No abstract available
Editorial: Going with the flow
01-12-2019 – Allen, Jacqueline E.
No abstract available
Safety of in-office laryngology procedures
01-12-2019 – Marinone Lares, Silvia G.; Allen, Jacqueline E.
Purpose of review A wide range of diagnostic and therapeutic laryngology procedures are currently performed in an office setting. In-office laryngology procedures (IOLP) are increasingly seen as standard-of-care, and while generally considered safe, high-quality evidence supporting the latter statement is lacking. This review aims to summarize recent literature regarding the safety of IOLP.
Recent findings There is a paucity of guidelines and standardized protocols for IOLP. To date, there is one available safety protocol specific to in-office laser procedures. Haemodynamic changes during IOLP have been documented and the significance of these changes continues to be unclear. Therefore, monitoring of vital signs is recommended. Continuing antithrombotic therapy during IOLP also appears safe, and this decision may be left to surgeon discretion. A protocol for management of antithrombotic therapy prior to in-office laser procedures is available. Actual serum lidocaine levels following topical application of mixed lidocaine preparations falls well below reported toxic levels but persists for longer than previously reported.
Summary IOLP are safer that suspension laryngoscopy under general anaesthetic. Although complication rates of IOLP are low, patient characteristics and potential complications of both the procedure and of topical anaesthetic use must be considered. One must be prepared and equipped to deal with these potential complications.
Occupational voice is a work in progress: active risk management, habilitation and rehabilitation
01-12-2019 – Phyland, Debra; Miles, Anna
Purpose of review The current article reviews recent literature examining occupational voice use and occupational voice disorders (January 2018–July 2019).
Recent findings Our understanding of the prevalence of voice disorders and work-related vocal use, vocal load and vocal ergonomics (environmental and person influences) across different occupations is continuing to build. There is encouraging evidence for the value of intervention programs for occupational voice users, particularly of late with performers, teachers and telemarketers. Education and prevention programs are emerging for other ‘at risk’ occupations.
Summary Occupational health and workforce legislation does not adequately acknowledge and guide educational, preventive and intervention approaches to occupational voice disorders. Voice disorders are prevalent in certain occupations and there is an urgent need for research to support occupational voice health and safety risk measurement, prevention and intervention. Large population-based studies are required with a focus on the health and economic burden of occupational voice disorders.
Dysphagia lusoria: problem or incidentaloma?
01-12-2019 – Epperson, Madison V.; Howell, Rebecca
Purpose of review To address the incidental versus pathogenic nature of dysphagia lusoria and to provide a review of the cause, clinical presentation, diagnosis, and treatment of this condition with respect to recent literature.
Recent findings Case reports comprise the majority of recent literature concerning dysphagia lusoria. Many patients with an aberrant right subclavian artery (ARSA) have additional coexisting vascular anomalies. While most individuals present around age 50, some present as children and neonates. Of note, this population may present with dysphagia as opposed to respiratory findings alone, as previously described. In the diagnostic workup, most patients receive a battery of radiologic tests, which may not be necessary. Significantly, dietary modifications and medical management alone may resolve symptoms. Nonetheless, a wide range of operative techniques are available for the treatment of dysphagia lusoria.
Summary Clinicians should have a higher suspicion for dysphagia lusoria in patients with known vascular, heart, or chromosomal anomalies. Diagnosis should begin with a barium esophagram followed by a computed tomography angiogram or magnetic resonance angiogram. Avoid unnecessary studies. In many cases, an ARSA may be an incidental finding with comorbid gastroesophageal reflux disease or another medical condition responsible for the symptoms. Medical versus surgical management should be considered on a case-by-case basis.
Gastric inlet patches: symptomatic or silent?
01-12-2019 – Cock, Charles; Hamarneh, Zaki
Purpose of review The purpose of this review is to assess recent literature on the clinical relevance of the gastric inlet patch with particular focus on endoscopic diagnosis and treatment, the relationship of the inlet patch to laryngopharyngeal reflux disease and the association of proximal esophageal adenocarcinoma with inlet patch.
Recent findings Recent studies suggest endoscopic diagnosis of inlet patch increases with endoscopist awareness (up to 10-fold) and when using enhanced imaging techniques such as narrow band imaging (up to three-fold). The literature remains mixed on the association of inlet patch with laryngopharyngeal symptoms or globus sensation. Studies of endoscopic ablation, using argon plasma coagulation or radiofrequency ablation have shown improved laryngopharyngeal reflux symptom scores posttreatment. Proximal esophageal adenocarcinomas are rare but often associated with inlet patch when they occur. Case studies have described endoscopic resection of malignant lesions related to inlet patch, using endoscopic mucosal resection or submucosal dissection.
