Annals of Otology Rhinology and Laryngology

Preoperative Maxillary Sinus Imaging and the Outcome of Sinus Floor Augmentation and Dental Implants in Asymptomatic Patients

21-10-2019 – Amit Ritter,Noa Rozendorn,Gal Avishai,Eli Rosenfeld,Ilan Koren,Ethan Soudry

Journal Article

Preoperative maxillary sinus imaging findings have been suggested to be associated with complications and outcomes of sinus lift and dental implant procedures; nonetheless the evidence is controversial. The aim of this study was to examine the association between preoperative maxillary sinus imaging findings and outcomes of sinus lift and dental implant procedures in asymptomatic patients. We included all patients who underwent maxillary sinus lift and dental implant procedures between 2014 and 2017. Maxillary sinus imaging findings were extracted from pre-procedural dental computed tomography scans, and outcomes of the procedures were assessed. A total of 145 procedures were included. No sinonasal symptoms were reported preoperatively. In 46% of cases maxillary sinus imaging was abnormal. The most common imaging finding was peripheral mucosal thickening (38%). Sinus floor cyst/polyp was identified in 13% of the cases, of which 47% occupied more than 50% of the sinus volume. Partial or complete opacification of the maxillary sinus was documented in 3% of cases. The sinus ostium and ostiomeatal complex were obstructed in 7% and 1%, respectively. Mucosal perforation was documented in 22% of cases and was inversely related to mucosal thickening ( Incidental maxillary sinus imaging findings such as mucosal swelling, cysts or polyps, regardless of their severity or size, and maxillary ostial obstruction may not need to be addressed prior to sinus augmentation and dental implant procedures in asymptomatic patients. Patients with complete sinus opacification should be referred to an otolaryngologist prior to surgery. Further controlled trials, in larger cohorts, are needed to corroborate our findings.

Isolated Congenital Middle Ear Malformations: Comparison of Preoperative High-Resolution CT and Surgical Findings

21-10-2019 – Na Zhang,Yi Li,Xiaobo Ma,Danni Wang,Shuling Li,Fei Yan,Shouqin Zhao

Comparative Study, Journal Article

To compare preoperative temporal bone high-resolution computed tomography (HRCT) readings to intraoperative findings during exploratory tympanotomy for suspected cases of isolated congenital middle ear malformations (CMEMs) and summarize the malformations that can and cannot be diagnosed with HRCT. A retrospective study was conducted. All cases were confirmed as isolated CMEMs during surgery. Detailed clinical records were reviewed, with a focus on imaging and surgical findings. One hundred and thirty-two patients and 145 ears were reviewed. Ninety cases (62.1%) could be identified as isolated CMEMs and at least one as middle ear anomaly using preoperative HRCT. Fifty-five cases (37.9%) were reported to be completely normal and the patients underwent exploratory tympanotomy to determine the final diagnosis. Stapes fixation, either alone or associated with other ossicular chain anomalies, contributed to 53.1% of the cases. Most cases of aplasia or dysplasia of the ossicular chain, for example, aplasia/dysplasia of the long process of the incus, aplasia of the stapes’ superstructure, and atresia of the oval window were easily identified in preoperative HRCT. However, fixation of the ossicular chain can be elusive in HRCT, and exploratory tympanotomy is needed for a definitive diagnosis. HRCT provides helpful preoperative clinical information in CMEM and may obviate the need for middle ear exploration in some cases. The negative findings (anomalies that are difficult to identify through preoperative HRCT) and the positive findings (anomalies that are relatively easy to identify through preoperative HRCT) were summarized.

Detection of Pepsin in Oral Secretions of Infants with and without Laryngomalacia

21-10-2019 – Miles J. Klimara,Tina L. Samuels,Nikki Johnston,Robert H. Chun,Michael E. McCormick

Journal Article

Laryngomalacia is a common cause of stridor in infants and is associated with laryngopharyngeal reflux (LPR). Although pepsin in operative supraglottic lavage specimens is associated with severe laryngomalacia, detection of pepsin in oral secretions has not been demonstrated in an outpatient setting. Children <2 years old with laryngomalacia diagnosed by flexible laryngoscopy and children without stridor were selected. Oral secretion samples were obtained in clinic from all subjects. Pepsin, IL-1β, and IL-8 enzyme-linked immunosorbent assays were performed to determine presence of LPR. Sixteen laryngomalacia and sixteen controls were enrolled. Pepsin was detected more frequently in oral secretions of patients with laryngomalacia (13/16) than in controls (2/16; Pepsin in saliva appears to be associated with laryngomalacia, suggesting a role for salivary pepsin as a noninvasive marker of LPR in patients with laryngomalacia. Future studies will determine the utility of this test in laryngomalacia.

Surgical Management of Vestibular Schwannoma: Practice Pattern Analysis via NSQIP

22-10-2019 – Vijay A. Patel,Mitchell Dunklebarger,Kalins Banerjee,Tom Shokri,Xiang Zhan,Huseyin Isildak

Journal Article

Characterize current perspectives in the surgical management of vestibular schwannoma (VS) to guide otolaryngologists in understanding United States practice patterns. A retrospective analysis of ACS-NSQIP database was performed to abstract all patients from 2008 to 2016 who underwent VS resection using ICD-9/10 codes 225.1 and D33.3, respectively. The specific surgical approach employed was identified via CPT codes 61520, 61526/61596, and 61591, which represent retrosigmoid (RS), translabyrinthine (TL) and middle cranial fossa (MCF) approaches, respectively. Analyzed outcomes include general surgical complications, total length of stay, and reoperation. A total of 1671 VS cases were identified, 1266 (75.7%) were RS, 292 (17.5%) were TL, and 114 (6.8%) were MCF. The annual number of cases increased over the study period from 15 to 375, which is chiefly attributed to increased institutional participation in ACS-NSQIP. Perioperative variables including BMI ( There is increased employment of RS approach for the operative management of VS, which likely is the result of increased reliance on both stereotactic radiosurgery and observation as alternative treatment strategies.

The Impact of Medical Scribes on Patient Satisfaction in an Academic Otolaryngology Clinic

23-10-2019 – Katherine R. Keefe,Jessica R. Levi,Christopher D. Brook

Journal Article

Evidence shows that scribes can improve provider efficiency and satisfaction in several settings, but is mixed on whether scribes improve patient satisfaction. We studied whether scribes improved patient satisfaction in an academic otolaryngology clinic. The authors performed a retrospective review of patient responses to the Press Ganey survey between 12/2016 and 12/2017. Their responses about satisfaction with the provider and wait times were examined. Three providers worked with scribes during this year; each spent six months with a scribe and six without. The authors compared survey responses from periods with and without scribes using the Fischer exact test. Average overall provider ratings were compared using the Student’s A total of 87 patients filled out Press Ganey surveys for the 3 providers over the year: 54 for visits without scribes, and 33 for visits with scribes. Fischer exact analysis demonstrated no significant difference in satisfaction with providers and wait times for both individual providers and all providers combined (all Patient satisfaction with wait times and providers was high overall and was not affected by the presence of a medical scribe.

Gene Expression Analysis to Investigate Biological Networks Underlying Nasal Inflammatory Dysfunctions Induced by Diesel Exhaust Particles Using an In Vivo System

24-10-2019 – Hyun Soo Kim,Byeong-Gon Kim,Sohyeon Park,Nahyun Kim,An-Soo Jang,Young Rok Seo,Moo Kyun Park

Journal Article

Diesel exhaust particles (DEP)s are notorious ambient pollutants composed of a complex mixture of a carbon core and diverse chemical irritants. Several studies have demonstrated significant relationships between DEP exposure and serious nasal inflammatory response In the present study, we identified DEP-induced gene expression profiles under short-term and long-term exposure, and identified signaling pathways based on microarray data for understanding effects of DEP exposure in the mouse nasal cavity. Alteration in gene expression due to DEP exposure provokes an imbalance of the immune system via dysregulated inflammatory markers, predicted to disrupt protective responses against harmful exogenous substances in the body. Several candidate markers were identified after validation using q
RT-PCR, including S100A9, CAMP, IL20, and S100A8. Although further mechanistic studies are required for verifying the utility of the potential biomarkers suggested by the present study, our

Neck Surgery with Hypnosis: An Evaluation Based Upon Patient’s Self Assessment

29-10-2019 – Marie Jaouen,Valentine Parent,Maxime Codet,Véronique Gerard,Anita Chatellier-Miras,Cécile Chaize,Olivier De Crouy Chanel,Franck Jegoux

Journal Article, Observational Study

Surgery with hypnosis avoids the use of general anesthesia (GA). It also shortens hospitalization and promotes outpatient surgery. The objective of this study has been to assess the satisfaction of operated patients. No previous study has focused on patient satisfaction in a prospective design. In this prospective, non-randomized, observational study, all patients operated with hypnosis between 2009 and 2017 in the Ear, Nose, and Throat department of a tertiary care hospital were selected. All patients were asked to fill a questionnaire based on a previously validated questionnaire incremented with complementary questions. Questionnaires were completed immediately after surgery for 31 patients and after 6 months for 20 patients. Global Satisfaction Index (GSI) was self-assessed on a scale ranging from 1 to 10. Patients were asked; whether they felt comfortable during the operation, whether hypnosis helped them, whether the experience matched their expectations, whether they would revisit or recommend it to someone else and whether they considered to have been sufficiently informed before the procedure. The data was analyzed using a linear regression model with During the inclusion period, no patient required conversion to GA. A total of 48 questionnaires were evaluated. The median of the GSI was 8/10. GSI significantly correlated with patient comfort ( This study reveals that patients’ global satisfaction after hypnosis is high. This is significantly related to the quality of preoperative information and to the experience of the surgical team. It also suggests that patients are more likely to benefit from hypnosis if the surgery is longer.

Risk of Mortality between Untreated and Treated Papillary Thyroid Cancer: A Matched Cohort Analysis

29-10-2019 – Jonathan K. Lin,Lori C. Sakoda,Jeanne Darbinian,Melissa Socarras,Whitney Chiao,Nathaniel Calixto,Charles Quesenberry,Deepak Gurushanthaiah,Kevin H. Wang,Megan Durr

Journal Article

To examine the association between treatment status and mortality risk among patients with papillary thyroid cancer (PTC). We identified 3,679 adults with PTC. Thirty-one untreated patients were matched to 155 treated patients. Hazards ratios (HR) and 95% confidence intervals (CIs) were calculated to estimate all-cause and disease-specific mortality. A low-risk subgroup was analyzed for differences in all-cause mortality. The adjusted HRs (95% CIs) for all-cause mortality at 5 and 10 years were 4.2 (1.7-10.3) and 4.1 (1.9-9.4) and for disease- specific mortality were 14.1 (3.4-59.3) and 10.2 (2.9-36.4), respectively, for untreated versus treated patients. The adjusted HRs (95% CIs) for all- cause mortality was 0.7 (0.1-6.4) for low-risk untreated versus matched treated patients. Compared to treated patients, untreated PTC patients were at higher risk of death while low-risk untreated PTC patients had comparable rate of metastasis and no increased risk of all-cause mortality.

Endoscopic Transoral Hybrid Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy

01-11-2019 – Meijin Nakayama,Ryan K. Orosco,F. Christopher Holsinger,Giuseppe Spriano,Giovanni Succo,Armando De Virgilio,Nobuhiko Oridate

Journal Article

The hybrid supracricoid partial laryngectomy with cricohyoidoepiglottopexy (SCPL-CHEP, that is, open partial horizontal laryngectomies OPHL Type IIa) has been described using a flexible next generation robotic surgical platform for manipulation. We sought to evaluate the feasibility of performing this procedure using endoscopic transoral (Endo
T) surgical techniques without robotics. Preclinical cadaveric study using two human cadavers. Hybrid SCPL-CHEP was performed with a flexible endoscope for visualization and hand-held instruments for manipulation (SILS Hook monopolar and Dissect, HAVAS Laryngo
FIT malleable straight jaw instruments, and Stratafix 4-0 spiral knotless barbed suture). Endo
T hybrid SCPL-CHEP was successfully performed. The hand-manipulated rigid instruments allowed for transoral incisions and mucosal suturing. We provide the procedural steps of Endo
T hybrid techniques. Endo
T hybrid SCPL-CHEP was technically feasible in the preclinical cadaveric laboratory setting and appeared comparable to the hybrid SCPL-CHEP via transoral robotic surgery (TORS). Selected handheld instruments and flexible endoscopy appear to facilitate minimally invasive surgery of the larynx. This novel procedure and technique warrant further clinical study for consideration of feasibility, applicability, and patient benefit.

“In-Office Balloon Sinus Ostial Dilation with Concurrent Antiplatelet and Anticoagulant Therapy for Chronic Rhinosinusitis without Nasal Polyps”

06-11-2019 – Thomas S. Higgins,Bülent Öcal,Ridwan Adams,Arthur W. Wu

Journal Article

Functional endoscopic sinus surgery (FESS) and balloon sinus ostial dilation (BSD) are well-recognized minimally invasive surgical treatments for chronic rhinosinusitis without nasal polyps (CRSs
NP) refractory symptoms to medical therapy. Patients on antiplatelet and anticoagulant therapies (AAT) usually are recommended to discontinue their medications around the period of endoscopic sinus surgery. The goal of this study is to assess the clinical experience of BSD in CRSs
NP patients with concurrent anticoagulant or antiplatelet therapy. A review of prospectively-collected clinical data from October 2012 to March 2017 were used to perform a cohort study of subjects with CRSs
NP who met criteria for surgical intervention while on antiplatelet and anticoagulant therapy. Data were collected on demographics, details of the procedures, type of AAT used, pre- and postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores, and complications. Thirty-five patients underwent in-office BSD while on antiplatelet and/or anticoagulant therapy. The mean difference in pre- and postoperative SNOT-22 scores of 9.9 (SD 14.4, In-office BSD appears to be a safe alternative to endoscopic sinus surgery in select patients who cannot discontinue antiplatelet and anticoagulant therapy. IV.

Five-year Survival Data on the Role of Endoscopic Endonasal Nasopharyngectomy in Advanced Recurrent rT3 and rT4 Nasopharyngeal Carcinoma

08-11-2019 – Eugene Hung Chih Wong,Yew Toong Liew,Siow Ping Loong,Narayanan Prepageran

Journal Article

Endoscopic endonasal nasopharyngectomy (EEN) for recurrent nasopharyngeal carcinoma (r
NPC) is being increasingly used due to the added high magnification, reduced morbidities associated with open procedures and good survival outcomes. Most studies looked at usage of EEN in patients with lower recurrent staging (r
T1 and r
T2) although more and more surgeons are studying the outcome of EEN in advanced r
NPC (r
T3 and r
T4). The aims of this study were to report the long-term 5-year survival outcome of EEN performed in patients with advanced r
NPC, and to determine any prognostic factors for patients’ survival. All patients who underwent EEN for advanced r
NPC between January 2003 and December 2015 inclusive were analyzed. All surgeries were performed in University Malaya Medical Centre in Kuala Lumpur and Queen Elizabeth Hospital in Sabah. We reported the 5-year overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS) and any related complications and significant prognostic factors. Twelve patients with r
NPC (2 r
T3 and 10 r
T4) were followed-up over a mean duration of 44.8 months (range, 40-440 weeks). The 5-year OS was 50.0% (mean 44.75 months), DFS was 25.0% (mean 35.25 months) and the DSS was 58.3% (mean 43.33 months). No severe operative complications were encountered and no independent prognostic factors for survival outcome were identified. This is the first report in English that exclusively described the long-term 5-year survival data in patients with both r
T3 and r
T4 recurrent NPC after EEN. The data suggest that EEN is a feasible treatment to improve survival with minimal morbidities in patients with r
T3 and r
T4 recurrent NPC. However, more studies with larger patient size is recommended.

Quality and Readability of Online Information on In-Office Vocal Fold Injections

08-11-2019 – Grace S. Yi,Amanda Hu

Journal Article

Vocal fold injection augmentations are increasingly being performed in the office setting on awake patients, as opposed to the operating room. These procedures thus require patient cooperation and education. As the Internet is a widely-used resource for patients, our aim was to assess the quality and readability of online resources on in-office awake vocal fold injections. An online Google search using the terms “office vocal fold injection medialization” and “awake vocal fold injection” was conducted. The first 50 English-language websites were categorized into professional- and patient-targeted, and major and minor sources. They were analyzed using the Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL) test, and DISCERN quality score. Fifty websites were evaluated, and the overall DISCERN score was 2.60 ± 1.01, the mean FRES was 32.16 ± 19.10, and the mean FKGL was 13.76 ± 4.12. Between the 25 professional-targeted and 25 patient-targeted websites, professional-targeted sites had significantly higher DISCERN ( Our study shows that half of the top Google results for our topic were not written for patient education, but rather for health care professionals. The reading level of this information exceeds the recommended grade level for patient education materials, and may be less comprehensible than intended. While patient-targeted materials are easier to read than professional-targeted sites, they are of lower quality. The quality of the available online information on this topic is suboptimal for both patients and health care providers. This research highlights the need for more appropriate patient education materials given low health literacy rates.

Yolk Sac Tumors of the Head and Neck in Aicardi Syndrome

23-10-2019 – Madison V. Epperson,Hayley L. Born,Dehua Wang,Charles M. Myer

Case Reports, Journal Article

To understand that yolk sac tumors (YSTs) of the head and neck (H&N) are exceedingly rare and typically carry a poor prognosis. To acknowledge the possibility of increased incidence in patients with Aicardi Syndrome and the ramifications this has on early diagnosis and treatment in this population. To date, four germ cells tumors of the H&N have been reported in patients with Aicardi Syndrome. This report presents the second known case of a H&N YST in a patient with Aicardi syndrome. In both cases, the patient was initially misdiagnosed given unconvincing radiologic evidence. However, tissue diagnosis and elevated alpha-fetoprotein (AFP) levels were suggestive of a YST. In contrast to the poor prognosis previously described, both patients with Aicardi syndrome had an excellent chemotherapeutic response exhibited by normalization of AFP levels and imaging. Rare germ cell tumors of the H&N, such as YSTs, have now been documented in several patients with Aicardi syndrome, indicating a possible association given the rarity of these tumors in the population. YSTs should be considered in the differential diagnosis of H&N masses in these patients, with emphasis on early tissue diagnosis and treatment.

Book Review: Key Topics in Otolaryngology

01-11-2019 – Samia F. Nawaz

Follow-Up Adherence Is Associated with Outcomes After Endoscopic Sinus Surgery

21-02-2020 – Sarek A. Shen,Aria Jafari,Jesse R. Qualliotine,Adam S. DeConde

Journal Article

Clinical follow-up after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) allows for assessment of the sinonasal cavity, debridement, and tailoring of medical therapies. Frequency and timing of postoperative clinical visits is debated, but the impact of adherence on disease-specific outcomes is not well understood. In this longitudinal study, we assessed the association between follow-up adherence and quality of life (QOL) outcomes in the 12 months after ESS. A retrospective review of patients undergoing ambulatory ESS for CRS between 11/2016 and 1/2018 was performed. We assessed sociodemographic characteristics, radiographic severity, and QOL utilizing the 22-item sinonasal outcome test (SNOT-22). Patients were categorized as “non-adherent,” “moderately-adherent,” and “fully-adherent” to a 1-, 3- and 5-week postoperative visit schedule. A total of 166 patients met the inclusion criteria. Of these, 55 (33.1%) were fully-adherent, 105 (63.2%) were moderately-adherent, and 6 (3.6%) were non-adherent within the 6 weeks following ESS. In the immediate postoperative period, fully-adherent patients demonstrated worse QOL (SNOT-22: 31.2 ± 23.1 vs 27.5 ± 17.6, Despite worse symptom severity in the immediate postoperative period, patients who are more adherent to the follow-up schedule demonstrated slower return of symptoms in the extra-rhinological and ear-facial domains. These findings suggest that clinical adherence and management may impact the long-term evolution of ESS outcomes.

Cricoid Chondronecrosis: Case Report and Review of Literature

19-02-2020 – Mark M. Mims,Andree A. Leclerc,Libby J. Smith

Journal Article

Cricoid chondronecrosis is a rare entity that has significant consequences for patients. Reports of its occurrence are scattered in the literature and currently there is no comprehensive review to help guide providers. A case report from our institution is presented. A review of available literature is then provided with assessment of risk factors, signs and symptoms at presentation, laryngeal exam findings, radiologic findings, and surgical techniques. Twenty-four cases of cricoid chondronecrosis were reviewed from the literature. Patient age ranged from 8 months to 76 years. A history of endotracheal intubation for various reasons was present in all but two cases, and duration of intubation ranged from 6 hours to 28 days. Patients presented with airway compromise in all but two cases-one asymptomatic patient with prior tracheostomy and another with dysphagia after radiation. Dysphonia (n = 6) and dysphagia (n = 3) were less commonly present. Subglottic stenosis (n = 19) was the most common exam finding followed by vocal fold impairment (n = 11). When CT scan findings were reported, fragmentation of the cartilage and/or hypodensity of the central lamina were described in all but one case. Interventions ranged from observation on antibiotics and steroids to surgical therapies including tracheostomy, dilation, and posterior cricoid split, with or without stent placement. Cricoid chondronecrosis is a serious, rare entity that can occur even after a short period of endotracheal intubation. Providers must have a high level of suspicion in patients that present with upper airway dyspnea with a history of prior intubation. Level 4.

Patient Satisfaction and Efficiency Benefits of a Novel Multidisciplinary Rhinology and Allergy Clinic

15-02-2020 – Kevin L. Li,Christina H. Fang,Denisa Ferastraoaru,Nadeem A. Akbar,Elina Jerschow,Waleed M. Abuzeid

Journal Article

Chronic rhinosinusitis (CRS) is a chronic inflammatory disease of the sinonasal mucosa and with strong associations to other immune-mediated comorbidities. Patients often require referral to both an otolaryngologist and an allergist/immunologist. This study is the first in the literature to describe a multidisciplinary clinic that offers patient care by subspecialists in rhinology and in allergy/immunology. One hundred twenty-nine patients were seen in the Comprehensive Sinus and Allergy Clinic (CSAC) between January 2016 and June 2017 and 43 selected patients were seen in both the standalone allergy and rhinology clinics over the same time period. Patient satisfaction was retrospectively assessed using a modified Press-Ganey satisfaction survey. Time to evaluation and time to follow up appointment were compared between the CSAC and both the standalone rhinology and allergy/immunology clinics. Patients seen in the CSAC reported high satisfaction with the amount of time spent with the physicians (98.3%), quality of medical care (9.3 ± 1.0), and most importantly, the convenience of seeing two physicians in one day (9.5 ± 1.2). Time from referral placement to clinic evaluation ( Patients reported high satisfaction with the medical care provided and were also seen much faster in our multidisciplinary clinic as compared to standalone rhinology or allergy/immunology clinics. Overall, a multidisciplinary approach may be beneficial to patients presenting to tertiary referral centers with CRS and atopic conditions.

Effect of Laryngeal Suspension and Upper Esophageal Sphincter Myotomy for Severe Dysphagia Due to Brainstem Disease

10-02-2020 – Seiko Shibata,Hitoshi Kagaya,Yasunori Ozeki,Eiichi Saitoh,Yoichiro Aoyagi,Yoshihiro Iwata,Kazuo Sakurai

Journal Article

Surgical procedure is considered in patients with severe dysphagia when conservative treatment fails. This study aimed to evaluate laryngeal suspension (LS) and upper esophageal sphincter (UES) myotomy for treating severe dysphagia due to brain disease. Fourteen patients underwent LS and UES myotomy, with a median follow-up of 5 years and 6 months when conservative treatment failed. The penetration-aspiration scale (PAS), the Dysphagia Severity Scale (DSS), the Eating Status Scale (ESS), and diet contents were evaluated just before surgery, at discharge, and at the last follow-up. Preoperative intake was tube feeding in all patients. The patients learned the extended head and flexed neck posture to open the esophageal inlet. PAS, DSS and ESS scores, and diet contents were significantly improved at discharge compared with before surgery, and were maintained until the last follow-up. Eight patients had pneumonia during their hospital stay, and five had pneumonia between discharge and at the last follow-up. Age was significantly, negatively correlated with DSS and ESS at the last follow-up. Although LS and UES myotomy require a long inpatient rehabilitation and the risk of pneumonia after surgery is high, the outcome is favorable and the effects last for a long time.

