Laryngoscope

Laryngoscope

Antitumor effect of insulin‐like growth factor‐1 receptor inhibition in head and neck squamous cell carcinoma

21-08-2019 – Christine E. Lehman, Ashraf A. Khalil, Mark J. Axelrod, Michael I. Dougherty, Stephen S. Schoeff, Linnea E. Taniguchi, Rolando E. Mendez, Abel P. David, Patrick O. McGarey, Matthew A. Hubbard, Lane Donaldson, Henry F. Frierson, Edward B. Stelow, Stefan Bekiranov, Julia D. Wulfkuhle, Emanuel F. Petricoin, Daniel G. Gioeli, Mark J. Jameson

Journal Article

Objectives
The insulin‐like growth factor‐1 receptor (IGF1R) has been implicated in therapeutic resistance in head and neck squamous cell carcinoma (HNSCC), and small molecule tyrosine kinase inhibitors (TKIs) of IGF1R activity may have anticancer activity. Therefore, the relationship between survival and IGF1R expression was assessed for oral cavity (OC) cancer, and the antitumor effects of two IGF1R‐TKIs, OSI‐906 and BMS‐754807, were evaluated in HNSCC cell lines in vitro.
Methods
Clinical outcome data and tissue microarray immunohistochemistry were used to generate IGF1R expression‐specific survival curves. Immunoblot, alamar
Blue proliferation assay, trypan blue exclusion viability test, clonogenic assay, flow cytometry, and reverse phase protein array (RPPA) were used to evaluate in vitro responses to IGF1R‐TKIs.
Results
For patients with stage III/IV OCSCC, higher IGF1R expression was associated with poorer overall 5‐year survival (P = 0.029). Both BMS‐754807 and OSI‐906 caused dose‐dependent inhibition of IGF1R and Akt phosphorylation and inhibited proliferation; BMS‐754807 was more potent than OSI‐906. Both drugs reduced HNSCC cell viability; only OSI‐906 was able to eliminate all viable cells at 10 μM. The two drugs similarly inhibited clonogenic cell survival. At 1 μM, only BMS‐754807 caused a fourfold increase in the basal apoptotic rate. RPPA demonstrated broad effects of both drugs on canonical IGF1R signaling pathways and also inhibition of human epidermal growth factor receptor‐3 (HER3), Src, paxillin, and ezrin phosphorylation.
Conclusion
OSI‐906 and BMS‐754807 inhibit IGF1R activity in HNSCC cell lines with reduction in prosurvival and proliferative signaling and with concomitant antiproliferative and proapoptotic effects. Such antagonists may have utility as adjuvants to existing therapies for HNSCC.
Level of Evidence
NALaryngoscope, 2019

Variability in pathologic interpretation of mandibular invasion

21-08-2019 – Arya W. Namin, Robert P. Zitsch, Lester J. Layfield

Journal Article

Objectives/Hypothesis
Our objective was to identify the accuracy, sensitivity, and specificity of pathological interpretation of mandibular invasion by oral cavity squamous cell carcinoma (SCC) and compare the sensitivity of detecting mandibular invasion in the erosive versus the infiltrative patterns of invasion. We also aimed to describe the significance of the terminology the carcinoma “abuts the mandible” in pathologic interpretation of mandibular invasion.
Study Design
Retrospective case series.
Methods
Mandibulectomy specimens from patients who underwent surgical treatment for oral cavity SCC between January 1, 2005 and December 31, 2015 were retrospectively reviewed by a board‐certified anatomic pathologist. The accuracy of pathologic interpretation of mandibular invasion was calculated using the retrospective interpretation of bone invasion as the true interpretation, which was compared to the interpretation on the original pathology report. Incidence of encountering the terminology the carcinoma “abuts the mandible” in the pathology report was calculated.
Results
A series of 108 consecutive mandibulectomy specimens were reviewed. Sixty‐nine percent (74/108) of cases were interpreted as having mandibular invasion. The accuracy of interpreting mandibular invasion was 84%. The sensitivities for interpretation of mandibular invasion for the erosive and infiltrative patterns of invasion were 77% (30/39) and 91% (32/35), respectively (P = .08). Nine percent (10/108) of pathology reports utilized the terminology the carcinoma “abuts the mandible,” and 80% (8/10) of these cases exhibited mandibular invasion.
Conclusions
The accuracy of identifying mandibular invasion is 84%, indicating a certain degree of sampling error and variability in interpretation. A precise pathologic definition of mandibular invasion should be applied during the interpretation of these specimens to minimize variability.
Level of Evidence4 Laryngoscope, 2019

Ninth editor‐in‐chief of the laryngoscope

20-08-2019 – Samuel H. Selesnick

Editorial

Subglottic cauterization: An atypical approach for atypical croup

20-08-2019 – Lyndy J. Wilcox, Michael J. Rutter

Journal Article

Infection Rates After Microlaryngeal and Open Phonosurgery: The Role of Postoperative Antibiotics

19-08-2019 – Scott A. Roof, Rocco M. Ferrandino, Dillan F. Villavisanis, Michael V. Amato, Benjamin J. Rubinstein, Mark S. Courey, Peak Woo

Journal Article

Objective
Although it is known that the airway has bacterial contamination that seeds the surgical site during microlaryngeal surgery, literature on the use of postoperative antibiotics is lacking. We performed a retrospective analysis of open phonosurgical and phonomicrosurgical cases at a single institution to assess whether use of postoperative antibiotics impacts the incidence of surgical site infections (SSI).
Methods
In this retrospective cohort study, we reviewed 228 phonomicrosurgery and 53 open phonosurgery cases performed for benign diseases. Surgeries were performed by two laryngologists between February 2016 and August 2018. The surgeons differ in their postoperative antibiotic regimens: no antibiotics versus a 5‐ to 7‐day postoperative course.
Data collected include demographics, medical comorbidities, type of benign laryngeal disease, and surgical procedure. The primary outcome measure was postoperative infection, defined as the patient requiring a new prescription for antibiotics, an extended course of antibiotics, or any mention of infection at follow‐up/emergency visits within the first month postoperatively.
Results
The overall rate of SSI was 3.1% and 0% for phonomicrosurgery and open phonosurgery cases, respectively. For phonomicrosurgery, there was no difference in the rate of SSI for patients who received or did not receive antibiotics perioperatively: 2.9% versus 3.2% (P = 0.99). Similarly, there was no difference in the infection rate for open phonosurgical cases.
Conclusion
Infection rates after endoscopic and open phonosurgery are low. In this study, we found no evidence to suggest a protective effect associated with postoperative use of antibiotics.
Level of Evidence4 Laryngoscope, 2019

Cadmium, obesity, and education, and the 10‐year incidence of hearing impairment: The beaver dam offspring study

19-08-2019 – Dayna S. Dalton, Carla R. Schubert, Alex Pinto, Mary E. Fischer, Guan‐Hua Huang, Barbara E. K. Klein, Ronald Klein, James S. Pankow, Adam J. Paulsen, Michael Y. Tsai, Ted S. Tweed, Karen J. Cruickshanks

Journal Article

Objectives/Hypothesis
To determine the 10‐year incidence of hearing impairment (HI) and associated risk factors in the Beaver Dam Offspring Study (BOSS; 2004–present), a large middle‐aged cohort followed for 10 years.
Study Design
Prospective cohort study.
Methods
Hearing thresholds were measured at baseline (2005–2008) and 5‐ (2010–2013) and 10‐year (2015–2017) follow‐up examinations. HI was defined as a pure‐tone average >25 d
B HL in either ear. BOSS participants free of HI at baseline with at least one follow‐up examination (N = 2,065) were included. Potential risk factors evaluated included cardiovascular measures, health history, lifestyle factors, inflammatory markers, vitamins D and B12, lead, and cadmium.
Results
Participants were 21 to 79 years (mean age = 47.9 years) at baseline. The 10‐year cumulative HI incidence was 17.4% (95% confidence interval CI: 15.7–19.2) and was twice as likely in men (24.4%, 95% CI: 21.5–27.7) than in women (12.2%, 95% CI: 10.3–14.3). In a multivariable adjusted model, age (hazard ratio HR = 1.48, 95% CI: 1.38–1.59, per 5 years), male sex (HR = 2.47, 95% CI: 1.91–3.18), less than a college education (HR = 1.35, 95% CI: 1.02–1.79), body mass index (HR = 1.03, 95% CI: 1.01–1.05, per kg/m2), and higher cadmium levels (HR = 1.42, 95% CI: 1.05–1.92, quintile 5 vs. quintiles 1–4) were associated with the 10‐year cumulative incidence of HI. There was no association between high lead levels, vitamins D or B12, and 10‐year incidence of HI.
Conclusions
In addition to age and sex, obesity, education, and blood cadmium levels were associated with increased incidence of HI. These prospective results add to evidence that age‐related HI is a multifactorial preventable disorder.
Level of Evidence2b Laryngoscope, 2019

What is the oncologic safety of using the submental flap to reconstruct oral cavity cancer defects?

19-08-2019 – Brent A. Chang, Ameya A. Asarkar, Cherie‐Ann O. Nathan

Journal Article

Diode laser thermal effect on the paranasal sinus osteoma

16-08-2019 – Sergei Karpishchenko, Elizaveta Bolozneva

Journal Article

Use of bovine pericardium for the treatment of anterior iatrogenic glottic web

16-08-2019 – Enrique Zapater, Natsuki Oishi, