. If patients who reported a score of 2 or higher on the MDASI-HN Dry Mouth item are flagged as requiring follow-up, the number of patients missed by MDASI-HN drops to 15.
Conclusion In an HNC clinic where MDASI-HN is routinely administered, assessment of symptoms and QoL might be enhanced by reducing the value at which MDASI Dry Mouth is considered moderate–severe to 2.
Level of Evidence3 Laryngoscope, 132:2388–2395, 2022

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Gemcitabine Versus Docetaxel Plus Cisplatin as Induction Chemotherapy in Nasopharyngeal Carcinoma

Qian Chen, Shan Li

Publication date 12-11-2022


Objectives To compare tumor volume reduction after induction chemotherapy (IC) with gemcitabine plus cisplatin (GP) and docetaxel plus cisplatin (DP) and to evaluate the influence on subsequent radiotherapy in locoregionally advanced nasopharyngeal carcinoma (NPC).
Study Design Retrospective clinical study.
Methods Patients who received GP or DP IC followed by concurrent chemoradiotherapy (CCRT) were retrospectively enrolled. Propensity score matching (PSM) was adopted to control the balance between the GP and DP groups.
ResultsA total of 41 patients treated with GP and 53 patients treated with DP were enrolled. After matching, 33 sub-pairs of 66 patients were generated in the post-PSM cohort. As compared with DP, GP was superior in its gross tumor volume of the nasopharynx (GTVnx) reduction (28.88% vs. 18.73%; P = .014) but equivalent in its gross tumor volume of the lymph nodes (GTVnd) reduction (37.58% vs. 29.79%; P = .229). Univariate and multivariate analyses confirmed that the chemotherapy regimen was an independent factor associated with the reduction in GTVnx (P = .011). The GP group exhibited advantages in the dosimetric parameters of the planning target volume of high-risk volume and low-risk volume (PTV1 and PTV2), lenses, temporal lobes, and parotid glands. Univariate and multivariate analyses confirmed that chemotherapy regimen was an independent factor associated with the dosimetric parameters of PTV1, PTV2, lenses, temporal lobes, and parotid glands.
ConclusionGP regimen achieves a greater GTVnx reduction than DP regimen and has an advantage in the dosimetry of subsequent CCRT.
Level of Evidence3 Laryngoscope, 132:2379–2387, 2022

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Laser‐Assisted Sialolithotripsy: A Correlation of Objective and Subjective Outcomes

Varun Rai, Rohan R Walvekar, Jatin Verma, Uday Monga, Devinder Rai, Manish Munjal

Publication date 12-11-2022


Objective To analyze the long-term symptomatic results of laser-assisted sialolithotripsy (LAS) in cases of obstructive sialolithiasis and correlate with objective criteria using diagnostic sialendoscopy (DS) as a method of examination.
Methods This is a retrospective study comprising 50 consecutive patients who underwent holmium-YAG LAS and completed follow-up of at least 6 months. Symptom scoring and endoscopic scoring were done at 6 weeks and 6 months intervals for further study purposes.
Results At the end of 6 weeks post-LAS, 70% patients were asymptomatic (A-sym) and only 30% had residual symptoms (Sym). However, obstructed duct (OB-duct) was observed on endoscopic scoring in 88% due to stenosis, residual stones, or both stenosis and residual stones. The obstructed ducts were treated in outpatient clinic and followed up over time, leading to 98% of patients being in A-sym group at the end of study period of 6 months. At the end of study, 82% of patients had clear duct (CL-duct).
Conclusion Holmium LAS is a viable option for the management of intermediate-sized stones. LAS if used judiciously, and in properly selected cases, has high rate of stone fragmentation and symptom resolution. A vigilant postoperative protocol taking into account residual mealtime symptoms and altered salivary characteristics combined with early DS can help identify and treat patients with residual stone fragments and ductal stenosis.
Level of Evidence3 Laryngoscope, 132:2344–2349, 2022

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Ultrasound Guided Biopsy in Patients With HPV‐Associated Oropharyngeal Squamous Cell Carcinoma

"Travis J. Haller, Kathryn M. Van Abel, Linda X. Yin, Christine M. Lohse, Dontre Douse, Joseph N. Badaoui, Daniel L. Price, Jan L. Kasperbauer, Eric J. Moore"

Publication date 12-11-2022


Objectives To identify the differences in sensitivity and accuracy between ultrasound-guided and palpation-guided fine needle aspirations (FNA) of suspicious lymph nodes in patients with human papillomavirus (HPV) (+) oropharyngeal squamous cell carcinoma (OPSCC). Additional objectives included identifying patient specific factors affecting biopsy accuracy and evaluating potential differences in accuracy between fine and core needle biopsies.
Study Design Retrospective chart review.
Materials and MethodsA retrospective study of diagnostic sensitivity was completed at a single tertiary care center between 1/1/2006–12/31/2016. Participants included patients who underwent pretreatment FNA biopsy with HPV(+)OPSCC confirmed pathologically following neck dissection or excisional lymph node biopsy. A true positive (TP) on FNA biopsy was defined as an FNA biopsy concerning for squamous cell carcinoma (SCC) that was confirmed on excisional biopsy or neck dissection. A false negative (FN) was defined as a negative FNA but metastatic disease identified on excisional biopsy or neck dissection. Sensitivity was calculated as TPs/(TPs + FNs). Sensitivity was compared among techniques using chi-square and Fisher exact tests.
ResultsA total of 209 FNA biopsies among 198 patients were included in the study, including 31 (15%) palpation-guided FNAs, 160 (77%) ultrasound-guided FNAs, and 18 (9%) ultrasound-guided FNA + core biopsies. Sensitivity was significantly different among palpation-guided FNA, ultrasound-guided FNA, and ultrasound-guided FNA + core biopsies (48% vs. 83% vs. 94%, respectively; P < .001) but there was no significant difference in sensitivity between ultrasound-guided FNA versus ultrasound-guided FNA + core biopsies (P = .31).
Conclusion The use of ultrasound guidance in FNA biopsies of nodal metastases in HPV(+)OPSCC improves sensitivity compared to palpation guidance alone. Ultrasound guided biopsies are preferred in patients with suspected nodal metastasis from HPV(+)OPSCC.
Level of Evidence3 Laryngoscope, 132:2396–2402, 2022

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Survey of Pediatric Otolaryngology Frenotomy Practice Patterns

Sanidhya Dhir, Barcleigh P. Landau, Stefan Edemobi, Anna K. Meyer, Megan L. Durr

Publication date 12-11-2022


Objectives Assess current frenotomy practice patterns of pediatric otolaryngologists via a cross-sectional survey.
Study Design Survey study.
MethodsA 31-question electronic survey assessing frenotomy practice patterns was distributed to all American Society of Pediatric Otolaryngology (ASPO) members. Descriptive statistics were used to summarize responses and demographics of respondents.
Results Of all ASPO members, 41% (240/588) completed the survey. Most respondents, 185 (77%), reported increased frenotomy referrals over the last 5 years and 144 (60%) described the current number of referrals as “too many.” The two primary lingual frenotomy indications identified in infants were: breastfeeding/nipple pain (92%) and inability to latch (83%). For older children, speech difficulty (87%) was the primary indication. Maxillary frenotomy indications in infants varied amongst respondents. For analgesia during in-office frenotomy procedures, respondents used glucose/sucrose drops (48%), topical lidocaine (29%), or no pain control measure (27%). For post-procedure care, respondents recommended continuing lactation support (45%), massaging/stretching the wound (38%), or none (40%). Most respondents, 143 (60%), reported having seen a complication from frenotomy, and the most reported frenotomy complications were frenulum re-attachment and excessive bleeding.
Conclusions In the last 5 years, otolaryngologists have seen an increase in referrals for frenotomy. Pediatric otolaryngologists have varying practice patterns with regards to ankyloglossia diagnosis and treatment. The reported indications for frenotomy varied amongst pediatric otolaryngologists especially with respect to maxillary frenotomy. Practice patterns also varied with respect to procedural pain control and frenotomy aftercare recommendations. More frenotomy research is needed to establish a standard of care for patients with ankyloglossia.
Level of Evidence4 Laryngoscope, 132:2505–2512, 2022

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Modified Endoscopic Dacryocystorhinostomy: A Clubhead‐Shaped Nasal Mucoperiosteal Flap Technique

Tiechuan Cong, Yuan Wu, Ying Gao, Quangui Wang, Yong Qin

Publication date 12-11-2022


A modified endoscopic dacryocystorhinostomy technique using a clubhead-shaped nasal flap combined with a posteriorly hinged lacrimal flap was designed for tension-free anastomosis with the surrounding mucoperiosteum. This technique showed satisfactory outcomes that facilitated the maintenance of the rhinostomy in eight cases with nasolacrimal duct obstruction. Laryngoscope, 132:2314–2318, 2022

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Alginates for Protection Against Pepsin‐Acid Induced Aerodigestive Epithelial Barrier Disruption

Tina L. Samuels, Ke Yan, Nishma Patel, Kate Plehhova, Cathal Coyle, Bryan P. Hurley, Nikki Johnston

Publication date 12-11-2022


Objective Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are chronic conditions caused by backflow of gastric and duodenal contents into the esophagus and proximal aerodigestive tract, respectively. Mucosal barrier dysfunction resultant from the synergistic actions of chemical injury and the mucosal inflammatory response during reflux contributes to symptom perception. Alginates effectively treat symptoms of mild to moderate GERD and have recently shown benefit for LPR. In addition to forming a “raft” over gastric contents to reduce acidic reflux episodes, alginates have been found to bind the esophageal mucosa thereby preserving functional barrier integrity measured by transepithelial electrical resistance. The aim of this study was to further examine the topical protective capacity of alginate-based Gaviscon Advance (GA) and Double Action (GDA) against pepsin-acid mediated aerodigestive epithelial barrier dysfunction in vitro.
Study Design Translational.
Methods Immortalized human esophageal and vocal cord epithelial cells cultured in transwells were pretreated with liquid formula GA, GDA, matched viscous placebo solution, or saline (control), then treated for 1 h with saline, acid (pH 3–6) or pepsin (0.1–1 mg/ml) at pH 3–6. Endpoint measure was taken of horseradish peroxidase (HRP) allowed to diffuse across monolayers for 2 h.
Results Pepsin (0.1-1 mg/ml) at pH 3-6 increased HRP flux through cultures pretreated with saline or placebo (p < 0.05); acid alone did not. GA and GDA prevented barrier dysfunction.
ConclusionsGA and GDA preserved epithelial barrier function during pepsin-acid insult better than placebo suggesting that protection was due to alginate. These data support topical protection as a therapeutic approach to GERD and LPR. Laryngoscope, 132:2327–2334, 2022

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Sinonasal Mucosal Melanoma: Role of Tumor Proliferative Indices and Pathological Factors in Survival

Ruifeng Guo, Sarah M. Jenkins, Brian J. Johnson, Katelyn Reed, Trynda Kroneman, Garret Choby

Publication date 12-11-2022


Sinonasal mucosal melanoma patients with higher Ki67 indices and higher mitotic rate had worsened overall and recurrence/metastasis-free survival (OS and RMFS). However, those with brisk tumor infiltrating lymphocytes have improved RMFS. Patients on immunotherapy who had Ki67<40% had better 3-year OS compared to those with higher Ki67 index.
Objective The objective of this study is to determine the association of proliferation indices and pathologic biomarkers on overall and recurrence/metastasis-free survival (OS and RMFS) in patients with sinonasal mucosal melanoma (SNMM) and to assess the genetic mutational landscape of SNMM.
Methods This is a retrospective cohort study of 45 SNMM patients without neoadjuvant therapy who underwent surgical therapy with curative intent and had tumor tissue available for histopathologic review, molecular analysis, and genetic mutational assessment. The OS and RMFS were assessed for associations with numerous tumor and patient-related factors.
Results Among proliferative indices, higher Ki67 and mitotic rates were associated with worsened OS and RMFS (Ki67: p = 0.0007 and p < 0.0001; mitotic rate: p = 0.005 and p = 0.0009, respectively). The presence of brisk tumor-infiltrating lymphocytes (TILs) was associated with improved RMFS (p = 0.007) and the presence of lymphovascular invasion was associated with worsened OS and RMFS (p = 0.02 and p = 0.04, respectively). Patients with amelanotic tumors were more likely to have higher T-stage (p = 0.046), less likely to have brisk TILs (p = 0.02) and had worsened RMFS (p = 0.03). Patients on immunotherapy with tumor Ki67 < 40% had better 3-year OS compared to those with higher Ki67 index (p = 0.004). Actionable genetic mutations such as BRAF V600E are rare and present in only 1 of 20 patients tested.
Conclusion In SNMM patients, pathologic and proliferation markers such as Ki67, mitotic rate and brisk TILs are associated with survival and may be considered in future staging systems. Clinical response to immunotherapy appears to correlate with the Ki67 index. Given the distinct genetic profile of SNMM, targeted therapies against the MAPK kinase pathway have limited utility.
Level of Evidence3 Laryngoscope, 132:2350–2358, 2022

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Computational Analysis of the Droplet‐Stimulated Laryngeal Adductor Reflex in High‐Speed Sequences

Jacob Friedemann Fast, Andra Oltmann, Svenja Spindeldreier, Martin Ptok

Publication date 12-11-2022


Objectives/Hypothesis The laryngeal adductor reflex (LAR) is an important protective mechanism of the airways. Its physiology is still not completely understood. The available methods for LAR evaluation offer limited reproducibility and/or rely on subjective interpretation. A new approach, termed Microdroplet Impulse Testing of the LAR (MIT-LAR), was recently introduced. Here, the LAR is elicited by a droplet and a laryngoscopic high-speed recording is acquired simultaneously. In the present work, image-processing algorithms for autonomous MIT-LAR sequence analysis were developed. This allowed the automated approximation of kinematic LAR parameters in humans.
Study Design Development and testing of computational methods.
Methods Computational image processing enabled the autonomous estimation of the glottal area, the glottal angle, and the vocal fold edge distance in MIT-LAR sequences. A suitable analytical representation of these glottal parameters allowed the extraction of seven relevant LAR parameters. The obtained values were compared to the literature.
ResultsA generalized logistic function showed the highest average goodness of fit among four different analytical approaches for each of the glottal parameters. Autonomous sequence analysis yielded bilateral LAR response latencies of (229 ± 116) ms and (182 ± 60) ms for cases of complete and incomplete glottal closure, respectively. The initial/average/maximum angular vocal fold adduction velocity was estimated at (157 ± 115) °s−1/(891 ± 516) °s−1/(929 ±  583) °s−1 and (88 ± 53) °s−1/(421 ± 221) °s−1/(520 ± 238) °s−1 for complete and incomplete glottal closure, respectively.
Conclusion The automated extraction of LAR parameters from laryngoscopic high-speed sequences can potentially increase the objectiveness of optical LAR characterization and reduce the associated workload. The proposed methods may thus be helpful for future research on this vital reflex.
Level of EvidenceNA Laryngoscope, 132:2412–2419, 2022

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Incidental FDG‐Avid Focuses in Palatine Tonsils on PET/CT

Kasper Basse Reinholdt, André Henrique Dias, Camilla Molich Hoff, Lars Christian Gormsen, Tejs Ehlers Klug

Publication date 12-11-2022


Objectives The management of incidental findings of FDG-avid tonsils on PET/CT (IFT) is unclear. We aimed to explore the prevalence of malignancy in IFT, identify risk factors for malignancy, and calculate optimal cutoffs of maximum standardized uptake values (SUVmax) to discriminate between benign and malignant lesions.
Methods All patients who were tonsillectomized at our institution because of IFT from October 2011 to December 2020 were included. Patients undergoing PET/CT due to suspected tonsillar disease or cancer of unknown primary were excluded.
Results In total, 77 patients were included, of which 11 (14%) of them had IFT malignancy. Dysphagia (p = 0.019) and alcohol abuse (p = 0.035) were associated with malignancy. Absolute SUVmax cutoff (≥9: sensitivity 100%; specificity 53%) was superior to SUVmax side-to-side ratio (≥1.
5: sensitivity 64%; specificity 70%) to discriminate between benign and malignant lesions.
Conclusion We recommend tonsillectomy for patients with IFT displaying SUVmax ≥ 9.0, ratio ≥ 1.5, or symptoms or findings suggesting malignancy.
Level of Evidence3 Laryngoscope, 132:2370–2378, 2022

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Ambulatory Blood Pressure Variability after Adenotonsillectomy in Childhood Sleep Apnea

Kun‐Tai Kang, Shuenn‐Nan Chiu, Wen‐Chin Weng, Pei‐Lin Lee, Wei‐Chung Hsu

Publication date 12-11-2022


Objective To investigate the influence of adenotonsillectomy (T&A) on ambulatory blood pressure (BP) variability in children with obstructive sleep apnea (OSA).
Study Design Prospective, interventional study.
Methods Children with OSA symptoms were recruited from a tertiary center. After OSA diagnosis was confirmed (ie, apnea-hypopnea index AHI > 1), these children underwent T&A for treatment. We performed polysomnography and 24-hour recordings of ambulatory BP before and 3 to 6 months postoperatively. Ambulatory BP variability was presented as the standard deviation of mean blood pressure in the 24-hour monitoring of ambulatory BP. Differences in BP variability among different subgroups were tested using a multivariable linear mixed model.
ResultsA total of 190 children were enrolled (mean age: 7.8 ± 3.3 years; 73% were boys; 34% were obese). The AHI significantly decreased from 12.3 ± 17.0 to 2.7 ± 5.5 events/hr after T&A. Overall, daytime, and nighttime ambulatory BP did not significantly change postoperatively, and overall, daytime, and nighttime ambulatory BP variability did not differ significantly preoperatively and postoperatively. In the subgroup analysis, children aged <6 years demonstrated a significantly greater decrease in ambulatory BP variability postoperatively than those aged >6 years (nighttime diastolic BP variability: 9.9 to 7.7 vs. 8.9 to 9.4). Children with hypertension also showed a significantly greater decrease in ambulatory BP variability than those without hypertension.
Conclusions We concluded that overall ambulatory BP variability does not significantly change after T&A in children with OSA. Moreover, young-aged and hypertensive children demonstrate a significant decrease in BP variability after T&A.
Level of Evidence4 Laryngoscope, 132:2491–2497, 2022

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Melkersson‐Rosenthal‐syndrome ‐ A Rare Case of Laryngeal Involvement

Nina Wenda, Nicole Christina Stuhrmann, Anna Messerschmid, Elisabeth Märker‐Hermann, Jan Gosepath

Publication date 12-11-2022


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Interference With Implanted Upper Airway Stimulation Device by Phones With Magnet Technology

Andrea Plawecki, Nitika Tripathi, Maria Tovar Torres, Kathleen Yaremchuk

Publication date 12-11-2022


Recent studies have raised concern regarding electromagnetic interference from new cellular phones that incorporate novel magnetic technology with the function of implanted medical devices. This case series evaluates the effect of these cellular devices on the implanted hypoglossal nerve stimulator. This case series tested the function of hypoglossal nerve stimulator device in the presence of the i Phones 12 and 13 and found interference with the implant function in all three patients. Patients implants can now be informed about the potential for cellular phones with magnetic technology to cause interference with their devices.
Newer i Phone models with Mag Safe magnetic technology can cause electromagnetic interference with the Inspire upper airway stimulator device (a surgical implant for the treatment of obstructive sleep apnea). Laryngoscope, 132:2513–2515, 2022

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In Response to Anatomical Features Around Eustachian Tube in Eosinophilic Otitis Media with Eosinophilic Sinusitis: Correspondence

Shinya Ohira

Publication date 12-11-2022


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Anatomical Features Around Eustachian Tube in Eosinophilic Otitis Media with Eosinophilic Sinusitis: Correspondence

Eduardo Garcia‐Martinez, Francisco Javier Arrambide‐Garza, Natalia Villarreal‐Del‐Bosque, José Luis Treviño‐González, Santos Guzman‐Lopez, Alejandro Quiroga‐Garza

Publication date 12-11-2022


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Masthead

Publication date 12-11-2022


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Table of contents

Publication date 12-11-2022


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A Systematic Review of Eustachian Tube Procedures for Baro‐challenge Eustachian Tube Dysfunction

Mallory J. Raymond, Michael C. Shih, Phillip Ryan Elvis, Shaun A. Nguyen, Emily Brennan, Ted A. Meyer, Paul R. Lambert

Publication date 12-11-2022


Objective To examine the effectiveness of Eustachian tube procedures for the treatment of baro-challenge Eustachian tube dysfunction.
Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, databases, including Pub Med (National Library of Medicine, National Institutes of Health), Scopus (Elsevier), and CINAHL (EBSCO), were searched for articles examining the effectiveness of Eustachian tube procedures for baro-challenge Eustachian tube dysfunction. Outcome measures included symptom resolution, ability to return to work, equalization problems (EP) scores, Eustachian Tube Dysfunction Questionnaire (ETDQ-7) scores, and pressure chamber testing parameters. Pooled meta-analysis was performed for dichotomous measures and ETDQ-7 scores.
Results Eleven articles with 81 patients were included. Seventy-two patients from 10 articles underwent balloon Eustachian tube dilation; nine patients in 1 study underwent laser Eustachian tuboplasty (LET). All 81 patients were preoperatively symptomatic with barometric pressure change, and 26/30 (86.7%) were unable to work due to symptoms. On meta-analysis, after balloon dilation Eustachian tuboplasty (BDET), 82.5% (n = 30 95% confidence interval: 42%–100%) had improvement in ability to valsalva, 79.1% (n = 16 57.9%–94.1%) in ability to return to work, and 84.3% (n = 69 69.8%–94.7%) in any symptom. Of 25 patients with individual ETDQ-7 scores, 79.1% 51.4, 96.9 had improvements after BDET. For four case series with 36 patients, ETDQ-7 scores decreased by 1.2 0.7, 1.7 (p < 0.00001). Of 20 patients with preoperative ETDQ-7 scores >2.0, there was a mean decrease of 2.1 1.3, 2.8 (p < 0.00001).
Conclusion From the available evidence, Eustachian tube procedures appear to be effective at improving symptoms of baro-challenge Eustachian tube dysfunction. However, higher quality evidence is needed to support making definite recommendations for the use of balloon Eustachian tube dilation or LET for these patients. Laryngoscope, 132:2473–2483, 2022

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Mitochondrial Disease and Hearing Loss in Children: A Systematic Review

"Sebastian Roesch, Anna OSullivan, Georg Zimmermann, Alois Mair, Cvetka Lipuš, Johannes A. Mayr, Saskia B. Wortmann, Gerd Rasp"

Publication date 12-11-2022


Abstract Objectives Hearing loss is a clinical symptom, frequently mentioned in the context of mitochondrial disease. With no cure available for mitochondrial disease, supportive treatment of clinical symptoms like hearing loss is of the utmost importance. The aim of this study was to summarize current knowledge on hearing loss in genetically proven mitochondrial disease in children and deduce possible and necessary consequences in patient care.
Methods Systematic literature review, including Medline, Embase, and Cochrane library. Review protocol was established and registered prior to conduction (International prospective register of systematic reviews—PROSPERO: CRD42020165356). Conduction of this review was done in accordance with MOOSE criteria.
ResultsA total of 23 articles, meeting predefined criteria and providing sufficient information on 75 individuals with childhood onset hearing loss was included for analysis. Both cochlear and retro-cochlear origin of hearing loss can be identified among different types of mitochondrial disease. Analysis was hindered by inhomogeneous reporting and methodical limitations.
Conclusion Overall, the findings do not allow for a general statement on hearing loss in children with mitochondrial disease. Retro-cochlear hearing loss seems to be found more often than expected. A common feature appears to be progression of hearing loss over time. However, hearing loss in these patients shows manifold characteristics. Therefore, awareness of mitochondrial disease as a possible causative background is important for otolaryngologists. Future attempts rely on standardized reporting and long-term follow-up.
Level of EvidenceNA Laryngoscope, 132:2459–2472, 2022

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Rhinoplasty Patients Do Not Have Higher Rates of Antidepressant, Anxiolytic, and ADHD Medication Use

Lillian W. Dattilo, Alan D. Workman, Roy Xiao, David A. Shaye, Linda N. Lee, Robin W. Lindsay, Neil Bhattacharyya

Publication date 12-11-2022


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Phantosmia May Predict Long‐Term Measurable Olfactory Dysfunction After COVID‐19

Jai‐Sen Leung, Valentina Paz Cordano, Eduardo Fuentes‐López, Antonia Elisa Lagos, Francisco Gustavo García‐Huidobro, Rodrigo Aliaga, Luis Antonio Díaz, Tamara García‐Salum, Erick Salinas, Adriana Toro, Claudio Andrés Callejas, Arnoldo Riquelme, James N. Palmer, Rafael A. Medina, Claudia González G

Publication date 12-11-2022


Olfactory dysfunction following COVID-19 persisted in 29% of the patients after 1 year of infection. Phantosmia at baseline and 1 month were associated with a worse evolution, but their presence may represent ongoing regeneration. Longer follow-up is required in these patients.
Objectives Persistent olfactory dysfunction (OD) after 6 months caused by SARS-CoV-2 infection has been reported with a variable prevalence worldwide. This study aimed to determine the prevalence of long-term OD and identify predisposing factors.
MethodsA prospective cohort study was conducted on 100 adults with COVID-19. Olfactory function was assessed with the University of Pennsylvania Smell Identification Test and a symptom survey at the onset of disease and 30 days later. Patients with persistent quantitative OD at the second assessment were reevaluated after 1 year. Demographic variables, symptoms, and the degree of smell loss were analyzed.
Results Participants included 100 patients. The mean age was 42.2 ± 15.6 years, 55 (55%) were female, and 56 (56%) were outpatients. Baseline smell loss was identified in 75/100 (75%) patients, decreasing to 39/95 (40%) after 1 month, and persisting in 29 patients after 1 year. Phantosmia at baseline was the only risk factor identified for persistent OD after 1 year (relative risk 2.51; 95% confidence interval 1.53–4.12; p < 0.001). Regardless of the outcome in smell function, a significant decline in olfaction was associated with the presence of phantosmia at 1 month (β = −12.39; 95% CI −19.82 to −4.95; p < 0.01).
ConclusionsSARS-CoV-2 (2019–2020 variants) produced a highly frequent OD that persisted in 29% of the patients after 1 year. The presence of phantosmia at baseline and 1 month was associated with a worse evolution, but phantosmia may interfere with the performance in an identification smell test. A longer follow-up is required in these patients.
Level of Evidence2 Laryngoscope, 132:2445–2452, 2022

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Oroantral Fistula Closure Using Double‐Layered Flap: Greater Palatine Artery Flap and Buccal Fat Pad

Beatriz Arana‐Fernández, Alfonso Santamaría‐Gadea, Fernando Almeida‐Parra, Franklin Mariño‐Sánchez

Publication date 11-11-2022


A novel surgical technique based on a combined approach to oroantral fistula closure using a double-layered flap: greater palatine artery pedicled flap and buccal fat pad combination. Laryngoscope, 2022

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Posisep Versus PureRegen Gel for Post ESS Nasal Packing – A Randomized Blinded Prospective Study

Itay Chen, Maru Gete, Jean Yves Sichel, Boaz Forer

Publication date 10-11-2022


Objective Endoscopic sinus surgery (ESS) is the procedure of choice for chronic rhinosinusitis (CRS). Adhesions are the most common postoperative complications, causing recurrent disease and revision surgery. Postoperative care is thus essential for the healing of the operated cavity. A wide variety of packing materials are used to prevent bleeding and adhesions postoperatively.
Two main absorbable packing materials are used: Foam-based packs (e.g., Posisep and Nasopore) and gel-based packs (Pure Regen Gel – PRG). The current study is a randomized, blinded, prospective analysis of cavity healing using Posisep and PRG in ESS, aiming to compare the pros and cons of the two.
Methods Patients with bilateral symmetric CRS were recruited for the study. At the end of surgery, one side was randomly packed with Posisep, whereas the other was packed with PRG. The postoperative cavity cleaning was video recorded and a blinded physician evaluated the mucosal healing.
Results The side packed with Posisep had significantly less middle turbinate (MT) lateralization and adhesions yet dissolved significantly slower than the PRG, causing more mucosal edema. Severe MT scarring requiring recurrent medialization and adhesiolysis was exclusively observed in the PRG group. All differences were observed in the early postoperative period (up to 12 weeks after surgery). By that time, only the MT position was significantly different between groups, despite recurrent adhesiolysis and medialization.
Conclusion The authors recommend using Posisep for MT support only when it is unstable or lateralized. Packing the surgical cavity in other cases with PRG is more beneficial.
Level of Evidence2 Laryngoscope, 2022

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Ultrasonographic Features of Salivary Glands after Radioiodine Therapy in Patients with Thyroid Cancer

Nir Tsur, Gal Avishai, Uri Alkan, Roy Hod, Thomas Shpitzer, Eden Bitton, Hanna Gilat

Publication date 10-11-2022


Chronic sialadenitis is the most common radioactive iodine (RAI) treatment complication. We explored the sonographic features of the major salivary glands in patients with papillary thyroid cancer (PTC) treated with RAI. RAI treatment following thyroidectomy is associated with a dose-response effect and adverse changes in the major salivary glands and should be prescribed carefully.
Objective Chronic sialadenitis is the most common complication of radioactive iodine (RAI) treatment. The aim of the study was to ascertain sonographic features of the major salivary glands in patients with papillary thyroid cancer (PTC) treated with RAI.
Methods The database of a tertiary medical center was retrospectively searched for consecutive patients who underwent total thyroidectomy for PTC in 2011–2020 with ultrasound follow-up after 1 year. Changes in ultrasound features of the major salivary glands were compared between patients treated or not treated with RAI postoperatively.
Results The cohort included 158 patients, of whom 109 (69%) were treated postoperatively with RAI (mean dose, 131 m Ci) and 49 were not (control group). Sonographic changes were observed in the major salivary glands in 43% of the study group and 18% of the control group (p = 0.002), including coarse echotexture, decreased echogenicity, fibrosis, and atrophy. Higher RAI doses were significantly correlated with the prevalence and severity of glandular changes (p < 0.0001).
ConclusionRAI treatment following thyroidectomy is associated with a dose–response effect and adverse changes in the major salivary glands and should be prescribed carefully.
Level of Evidence4 Laryngoscope, 2022

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Endoscopic Versus Microscopic Type‐1 Tympanoplasty: A Meta‐Analysis of Randomized Trials

Thomas J. Crotty, Eoin F. Cleere, Ivan J. Keogh

Publication date 09-11-2022


Although microscope-assisted tympanoplasty remains the gold standard, the merits of endoscopic approaches have been well-documented. This meta-analysis compares the outcomes of endoscopic to microscopic tympanoplasty incorporating only randomized trials. The result from this meta-analysis provides level 1 evidence demonstrating that endoscopic and microscopic-assisted type-1 tympanoplasty have similar outcomes in both graft success and hearing improvement, with endoscopic approaches yielding a shorter operative time.
Objectives Totally endoscopic ear surgery is becoming increasingly utilized in otologic practice. Although the well-established microscope-assisted tympanoplasty remains the most common technique to repair a tympanic membrane defect, the merits of endoscopic approaches have been well-documented. This systematic review and meta-analysis compares the outcomes of endoscopic to microscopic tympanoplasty incorporating only randomized trials.
Study Design Systematic review and meta-analysis.
MethodsA comprehensive search of Pub Med/MEDLINE, Scopus, Cochrane Library, and EMBASE was conducted. All randomized studies comparing endoscopic to microscopic tympanoplasty were collected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Quality assessment was carried out utilizing the Risk of Bias 2.
Results The initial search identified 1711 studies, of which 9 met the inclusion criteria comprising of 540 patients (microscopic tympanoplasty 51.5%; endoscopic tympanoplasty 49.5%). The mean age was 32.5 years with a similar number of males (50.1%) and females (49.9%). Both endoscopic and microscopic groups had comparable outcomes with regards to graft success rate (RD 0.00; 95% confidence interval CI, −0.04 to. 0.05; p = 0.87) and hearing improvement (MD 0.57 dB; 95% CI, −1.23 to 2.36; p = 0.54). A significantly shorter operative time was noted in the endoscopic group (MD, −24.73 min; 95% CI, −38.56 to −10.89; p = 0.0005).
Conclusion Our results, assimilating level 1 evidence, demonstrates that endoscopic and microscopic-assisted type-1 tympanoplasty have similar outcomes in both graft success and hearing improvement, with endoscopic approaches yielding a shorter operative time.
Level of Evidence1 Laryngoscope, 2022

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Characteristics of Orbital Injuries Associated with Maxillofacial Trauma

James F. Eng, Sami Younes, Brielle R. Crovetti, Katherine J. Williams, Angela D. Haskins, David J. Hernandez, Michael T. Yen, Krista L. Olson, Richard C. Allen, Sunthosh K. Sivam

Publication date 03-11-2022


Introduction The incidence of ocular injury associated with maxillofacial trauma remains poorly defined, with reported rates ranging from 0.8% to 92%. Our study aims to more accurately characterize ocular injuries associated with midface fractures.
Methods We performed a retrospective review of 1677 patients from 2015 to 2020 with midface fractures at a Level I trauma center. Isolated nasal bone and frontal process of the maxilla fractures were excluded. Demographic information, mechanism of injury, need for surgery, and ophthalmologic findings were documented. Statistical analysis was conducted using SPSS.
Results773 patients between the ages of 15 and 92 were identified. Trauma most commonly resulted from assault (63.8%). The association between the mechanism of injury and ocular injury was statistically significant (p = 0.003), with 78.6% of gunshot wounds and 44.3% of assault patients having an ocular injury. The Ophthalmology service evaluated 62.6% of cases preoperatively. Minor ocular injury occurred in 36% of patients, including 46.1% of isolated orbital floor, and 28.2% of zygomaticomaxillary complex fractures. Major ocular injury occurred in 10.5% of patients.
Conclusions Over 10% of patients with midface fractures were found to have major ocular injuries. Ophthalmologic exams should be performed for all patients with midface fractures to guide clinical decision making and prevent further intraoperative ocular insults.
Level of Evidence Level 4. This study represents a retrospective cohort study analyzing ocular injuries detected in patients presenting to a Level I trauma center with maxillofacial fractures between 2015 and 2020 Laryngoscope, 2022

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Predictive Outcomes of Deep Learning Measurement of the Anterior Glottic Angle in Bilateral Vocal Fold Immobility

Elliana Kirsh DeVore, Nat Adamian, Nate Jowett, Tiffany Wang, Phillip Song, Ramon Franco, Matthew Roberts Naunheim

Publication date 03-11-2022


The objective of this research was to apply a computer vision tool for assessment of anterior glottic angle (AGA) in patients with bilateral vocal fold immobility (BVFI), and to compare the AGA in BVFI with that of unilateral vocal fold immobility (UVFI) and normal larynges (NL) as measured by the algorithm. The computer vision tool was able to quantitatively assessof the AGA from videolaryngoscopy, demonstrating ability to discriminate between patients with BVFI, UVFI, and normal controls, as well as to predict need for operative airway intervention. This tool may be useful for assessment of other neurological laryngeal conditions and may help guide decision-making in laryngeal surgery.
Objective(1) To compare maximum glottic opening angle (anterior glottic angle, AGA) in patients with bilateral vocal fold immobility (BVFI), unilateral vocal fold immobility (UVFI) and normal larynges (NL), and (2) to correlate maximum AGA with patient-reported outcome measures.
Methods Patients wisth BVFI, UVFI, and NL were retrospectively studied. An open-source deep learning-based computer vision tool for vocal fold tracking was used to analyze videolaryngoscopy. Minimum and maximum AGA were calculated and correlated with three patient-reported outcomes measures.
Results Two hundred and fourteen patients were included. Mean maximum AGA was 29.91° (14.40° SD), 42.59° (12.37° SD), and 57.08° (11.14° SD) in BVFI (N = 70), UVFI (N = 70), and NL (N = 72) groups, respectively (p < 0.001). Patients requiring operative airway intervention for BVFI had an average maximum AGA of 24.94° (10.66° SD), statistically different from those not requiring intervention (p = 0.0001). There was moderate negative correlation between Dyspnea Index scores and AGA (Spearman r = −0.345, p = 0.0003). Maximum AGA demonstrated high discriminatory ability for BVFI diagnosis (AUC 0.92, 95% CI 0.81–0.97, p < 0.001) and moderate ability to predict need for operative airway intervention (AUC 0.77, 95% CI 0.64–0.89, p < 0.001).
ConclusionsA computer vision tool for quantitative assessment of the AGA from videolaryngoscopy demonstrated ability to discriminate between patients with BVFI, UVFI, and normal controls and predict need for operative airway intervention. This tool may be useful for assessment of other neurological laryngeal conditions and may help guide decision-making in laryngeal surgery.
Level of EvidenceIII Laryngoscope, 2022

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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 02-11-2022


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Synchronous Second Primary Cancers of Hypopharyngeal Carcinoma in the Image‐Enhanced Endoscopy Era

Xi Luo, Xiaodong Huang, Shaoyan Liu, Xiaolei Wang, Jingwei Luo, Jianping Xiao, Kai Wang, Yuan Qu, Xuesong Chen, Ye Zhang, Jingbo Wang, Jianghu Zhang, Guozhen Xu, Li Gao, Runye Wu, Junlin Yi

Publication date 02-11-2022


(1) We found synchronous invasive malignancies decreased the survival of patients with hypopharyngeal carcinoma; (2) We found patients with synchronous Tis in esophageal or stomach did not deteriorate outcome; (3) Routine screening with image-enhanced endoscopy should be recommended to detect early-stage second primary malignancies.
Objectives To explore the prevalence of hypopharyngeal carcinoma (HPC) with synchronous second primary malignancies (Syn-SPMs), their impact on clinical outcomes, and associated risk factors in the image-enhanced endoscopy era.
Materials and Methods We retrospectively analyzed 673 patients newly diagnosed with HPC at our cancer center between 2009 and 2019.
The patients were divided into three groups: (a) no second primary malignancies (N-SPMs, n = 533); (b) synchronous carcinoma in situ (Syn-Tis, n = 60); (c) synchronous invasive tumors (Syn-invasive, n = 80). Propensity score matching was conducted to balance the N-SPMs and Syn-invasive groups at a 3:1 ratio.
Results Most (96.1%) underwent pretreatment esophagogastroduodenoscopy evaluation with image-enhanced endoscopy.
The incidence rates were: Syn-SPMs, 20.8%; Syn-Tis, 8.9%; Syn-invasive, 11.9%. At a median follow-up of 66.7 months, the Syn-Tis and N-SPMs groups had a similar 5-year overall survival (OS; 45.6% vs. 44.5%; hazard ratio HR, 0.956; 95% confidence interval CI, 0.660–1.385; p = 0.806). Compared to the N-SPMs group, the Syn-invasive group had poorer 5-year OS (27.0% vs. 52.9%; HR, 2.059; 95% CI, 1.494–2.839; p < 0.001). Alcohol consumption was significantly associated with Syn-SPMs occurrence (odds ratio, 2.055, 2.414, and 3.807 for light, intermediate, and heavy drinkers, respectively).
Conclusion The prevalence of Syn-SPMs among patients with HPC was high. Syn-invasive SPMs decreased the survival of patients with HPC. Routine screening with image-enhanced endoscopy should be recommended to detect early-stage SPMs, especially for heavy alcohol drinkers.
Level of EvidenceIII Laryngoscope, 2022

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Acute In Vitro and In Vivo Effects of Dexamethasone in the Vocal Folds: a Pilot Study

Gary Gartling, Ryosuke Nakamura, Lea Sayce, Zachary Zimmerman, Alysha Slater, Azure Wilson, Renjie Bing, Ryan C. Branski, Bernard Rousseau

Publication date 01-11-2022


Atrophy has been reported following dexamethasone injection into the vocal folds. Dexamethasone increased MuRF-1 gene expression in TA myoblasts. A single injection of dexamethasone, however, did not alter atrogene expression, TA morphology, or epithelial thickness in vivo.
Objectives/Hypothesis Glucocorticoids (GC)s are commonly employed to treat vocal fold (VF) pathologies. However, VF atrophy has been associated with intracordal GC injections. Dexamethasone-induced skeletal muscle atrophy is well-documented in other tissues and believed to be mediated by increased muscle proteolysis via upregulation of Muscle Ring Finger (MuRF)-1 and Atrogin-1. Mechanisms of dexamethasone-mediated VF atrophy have not been described. This pilot study employed in vitro and in vivo models to investigate the effects of dexamethasone on VF epithelium, thyroarytenoid (TA) muscle, and TA-derived myoblasts. We hypothesized that dexamethasone will increase atrophy-associated gene expression in TA muscle and myoblasts and decrease TA muscle fiber size and epithelial thickness.
Study Design In vitro, pre-clinical.
MethodsTA myoblasts were isolated from a female Sprague–Dawley rat and treated with 1 μM dexamethasone for 24-h. In vivo, 15 New Zealand white rabbits were randomly assigned to three treatment groups: (1) bilateral intracordal injection of 40 μL dexamethasone (10 mg/ml; n = 5), (2) volume-matched saline (n = 5), and (3) untreated controls (n = 5). Larynges were harvested 7-days post-injection. Across in vivo and in vitro experimentation, MuRF-1 and Atrogin-1 mRNA expression were measured via RT-qPCR. TA muscle fiber cross-sectional area (CSA) and epithelial thickness were also quantified in vivo.
Results Dexamethasone increased MuRF-1 gene expression in TA myoblasts. Dexamethasone injection, however, did not alter atrophy-associated gene expression, TA CSA, or epithelial thickness in vivo.
Conclusion Dexamethasone increased atrogene expression in TA myoblasts, providing foundational insight into GC induced atrophic gene transcription. Repeated dexamethasone injections may be required to elicit atrophy in vivo.
Level of EvidenceN/A Laryngoscope, 2022

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Extent of Surgery for Follicular Thyroid Carcinoma

Nikhit Kethidi, Sudeepti Vedula, Dhvani Shihora, Rushi Patel, Richard C. W. Park

Publication date 01-11-2022


Our study informs physicians and patients on the survival outcomes of undergoing operation for follicular thyroid cancer particularly when using clinical T staging as a stratification method. Similar survival between thyroidectomy versus lobectomy emphasizes that decisions on extent of surgery should take into careful consideration future quality of life as total thyroidectomy requires lifelong pharmacotherapy and higher risk of injury to adjacent structures whereas lobectomy poses higher risk of recurrence. Our findings suggest that demographic factors may ultimately play a bigger role in deciding extent of thyroid resection surgery given similar rates of survival.
Objectives To examine the association between the extent of surgery and overall survival in follicular thyroid cancer (FTC) patients.
Study Design Retrospective analysis of the National Cancer Database (NCDB).
Methods Patients who underwent surgical intervention for FTC from 2004 to 2015 were selected. Patients were >18 years old, with tumor size 1–4 cm, no other malignancies, and >0 follow up time.
Patients were divided into two cohorts based on extent of surgery: lobectomy (≥1 lobe resected) and thyroidectomy (total or near total resection). Pearsons chi-squared analysis was used to compare cohorts. Kaplan–Meier survival and Cox hazards models were utilized to determine overall survival between two cohorts with p < 0.05 used for significance.
ResultsA total of 6871 patients were identified with FTC, of which 1507 patients underwent lobectomy and 5364 patients underwent total thyroidectomy. There were no significant differences in patient demographics, comorbidity index, local spread, or tumor grade. Patients undergoing lobectomy had mean survival of 12.94 versus 12.71 years for those undergoing thyroidectomy. Extent of surgery was not associated with a significant difference in survival (5 years OS = 96% in lobectomy and 95.5% in total thyroidectomy, p = 0.08). Stratification by tumor grade resulted in no significant difference in survival between lobectomy and thyroidectomy.
Conclusion Survival time was not significantly different in patients with more extensive resection of FTC.
Level of Evidence3 Laryngoscope, 2022

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How to Improve the Outcomes of Anterior Septal Perforations Repair With Combined Flaps

Octavio Garaycochea, Camilo Rodríguez Van Strahlen, María J. Rojas‐Lechuga, Isam Alobid

Publication date 01-11-2022


The combination of a partial inverted edges with an either extended anterior ethmoidal flap or greater palatine artery flap, in which the anterior incision includes contralateral mucosa (Zig Zag anterior flap-incision). Laryngoscope, 2022

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Are Mobile Applications in Laryngology Designed for All Patients?

Eseosa Odigie, Katerina Andreadis, Iyra Chandra, Valentina Mocchetti, Hal Rives, Steven Cox, Anaïs Rameau

Publication date 01-11-2022


While the quality and functionality of most laryngology apps were found to be acceptable, the vast majority of apps did not meet recommended standards of health literacy or provide accessibility and inclusivity features. This likely reflects the lack of regulation and guidelines for the development of health apps, and can be ultimately harmful to vulnerable patient populations. Healthcare providers ought to work with app developers to ensure equitable access to the digital environment, so that all patients are able to engage with these resources.
Objectives Mobile applications (apps) are multiplying in laryngology, with little standardization of content, functionality, or accessibility. The purpose of this study is to evaluate the quality, functionality, health literacy, readability, accessibility, and inclusivity of laryngology mobile applications.
Methods Of the 3230 apps identified from the Apple and Google Play stores, 28 patient-facing apps met inclusion criteria.
Apps were evaluated using validated scales assessing quality and functionality: the Mobile App Rating Scale (MARS) and the Institute for Healthcare Informatics App Functionality Scale. The Clear Communication Index (CDC) Institute of Medicine Strategies for Creating Health Literate Mobile Applications, and Patient Education Materials Assessment Tool (PEMAT) were used to evaluate apps health literacy level. Readability was assessed using established readability formulas. Apps were evaluated for language, accessibility features, and representation of a diverse population.
Results Twenty-six apps (92%) had adequate quality (MARS score > 3). The mean PEMAT score was 89% for actionability and 86% for understandability. On average, apps utilized 25/33 health literate strategies. Twenty-two apps (79%) did not pass the CDC index threshold of 90% for health literacy. Twenty-four app descriptions (86%) were above an 8th grade reading level. Only 4 apps (14%) showed diverse representation, 3 (11%) had non-English language functions, and 2 (7%) offered subtitles. Inter-rater reliability for MARS was adequate (CA-ICC = 0.715).
Conclusion While most apps scored well in quality and functionality, many laryngology apps did not meet standards for health literacy. Most apps were written at a reading level above the national average, lacked accessibility features, and did not represent diverse populations. Laryngoscope, 2022

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Response to “In reference to ‘Prediction of Oxygen Desaturation by Using Sound Data From a Noncontact Device’”

Jeong‐Whun Kim, Sung‐Woo Cho

Publication date 01-11-2022


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In reference to Prediction of Oxygen Desaturation by Using Sound Data From a Noncontact Device: A Proof‐of‐Concept Study

Merih Onal, Ozkan Onal

Publication date 01-11-2022


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Identification Accuracy of Safety‐Relevant Environmental Sounds in Adult Cochlear Implant Users

Nathan R. Luzum, Benjamin L. Hamel, Valeriy Shafiro, Michael S. Harris

Publication date 01-11-2022


Twenty-one experienced cochlear implant users completed an Environmental Sound Identification (ESI) test consisting of 42 common environmental sounds, 28 of which were relevant to personal safety. Overall ESI accuracy was 57% correct for the safety-relevant sounds and 55% correct for control sounds, suggesting mediocre ESI accuracy in postlingual adult CI users. Deficits in identification of these sounds may put CI listeners at increased risk of accidents or injuries and may require a specific rehabilitation program to improve CI outcomes.
Objective Examine cochlear implant (CI) users ability to identify safety-relevant environmental sounds, imperative for safety, independence, and personal well-being.
Methods Twenty-one experienced adult CI users completed an Environmental Sound Identification (ESI) test consisting of 42 common environmental sounds, 28 of which were relevant to personal safety, along with 14 control sounds. Prior to sound identification, participants were shown sound names and asked to rate the familiarity and, separately, relevance to safety of each corresponding sound on a 1–5 scale.
Results Overall ESI accuracy was 57% correct for the safety-relevant sounds and 55% correct for control sounds. Participants rated safety-relevant sounds as more important to safety and more familiar than the non-safety sounds. ESI accuracy significantly correlated with familiarity ratings.
Conclusion The present findings suggest mediocre ESI accuracy in postlingual adult CI users for safety-relevant and other environmental sounds. Deficits in the identification of these sounds may put CI listeners at increased risk of accidents or injuries and may require a specific rehabilitation program to improve CI outcomes.
Level of Evidence4 Laryngoscope, 2022

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"Exploring Patients Preference of Patient‐Reported Outcome Measures in Laryngeal Movement Disorders"

Grant E. Gochman, Christopher D. Dwyer, VyVy N. Young, Clark A. Rosen

Publication date 31-10-2022


Background Despite many available patient-reported outcome measures (PROMs) for laryngeal movement disorders, there is a lack of patient input regarding which PROM most accurately and conveniently captures aspects related to their vocal disease. This study aimed to assess patients preferences among a selection of voice-related PROMs (Voice Handicap Index-10 VHI-10, OMNI-Vocal Effort Scale OMNI-VES, Communicative Participation Item Bank-General Short Form CPIB-10, and Visual Analog Scales VAS) within the laryngeal movement disorder population and investigate associations between selected instruments.
Methods Prior to botulinum toxin A injection, patients with laryngeal dystonia and/or essential tremor of the vocal tract were administered the VHI-10, OMNI-VES, CPIB-10, and three novel VAS questions in a randomized order. Patients rank ordered the four PROMs based on the PROMs reflection of their voice problems. Pearsons correlation coefficients evaluated pairwise associations among PROM scores. Fishers exact test compared the preferred PROM rankings.
Results Seventy patients (53 female, mean age = 60.7 years) participated. The VHI-10 and CPIB-10 were most preferred at 33.9% and 27.4% respectively. The OMNI-VES and VAS scales were less favored (19.4%, each). When analyzed by age ≥60 years, the CPIB-10 was most favored (33.3%), but for age <60 years, VHI-10 was most preferred (42.3%). There was a strong correlation between scores of all administered PROMs (strongest correlation between OMNI-VES and VAS, r = 0.8, p < 0.001; the weakest correlation between OMNI-VES and VHI-10, r = 0.6, p < 0.001).
Conclusions With an increasing trend in PROMs usage and a strong correlation between all evaluated outcome instruments, insight regarding patients PROM preferences is an area for further consideration.
Level of EvidenceN/A Laryngoscope, 2022

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An Endoscopic Cap Electrode for Posterior Cricoarythenoid Muscle Stimulation in a Porcine Model

Matthias Leonhard, Roberto Plasenzotti, Wolfgang Vogel, William Denny, Berit Schneider‐Stickler

Publication date 31-10-2022


The article describes the development of a diagnostic procedure with a novel endoscopic cap to identify patients with vocal fold immobility who are eligible for implantation of future laryngeal pacing systems. The concept aims at transferring the examination to a gastroscopy setting.
Objective Laryngeal pacing (LP) is a highly anticipated therapeutic option for patients suffering from bilateral vocal fold paralysis with synkinesis. Identification of candidate patients requires confirmation of a stimulable posterior cricoidarythenoid muscle (PCA) by neuromuscular electrical stimulation (NMES). A silicone endoscopic cap electrode (ECE50) was designed to be operated as an endoscopic extension tip for selective PCA stimulation and confirmation of a glottic opening movement in a setting comparable to a gastroscopy procedure.
MethodsA porcine animal model (n = 6) was applied to develop and test endoscopic cap prototypes in general anesthesia and sedation at a biomedical research center. Two ENT endoscopy experts evaluated and refined the cap design and performance in regard to procedure safety, endoscope handling, accessibility of the PCA by the transoral approach and selective muscle stimulation.
Results Vocal fold opening movements could be evoked by the investigators in 9 of 12 PCA muscles to stimulate with similar electric parameters. The endoscopic approach using the ECE50 proved to be atraumatic and sufficiently controlled under sedation to locate the required hotspot for NMES of the PCA.
Conclusion The functionality of the novel endoscopic cap concept has been proven in a porcine model. It can be expected to be transferable to human application and to be of diagnostic importance in the screening and identification of LP candidate patients in future.
Level of EvidenceNA Laryngoscope, 2022

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Single‐Port Transaxillary Robotic Modified Radical Neck Dissection (STAR‐RND): Initial Experiences

Joon Ho, Donggyu Kim, Ji‐Eun Lee, Jin Kyong Kim, Cho Rok Lee, Sang‐Wook Kang, Jong Ju Jeong, Kee‐Hyun Nam, Woong Youn Chung

Publication date 29-10-2022


This study aimed to demonstrate the usefulness of single-port transaxillary robotic radical neck dissection (STAR-RND) for metastatic thyroid cancer, and its potential to make small and invisible surgical wounds possible compared to open modified radical neck dissection.
Objectives This study aimed to demonstrate the usefulness of single-port transaxillary robotic modified radical neck dissection (STAR-RND) for metastatic thyroid cancer, and its potential to make small and invisible surgical wounds possible compared to open modified radical neck dissection.
Methods Between January 2020 and July 2021, 30 thyroid cancer patients who underwent lateral neck dissection surgery with the da Vinci SP at Yonsei University Health System (Seoul, Korea) were studied.
Results All 30 patients, diagnosed with papillary thyroid cancer were women. The average operating time was 293.80 ± 36.58 (min), and the average postoperative hospital stay was 4.77 ± 0.57 (days). All patients were discharged after the expected number of hospitalization days without major complications.
ConclusionSTAR-RND is technically feasible and safe with a short length of the incision. To our knowledge, this is the first report on the use of a single-port robotic system for modified radical neck dissection.
Level of Evidence by Using 2011 OCEBM4 Laryngoscope, 2022

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Long‐Term COVID‐19 Smell and Taste Disorders Differ Significantly from Other Post‐Infectious Cases

Dovile Stankevice, Alexander Wieck Fjaeldstad, Jane Agergaard, Therese Ovesen

Publication date 28-10-2022


IntroductionCOVID-19 is causing a wide range of clinical manifestations. Severe complications and long-lasting sequelae have been identified. Thus, olfactory disorders are reported in up to 86% of cases in mild and moderate COVID-19 infections. We present the first study comparing simple and complex post-COVID-19 cases with matched non-COVID-19 post-infectious smell and taste disorders.
MethodsA total of 328 patients were recruited from the University Clinic for Flavour, Balance and Sleep, Ear-nose-throat Department, Goedstrup Hospital, Denmark. A non-COVID -19 post-infectious population of 148 individuals was identified from the Redcap database, and was matched by duration of smell and taste disorders. Post-COVID-19 patients were divided into 99 patients with simple smell and taste disorders (only suffering from smell and taste disorders after COVID-19); and (81 patients with complex smell and taste disorder plus several other post-COVID-19 complaints). Besides patient-reported outcome measures (PROM) questionnaires and quality of life score (QoL), ear-nose-throat examination, Mini-Mental State Examination (MMSE), orthonasal smell test (Sniffings sticks), retronasal quick test, and taste screening were performed.
Results Cases with post-COVID-19-related smell and taste disorders deviated from non-COVID-19 post-infectious cases; the patients were younger, had a lower occurrence of anosmia/ageusia, and had higher overall smell test scores. In contrast, patients with post-COVID-19-related smell and taste disorders more frequently complained of distorted senses. Parosmia and phantosmia were more prevalent among patients with simple post-COVID-19 complaints than among complex cases and their QoL were more negatively affected.
Conclusion Smell and taste function differ significantly between post-COVID-19 and other non-COVID-19 post-viral cases.
Level of Evidence3Laryngoscope, 2022

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The Use of Dissemination and Implementation to Improve Multimodal Analgesia in Head and Neck Surgery

Yelizaveta Shnayder, Maraya M. Baumanis, Adam Brown, Adam Reese, Andrés M. Bur, Kiran Kakarala, Kevin J. Sykes

Publication date 28-10-2022


The use of a multimodal analgesia approach in a Randomized Clinical Trial including acetaminophen, ketorolac, gabapentin, and a neurogenic extremity block in patients undergoing major head and neck ablative and reconstructive surgery significantly reduced the need for opioids in the immediate postoperative period of a seven-day hospital stay. Coordination of care and reducing variability in pain medication administration were highly dependent on dissemination and implementation processes put in place for perioperative phases of care.
Objectives To optimize the delivery of multimodal analgesia to patients undergoing major head and neck oncologic surgeries.
Methods Pilot study included patients enrolled to receive either scheduled acetaminophen and as-needed opioids (control group) or scheduled acetaminophen, gabapentin, ketorolac, and as-needed opioids (experimental group). RCT, a hybrid type 1 effectiveness-implementation pragmatic trial, was designed to test the effectiveness of the intervention. Arm A received scheduled acetaminophen and as-needed opioids. Arm B received scheduled gabapentin, ketorolac, a regional nerve block at the free tissue donor site, scheduled acetaminophen and as-needed opioids.
Results Pilot: Thirty-one patients undergoing major head and neck surgery were enrolled. Mean MMEs administered in control group (n = 15) was 251.60 mg (SD = 224.57 mg); mean MMEs in Experimental group (n = 16) was 195.78 mg (SD = 131.08 mg), p = 0.401. LOS was 8.0 days in control versus 7.0 days in experimental group (p = 0.054).
RCT: Interim analysis for safety and futility was planned during trials design after 30 patients (n = 14 Arm A, and n = 16 Arm B). Mean MMEs administered were 135.1 mg in Arm A, (SD = 86.0 mg) versus mean MME of 51.3 mg in Arm B (SD = 43.3 mg, (p < 0.05)). Given clear superiority results, the trial was prematurely terminated. Functional pain scores, LOS, and complications were similar between the arms (p > 0.05).
Variability of mean MME was compared before and after implementation of the management protocols: SD in RCT#1 was 181.46 mg versus 124.6 mg in RCT#2.
Conclusion Multimodal analgesia significantly reduced the need for opioids in patients undergoing major head and neck surgery.
Level of Evidence1, Randomized Clinical Trial Laryngoscope, 2022

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The Necessity of Nostril Retention Application After Secondary Unilateral Cleft Rhinoplasty

Shiming Zhang, Min Wu, Jiali Chen, Jiayi Yin, Karim A. Sakran, Yan Wang, Ni Zeng, Chao Yang, Bing Shi, Hanyao Huang

Publication date 27-10-2022


The nostril retention after secondary unilateral cleft rhinoplasty could help preserve nasal morphology but worsen the patients quality of life of the patients. The necessity of nostril retention should consider the forms of nasal deformity and the patients quality of life.
Background This study aims to investigate the necessity of nostril retention after secondary unilateral cleft rhinoplasty.
Methods Seventy four patients who underwent secondary unilateral cleft rhinoplasty were categorized into control group, nasal retainer group, and nasal clip group. A nasal retainer or nasal clip was applied 7 days after secondary correction and retained in the nostrils of the patients for 6 to 12 months. Measurements from pre- and post-operative photos and patient-reported outcomes were used in this study.
Results After 6 to 12 months, although relapse still occurred in three groups, the nasal retainer group showed a better effect in the ratio of nostril height, whereas the nasal clip group showed a significant improvement in the ratio of nasal base. And both the two groups also showed significant improvement in the ratio of nasal columella. Patients from the control group generally had lower Derriford Appearance Scale (DAS) scores than the nasal retainer group and nasal clip group. Wearing a nasal retainer may negatively influence self-concept, facial self-consciousness of appearance and physical state, and significant differences in mean scores were also found in 9 items.
Conclusions The nostril retention after secondary unilateral cleft rhinoplasty could help preserve nasal morphology and reduce postoperative relapse but worsen the patients quality of life. The necessity of applying the nostril retention should consider the forms of nasal deformity and the potential influence on the quality of life.
Level of Evidence3 Laryngoscope, 2022

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Cognitive Assessment in Elderly Cochlear Implant Recipients: Long‐Term Analysis

Jacques A. Herzog, Craig A. Buchman, Dorina Kallogjeri, Stephanie Chen, Cameron Wick, Nedim Durakovic, Matthew A. Shew

Publication date 27-10-2022


This represents the largest single-center study to date measuring long-term cognitive and speech outcomes in elderly patients following cochlear implantation. Speech outcomes significantly improved and were durable for 4+ years following implantation in both normal and mild cognitively impaired cohorts. Cognitive function seems to decline at similar rates regardless of pre-operative cognitive status.
Objectives To examine long-term speech and cognition outcomes in older adult cochlear implant (CI) recipients. First, by evaluating if CI performance was maintained over an extended follow-up period regardless of preoperative cognitive status. Secondly, by evaluating if there was a difference in the rate of cognitive decline between preoperative mild and normal cognition following CI over an extended period of time.
Study Design and Setting Retrospective cohort study.
MethodsCI recipients ≥65 years of age implanted between 2009 and 2014 with 4+ years follow up. Pre- and postoperative audiometric and speech outcome assessments were collected. Cognitive status was measured using the mini mental status examination (MMSE) at numerous time points.
Results Fifty-three patients met inclusion. Patients were divided into two groups based on preoperative MMSE with scores considered normal (28–30) and those with mildly impaired cognition (MIC, scores 25–27). Audiometric and speech performance improved significantly at one-year post implantation and this was maintained without significant change at 4+ years, regardless of cognitive status. Mixed modeling analysis controlling for age demonstrated no significant difference in the rate of cognitive decline at 4+ years post implantation between the normal cognition cohort (1.74; 95%CI 0.89–2.6) and MIC (2.9; 95%1.91–3.88).
Conclusion Speech performance was significantly improved and sustained after CI in both normal cognition and MIC patients. The rate of cognitive decline in older adult CI patients appears to be similar regardless of preoperative cognitive status. Although results demonstrate rates of cognitive decline following CI did not differ between cognition groups over 4+ years, future studies will need to further investigate this over extended time periods with a more comprehensive cognitive testing battery.
Level of Evidence Level 4 Laryngoscope, 2022

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Spindle Cell Carcinoma of the Head and Neck: Clinical Characteristics and Molecular Signatures

Mei‐Chun Lin, Chia‐Lang Hsu, Shih‐Fan Lai, Yen‐Lin Huang, Min‐Shu Hsieh, Tseng‐Cheng Chen, Chun‐Nan Chen, Cheng‐Ping Wang, Tsung‐Lin Yang, Jenq‐Yuh Ko, Mong‐Hsun Tsai, Pei‐Jen Lou

Publication date 27-10-2022


Spindle cell carcinoma arising from a previously irradiated field is a predictor of dismal survival. Both genetic and microenvironmental factors contribute to this highly invasive tumor.
Objective/Hypothesis Spindle cell carcinoma of the head and neck (HNSpCC) is a rare variant of head and neck squamous cell carcinoma (HNSCC). This study evaluated the clinical characteristics and molecular signatures of such tumors.
Study Design Retrospective analysis.
Methods Medical records of patients diagnosed with HNSpCC from 1996 to 2018 were reviewed. The clinicopathologic features, treatment modalities, and survival status were carefully recorded. Whole exome sequencing (WES) was performed to evaluate the genetic signatures of HNSpCC.
Results We found that among all 71 patients included in this study, the majority of them were male, with tumors developing predominantly in the oral cavity. The 1-, 3-, and 5-year disease-specific survival (DSS) rates were 64.6%, 49.5%, and 43.9%, respectively. A high local recurrence (LR) and distant metastasis (DM) rate (47.9%–25.3%, respectively) were observed. A significant proportion (28.2%) of patients with the worst prognosis had history of previous head and neck cancer (HNC) and had been treated with radiotherapy (RT). WES revealed that those post-RT SpCC shared common mutations with their previous HNC (pre-RT SCC), but gained additional genetic traits, such as hypoxia and cell-ECM interaction that were favorable for survival in an irradiated microenvironment. Distinct genetic landscapes in primary and post-RT SpCC were also found.
Conclusions This study demonstrates that HNSpCC is a unique entity with more aggressive behavior than conventional HNSCC. HNSpCC arising from a previously irradiated field is a predictor of dismal survival. Both genetic and microenvironmental factors contribute to this highly invasive tumor.
Level of Evidence Level 4 Laryngoscope, 2022

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Impact of Serial Intralesional Steroid Injections on Idiopathic Subglottic Stenosis

Matthew R. Hoffman, Ankita Patro, Li‐Ching Huang, Sheau‐Chiann Chen, Lynn D. Berry, Alexander Gelbard, David O. Francis, North American Airway Collaborative, Catherine Anderson, Milan R. Amin, Michael S. Benninger, Joel H. Blumin, Jonathan M. Bock, Paul C. Bryson, Paul F. Castellanos, Matthew S. Clary, Seth M. Cohen, Brianna K. Crawley, Seth H. Dailey, James J. Daniero, Alessandro Alarcon, Donald T. Donovan, Eric S. Edell, Dale C. Ekbom, Daniel S. Fink, Ramon A. Franco, C. Gaelyn Garrett, Elizabeth A. Guardiani, Alexander T. Hillel, Henry T. Hoffman, Norman D. Hogikyan, Rebecca J. Howell, Michael M. Johns, Jan L. Kasperbauer, Sid M. Khosla, Cheryl Kinnard, Robbi A. Kupfer, Alexander J. Langerman, Robert J. Lentz, Robert R. Lorenz, David G. Lott, Samir S. Makani, Fabien Maldonado, Kyle Mannion, Laura Matrka, Andrew J. McWhorter, Albert L. Merati, Matthew Mori, James L. Netterville, Karla O’Dell, Julina Ongkasuwan, Gregory N. Postma, Lindsay S. Reder, Sarah L. Rohde, Brent E. Richardson, Otis B. Rickman, Clark A. Rosen, Michael J. Rutter, Guri S. Sandhu, Joshua S. Schindler, G. Todd T. Schneider, Rupali N. Shah, Andrew G. Sikora, Robert J. Sinard, Marshall E. Smith, Libby J. Smith, Ahmed MS. Soliman, Sigríður Sveinsdottir, Douglas J. Van Daele, David Veivers, Sunil P. Verma, Paul M. Weinberger, Philip A. Weissbrod, Christopher T. Wootten, Yu Shyr

Publication date 26-10-2022


Objectives Serial intralesional steroid injection (SILSI) has been increasingly used to treat idiopathic subglottic stenosis (iSGS). Prior studies have shown effectiveness, but not in all patients. This multi-institutional study evaluates the effect of SILSI on time to recurrent operation, peak expiratory flow (PEF), and dyspnea.
Methods Post-hoc secondary analysis of the North American Airway Collaborative data were performed to evaluate the outcomes of iSGS patients undergoing and not undergoing SILSI. The primary outcome was time to recurrent operation, evaluated using Kaplan–Meier curves and Cox regression analysis. Secondary outcomes were change in PEF and clinical chronic obstructive pulmonary disease questionnaire (CCQ) score. Within patients undergoing SILSI, demographics, time from last procedure, and PEF at initiation of SILSI were evaluated to determine the effect on recurrence.
Results Two hundred and ninety patients were included, 238 undergoing endoscopic dilation alone and 52 undergoing dilation and SILSI. No differences in baseline characteristics were observed. There was no difference in time to recurrence (hazard ratio: 0.64; p = 0.183). There were no differences in PEF or CCQ across the 2.5-year study period. Among 52 patients undergoing SILSI, PEF at the time of starting SILSI did not affect recurrence (χ2 = 0.09, p = 0.77).
Conclusion Patients undergoing and not undergoing SILSI had similar times to recurrence, PEF, and CCQ. Factors predicting recurrence among patients undergoing SILSI were not identified. These results support a randomized controlled trial with a uniform SILSI protocol to quantify the effects of SILSI on objective and subjective outcomes and help determine which iSGS patients benefit most.
Level of Evidence3 Laryngoscope, 2022

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Application of Machine Learning to Predict Hearing Outcomes of Tympanoplasty

Hajime Koyama, Akinori Kashio, Tsukasa Uranaka, Yu Matsumoto, Tatsuya Yamasoba

Publication date 26-10-2022


This study aims to create machine learning program to predict postoperative air-bone gap in tympanoplasty. Random forest model achieved more precise prediction than classical scoring models and clarified influential factors.
Objective This retrospective study aimed to evaluate the performance of machine learning techniques in predicting air-bone gap after tympanoplasty compared with conventional scoring models and to identify the influential factors.
Methods We reviewed the charts of 105 patients (114 ears) with chronic otitis media who underwent tympanoplasty. Two numerical scoring systems (middle ear risk index MERI and ossiculoplasty outcome parameter staging OOPS) and three algorithms (random forest RF, support vector machine SVM, and k nearest neighbor kNN) were created. Experimental variables included age, preoperative air-bone gap, soft-tissue density lesion in the tympanic cavity in CT, otorrhea, surgical history, ossicular bone problems in CT, tympanic perforation location, perforation type (central or marginal), grafting material, smoking history, endoscopy use, and the operator whose experience was 20 years or longer, or shorter. Binary classification, postoperative air-bone gap ≤15 or >15 dB, and multiclass classification, classification into seven categories by 10 dB, were performed, and the percentages of correct prediction were calculated. The importance of features in the RF model was calculated to identify influential factors.
Results The percentages of correct prediction in binary classification were 62.3%, 72.8%, 81.5%, 81.5%, and 81.5% in MERI, OOPS, RF, SVM, and kNN, respectively, and those in multiclass classification were 29.8%, 21.9%, 63.1%, 44.7%, and 50% in the same order. The RF model suggested larger preoperative air-bone gap, and older age could make the postoperative air-bone gap larger.
Conclusion The machine learning techniques, especially the RF model, are promising methods for precise postoperative air-bone gap prediction.
Level of Evidence4 Laryngoscope, 2022

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Time to Local Recurrence as a Predictor of Survival in Adult Head and Neck Soft Tissue Sarcoma

Ke Jiang, Shao‐Hui Cai, Bi‐Yi Ou, Ding‐fu Du, Yuan‐Xiang Guan, Shu‐Wei Chen, Yao Liang

Publication date 26-10-2022


The present study demonstrated that local recurrence, especially ELR, had an unfavourable effect on OS and SAR, and it showed that TTLR could serve as a promising predictor for prognosis in patients with HNSTS. Moreover, for patients with local recurrence, aggressive secondary surgical treatment may improve long-term survival.
Objectives We sought to evaluate the impact of the time interval from surgical resection to local recurrence (TTLR) on clinical outcomes in head and neck soft tissue sarcoma (HNSTS).
MethodsA total of 401 patients who underwent R0 resection for primary HNSTS were included in this study. Patients with local recurrence as the first event after their initial resection were divided into early local recurrence (ELR) or late local recurrence (LLR) groups according to TTLR. Multiple survival analyses were performed to identify the independent prognostic predictors of overall survival (OS) and survival after local recurrence (SAR).
Results Two hundred and nine of the 401 patients (52.1%) developed local recurrence during a median follow-up period of 134.6 months. Patients in the ELR group had a shorter median OS time (35.0 vs. 120.6, p < 0.001) and lower 5-year OS rate (47.7% vs. 80.9%, p < 0.001) than those in the LLR group. Moreover, the ELR group exhibited worse SAR (p = 0.001) than the LLR group, and multivariate analyses demonstrated TTLR as an independent prognostic factor for SAR (p = 0.048) and OS (p = 0.004). Additionally, re-resection significantly prolonged SAR than other salvage interventions or no treatment (p < 0.001).
Conclusion In patients with HNSTS, ELR after R0 resection presents adverse effects on OS and SAR than those with LLR, and TTLR could serve as a promising predictor for survival. Salvage therapies, especially the re-resection could improve SAR and should be recommended when there are surgical indications after recurrence.
Level of Evidence Level 3 Laryngoscope, 2022

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Gender Disparities in Otolaryngology: A Case Report Reflecting Global Perspectives

Hawa M. Ali, Stellina Y. H. Lee, Farizeh Jashek‐Ahmed, Amina Seguya, Erynne Faucett, Jenna Van Beck, Emma Stapleton, Shazia Peer, Inna A. Husain, Joshua Wiedermann, Valerie Salano, Global OHNS

Publication date 26-10-2022


Objectives To explore the impact of female sex on the experiences of trainees and surgeons in otolaryngology from LMIC and HIC.
Methods This study includes perspectives of five consultants and two resident physicians from the United States, United Kingdom, Uganda, Kenya and South Africa.
Results Six themes emerged from these interviews. Overall, LMIC and HIC women shared similar experiences of microaggressions during patients, working along ancillary staff, related to pregnancy, imposter syndrome, difficulties during job search, and unique barriers as consultant.
Conclusions The findings of this study highlight that gender disparities are present at all levels in Otolaryngology but can present differently depending on context. Laryngoscope, 2022

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In Response to Incidental Parathyroidectomy Among Pediatric Patients Undergoing Thyroid Surgery

Hedyeh Ziai, Paolo Campisi, Jonathan D. Wasserman

Publication date 25-10-2022


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In Reference to Incidental Parathyroidectomy Among Pediatric Patients Undergoing Thyroid Surgery

Sabaretnam Mayilvaganan, Sarrah Idrees, Panchangam Rama Kant Bhargav

Publication date 25-10-2022


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Effect of Ambient Air Pollutants on the Medical Costs of Allergic Rhinitis in Seoul, Korea

Jin Youp Kim, Yujin Park, Su Hwan Kim, Seong Pyo Kim, Seok‐Won Park, Hyung‐Jin Yoon

Publication date 25-10-2022


To consider the seasonality and monthly differences of both allergic rhinitis and air pollutants, we performed a time-series analysis using the seasonal autoregressive integrated moving average (SARIMA) model to adjust for monthly differences and seasonality. Covariate-adjusted SARIMA analysis showed that 6.22%, 11.27%, and 11.05% increases in the medical costs of AR corresponded to an increase in 1 SD of PM10, NO2, and CO. This analysis provides a better understanding of the health and economic effects of ambient air pollutants on allergic rhinitis.
Background Ambient air pollutants are considered significant factors that influence allergic diseases. This study aimed to evaluate the effect of ambient air pollution on the medical costs of allergic rhinitis (AR) through a time-series analysis.
Methods We used data from the Korean National Health Insurance Database from January 2016 to December 2019. The total cost for medical management and outpatient prescriptions for AR, estimated by the National Health Insurance Service for 25 districts, was summed as the total medical costs. The monthly concentrations of PM10, PM2.5, NO2, CO, O3, and SO2 were calculated, and time-series analysis was performed to evaluate the effect of ambient air pollutants on the medical cost of AR using the seasonal autoregressive integrated moving average (SARIMA) model.
Results Time-series analysis revealed that the concentrations of PM10, NO2, and CO were significantly associated with an increased medical cost of AR when adjusting for monthly differences and seasonality (p = 0.048, p = 0.001, and p = 0.001 respectively). The increase in medical costs of AR was 6.22% (95% confidence interval CI: 0.0%–12.37%), 11.27% (95% CI: 6.03%–16.50%), and 11.05% (95% CI: 7.09%–15.01%) per one standard deviation increase in PM10, NO2, and CO respectively.
Conclusions The monthly concentrations of PM10, NO2, and CO were significantly associated with the increased medical costs of AR when adjusting for monthly differences and seasonality. This analysis provides a better understanding of the health and economic effects of ambient air pollutants on AR.
Level of EvidenceN/A Laryngoscope, 2022

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5‐Aminolevulinic Acid‐Mediated Photodynamic Therapy Improves Vocal Fold Wound Healing in Rats

Chi Zhang, Wenting Pang, Ting Gong, Jack J. Jiang, Matthew Silverman, Gelin Li

Publication date 24-10-2022


We performed the first in vivo experiment focusing on the effects of PDT on vocal fold wound healing. It can not only reduce vocal scar formation when applied immediately after injury, but also remodel scarred tissue when applied 4 weeks after injury. PDT may serve as a minimally invasive treatment for vocal fold lesions with slight vocal scarring.
Objective Studies showed that photodynamic therapy (PDT) might be able to prevent vocal fold scar formation when treating laryngeal lesions. We aim to investigate if PDT improves vocal wound healing and reduces scar formation in both prophylactic and remodeling procedures performed in vivo.
Study Design In vivo.
Methods Vocal fold stripping was performed in Sprague–Dawley rats. PDT was performed with intraperitoneal injection of 100 mg/kg 5-Aminolevulinic Acid (5-ALA) and 635 nm laser irradiation of 20, 40, and 60 J/cm2. PDT was performed immediately after surgery to study the prophylactic effect and 4 weeks after surgery to study the remodeling effect. Gene expression was evaluated with real-time PCR at 1 week after PDT. Histologic evaluations were performed 12 weeks after PDT, including hematoxylin–eosin, Masson, Alcian blue staining, and immunohistochemical staining of collagen I and III.
ResultsPDT induced similar effects on the vocal fold wound healing outcomes in both prophylactic and remodeling procedures. Expression of MMP8, MMP13, HAS2, and TGFβ1 was significantly elevated. Histologic evaluation revealed significantly increased thickness, decreased density of collagen, and increased deposition of hyaluronic acid in the lamina propria. Immunohistochemistry also revealed better distribution and reduced density of collagen I and III. The most obvious changes were seen in the 60 J/cm2 PDT group.
ConclusionPDT could significantly improve vocal wound healing by providing both prophylactic effects and remodeling effects. It may be a minimally invasive treatment for vocal fold lesions with slight vocal scarring, and may be used to treat acute or chronic vocal injury to reduce vocal scarring.
Level of EvidenceN/A Laryngoscope, 2022

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In Reference to: How Many Nodes to Take? Lymph Node Ratio Below 1/3 Reduces Papillary Thyroid Cancer Nodal Recurrence

Uchechukwu C. Megwalu

Publication date 22-10-2022


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Abnormal Laryngopharyngeal Sensation in Adductor Laryngeal Dystonia Compared to Healthy Controls

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

Publication date 22-10-2022


Laryngopharyngeal sensation is increased in adductor laryngeal dystonia compared to controls. The identification of increased laryngeal hypersensitivity in these patients may improve understanding of AdLD pathophysiology and identify future targets for intervention.
Background/Objectives Laryngeal sensory abnormality has been implicated as a component of adductor laryngeal dystonia (AdLD). The study objective was to assess laryngopharyngeal sensation in AdLD utilizing a calibrated, tactile aesthesiometer to deliver differential stimuli to lateral pyriform sinus (LPS), aryepiglottic fold (AEF), and false vocal fold (FVF).
Methods Patients with known Botox-responsive AdLD underwent sensory testing using a previously-validated methodology involving calibrated tactile stimuli (6–0, 5–0, 4.5–0, 4–0 nylon monofilaments). Laryngeal adductor reflex (LAR) and participant-rated perceptual strength of stimulI were evaluated. Responses were compared to normative controls (n = 33). Two-samples, Mann–Whitney and Fisher exact tests compared mean strength ratings and LAR between AdLD and control groups. Mixed-effects logistic regression and linear models assessed association of filament size, stimulus site, age, sex, and LD status on LAR and perceptual strength rating respectively.
Results Thirteen AdLD patients (nine women, mean age 60+/−15 years) completed testing. Average LAR response rates were higher amongst all filament sizes in AdLD versus controls at LPS (56.3% vs. 35.7%) and AEF (96.1% vs. 70.2%) with comparable rates at FVF (90.2% vs. 91.7%). AdLD had 3.3 times the odds of observed LAR compared to controls (p = 0.005), but differences in subjective detection of stimuli, perceptual strength ratings, and cough/gag rates were insignificant on multivariate modeling (p > 0.05).
Conclusions This is the first study to objectively assess laryngopharyngeal sensation in AdLD. Findings demonstrated increased laryngopharyngeal sensation in AdLD compared to controls. The identification of increased laryngeal hypersensitivity in these patients may improve understanding of AdLD pathophysiology and identify future targets for intervention.
Level of Evidence2 Laryngoscope, 2022

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Expression of Glial Cell‐Derived Neurotrophic Factor Receptors Within Nucleus Ambiguus During Rat Development

Quinton Blount, Ignacio Hernandez‐Morato, Yalda Moayedi, Michael J. Pitman

Publication date 22-10-2022


In this paper, we show differences of Glial Cell-Derived Neurotrophic Factor (GDNF)receptors in the nucleus ambiguus during development from E14 to E20 and in the rat adulthood. We observed that there is timing of production of the different members of GDNF receptors in the motoneurons innervating the larynx and we try to establish differences between nucleus ambiguus and the other motor nuclei of the medulla oblongata such as facial and hypoglossus nuclei. These findings support the idea that GDNF may play a role during motor innervation of the rat larynx.
Objective The nucleus ambiguus (NAmb) is a column of neurons in the medulla oblongata, involved in bulbar functions. Expression of Glial Cell-Derived Neurotrophic Factor (GDNF) and its receptors (GDNFR) is observed within the cell bodies during reinnervation following recurrent laryngeal nerve (RLN) injury. Little is known regarding GDNFR expression in the formation of the NAmb and the laryngeal innervation during embryogenesis. Understanding the timing and pattern of GDNFR expression in embryogenesis versus after RLN injury may provide insights into therapeutic targets for regeneration after RLN injury.
Study Design Laboratory experiment.
Methods Rat brainstems at E14.5/E16.5/E18.5/E20.5/adult were stained for GDNFR: GFRα-1/GFRα-2/GFRα-3/Ret. Islet1 and choline acetyltransferase were used as cell body markers. Sections were observed using fluorescent microscopy and quantified through manual cell counting.
Results Expression of GFRα-1, GFRα-3, and Ret was identified within the NAmb, hypoglossal, and facial nuclei of the adult medulla. During development, GFRα-1 immunoreactivity was seen at E20.5. GFRα-2 expression was not observed at any timepoint. GFRα-3 expression began at E16.5. Ret expression within nerve fibers in the NAmb were observed beginning at E14.5, but never in the cell bodies.
Conclusion Embryonic GDNFR expression in the NAmb differs from that of the adult after RLN injury. The developing brainstem experienced upregulation at discrete timepoints with signaling sustained through adulthood. In contrast, adult RLN-transected rats experienced patterns of up and down regulation. GFRα-1 may contribute to muscle targeting and neuromuscular junction maturation, GFRα-3 may contribute to both, as well as axon guidance. It is likely that GDNF is functioning via a Ret-independent pathway.
Level of EvidenceNA Laryngoscope, 2022

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An Ex Vivo Investigation of Tactile Aesthesiometer Force in Laryngopharyngeal Sensory Testing

Joseph Kidane, Grant E. Gochman, W. John Boscardin, Clark A. Rosen, VyVy N. Young, Yue Ma

Publication date 21-10-2022


This study aims to evaluate the effect of size, saliva, successive compressions, and angles of tissue contact on stimulus force delivered by Cheung-Bearelly aesthsiometers using an ex vivo stimulus delivery device. Small aesthsiometers can deliver consistent stimuli up to 60° deviation from orthogonal tissue contact, while only up to 15° deviation for large aesthesiometers. Repeated compressions can decrease force delivered, but this reduction is primarily clinically insignificant, and salivary forces do not significantly alter force delivered.
Background/Objective Cheung–Bearelly aesthesiometers can deliver buckling-force stimuli to the laryngopharynx and objectively evaluate sensation. Ambiguity surrounds the transformation of stimuli in the laryngopharyngeal environment. This study aims to evaluate the effect of aesthesiometer size, saliva, successive compressions, and angles of tissue contact on stimulus force delivered.
Methods An ex vivo stimulus delivery device was constructed to measure the buckling force of aesthesiometers. Dry and saliva-saturated aesthesiometers (6–0, 5–0, 4.5–0, and 4–0) were each compressed six times on cadaveric buccal mucosa on an electronic balance. The force for each compression was recorded at 0, 15, 30, 45, and 60° from the vertical plane. 240 compressions were analyzed utilizing a mixed-effects statistical model.
Results The mean force delivered by the 6–0, 5–0, 4.5–0, and 4–0 aesthesiometers were 0.017, 0.082, 0.120, and 0.268 g respectively (p < 0.001). Mean force significantly reduced for the 4–0 aesthesiometer at 30° (p = 0.003) and 60° (p = 0.001). Force decreased by the 4th compression for the 5–0 aesthesiometer (p = 0.004) and after one compression for the 4.5–0 (p = 0.004) and 4–0 (p < 0.001) aesthesiometer. By the 4th compression, the 4.5–0 aesthesiometer was indistinguishable (p > 0.05) from the 5–0 aesthesiometer. The effect of saliva was insignificant (p = 0.83).
Conclusion Aesthesiometers can deliver discrete buckling-force stimuli to evaluate laryngopharynx sensory function. Up to 60° (15° for 4–0 aesthesiometer) deviation from orthogonal tissue contact and salivary forces do not significantly alter force delivered. 4.5–0 aesthesiometers should be exchanged after three compressions. For all other aesthesiometers, force reduction after six compressions is likely clinically insignificant given current laryngopharyngeal sensory testing protocols.
Level of EvidenceN/A Ex Vivo Laboratory Design Laryngoscope, 2022

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Endoscopic Medial Orbitotomy for Lateral Access to Anterior Cranial Base Pathology

Ryan Rimmer, Mathew Geltzeiler

Publication date 19-10-2022


This article showcases a technique to further expand the endoscopic endonasal approach to the skull base by traversing the orbit for further lateral exposure. Laryngoscope, 2022

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Positive Predictive Value of Endoscopic Findings to Diagnose Vocal Fold Paresis

Sarah K. Rapoport, Usmaan Basharat, Diana N. Kirke, Mark S. Courey

Publication date 19-10-2022


Objective Laryngoscopy corresponding with laryngeal electromyography (LEMG) is essential in diagnosing vocal fold paresis. However, baseline asymmetry or other diseases oftentimes confound the exam, making diagnosis difficult. There is currently no agreed upon endoscopic criteria proven to reliably correlate with LEMG findings. We define a set of endoscopic findings termed “paresis triad” that, when present together, reliably correlate with LEMG. The paresis triad consists of (1) hypocontraction of the weak side of the larynx with increased ventricular show, (2) hypercontraction of the intact side with bulging of the false fold covering the ventricle, and (3) tilting of the interarytenoid cleft to the weak side.
Methods We performed a retrospective review of patients with laryngeal asymmetry on laryngoscopy.
Patients were divided into two groups: those with consistent paresis triad findings across all pitches and intensities, and those without. All patients underwent LEMG by a neurolaryngologist blinded to the laryngoscopic findings. The endoscopies were then rereviewed in a blinded manner by a second laryngologist to assess inter- and intrarater reliability for identification of the triad.
Results Twelve patients met inclusion criteria (age 50 +/−15, 7F:5M). Nine had the paresis triad. Three had an inconsistent triad. All patients with the paresis triad had LEMG findings consistent with neurologic injury on the suspected side. All patients with inconsistent triad findings had normal LEMG.
Conclusions Our findings suggest the proposed laryngoscopic paresis triad may be useful objective criteria to diagnose paresis without the need for LEMG. Further prospective studies should examine a larger series of patients.
Level of Evidence4 Laryngoscope, 2022

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Otology Demystified – A Diagnostic Oto‐Endoscopic Colour Atlas. Vijayendra Honnurappa, Sangeetha Ramadass, Nilesh Mahajan, Vinay Kumar Vijayendra. Bangalore: Self‐Published, 2022, 387 pp. US$ 200 (14,000 INR). ISBN: 978‐93‐5636‐708

Nirmal Patel

Publication date 18-10-2022


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Cochlear Implants for Single‐Sided Deafness: Quality of Life, Daily Usage, and Duration of Deafness

"Nathan R. Lindquist, Jourdan T. Holder, Ankita Patro, Nathan D. Cass, Kareem O. Tawfik, Matthew R. OMalley, Marc L. Bennett, David S. Haynes, René H. Gifford, Elizabeth L. Perkins"

Publication date 18-10-2022


The current study was undertaken to report our experience for adults undergoing cochlear implantation (CI) for single-sided deafness (SSD). We present the largest cohort of patients with SSD treated with CI to date. This group demonstrates significant benefit with regards to speech recognition scores, tinnitus measures, and quality of life metrics. We present novel insights regarding the CIQOL-10 measure, correlation of speech recognition and QoL scores with daily usage “datalogging” as well as the impact of duration of deafness on outcomes for patients with CI for SSD.
Objective To report our experience for adults undergoing cochlear implantation (CI) for single-sided deafness (SSD).
Methods This is a retrospective case series for adults with SSD who underwent CI between January 2013 and May 2021 at our institution. CNC and Az Bio speech recognition scores, Tinnitus Handicap Inventory (THI), Speech, Spatial, and Qualities of Hearing Scale (SSQ12), datalogging, and the Cochlear Implant Quality of Life (CIQOL)-10 Global measure were utilized.
Results Sixty-six adults underwent CI for SSD (median 51.3 years, range 20.0–74.3 years), and 57 (86.4%) remained device users at last follow-up. Compared to pre-operative performance, device users demonstrated significant improvement in speech recognition scores and achieved peak performance at six months post-activation for CNC (8.0% increased to 45.6%, p < 0.0001) and Az Bio in quiet (12.2% increased to 59.5%, p < 0.0001). THI was decreased at 6 months post-implantation (58.1–14.6, p < 0.0001), with 77% of patients reporting improved or resolved tinnitus. Patients demonstrated improved SSQ12 scores as well as the disease-specific CIQOL-10 Global questionnaire. Duration of deafness was not associated with significant differences in speech recognition performance. Average daily wear time was positively associated with CNC and Az Bio scores as well as post-operative CIQOL-10 scores.
Conclusions Herein we present the largest cohort of adult CI recipients with SSD with data on speech recognition scores, tinnitus measures, and SSQ12. Novel insights regarding the correlation of datalogging, duration of deafness, and CI-specific quality of life (CIQOL-10) metrics are discussed. Data continue to support CI as an efficacious treatment option for SSD.
Level of EvidenceIV Laryngoscope, 2022

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