Gastropharyngeal Anastomotic Leak in Medullary Thyroid Carcinoma Following Initiation of a Tyrosine Kinase Inhibitor: A Case Report of an Unusual Side Effect of Cabozantinib

10-02-2020 – Jaeger Ackerman,Sean Kent,Paul Walker

Journal Article

Medullary thyroid carcinoma (MTC) accounts for 1% to 2% of thyroid cancers in the United States. When identified early, total thyroidectomy is most often curative. However, in advanced disease, more aggressive treatment such as laryngectomy and esophagectomy may be indicated. Postsurgical fistula formation and leak is a potential complication in such cases. These fistulas are most likely to occur at the anastomotic site in cases of laryngectomy or esophagectomy. Concomitant chemotherapy and radiation increase this risk. Tyrosine kinase inhibitors (TKI) such as Cabozantinib are used as therapy for metastatic MTC. These drugs have previously been associated with dehiscence of anastomotic sites in the gastrointestinal tract. While previously identified in the bowel, this report represents the first documented case of gastropharyngeal anastomosis leak described in the context of TKI use for head and neck cancer. We present the case of a 72-year-old male previously diagnosed with MTC. His gastropharyngeal anastomosis status-post laryngopharyngectomy and gastric pull up had been stable for 23 years. Over the past year, he developed back pain and was found to have spinal metastases of MTC. He was subsequently started on Cabozantinib to slow the progression of the disease. Within months of starting this TKI, a bleeding pharyngocutaneous fistula developed at the anastomosis site of the gastric pull up and pharynx. Upon discontinuation of Cabozantinib, the fistula healed with no further complications. To our knowledge, this is the first documented case of gastropharyngeal anastomotic leak related to TKI use. A causal relationship is highly plausible given the previously stable anastomosis and the suspicious advent of complications within months of initiation of this new drug. While previously limited to cases of intraabdominal bowel dehiscence, this report now suggests that wound dehiscence must be considered a known side effect of TKIs throughout the gastrointestinal tract, including the gastropharynx. As such, the risk of anastomotic dehiscence should be discussed with the patient prior to starting a TKI.

Using a 4K-3D Exoscope for Upper Airway Stimulation Surgery: Proof-of-Concept

10-02-2020 – Vijay A. Patel,Neerav Goyal

Journal Article

Demonstrate the potential of the 4K-3D exoscope during upper airway stimulation surgery (UAS). A proof-of-concept study was performed to evaluate the feasibility of the exoscope during three consecutive UAS. The exoscope was employed during UAS including cuff electrode and sensing lead placement. Three cases were successfully completed without adverse perioperative event; mean operative time was 200 minutes (range 188-218 minutes) with a successive reduction in operative time. This experience demonstrates the potential viability of the exoscope for UAS; it is a safe, innovative, and effective alternative or adjunct to existing visualization modalities. Notable advantages include improved ergonomics, unobstructed surgical field access, wide depth of field visualization, and short learning curve. Future technological enhancements could allow the exoscope to become a promising next-generation tool in the armamentarium of the contemporary sleep surgeon.

Melanoma Characteristics in Patients with a History of UV Tanning Bed Usage

07-02-2020 – Kristy Truong,Mohammed Milhem,Nitin A. Pagedar

Journal Article

The purpose of this study was to evaluate the effect of tanning bed use on the behavior of subsequent melanomas. Cases of invasive cutaneous melanoma who completed a baseline questionnaire within 1 year of biopsy were ascertained using an institutional registry. Patients were categorized into one of two groups: (1) no history of UV tanning bed usage or (2) any history of tanning bed usage. Data analysis looked for group differences on the following variables: TNM staging, mitotic rate, family history of melanoma, and basic demographic variables. Among 141 cases, a higher percentage of women (48.28%) reported tanning bed usage compared to men (26.51%, If we remove the subject with MUP on the basis that more of these are mucosal in origin, lower TNM stage at presentation are found in patients with no tanning bed melanoma compared to those with history of tanning bed usage. In addition, tanning bed patients are younger and more likely female but with an equivalent mortality rate. Case Series.

Survival Outcomes and Prognostic Factors of Open Partial Laryngeal Surgery: A Thirty Years’ Experience

07-02-2020 – Oreste Gallo,Angelo Cannavicci,Chiara Bruno,Giandomenico Maggiore,Luca Giovanni Locatello

Journal Article

Open partial laryngeal surgery (OPLS) represents a wide array of procedures that can be fitted to treat different types of laryngeal cancer (LC). We would like to present our 30-years’ institutional experience, to analyze survival outcomes and to critically discuss prognostic factors. We reviewed all cases of OPLS performed at our Institution from 1982 to 2016 for LC. Survival analysis by Kaplan-Meier estimate was performed and prognostic variables by multivariate analysis were identified. Mean follow-up time was 68.3 months, 30-day mortality 0.2%, subsequent functional total laryngectomy (TL) was 1.01%. Over 80% of cases were stage I to II. We had 25 local, 62 regional and eight distant recurrences. Local control was 94.9%, overall survival (OS) was 83.4% and disease-specific survival (DSS) was 87.7%. The two major risk factors significantly associated with the risk of death were c
T and c
N stage. CONCLUSIONS: We have confirmed that OPLS represents an oncologically sound option in the treatment of LC despite the emergence of non-surgical strategies and new transoral mininvasive techniques. Our results highlight that accurate staging, correct selection of the patient and a strong surgical expertise are of paramount importance in this type of surgery.

Effect of Over the Counter Ibuprofen Dosing after Sinus Surgery for Chronic Rhinosinusitis: A Prospective Cohort Pilot Study

07-02-2020 – Craig Miller,Ian M. Humphreys,Greg E. Davis

Journal Article

Management of pain following endoscopic sinus surgery (ESS) often involves intermittent use of opioid medications. Given the current opioid crisis, many surgeons aim to minimize opioid prescriptions. However, surgeons often avoid the use of NSAIDs following ESS out of concern for increased bleeding risk. We sought to evaluate the effectiveness and safety of over the counter dosing of ibuprofen on pain and bleeding rates following ESS. Prospective cohort pilot study of patients undergoing ESS. Patients self-selected either control arm (acetaminophen and PRN oxycodone) or intervention arm (alternating ibuprofen with acetaminophen, and PRN oxycodone). Outcome measures included pain (10-point visual analog scale [VAS]), bleeding rate (10-point VAS), and number of opiate pills consumed. Thirty-nine patients completed the study (15 control and 24 intervention). Overall, patients in the intervention arm reported decreased pain levels at days 1 (-0.9 [95%CI: -2.2, 0.5], 3 (-0.9 [95%CI: -2.3, 0.5]), and 7 (-0.6 [95%CI: -1.8, 0.6]), as well as decreased postoperative bleeding at those same days -0.9 [95%CI: -2.1, 0.4], -0.9 [95%CI: -2.1, 0.4], and -0.7 [95% CI: -1.2, -0.7], compared to controls. Opiate consumption was similar between groups with patients consuming on average four opiate pills (oxycodone 5 mg). Over the counter dosing of ibuprofen along with acetaminophen may yield better pain control after sinus surgery compared to acetaminophen alone. Additionally, there was no significant difference in epistaxis in the ibuprofen cohort compared to the cohort who did not take ibuprofen. Furthermore, this study showed very few opioid pills were consumed after routine ESS regardless of pain regimen prescribed. A larger trial is needed to make definitive statements on safety and efficacy. .

Congenital Midline Cervical Cleft: First Report and Genetic Analysis of Two Related Patients

07-02-2020 – Maheer M. Masood,Piotr Mieczkowski,Ewa P. Malc,Ann Katherine M. Foreman,James P. Evans,J. Madison Clark,Austin S. Rose

Journal Article

Congenital midline cervical cleft (CMCC) is a rare congenital anterior neck anatomical anomaly. We present the case of two related patients (grandchild and maternal grandmother) who were both born with a congenital midline cervical cleft along with genetic analysis. Clinical examination of both patients and surgical excision of the grandchild was performed. Genetic analysis with exome sequencing (ES) was conducted for both patients. Genetic analysis with exome sequencing (ES) revealed apparently novel single nucleotide variants in 66 genes present in both proband and grandmother. Five of these variants are predicted to cause frameshifting in the coding region of the respective genes and truncated proteins ( To our knowledge, this is the first case of two related patients with a congenital midline cervical cleft. The results of our genetic analysis reveal potential relevance to CMCC development.

Bitter Taste Perception of the Human Tongue Mediated by Quinine and Caffeine Impregnated Taste Strips

07-02-2020 – David T. Liu,Gerold Besser,Florian Oeller,Christian A. Mueller,Bertold Renner

Journal Article

Tests for gustatory function have become increasingly important in diagnosis and treatment of patients with taste disorders. While caffeine and quinine hydrochloride solutions have been used for global testing of bitter perception, only quinine has been used to test regional bitter perception by means of taste strips. The aim of the present study was to validate caffeine impregnated taste strips as an alternative to quinine taste strips for assessment of regional bitter perception. A total of 46 healthy volunteers (mean age/range, 23/19-27 years) were included in this study. Quinine and caffeine impregnated taste strips were pairwise presented at different parts of the tongue. Perceived intensity and hedonic dislike were evaluated using labeled magnitude scales. Additionally, gustatory function was assessed using the taste strips test and overall sense of taste was rated using visual analog scales. Assessment of gustatory function demonstrated scores within the normogeusic range in most included subjects (mean/SD, 13.1/2.5). Notably, equally concentrated quinine and caffeine impregnated taste strips placed on different regions of the tongue did not lead to significant differences in perceived intensity or hedonic dislike, whereas quinine and caffeine impregnated taste strips of different concentrations placed on the same region on the tongue led to significant differences of perceived intensity and hedonic dislike. Furthermore, no correlation was found between self-assessment of gustatory function and taste strips scores. Caffeine seems to be a valid bitter compound for regional testing using taste strips and may be used alternatively to quinine.

Cochlear Implants in Alström Syndrome

05-02-2020 – Gheller Flavia,Gallo Samanta,Trevisi Patrizia,Caserta Ezio,Dassie Francesca,Maffei Pietro,Bovo Roberto

Journal Article

Too little is known about hearing loss rehabilitation in patients with Alström syndrome (AS). Benefits of hearing aids (HA) have not been fully documented and only one case treated with a Cochlear Implant (CI) has been described in the proceedings of a conference. Furthermore, comorbidities and risk of complications following surgical intervention may contraindicate Cochlear Implant procedures in these patients. The present case report concerns the first AS patient with CI in the literature. After reporting a concise description of the audiological profile of patients with AS described in the literature, the case of a 22-year-old woman with genetically confirmed Alström syndrome who underwent a sequential bilateral CI (Bi-CI) rehabilitation is reported. Audiological results before and after cochlear implantation are described. The patient showed an excellent functional outcome with CIs, which enabled her to achieve communicative, social and academic results comparable with her peers, and no complications occurred. AS is not necessarily an absolute contraindication to CI. For many AS patients, a good cognitive function and adequate life expectancy represent a clear indication to prompt and adequate hearing rehabilitation with CIs. The description of this type of clinical cases could in the future also generate indications for a tailored audiological treatment of patients with very specific needs, such as patients with Alström Syndrome.

The Prognosis of Lateral Cartilage Graft for Double-Layer Tympanic Membrane Graft in Type I Tympanoplasty

01-02-2020 – Zhengcai Lou

Letter

Adult Aortotracheal Fistula as Sequela of Double Aortic Arch Repair in Infancy: A Case Report

01-02-2020 – Andrew B. Rees,Jennifer P. Rodney,Mark R. Gilbert,Clayton A. Kaiser,Alexander H. Gelbard

Journal Article

Double aortic arch is a rare congenital malformation of the aortic arch that most frequently presents in childhood. Early surgical intervention typically yields excellent outcomes. To describe aortotracheal fistula as a rare, yet serious complication of vascular ring and subsequent aortic aneurysm in an adult patient. Clinical history, as well as radiographic and endoscopic imaging were obtained to describe the development, diagnosis, and clinical course of this patient’s aortotracheal fistula. Additionally, follow up data was obtained to document the healing of this fistula after surgical repair. We describe a case of a 46-year-old male with Di
George Syndrome and a double aortic arch, repaired in childhood, which developed into an aortotracheal fistula after tracheostomy placement as an adult. This case demonstrates that dangerous complications of a double aortic arch can persist into adulthood, even after surgical repair in infancy. Each patient’s unique anatomy must be considered when thinking about airway management and prevention of complications of this rare congenital anomaly.

Aging Effects on Esophageal Transit Time in the Upright Position During Videofluoroscopy

30-01-2020 – Kendrea L. (Focht) Garand,Lindsey Culp,Bin Wang,Kate Davidson,Bonnie Martin-Harris

Journal Article

The purpose of this study was to examine age-related effects on esophageal transit times (ETT) among healthy adult participants. A total of 175 healthy, non-dysphagic participants underwent a modified barium swallow study (MBSS), and ETT was recorded for two standardized swallowing tasks. Differences across age groups were determined using Kruskal-Wallis test. Relationships between an Esophageal Clearance (Modified Barium Swallow Impairment Profile Component 17) score and ETT were also explored. No significant differences were observed in ETT across age groups for nectar-thickened liquid ( Study findings failed to support age-related or sex-related differences in ETT for two standardized swallowing tasks administered during a MBSS in healthy individuals. The normative values following a standardized protocol in this study provide guidance in clinical interpretation of esophageal function.

Multi-Institutional Regional Otolaryngology Bootcamp

29-01-2020 – Brian P. Cervenka,Tsung-yen Hsieh,Sharon Lin,Arnaud Bewley

Journal Article

In order to increase junior resident physician proficiency and improve patient safety, simulation-based procedural training courses, or bootcamps, have been become an emerging educational tool. To compare pre- and post-course confidence levels and to assess station efficacy after completion of our single day bootcamp. We developed the University of California (UC) Davis otolaryngology bootcamp, a single day course including six cadaveric task trainer stations and four simulations. The six task trainer stations included (1) Epistaxis, (2) Cricothyrotomy/tracheostomy, (3) Peritonsillar abscess/auricular hematoma, (4) Nasal bone reduction/zygoma reduction/lateral canthotomy/canalicular trauma and probing, (5) Local nerve blocks, and (6) Soft tissue reconstruction. The simulations comprised of airway fire during tracheostomy, pediatric respiratory code during airway evaluation, dislodged pediatric tracheostomy tube in the ICU, and angioedema in the emergency department with inability to intubate or ventilate. Junior residents from multiple locoregional institutions were recruited to participate. Pre- and post-course Likert surveys assessing participant confidence and station efficacy were collected and analyzed. There was a statistically significant increase in resident confidence levels for all task trainer stations. All stations had a station efficacy Likert score average of 4 “very effective” or 5 “most effective.” A multi-institutional, locoregional, simulation-based bootcamp can be a valuable adjunct to junior resident training. It can promote camaraderie, pool limited resources, and may be cost-effective.

Factors Correlating to Burnout among Otolaryngology Residents

29-01-2020 – Leighton Reed,Madhu Mamidala,Rosemary Stocks,Anthony Sheyn

Journal Article

Physicians have high rates of burnout with an Otolaryngology burnout rate of 42%. The most studied burnout correlation is increased work hours. More recently, mindfulness training programs have been shown to decrease burnout and increase self-compassion. Regarding burnout studies specific to Otolaryngology residents, there have been few in the past decade. This study explores correlations between burnout and procedure involvement, non-clinical responsibilities and mindfulness practices along with gathering updated work hours data. A single survey question was shown to be a reliable substitute for Maslach Burnout Inventory in assessing burnout. A survey was sent to all US Otolaryngology residents to investigate the correlation of burnout to post-graduate year, work hours, procedure involvement, non-clinical responsibilities, and mindfulness practices. Residents were asked to answer questions regarding their previous year of training. Overall burnout was 50%. PGY-1 and PGY-5 were completed with a low burnout rate compared to other years. Increased work hours were confirmed to increase burnout. Increased involvement in procedures, decreased exercise, and increased time completing paperwork correlated with increased burnout. No other factors including mindfulness correlated with increased or decreased burnout. However, only 20% who practiced mindfulness training had this training offered by their department or university. Annals of Otology, Rhinology & Laryngology A 50% burnout rate is a concerning rate. Increased work hours and PGY-2 through PGY-4 correlated with increased burnout. Accessibility to mindfulness training was low. As mindfulness training is a proven activity to decrease burnout, more departments could benefit from providing these experiences to their residents.

Are Children Scheduled for Ventilation Tubes Insertion Overweight? A Cohort of Israeli Children

29-01-2020 – Ayala Klein,Oded Kraus,Alisa Luria,Sharon Ovnat Tamir,Tal Marom

Journal Article

To study the hypothesis that children scheduled for ventilation tube insertion (VTI), a surrogate procedure reflecting otitis media (OM) presence, are overweight or obese. Charts of Israeli children aged 0 to 9 years undergoing VTI with or without adenoidectomy between 9/1/17 and 3/31/19 in a secondary level hospital were retrospectively identified. We compared their mean body mass index (BMI, kg/m The VTI group included 83 children (mean age: 3.5 ± 1.8 years). The control group included 77 children (mean age: 6.3 ± 1.9 years). No statistically significant difference was found in the mean BMI values between both groups ( Children undergoing VTI were overweight when compared to their age- and gender-matched peers. This observation was more noticeable in boys.

Malignant Otitis Externa is Associated with Diabetes: A Population-Based Case-Control Study

24-01-2020 – Tzong-Hann Yang,Sudha Xirasagar,Yen-Fu Cheng,Chuan-Song Wu,Yi-Wei Kao,Ben-Chang Shia,Herng-Ching Lin

Journal Article

Despite studies reporting a possible association between malignant otitis externa (MOE) and diabetes, there are no large-scale population-based empirical studies. This nationwide, population-based case-control study explored the association of MOE occurrence with previously diagnosed diabetes. Data were retrieved from Taiwan’s National Health Insurance Research Database, 753 patients with MOE (cases) and 2 259 propensity score-matched patients without MOE (controls). Multiple logistic regressions were conducted to examine the association of MOE with previously diagnosed diabetes. In total, 728 (24.2%) out of 3 012 sample patients had diabetes prior to the index date. Chi-square test revealed a significant difference in diabetes prevalence among cases and controls (54.8% vs 13.9%, This study found an association between MOE and diabetes. One clinical practice implication of our study is that when a patient with diabetes complains of otalgia or otorrhea, and physical examination shows swelling of the ear canal or granulation growth, physicians should consider the possibility of MOE.

Quality of Patient Education Sections on Otitis Media Across Different Website Platforms

24-01-2020 – Kunal Ramanand Shetty,Rita Yu Wang,Anisha Shetty,Jessica Levi,Nicole Leigh Aaronson

Journal Article

To determine the quality, content, and readability of patient education materials pertaining to otitis media across several popular online platforms focused on otolaryngology and pediatric primary care education. Online patient materials related to otitis media and directed toward parents were collected from the American Association for Family Practice (AAFP), ENT-Health section of the American Academy of Otolaryngology-Head and Neck Surgery, Healthychildren.org from the American Academy of Pediatrics, Kids
Health from Nemours, Web
MD, and Wikipedia. Materials were analyzed for quality, content, and readability. The DISCERN instrument was used to score quality. A unique content score was generated based on the information provided on each website and on the medical and surgical management of otitis media. Readability scores were calculated using the Flesch-Kincaid Grade Level, Flesch Reading Ease Score, Gunning-Fog Index, Simple Measure of Gobbledygook, Coleman-Liau Index, and Automated Readability Index. Overall, content was well-balanced. Information from AAFP and Healthychildren.org was focused more on medical management than other sources. The average DISCERN scores showed all sources to be of good quality with minimal shortcomings. The AAFP and Kids
Health websites had some readability scores around the 8th-grade reading level, the National Institute of Health’s upper limit recommended for public health information; however, most websites were above this recommended reading level. Patient education materials related to otitis media on academic and certain popular internet sites are good sources to obtain high-quality information on the topic. Patient educational background, prior knowledge and understanding of otitis media, and physician-patient partnership goals should be taken into account when referring patients to online materials.

Nasal Septal Abscess Caused by Protrusion of a Dental Implant Into the Nasopalatine Duct: A Case Report

24-01-2020 – Emiel A. Kop,Wouter L. Lodder,Jan GAM de Visscher,Herbert van den Berge

Journal Article

A nasal septal abscess after placement of a dental implant is seldom seen and is usually caused by an infection around the implant. A septal haematoma following dental implantation leading to septal abscess formation has never been reported. We present a case of a patient who developed a septal abscess after dental implantation without accompanying signs of infection around the implant. On the computed tomography scan we found the implant protruding the nasopalatine duct which led to bilateral septal hemorrhage, resulting in abscess formation. The patient underwent reconstructive nasal septum surgery, using an autologous auricular cartilage graft. This resulted in a good nasal function and cosmetic outcome. Medical health care professionals should be aware of a septal abscess in case of an acute blocked nose even without prior nasal or facial trauma or nasal surgery. Reconstruction of the septal nasal cartilage using autologous conchal cartilage is a good solution to preserve nasal function as well as tip support.

Chemical, Electrical and Tactile Sensitivity Changes After Middle Ear Surgery

22-01-2020 – Robert Pellegrino,Thomas Hummel

Journal Article

Taste disturbances are often seen in patients after middle ear surgery due to the stress received by an unprotected chorda tympani. It has also been reported that loss in tactile sensitivity may accompany this issue. The current study was designed to measure electrical, chemical, and tactile sensitives of several senses involved in oral processing, smell, taste and touch, over time. Prospective cohort study. For three time points, one before middle ear surgery and two after operation (about 5 and 23 days), sensitivity thresholds were obtained using electrogustometry (electrical taste), taste strips (chemical taste), Sniffin’ Sticks (smell) and Von Frey Hairs (point-pressure tactile sensitivity). The results show a decline in both chemical and electrical taste responses. Additionally, the electrical taste response showed more sensitivity to deviations and no sign of recovery unlike the chemical taste response. Mechanosensory function of the anterior tongue and olfactory function was not strongly affected by middle ear surgery. Taste responses, but not mechanosensory or olfaction function, are altered after middle ear surgery. Due to the effects that taste loss has on quality of life, gustometry is recommended for this group of patients. 4.

Thyroglossal Duct Cyst Occupying Posterior Hyoid Space with Endolaryngeal Extension Presenting After Neck Trauma

22-01-2020 – Samuel Bosco,Jason E. Cohn,Marissa Evarts,Paul Papajohn,Raymond Lesser

Journal Article

Thyroglossal duct cysts are the most common congenital neck mass. They typically present as a painless midline neck mass in a child or young adult, but may also present later in adulthood when the cyst becomes symptomatic. Thyroglossal duct cysts are most commonly located inferior to the hyoid bone in close relation with the thyrohyoid membrane. Very rarely, they may extend intralaryngeal, occupy the posterior hyoid space, and present with dysphonia and/or dysphagia. To our knowledge, this is the 24th reported case in the literature. Case report with a comprehensive review of the literature. The patient was a 43-year-old male experiencing dysphonia and dysphagia following a motor vehicle accident. He was subsequently found to have a large thyroglossal duct cyst with endolaryngeal extension that was previously asymptomatic and undiagnosed. He underwent successful surgical excision which resulted in resolution of symptoms. This is the first reported case of a thyroglossal duct cyst in the posterior hyoid space with endolaryngeal extension being diagnosed following a traumatic event. This case illustrates the need to consider thyroglossal duct cyst in the differential diagnosis when working up a post-traumatic intralaryngeal neck mass. A secondary educational objective in this case is to be diligent to consider and rule out laryngeal fracture in the case of a neck mass presenting after trauma as they can easily be missed and present with many overlapping symptoms.

Accuracy and Reliability of Smartphone Self-Test Audiometry in Community Clinics in Low Income Settings: A Comparative Study

22-01-2020 – Josefin Sandström,DeWet Swanepoel,Claude Laurent,Göran Umefjord,Thorbjörn Lundberg

Journal Article

There is a lack of hearing health care globally, and tele-audiology and mobile technologies have been proposed as important strategies to reduce the shortfall. To investigate the accuracy and reliability of smartphone self-test audiometry in adults, in community clinics in low-income settings. A prospective, intra-individual, repeated measurements design was used. Sixty-three adult participants (mean age 52 years, range 20-88 years) were recruited from ENT and primary health care clinics in a low-income community in Tshwane, South Africa. Air conduction hearing thresholds for octave frequencies 0.5 to 8 k
Hz collected with the smartphone self-test in non-sound treated environments were compared to those obtained by reference audiometry. The overall mean difference between threshold seeking methods (ie, smartphone thresholds subtracted from reference) was -2.2 d
B HL (n = 467 thresholds, Smartphone self-test audiometry can provide accurate and reliable air conduction hearing thresholds for adults in community clinics in low-income settings.

Inter- and Intra-Rater Reliability of Laryngeal Sensation Testing with the Touch Method During Flexible Endoscopic Evaluations of Swallowing

21-01-2020 – James C. Borders,Meredith B. O’Dea,Edel McNally,Elizabeth Norberg,Merertu Kitila,Michael Walsh,Rui Liu,Jessica M. Pisegna

Journal Article

Sensation is an integral component of laryngeal control for breathing, swallowing, and vocalization. Laryngeal sensation is assessed by elicitation of the laryngeal adductor reflex (LAR), a brainstem-mediated adduction of the true vocal folds. During Flexible Endoscopic Evaluations of Swallowing (FEES), the touch method can be used to elicit the LAR to judge laryngeal sensation. Despite the prevalence of this method in clinical practice and research, prior studies have yet to examine inter- and intra-rater reliability. Four speech-language pathologists rated 125 randomized video clips for the presence, absence, or inability to rate the LAR. Fifty percent of video clips were re-randomized and re-rated 1 week later. Raters then created guidelines and participated in formal consensus training sessions on a separate set of videos. Ratings were repeated post-training. Overall inter-rater reliability was fair (κ = 0.22) prior to training. Pre-training intra-rater reliability ranged from fair (κ = 0.35) to almost perfect (κ = 0.89). Inter-rater reliability significantly improved after training (κ = 0.42, Adequate inter-rater reliability was not achieved when rating isolated attempts to elicit the LAR. Acceptable within-rater reliability was observed in some raters 1 week after initial ratings, suggesting that ratings may remain consistent within raters over a short period of time. Limitations and considerations for future research using the touch method are discussed.

Outcomes Assessment of Multi-Level Sleep Surgery in Syndromic Versus Non-Syndromic Children

10-01-2020 – Suqrat Munawar,Alexander P. Marston,Terral Patel,Shaun A. Nguyen,David R. White

Journal Article

Analyze the differences in length of stay, cost, disposition, and demographics between syndromic and non-syndromic children undergoing multi-level sleep surgery. Children with sleep disordered breathing or obstructive sleep apnea that had undergone sleep surgeries were isolated from the 1997 to 2012 editions of the Kids’ Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Children were then classified as syndromic or non-syndromic and stratified by level of sleep surgery (tonsillectomy & adenoidectomy, tonsillectomy & adenoidectomy plus other site surgery, other site surgery). Length of stay and cost were reported with Kruskal-Wallis one-way analysis of variance, disposition with binomial logistic regression, and demographics with chi-square. Syndromic children compared to non-syndromic children were more likely to have surgery beyond just tonsillectomy & adenoidectomy and also had a longer length of stay, higher total cost and non-routine disposition (all The potential risks/benefits need to be weighed carefully before undertaking sleep surgery in syndromic children. They experience a longer length of stay, higher cost, and non-routine disposition when compared to non-syndromic children. This is especially true when considering the transition from tonsillectomy & adenoidectomy to tonsillectomy & adenoidectomy plus other site surgery, as syndromic children experience a longer length of stay and non-syndromic children do not.

Image Guided Sclerotherapy of Masseteric Venous Malformations

08-01-2020 – Subhash Kumar,Kranti Bhavana,Bindey Kumar,Amit Kumar Sinha,Prem Kumar

Journal Article

To describe results of image guided sclerotherapy of venous malformations (VM) localized in the masseter muscle. Retrospective review of prospectively maintained data was done to include consecutive cases treated over 5-year period, with minimum 6 months follow-up. Sclerotherapy was done using ultrasound (US) guided needle puncture(s) of the lesions percutaneously, and 3% polidocanol foam injected under image guidance. Seventeen cases (10 male, 7 female) with mean age 15.6 years (range 6-28 years) were identified. Clinical presentation was with facial asymmetry, becoming pronounced on jaw clenching, and three cases had mild local pain. On US, the lesions appeared as partially compressible masses with anechoic spaces, showing color filling on releasing probe pressure. Fourteen had phleboliths. Eight patients had undergone magnetic resonance imaging, lesions appearing as oval, homogenous, lobulated, T2 hyperintense masses, with heterogeneous contrast enhancement. Number of sclerotherapy sessions were-single in four cases, two in eight cases and three in five cases, for total of 35 sessions (average 2.05 session per patient). The mean dose of drug injected per session was 1.85 m
L and total mean dose per patient was 2.79 m
L. Post-procedure vomiting occurred in one patient while all had local swelling and mild pain, lasting between 3 to 7 days. No facial nerve palsy or sloughing/ulceration/skin necrosis was noted. On US follow-up (6-26 months, mean 15.9 months), 12 patients had small echogenic masses without any vascularity, and five had small anechoic areas <25%. All patients had complete resolution of swelling and pain. For VMs localized to the masseter muscle, image guided sclerotherapy is highly effective and safe, and recommended as first line treatment.

Correlation of Nasal Fluid Biomarkers and Symptoms in Patients with Persistent Allergic Rhinitis

08-01-2020 – Su Il Kim,Oh Eun Kwon,Jung Min Park,Jeon Gang Doo,Seok Hyun Kim,Hae Rim Jung,Jin Young Min,Sung Wan Kim,Young Chan Lee,Young-Gyu Eun

Journal Article

This study investigated whether the biomarkers present in nasal fluid reflect the severity of symptoms in patients with persistent allergic rhinitis (PAR). We enrolled 29 PAR patients complaining of nasal symptoms and testing positive to skin prick test. Patients’ total nasal symptom score (TNSS) was measured and their nasal lavage fluid (NALF) was collected. The levels of biomarkers including Clara cell protein 16 (CC16), tryptase, and interleukin 5 (IL-5) in NALF were determined via enzyme-linked immunosorbent assay (ELISA). PAR patients were classified into persistent mild and persistent moderate-to-severe groups according to the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. The CC16 alone was significantly negatively correlated with TNSS ( The levels of CC16 alone among several NALF biomarkers showed an inverse correlation with symptoms of PAR patients.

Botulinum Toxin for the Treatment of Motor and Phonic Tics: A Case Report

07-01-2020 – Nikita Kohli,Andrew Blitzer

Journal Article

To present a unique approach to the treatment of motor and phonic tics. A 26-year-old male presented with motor and phonic tics including grunting, coughing, and throat clearing. The patient was treated with 2.5 units of onabotulinum toxin A (Bo
NT) to the facial mimetic musculature and 2.5 units to each supraglottic musculature via a transthyrohyoid membrane approach under fiberoptic visualization. The patient experienced reduction in the frequency, intensity, and interference with daily life of motor and phonic tics on the Yale Global Tic Severity Scale (YGTSS). This patient experienced subjective and objective decreases in tic severity using a unique approach in the treatment of phonic tics. Results suggest a novel approach in the treatment of phonic tics and bolster the data regarding safe and effective use of Bo
NT for tic disorder. Level V, case report.

Dual Coaptation of Facial Nerve Using Masseteric Branch of Trigeminal Nerve for Iatrogenic Facial Palsy: Preliminary Reports

31-12-2019 – Yoon Se Lee,Joong Ho Ahn,Hong Ju Park,Ho Jun Lee,Mi Rye Bae,Jong-Lyel Roh,Seung-Ho Choi,Soon Yuhl Nam,Sang Yoon Kim

Journal Article

Immediate facial nerve substitution or graft technique has been used for the repair of facial nerve defects occurring as a result of tumour dissection. However, some patients report unsatisfactory outcomes, such as difficulty in maintaining resting or smiling symmetry, due to persistent flaccid facial palsy. Here we evaluated the functional outcomes of transferring the masseteric branch of the trigeminal nerve to the facial nerve adjunct to facial nerve graft. We reviewed the medical records of seven patients who underwent facial reanimation surgery between 2014 and 2016. The patients were divided into two groups according to the type of facial reanimation surgery: group A, masseteric nerve innervation with interposition graft; group B, interposition graft only. The postoperative resting symmetry and dynamic movement were compared. Facial contraction was first observed in group A at 4 months and in group B at 7.3 months. Most of the patients achieved reliable resting symmetry; however, one patient in group B exhibited unsatisfactory facial weakness on the affected side. Group A patients showed better dynamic movement than group B patients. Eye closure, oral excursion and oral continence were better in group A than in group B patients. Smile symmetry in both groups was similar due to hyperkinetic movement in group A patients and flaccidity in group B patients. Dual innervation of the masseteric branch of the trigeminal nerve improves the dynamic movement of paralysed facial muscles and shortens the recovery period in patients with iatrogenic facial palsy.

The Association of Serum Eosinophilia with Structured Histopathology in Chronic Rhinosinusitis

31-12-2019 – Ashwin Ganti,Hannah N. Kuhar,Mike Eggerstedt,Mahboobeh Mahdavinia,Paolo Gattuso,Pete S. Batra,Bobby A. Tajudeen

Journal Article

Prior studies have demonstrated associations between serum eosinophilia and chronic rhinosinusitis (CRS) pathogenesis. However, the association of serum eosinophilia with histopathology profiling in CRS has not been fully delineated and may help better characterize CRS disease burden prior to surgery. A structured histopathology report of 13 variables was utilized to analyze sinus tissue removed during functional endoscopic sinus surgery (FESS). Complete blood count (CBC) with differential was drawn within 4 weeks prior to FESS. Serum eosinophilia was defined as >6.0% (>0.60 th/μL). Histopathology variables were compared among patients. A total of 177 CRS patients (37 with serum eosinophilia and 140 with normal serum eosinophilia) were analyzed. Compared to CRS patients with normal serum eosinophil counts, CRS patients with serum eosinophilia demonstrated increased polypoid disease (67.6% vs 35.0%, CRS patients with serum eosinophilia demonstrated severe disease burden on histopathology with high levels of polypoid disease and tissue eosinophilia. However, a considerable number of patients without serum eosinophilia demonstrated eosinophilic disease on histopathology, indicating that preoperative serum eosinophilia alone could not be reliably used to predict eosinophilic CRS. 4.

Effect of Unilateral Cordotomy on Perception of Dysphagia

31-12-2019 – Melissa Conklin,Matthew S. Clary,Elizabeth M. Cuadrado,Marie E. Jetté

Journal Article

CO Retrospective review was performed on sequential patients having undergone unilateral CO Fifteen patients were available for analysis; 10 patients underwent primary unilateral medial transverse cordotomy, 5 patients underwent revision cordotomy, and 20 unique procedures were included in the dataset. The median EAT-10 score during the visit prior to surgery was 3.5, whereas the post-surgery median score was 2. Furthermore, the median difference of 0 was statistically non-significant ( CO

Juvenile Nasopharyngeal Angiofibroma Outcomes and Cost: Analysis of the Kids’ Inpatient Database

26-12-2019 – Justin Yu,Jonathan S. Choi,Carla Giannoni,Akash J. Patel,K. Kelly Gallagher

Journal Article

To report trends in Juvenile Nasopharyngeal Angiofibroma (JNA) hospitalizations and identify key factors affecting treatment outcomes and cost of care in JNA patients. The Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database was queried for all cases of JNA between the years of 1997 and 2016. Key factors extracted were patient demographics, geographic region, hospital size, teaching status, elective admissions, and number of diagnoses and procedures performed during the hospitalization. These elements were correlated to length of stay (LOS) and cost-per-day (CPD) using a multiple linear regression (MLR). Regional variation in JNA diagnosis and changes in LOS and CPD trends over time were also analyzed. A total of 614 JNA patients were hospitalized in this time period, with a majority of patients identifying as male (98%) and Caucasian/White (55%). The average LOS has decreased by 0.14 day per year since 1997 ( These results indicate hospital characteristics, such as teaching status and geographic region, may predict differences in JNA outcomes and cost. Healthcare providers should be cognizant of these variations to ensure optimal patient outcomes and expenditures.

Supraglottoplasty in Neonates under One Month of Age

25-12-2019 – Peter Nagy,Samuel Dudley,Anthony Sheyn

Journal Article

Examine outcomes of patients 1 month of age or less who received supraglottoplasty. Demonstrate the feasibility and safety of supraglottoplasty in neonates <1 month of age. Charts were reviewed from 2015-2017. Patients with previously identified laryngomalacia requiring surgical intervention and age 1 month or less were identified. We collected data on age, gender, surgical technique, other airway lesions, time to extubation and discharge, and comorbidities. Six patients met the inclusion criteria of which four were male and two were female. Average age at time of surgery was 19.5 days. All patients had diagnosis of laryngomalacia made on flexible or direct laryngoscopy with increased work of breathing, reports of cyanotic episodes, or oxygen desaturations. All had feeding difficulties, and three had signs and history consistent with gastroesophageal reflux. Two patients underwent supraglottoplasty by CO Supraglottoplasty in children younger than 1 month of age is rare. Despite the rare occurrence, it appears to be feasible early in life in treating laryngomalacia. Neonates with respiratory failure, apneas, and cyanosis, or difficulty feeding due to laryngomalacia should be evaluated and treated with supraglottoplasty.

Abscopal Effect Following Immunotherapy and Combined Stereotactic Body Radiation Therapy in Recurrent Metastatic Head and Neck Squamous Cell Carcinoma: A Report of Two Cases and Literature Review

25-12-2019 – Jonathan S. Choi,Eugene R. Sansoni,Benjamin D. Lovin,Nathan R. Lindquist,Jack Phan,Lauren L. Mayo,Renata Ferrarotto,Shirley Y. Su

Journal Article

We present two patients with recurrent, metastatic head and neck squamous cell carcinoma (R/M HNSCC) after platinum-based chemotherapy and radiotherapy (RT) with complete response via abscopal effect following combined immunotherapy (IT) and stereotactic body radiation therapy (SBRT). We review the literature for patients undergoing combined treatment with IT and RT to identify potential cases of abscopal response. This is a case series with a contemporary review of the literature. Retrospective chart review identified two patients with potential abscopal responses after IT and RT for R/M HNSCC. The MEDLINE database was queried using the search terms “abscopal AND head and neck squamous cell carcinoma” and “immunotherapy AND stereotactic body radiation therapy.” Two patients with metastatic HNSCC developed complete responses via a possible abscopal effect following combined SBRT and IT. Interim follow-up of both patients revealed a sustained, complete response. We examine the immunogenic effects of RT and report the first cases of potential abscopal effect for R/M HNSCC. We also review several preclinical studies demonstrating the synergistic efficacy of combined RT and IT with a discussion of possible mechanism. Observation of abscopal effect with combined IT and RT is currently under investigation through several preclinical studies and trials. To the best of our knowledge, these are the first two reported cases of abscopal effect for patients with HNSCC. We report two patients with R/M HNSCC with sustained, complete response after systemic IT and local RT.

Jet Ventilation in the Pregnant Patient with Airway Stenosis: Surgical Safety and Outcomes

21-12-2019 – Philip D. Heichel,Christian P. Jacobsen,Luis L. Llamas,C. Blake Simpson,David G. Lott,Sunil Verma,Laura M. Dominguez

Journal Article

To review pregnancy outcomes and the safety of jet ventilation use in the gravid patient undergoing surgical airway intervention. A multi-institutional retrospective review of medical records was performed to identify women who underwent low-frequency jet ventilation during pregnancy for surgical treatment of airway stenosis. Postoperative complications were noted, and patients were interviewed regarding pregnancy outcomes. Six women were included in this series. No immediate complications relating to anesthesia or surgical intervention were noted in five of the six women. One patient with a well-known history of uncontrolled seizures experienced seizure activity postoperatively. One patient returned to the operating room at a later date for debridement of tracheal crusts. Five mothers delivered via cesarean section and one via spontaneous vaginal delivery. The mean gestation age was 37.3 weeks. One of the six infants delivered prematurely and three were delivered at low birth weight. Three of the six infants required elevated care immediately post-delivery but, at present, all are in good health. Low-frequency jet ventilation and surgical management of airway stenosis should be recognized as a safe treatment option in the gravid patient. Surgical intervention should not be delayed in patients with severe symptoms, particularly given the potential risk associated with prolonged corticosteroid use. 4.

Lateral Neck Radiography in Preoperative Evaluation of Adenoid Hypertrophy

21-12-2019 – Liuba Soldatova,Hansel J. Otero,David A. Saul,Christian A. Barrera,Lisa Elden

Journal Article

To assess the value of lateral neck radiographs in quantifying adenoid hypertrophy to help guide treatment decisions in patients with symptoms of nasal obstruction. Retrospective review. Quantitative radiologic grading of adenoids was correlated with the intraoperative grading to select cases in agreement between the two methods. The percent airway obstruction was calculated as a ratio of adenoid size to the size of the nasopharyngeal airway near the level of the choanae on the lateral neck radiographs for adenoidectomy cases in which radiographic and intraoperative grading of adenoid size were in agreement. A total of 426 adenoidectomy cases with preoperative lateral neck radiographs were reviewed (M:F = 254:172 for age range 9 months to 16 years), and only cases in agreement between radiographic and intraoperative adenoid grading were included in radiographic analysis (N = 234). The percent airway obstruction values were significantly different between “severely obstructive” (N = 137, mean = 94.71, SD = 6.55, range [72.00; 100.00]) and “moderately obstructive” adenoid categories (N = 97, mean = 78.53, SD = 6.91, range [63.67; 98.08]), not only within clinically relevant age groups (1-3 years, 4-7 years, 8-15 years), but also for the entire data set (95% CI [14.41; 17.95], Lateral neck radiographs can provide useful supplemental information on the degree of nasopharyngeal airway obstruction when other clinical findings do not clearly point toward adenoid hypertrophy as a primary cause of nasal obstruction. In our data set, a 65% nasopharyngeal airway obstruction represents a value two standard deviations below the mean for “moderately” obstructive adenoid category, and can be viewed as a simplified cut-off to indicate that the degree of adenoid enlargement is clinically relevant. This cut-off value can assist in evaluation of patients with symptoms of nasal obstruction. 4.

Fiberoptic Endoscopic Evaluation of Swallowing in Infants and Children: Protocol, Safety, and Clinical Efficacy: 25 Years of Experience

17-12-2019 – Claire Kane Miller,Jay Paul Willging

Journal Article

The application of fiberoptic endoscopic evaluation of swallowing (FEES) in the pediatric dysphagia protocol requires specialized knowledge of pediatric conditions that result in dysphagia, recognition of normal and abnormal laryngopharyngeal anatomy and function across ages, and the ability to identify maturational changes in anatomy and function of the aerodigestive tract that pertain to airway protection and swallowing function. Over the past 25 years, we have performed over 7,000 collaborative Otolaryngology and Speech-Language Pathology FEES examinations in patients ranging from 2 days of age to young adults. During this time period, we have monitored the safety of the procedure, explored the feasibility and utility of FEES across conditions, compared and contrasted FEES to the videofluoroscopic evaluation of swallowing (VFSS), and developed specific pediatric FEES protocols with operational definitions for identification and interpretation of swallowing parameters. FEES has proved to be a safe procedure in patients across ages. There have been no significant adverse events. FEES is comparable to the VFSS in the assessment of events before and after the swallow. It provides unique information regarding laryngopharyngeal anatomy and function, airway protection integrity, sensory threshold, and secretion management ability, as well as pharyngeal swallowing dynamics and the efficacy of compensatory swallowing strategies. There are specific indications and contraindications for pediatric FEES, and unique components that characterize the pediatric FEES protocols across ages and conditions. FEES procedures performed jointly by an Otolaryngologist and Speech-Language pathologist offer a team approach to interpretation and management recommendations.

Competitiveness of Otolaryngology Residency Applicants without a Home Program

17-12-2019 – James C. Wang,Pranati Pillutla,Nadia Tello,Rebecca Gabrilska,Mayank Aranke,Terrell Bibb,Philip D. Watkins,Joehassin Cordero

Journal Article

Investigate if otolaryngology residency home programs (HP) are associated with advantages in National Resident Matching Program match compared to applicants without HPs. Surveys were distributed to fourth-year medical students applying to otolaryngology residency (2015-2016 cycle) via OHNS (2015-2016) Applicants Closed Facebook Page and Otomatch. Applicant data analyzed included HP, United States Medical Licensing Examination (USMLE) scores, number of away rotations, and matching at top choice. Applicants were grouped: (1) HP, (2) no HP but have ENT staff (staff), and (3) no HP or staff (none). Ninety-five percent of survey participants matched into otolaryngology (n = 62). A sub-analysis of match preference among matching applicants revealed 63% of participants with HP matched to their first choice compared to 56% (staff) and 14% (none) ( Applicants applying to otolaryngology residency without HPs are as competitive as those who have HPs. However, without HPs, applicants tend to participate in more away rotations and are less likely to match at their top choice.

Cost Analysis of Implants in the Surgical Repair of Orbital Floor Fractures

13-12-2019 – Mark M. Mims,Eric W. Wang

Journal Article

Options for the management of orbital floor fractures continue to evolve offering both potential advantages as well as higher costs. To date, the effect of implant choice on the cost associated with the repair of orbital floor fractures has not been studied. A retrospective review at a tertiary care, level I trauma center examining all adult, uncomplicated orbital floor fractures that underwent open reduction and internal fixation from 2013 to 2016. Patients with concurrent operative facial fractures were excluded. The main outcomes were overall cost of care from injury to last follow-up and operating room-related costs. Costs were determined using computerized records of charges as well as the hospital Charge Description Master. Kruksal-Wallis rank sum tests were used to analyze for differences between groups. Twenty-eight patients fulfilled the inclusion criteria. Eight different stock, non-patient specific, implants were used for repair. The cost of individual types of implants ranged from $70.25 to $7 718.00. Total cost of care per patient across all implant types averaged $35 585.57 (range $25 586.26 to $49 985.74, In the setting of uncomplicated orbital floor fractures, surgeons should select an implant that allows them to carry out the repair in a safe, timely fashion. Additional large-scale studies would help to further delineate cost differences.

Centering a Deviated Nose by Caudal Septal Extension Graft and Unilaterally Extended Spreader Grafts

11-12-2019 – Yung Yuan Chen,Shin Ae Kim,Yong Ju Jang

Journal Article

The deviated nose presents a tremendous challenge for rhinoplasty surgeons, especially the correction of the cartilaginous dorsum deviation. In this study, we introduce the surgical techniques of correcting a deviated cartilaginous vault by creating a new center of the lower third using a caudal septal extension graft combined with unilaterally extended spreader grafts. This retrospective observational study was conducted in a university-based tertiary medical center from December 2014 to January 2018. Thirty-two patients who underwent primary open rhinoplasty for correction of a deviated nose using this method participated in the study. Patient characteristics and surgical records were collected. Anthropometric measurements and analyses were performed based on preoperative and postoperative photographs. The aesthetic outcome consensus of three rhinoplasty surgeons was evaluated specifically for nasal dorsum deviation correction. Postoperative complications were reviewed from the medical records. Among the 32 patients, there were 18 males and 14 females. The mean (SD) age of the patients was 26.7 (8.76) years. Anthropometric measurements showed significant improvements in dorsal deviation angle (a 3.7° change towards midline, Centering the cartilaginous vault using a caudal septal extension graft combined with unilaterally extended spreader grafts is a useful technical option in the correction of a deviated nose, and provides improvement in nasal tip projection and nostril shape.

The Ponticulus Ethmoidalis: A Newly Appreciated Anatomic Landmark in Endoscopic Sinus Surgery

11-12-2019 – William E. Bolger,Masaru Ishii,Meiyappan Solaiyappan,S. James Zinreich

Journal Article

Ethmoid sinus anatomy is so variable it has been referred to as a “labyrinth.” Accordingly, this provides a challenge for surgeons performing ethmoidectomy. Identifying consistent anatomic features or landmarks within the ethmoid sinus can aid surgeons performing sinus surgery. The goal of this investigation was to determine if subtle anatomic features are consistently present within the retrobullar recess and could potentially serve as a reliable landmark for surgeons performing ethmoid surgery. Ethmoid sinus anatomy was studied in 60 sinonasal complexes through several methods including gross anatomic dissection, endoscopic dissection and 3-D CT stereoscopic imaging. Review of gross sagittal sinonasal specimens revealed that the retrobullar recess was present in all specimens and a tissue bridge was noted emanating from the basal lamella deep within the retrobullar recess in 23/24 gross sagittal specimens; in 1/24 specimens it was quite small or difficult to appreciate. In the radiographic analysis, the tissue bridge was noted in 17/18, in 1/18 it was not appreciated. In the endoscopic dissections it was noted in 17/18, in 1/18 it was small or not appreciated. The small tissue bridge, or ponticulus within the retrobulbar recess was seen in nearly all ethmoid sinuses studied leading us to venture that could be used in surgery to orient surgical dissection through the basal lamella into the posterior ethmoid region.

The Impact of Betahistine versus Dimenhydrinate in the Resolution of Residual Dizziness in Patients with Benign Paroxysmal Positional Vertigo: A Randomized Clinical Trial

07-12-2019 – Mir Mohammad Jalali,Hooshang Gerami,Alia Saberi,Siavash Razaghi

Journal Article

The aim of this study was to compare the effects of betahistine with dimenhydrinate on the resolution of residual dizziness (RD) of patients with benign paroxysmal positional vertigo (BPPV) after successful Epley maneuver. In this double-blind, randomized clinical trial, patients with posterior semicircular canal type of BPPV were included. After execution of the Epley maneuver, patients were assigned randomly to one group for 1 week: betahistine, dimenhydrinate or placebo. The primary outcomes were scores of the Dizziness Handicap Inventory (DHI) and the modified Berg balance scale (m
BBS). All patients were asked to describe the characteristics of their subjective residual symptoms. Binary logistic regression analysis was performed to examine the predictors of improved RD. All analyses were conducted using SPSS 19.0. In total, 117 patients (age range: 20-65 years) participated in this study. After the Epley maneuver, 88 participants had RD. After the intervention, 38 patients exhibited an improved RD. Less than 50% of participants in the three groups showed mild to moderate dizziness handicap. However, there was no significant difference between m
BBS scores of groups before or after the intervention. Logistic regression was shown that patients with receiving betahistine were 3.18 times more likely to have no RD than the placebo group. Increasing age was associated with a decreased likelihood of improving RD ( The analysis of data showed that the use of betahistine had more effect on improving RD symptoms. We recommended future studies using objective indicators of residual dizziness.

Pediatric Drug Induced Sleep Endoscopy: A Simple Sedation Recipe

06-12-2019 – Adam C. Adler,Mary F. Musso,Deepak K. Mehta,Arvind Chandrakantan

Journal Article

To describe a minimalist approach to sedating children for DISE procedures. We searched existing literature and derived and tested our algorithm on patients using evidence-based studies. We were able to successfully sedate, without airway intervention, 15 highly complex children with a variety of comorbidities for DISE procedures. We describe a minimalistic sedation approach for DISE procedures in highly complex children. Further studies are required to compare this regimen to natural sleep states.

Efficacy of Multi-Modal Migraine Prophylaxis Therapy on Hyperacusis Patients

02-12-2019 – Mehdi Abouzari,Donald Tan,Brooke Sarna,Yaser Ghavami,Khodayar Goshtasbi,Erica M. Parker,Harrison W. Lin,Hamid R. Djalilian

Journal Article

To evaluate the efficacy of a multi-modal migraine prophylaxis therapy for patients with hyperacusis. In a prospective cohort, patients with hyperacusis were treated with a multi-modal step-wise migraine prophylactic regimen (nortriptyline, verapamil, topiramate, or a combination thereof) as well as lifestyle and dietary modifications. Pre- and post-treatment average loudness discomfort level (LDL), hyperacusis discomfort level measured by a visual analogue scale (VAS), and scores on the modified Khalfa questionnaire for severity of hyperacusis were compared. Twenty-two of the 25 patients (88%) reported subjective resolution of their symptoms following treatment. Post-treatment audiograms showed significant improvement in average LDL from 81.3 ± 3.2 d
B to 86.4 ± 2.6 d
B ( The majority of patients with hyperacusis demonstrated symptomatic improvement from migraine prophylaxis therapy, as indicated by self-reported and audiometric measures. Our findings indicate that, for some patients, hyperacusis may share a pathophysiologic basis with migraine disorder and may be successfully managed with multimodal migraine prophylaxis therapy.

Vagus Associated Neurogenic Cough Occurring Due to Unilateral Vascular Encroachment of Its Root: A Case Report and Proof of Concept of VANCOUVER Syndrome

02-12-2019 – Christopher R. Honey,Marie T. Krüger,Murray D. Morrison,Baljinder S. Dhaliwal,Amanda Hu

Journal Article

A patient is presented with neurogenic cough due to a unilateral vascular compression of a vagus nerve rootlet at the brainstem with complete resolution of cough following microvascular decompression of that nerve. This etiology of a neurogenic cough has not been previously reported to our knowledge. The proportion of patients with neurogenic cough refractory to all current therapies and suffering with this treatable condition remains to be defined. We introduce the concept of Vagus Associated Neurogenic Cough Occurring due to Unilateral Vascular Encroachment of its Root (VANCOUVER syndrome) and present the salient features of this condition. A case review is presented with details of the patient’s history, examination, imaging, laryngoscopy, intraoperative findings, and long-term clinical outcome. A 60-year-old man presented with a 15-year history of non-productive cough refractory to antibiotics, and anti-reflux medications. Investigations by an allergist, a cardiologist, a gastroenterologist, two pulmonologists, and an otolaryngologist were negative. MRI demonstrated a vascular compression of his left vagus nerve and microvascular decompression of that nerve resolved his symptoms. There were no surgical complications and the patient remains asymptomatic at 1 year. Neurogenic cough has been likened to a vagus nerve neuropathy in a similar way that trigeminal neuralgia is a trigeminal nerve neuropathy. Both cause intermittent sensory phenomena in their distribution and can be ameliorated with neuropathic medications. We demonstrate that neurogenic cough, like trigeminal neuralgia, may be caused by a vascular compression of its nerve root. A proposed mechanism of this type of neurogenic cough is presented along with a potential diagnostic paradigm for these patients.

The Usefulness of Respiratory Mechanic Instability in Evaluating the Effect of Continuous Positive Airway Pressure for Obstructive Sleep Apnea

29-11-2019 – Ji Ho Choi,Jae Yeup Jung,Ji Eun Moon,Se-Hwan Hwang

Journal Article

Respiratory mechanics instability (RMI) based on paradoxical movement is correlated with respiratory disturbance such as apnea-hypopnea index (AHI) and reflects the severity of obstructive sleep apnea (OSA). The purpose of this study was to identify RMI as a method for assessing the effectiveness of continuous positive airway pressure (CPAP) in the management for OSA. A total of 71 consecutive OSA patients with CPAP titration were included in this study. We compared sleep (sleep efficiency, arousal index, and sleep stages), respiratory (AHI, oxygen desaturation index ≥3% [ODI3], and lowest oxygen saturation), and RMI parameters (events, index, duration, and % of stage duration) between diagnostic polysomnography and CPAP titration data. All RMI parameters (events [157.5 ± 80.9 vs 80.0 ± 47.1; RMI may be a useful method for evaluating the effect of CPAP in OSA patients.

Experience with Minimally Invasive Ponto Surgery and Linear Incision Approach for Pediatric and Adult Bone Anchored Hearing Implants

27-11-2019 – Aren Bezdjian,Rachel Ann Smith,Nathalie Gabra,Luhe Yang,Marco Bianchi,Sam J. Daniel

Journal Article

To compare intra- and postoperative outcomes between the standard linear incision with tissue preservation and the Minimally Invasive Ponto Surgery (MIPS). A non-randomized retrospective cohort series. Medical files were reviewed of adult and pediatric bone anchored hearing implant recipients. Extracted outcomes included patient characteristics, implant survival, operative time, anesthesia use, intra and postoperative complications, soft tissue tolerability assessed by the Holger’s classification, and implant stability assessed by the Resonance Frequency Analysis (RFA). Outcomes were compared between two surgeries. A total of 59 implants were placed (21 MIPS; 38 linear). Conductive hearing loss was the most common etiology for implantation. Surgery was conducted under local anesthesia in 67% of MIPS patients and 16% of linear patients. No intraoperative complications were reported for both surgical approaches and no implants were lost. Patients undergoing implantation via the MIPS approach displayed less skin reaction postoperatively, however this was not significant ( The MIPS approach seems either similar or superior to the linear approach in all perioperative outcomes evaluated. Outcomes such as surgical duration, anesthesia choice and implant stability measurements support implantation through the MIPS approach for patients meeting eligibility criteria.

Functional and Aesthetic Outcomes of Extracorporeal Septoplasty: A Systematic Review and Meta-Analyses

25-11-2019 – Amishav Bresler,Roman Povolotskiy,Brandon Nguyen,Giancarlo F. Zuliani,Jean Anderson Eloy,Boris Paskhover,Peter Svider

Journal Article

The safety and efficacy of extracorporeal septoplasty (ECS) has long been debated. Our objective was to determine this technique’s functional and aesthetic outcomes and complications through a systematic review of the literature. PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science databases were evaluated for studies detailing functional or aesthetic outcomes of ECS. Bias was evaluated using the Cochrane Risk of Bias Tool and the Methodological Index for Non-randomized Studies (MINORS) score. Aesthetic and functional outcomes in addition to complications were evaluated using subjective and objective measures. Meta-analyses were performed when appropriate. Seventeen studies encompassing 1418 patients were included. The average MINORS score for observational studies was 9.2. Overall there was a significant improvement in subjective nasal function with a preoperative average Nasal Obstruction Symptom Evaluation (NOSE) score of 75 (±16) decreasing to 19.5 (±16.5) postoperatively for a mean difference (MD) of -55 (95% confidence interval (CI): -60 to -49.5). In terms of objective nasal function, at 6 months postoperatively, there was an improvement of nasal flow measured by rhinometry ranging from 70 to 71% across studies. Anthropometric measurements were utilized for objective aesthetic outcomes. There was a significant improvement in I-shaped deviations (MD: -2.7°, 95% CI: -5.6 to -0.16) and C-shaped deviations improved by 11.9° (95% CI +2.8-+21.2). Complication rates ranged from 0 to 18%. ECS can achieve significant improvements in the subjective and objective function of the nose. The associated complication rate is low but variable between surgeons.

Dexamethasone Use in the Treatment of Pediatric Deep Neck Space Infections

25-11-2019 – James B. Tansey,John Hamblin,Madhu Mamidala,Jerome Thompson,Jennifer Mclevy,Joshua Wood,Anthony Sheyn

Journal Article

Assess the outcome of Intravenous (IV) dexamethasone in the treatment of pediatric deep neck space infections (DNSI) in combination with IV antibiotics. Retrospective chart review of pediatric patients admitted for a DNSI from March 2014 to June 2016. Patient characteristics including demographics, abscess type, antibiotic, dexamethasone, surgery, culture, and length of stay (LOS) were obtained. Patients treated with antibiotics alone versus antibiotics and dexamethasone were compared. Primary outcome measures were rate of surgical drainage and LOS. Overall 153 patients with DNSI were identified, including 62 lateral neck, 18 parapharyngeal, 40 peritonsillar, 32 retropharyngeal, and 1 submandibular. All patients received antibiotics. Dexamethasone was used in 35% of patients. The rate of surgical drainage in the dexamethasone and non-dexamethasone group was 36% and 53% respectively ( Dexamethasone use was associated with a decreased rate of surgical drainage in pediatric patients with DNSI. Further prospective study is needed to determine the role of dexamethasone in treatment.

Comparison of Referral Pathways in Otolaryngology at a Public Versus Private Academic Center

22-11-2019 – Caitlin Bertelsen,Janet S. Choi,Anna Jackanich,Marshall Ge,Gordon H. Sun,Tamara Chambers

Journal Article

Delayed medical care may be costly and dangerous. Examining referral pathways may provide insight into ways to reduce delays in care. We sought to compare time between initial referral and first clinic visit and referral and surgical intervention for index otolaryngologic procedures between a public safety net hospital (PSNH) and tertiary-care academic center (TAC). Retrospective cohort study of eligible adult patients undergoing one of several general otolaryngologic procedures at a PSNH (n = 216) and a TAC (n = 161) over a 2-year time period. PSNH patients were younger, less likely to have comorbidities and more likely to be female, Hispanic or Asian, and to lack insurance. Time between referral and first clinic visit was shorter at the PSNH than the TAC (Mean 35.8 ± 47.7 vs 48.3 ± 60.3 days; Sociodemographic differences between PSNH and TAC patients, as well as differences in referral pathways between the types of institutions, influence progression of surgical care in otolaryngology. These differences may be targets for interventions to streamline care. 2c.

Office-Based Steroid Injections for Idiopathic Subglottic Stenosis: Patient-Reported Outcomes, Effect on Stenosis, and Side Effects

21-11-2019 – Matthew R. Hoffman,David O. Francis,Johnny P. Mai,Seth H. Dailey

Journal Article

Office-based steroid injection has shown promise for idiopathic subglottic stenosis (i
SGS). It is important to understand safety and patient-lived experience. We report patient experience related to airway restriction, voice, and side effects. Sixteen patients (51 ± 14 years) with mild-moderate (20-50%) stenosis undergoing office-based transnasal steroid injections were included; fourteen had prior operations. Patients typically underwent three injections, 1 month apart, followed by transnasal tracheoscopy 1 month later to evaluate outcome; number of injections can vary based on disease severity and response. Outcomes were Dyspnea Index (DI), Modified Medical Research Council (MMRC) dyspnea scale, voice handicap index-10 (VHI-10), and degree of stenosis (estimated from procedural video). At each visit, patients were queried about post-injection airway restriction and side effects. Paired DI decreased ( Steroid injections improved upper airway symptoms. Side effects were mild and transient. Improvement in DI did not correlate with percent stenosis.

The Nerve to Thyrohyoid Muscle as a Novel Donor Nerve for Laryngeal Reinnervation

18-11-2019 – M. Elise Graham,Marshall E. Smith

Journal Article

Recurrent laryngeal nerve (RLN) injury may be a consequence of surgical procedures of the skull base, neck, and chest, with adverse consequences to function and quality of life. Laryngeal reinnervation offers a potentially stable improvement in vocal fold position and tone. The classic donor nerve is the ansa cervicalis, but is not always available due to damage or sacrifice during previous neck surgeries. Our objective was to introduce the nerve to the thyrohyoid (TH) muscle as an alternate donor nerve for reinnervation, which has not previously been described. Case series of two patients using the TH nerve for laryngeal reinnervation after RLN injury, with description of surgical harvest. Follow-up results are available for 10 months (one patient) and 3 years (one patient) demonstrating both subjective and objective improvement in function. GRBAS scores were reduced. Maximal phonation time was improved. Patient rating of voice was stable or improved postoperatively. One patient described significant preoperative dyspnea which was significantly improved postoperatively, from a score of 24 to 10 out of 40 on the dyspnea handicap index. VHI was improved in one patient, but scores elevated in the other, despite a change from “moderately severe impairment” to “normal voice” subjectively. Neither patient experienced significant complications from the procedure. Laryngeal reinnervation procedures provide good outcomes in pediatric patients. When ansa cervicalis is not available as a donor nerve, the nerve to TH provides a reasonable alternative.

Identifying Disadvantaged Groups for Cochlear Implantation: Demographics from a Large Cochlear Implant Program

18-11-2019 – Anthony M. Tolisano,Natalie Schauwecker,Bethany Baumgart,Johanna Whitson,Joe Walter Kutz,Brandon Isaacson,Jacob B. Hunter

Journal Article

To identify demographic predictors of patients undergoing cochlear implantation evaluation and surgery. Consecutive adult patients between 2009 and 2018 who underwent cochlear implantation evaluation at a university cochlear implantation program were retrospectively identified to determine (1) cochlear implantation qualification rate and (2) pursuit of surgery rate with respect to age, gender, race, primary spoken language, marital status, insurance type, and distance to the cochlear implantation center. A total of 823 cochlear implantation evaluations were analyzed. Overall, 76.3% of patients qualified for cochlear implantation and 61.5% of these patients pursued surgery. Age was the only independent predictor for cochlear implantation qualification, such that, for each year younger, the odds of qualifying for cochlear implantation increased by 2.5% (OR 0.98; 95% CI: 0.96-0.99). Age, race, marital status, and insurance type were each independent predictors of the decision to pursue surgery. The odds of pursuing surgery increased by 2.8% for each year younger (OR 1.03; 95% CI: 1.01-1.05). Compared to White patients, non-Whites were half as likely to pursue surgery (OR 0.47; 95% CI: 0.25-0.88). Single (OR 0.49; 95% CI: 0.26-0.94) and widowed patients (OR 0.46; 95% CI: 0.23-0.95) were about half as likely to pursue surgery as compared to married patients. Patients with military insurance were 13 times more likely to pursue surgery as compared to patients with Medicare (OR 13.0; 95% CI: 1.67-101.4). Younger age is an independent predictor for a higher cochlear implantation qualification rate, suggesting the possibility for delayed candidacy referral. Rate of surgical pursuit in qualified cochlear implantation candidates is lower for racial minorities, single and widowed patients, and older patients.

Standard Setting of Competency in Mastoidectomy for the Cross-Institutional Mastoidectomy Assessment Tool

16-11-2019 – Thomas Kerwin,Gregory Wiet,Brad Hittle,Don Stredney,Paul De Boeck,Aaron Moberly,Steven Arild Wuyts Andersen

Journal Article

Competency-based surgical training involves progressive autonomy given to the trainee. This requires systematic and evidence-based assessment with well-defined standards of proficiency. The objective of this study is to develop standards for the cross-institutional mastoidectomy assessment tool to inform decisions regarding whether a resident demonstrates sufficient skill to perform a mastoidectomy with or without supervision. A panel of fellowship-trained content experts in mastoidectomy was surveyed in relation to the 16 items of the assessment tool to determine the skills needed for supervised and unsupervised surgery. We examined the consensus score to investigate the degree of agreement among respondents for each survey item as well as additional analyses to determine whether the reported skill level required for each survey item was significantly different for the supervised versus unsupervised level. Ten panelists representing different US training programs responded. There was considerable consensus on cut-off scores for each item and trainee level between panelists, with moderate (0.62) to very high (0.95) consensus scores depending on assessment item. Further analyses demonstrated that the difference between supervised and unsupervised skill levels was significantly meaningful for all items. Finally, minimum-passing scores for each item was established. We defined performance standards for the cross-institutional mastoidectomy assessment tool using the Angoff method. These cut-off scores that can be used to determine when trainees can progress from performance under supervision to performance without supervision. This can be used to guide training in a competency-based training curriculum.

Utility of Audiometry in the Evaluation of Patients Presenting with Dysphonia

16-11-2019 – Justin Ross,William L. Valentino,Alyssa Calder,David Bigly,Sammy Othman,Brian McKinnon,Robert T. Sataloff

Journal Article

Hearing loss has been implicated in dysphonia secondary to voice misuse, although the data supporting this claim are scant. Determining the prevalence of hearing loss in patients with dysphonia and correlating it with self-perception of vocal handicap may help clarify the value of audiometry in evaluation of patients with dysphonia. This is a retrospective chart review of all new voice patients (n = 405) presenting with dysphonia to the primary investigator between 2015 and 2018. Each new patient routinely undergoes audiometric and voice objective analyses. Main outcomes measured include prevalence, severity of hearing loss, and voice handicap index-10 (VHI-10). Of the 405 subjects reviewed, mean age was 49.0 years (SD = 17.4). 60.7% of subjects were female and 39.3% male. Patients with hearing loss defined as >25 d
B in worse ear with pure tone average (PTA) thresholds at 0.5, 1, 2, and 3 k
Hz (PTA-S) accounted for 18% of the total cohort. The prevalence of previously The prevalence of hearing loss in patients presenting with dysphonia in this cohort is similar to normative population data. This study has also demonstrated that the majority of these patients did not perceive any hearing loss. The reasons behind this may be a result of or associated with the patients’ dysphonia. Furthermore, clinicians should consider performing audiometric evaluation in patients with abnormal VHI-10 scores in the appropriate clinical context.

Pediatric Thyroidectomy: NSQIP-P Analysis of Adverse Perioperative Outcomes

16-11-2019 – Vijay A. Patel,Aliasgher Khaku,Michele M. Carr

Journal Article

This study identifies risk factors and 30-day adverse outcomes of pediatric patients undergoing thyroidectomy. Retrospective analysis utilizing the American College of Surgeons National Surgical Quality Improvement-Pediatric Database (2015-2016). Study population includes pediatric patients (≤18 years) who underwent hemithyroidectomy (HT), total thyroidectomy (TT), and total thyroidectomy with central neck dissection (TT+ND). A total of 720 cases were identified; mean age at time of surgery was 14.1 years, with a female-to-male ratio of 3.4:1. Following hospital discharge, there were 10 related readmissions, with 1 patient requiring reoperation for neck hematoma evacuation. Regression analysis revealed anesthesia time had a significant impact on total length of stay ( Contemporary pediatric thyroidectomy has a low incidence of 30-day general surgical postoperative complications. Future research efforts are necessary once thyroidectomy specific variables are incorporated into ACS-NSQIP-P, which will provide further insights into managing this unique patient population.

Validity and Reliability of the Reflux Sign Assessment

15-11-2019 – Jérôme R. Lechien,Alexandra Rodriguez Ruiz,Didier Dequanter,Francois Bobin,Francois Mouawad,Vinciane Muls,Kathy Huet,Bernard Harmegnies,Sarah Remacle,Camille Finck,Sven Saussez

Journal Article

To develop and validate the Reflux Sign Assessment (RSA), a clinical instrument evaluating the physical findings of laryngopharyngeal reflux (LPR). A total of 106 patients completed a 3-month treatment based on the association of diet, pantoprazole, alginate, or magaldrate with the LPR characteristics (acid, nonacid, mixed). Forty-two asymptomatic individuals completed the study (control group). The RSA results and reflux finding score (RFS) were documented for the LPR patients at baseline and after treatment. Intrarater reliability was assessed through a test-retest blinded evaluation of signs (7-day intervals). Interrater reliability was assessed by comparing the RSA evaluations of three blinded otolaryngologists through Kendall’s W. Responsiveness to change was evaluated through a comparison of the baseline and 3-month posttreatment findings. The RSA cutoffs for determining the presence and absence of LPR were examined by receiver operating characteristic (ROC) analysis. A total of 102 LPR patients completed the study (68 females). The mean age was 53 years. The mean RSA at baseline was 25.95 ± 9.58; it significantly improved to 18.96 ± 7.58 after 3 months of therapy ( The RSA is a complete clinical instrument evaluating both laryngeal and extralaryngeal findings associated with LPR. The RSA demonstrated high intra- and interrater reliabilities and responsiveness to change.

Book Review: The Power of the Voice

15-11-2019 – Victor Hsue,Andrew Lee

Book Review: Patient and Family-Centered Speech-Language Pathology and Audiology

13-11-2019 – Gina L. Palma

Book Review: Laryngeal Manifestations of Systemic Diseases

13-11-2019 – Catherina Yang,John P. Bent

Presentation and Management of Killian Jamieson Diverticulum: A Comprehensive Literature Review

09-11-2019 – Narmien Haddad,Pratima Agarwal,Jessica R. Levi,Jeremiah C. Tracy,Lauren F. Tracy

Journal Article

To examine the clinical presentation, diagnostic evaluation, and management of Killian-Jamieson diverticula (KJD) through literature review. A comprehensive literature review was conducted through December 2018 using keywords Killian-Jamieson diverticula/diverticulum. Data extracted included clinical presentation, imaging characteristics, surgical management, and postoperative care. PubMed and Google Scholar. Sixty-eight cases of KJD in 59 reports (29M:39F; median 58 years old) were identified for review. The most common presentation was dysphagia (n = 39), suspected thyroid nodule (n = 24) and globus (n = 14). The majority of KJD (n = 51) occur on the left, with rare reports of right side (n = 11) and bilateral (n = 5) presentation. Thirty-two cases describe surgical management: 22 utilizing a transcervical approach, with (n = 13) or without (n = 9) cricopharyngeal myotomy; and 10 reported endoscopic surgery. Diverticula managed transcervically averaged 3.8 cm in size in comparison to average 2.8 cm in the endoscopic group. Time to diet initiation after transcervical surgery averaged 4 days versus 2 days after endoscopic surgery. Complications were reported in 2/68 cases; both were diverticula recurrence after endoscopic surgery. Killian-Jamieson diverticula is a rare diagnosis that should be considered in the evaluation of dysphagia, globus, and also suspected thyroid nodule. When patient symptoms warrant intervention, a transcervical approach, with or without cricopharyngeal myotomy, is most commonly utilized. In recent years, an endoscopic approach has been presented as an alternative for smaller diverticula. Further understanding of the optimal treatment and postoperative management for KJD requires larger cohorts. 4.

Book Review: Textbook of Vertigo: Diagnosis and Management

09-11-2019 – Sean Mooney,John Bent

Outcomes Using a Postoperative Protocol in Pediatric Single-Stage Laryngotracheal Reconstruction

15-02-2019 – Prasad John Thottam,Taylor Gilliland,Nicholas Ettinger,Rahul Baijal,Deepak Mehta