Summary Prospective, multicenter studies of symptom association with inlet patch using validated symptom questionnaires and blinded sham-controlled treatments are needed to further clarify the role of such treatments, which to date are limited to a small numbers of centers with a special interest.
Chondroradionecrosis of the larynx
01-12-2019 – Farneti, Daniele; Fabbri, Christopher; Prencipe, Superga R.
Purpose of review Purpose of the present review is to revise the literature of the last 18 months, looking for novelties or new trends in diagnosis and therapeutical approaches to a very uncommon complicaton.
Recent findings Some comorbidities as well as prior surgical laryngeal treatment and lifestyle factors are known to increase tissue susceptibility to radiation injury and to complications due to endotracheal intubation.
Summary Chondroradionecrosis (CRN) of the larynx is a rare and severe complication of radiotherapy and endotracheal intubation which can be fatal if not managed promptly. In recent years, the trend in oncological surgery is organ preservation even in the advanced stage of laryngeal malignancies. However, in certain stages of squamous cell carcinomas, radiotherapy is necessary as a first or second line of treatment. Endotracheal intubation has also been associated with chondronecrosis and it is thought to be secondary to excessive pressure of the endotracheal tube or its cuff on the cartilage itself. Clinical diagnosis of CRN is extremely difficult and should be placed in differential diagnosis with postradiation outcomes and cancer recurrence. PET is useful, but biopsy is still required to confirm the diagnosis. The use of the laryngeal mask airway should prevent this complication and is a reasonable choice through which to administer general anesthesia in selected patients.
01-12-2019 – Burns, Hannah; Phillips, Nicholas
Purpose of review Laryngeal amyloidosis is a rare hematological disorder of plasma cells. The cause is still considered idiopathic. The otolaryngology literature predominantly comprises case reports and short series. The present review summarizes the amyloid literature more generally in order to assist the otolaryngologist managing this disorder.
Recent findings Distinguishing localized amyloidosis from systemic disease continues to be challenging. Both radiological and hematological investigations may assist. Surgery continues to be the predominant modality for treatment, but radiation and potentially medical approaches are on the horizon.
Summary When localized, this benign laryngeal disease carries an excellent prognosis. Clinicians should however be aware of systemic presentations and ensure patients receive long-term follow-up.
An update on treatment of voice-gender incongruence by otolaryngologists and speech-language pathologists
01-12-2019 – Pasternak, Kevin; Francis, David O.
Purpose of review The current review provides an update of literature published in the past 2 years related to treatment of voice-gender incongruence in the gender expansive population, commonly referred to as transgender voice modification.
Recent findings Four main themes have emerged in research during the review period. These include comparison of surgical and behavioral techniques for raising pitch, with consistent findings of a greater increase in fundamental frequency (F0) following endoscopic glottoplasty compared with cricothyroid approximation. Voice therapy similarly can increase pitch (F0), often to degrees commensurate with surgical approaches. A second theme identifies the perceptual correlates of gender in voice and communication, highlighting recent findings that perception of gender relates primarily to nonpitch-related features of voice. A third theme is the importance of considering patient-reported outcomes in treatment and research. Finally, several recent studies challenge the assumption that transmasculine individuals taking HRT are satisfied with their voice and communication.
Summary Speech-language pathologists and otolaryngologists should work collaboratively to treat voice-gender incongruence. Together, we should consider treatment evidence, individual patient goals, and validated patient-reported outcome measures when recommending treatment and evaluating outcomes. Understanding the nuance of how each individual defines benefit is critical to clinicians whose aim is to personalize and optimize treatment of voice-gender incongruence. This is particularly important as management broadens to include individuals across the gender spectrum.
Medications and the larynx
01-12-2019 – Harounian, Jonathan; Postevka, Eugene; Jamal, Nausheen
Purpose of review The larynx is a complex organ that houses some of the most intricate structures of the human body. Owing to its delicate nature, the larynx is affected by different medications to varying degrees. Many of these effects manifest in subjective complaints in ones voice or swallow. This review article invokes the present available literature to describe the effects different medical agents have on the functionality of the laryngeal structures.
Recent findings Multiple available studies explore the effects of inhaled corticosteroids on the larynx. While laryngeal candidiasis is a well known complication of chronic steroid use, other rarer fungal infections have also demonstrated themselves as risks. Among anesthetics, the literature suggests that sevoflurane in standard and high doses does not appear to significantly reduce the risk of laryngospasm. The use of topical and intravenous lidocaine appear to have conflicting evidence regarding their use in laryngospasm prevention, whereas postoperative sore throat, hoarseness, and cough may be prevented with preinduction nebulization of ketamine and magnesium sulfate or budesonide.
Summary Further study is warranted to explore the effects that these and other classes of agents, such as antibiotics, have on the structure and function of the larynx.
Pediatric ossiculoplasty: optimizing outcomes
01-12-2019 – Kaffenberger, Thomas M.; Eichar, Bradley; Chi, David H.
Purpose of review Despite years of research, pediatric ossiculoplasty remains a challenging surgery with numerous variables factoring into successful outcomes. The aim of this review is to summarize recent publications on surgical technique, timing, and reconstruction materials.
Recent findings The cause behind ossicular discontinuity does not seem to play a role in hearing results after ossiculoplasty; however, revision surgery is associated with worsening outcomes. The status of the ossicles remains an active area of interest, but the data remain mixed in terms of them playing a role in predicting outcomes in adults and pediatric patients. There remains debate regarding the utility of staging the reconstruction and is often undertaken on a case-by-case basis. Other recent publications highlight positive outcomes associated with canal wall-up procedures, titanium prostheses, and partial ossicular reconstruction prostheses. Endoscopic middle ear surgery in ossiculoplasty has been shown to be successful in monitoring and removal of disease and helpful in reconstruction.
Summary Pediatric ossiculoplasty remains a challenging yet rewarding procedure. The bulk of publications are retrospective making much of the literature difficult to interpret. There remains a need for prospective and well controlled studies in both adult and pediatric populations.
Otitis media: what is new?
01-12-2019 – Shirai, Nanako; Preciado, Diego
Purpose of review To review the latest literature on otitis media diagnosis, guidelines, treatment, and pathophysiology.
Recent findings Although otitis media remains one of the most common reasons for outpatient visits, antibiotic prescriptions, and surgery in the United States, little progress has been made in terms of developing novel treatments for the prevention and resolution of this condition, indicating the urgent need to continue investigations into the pathophysiology of this disorder. The recent past has seen the publication of new guidelines for the management of both acute otitis media, chronic otitis media and tympanostomy tube placement. Exciting technologies are being investigated into novel means to improve the diagnosis of otitis media, reviewed herein. Advancements in mucosal immunology and genetics have offered clues as to the underlying pathophysiology influencing otitis media propensity. Future research into modifying these pathophysiologic underpinnings, potentially through the usage of transtympanic drug delivery systems, should greatly influence the management of this condition.
Summary Research into novel methods for otitis media pathophysiology, diagnosis and treatment has seen great strides in the recent past. Avenues towards markedly altering the evaluation and management of the condition are likely to be adopted into clinical practice over the coming years.
Pediatric hereditary angioedema: what the otolaryngologist should know
01-12-2019 – Bailey, C. Eric; Carr, Michele M.
Purpose of review To review pediatric hereditary angioedema for otolaryngologists, with emphasis on articles within the past 12–18 months.
Recent findings Biologic therapies are accepted for adult hereditary angioedema (HAE), but have been studied less for pediatric HAE. Recent literature supports expanded use of biologic agents in pediatrics as acute treatment and prophylaxis. Available agents include plasma-derived C1 esterase inhibitors (C1-INH) (Berinert, Haegarda, Cinryze), recombinant C1-INH (Ruconest), bradykinin B2 receptor inhibitor (Icatibant), and kallikrein inhibitors (Ecallantide and lanadelumab). Of these, only Berinert is Food and Drug Administration (FDA) approved for acute therapy for children under 12 years of age. Ruconest is approved for treatment of acute attacks over age 13. Ecallantide also has FDA approval as acute treatment for age 12 and older, while lanadelumab and Haegarda are prophylactic agents for adolescents. Icatibant lacks FDA approval in patients under 18 years of age. Cinryze has FDA approval only for prophylaxis for children as young as 6 years old.
Summary Pediatric HAE is a potentially life-threatening disease. Targeted biologic agents have gained acceptance in treatment of acute attacks, and their use as prophylactic agents is changing the focus of management from acute intervention to preventive management. While intubation or surgical airway management may still be necessary, early intervention or prophylaxis can decrease morbidity and improve quality of life.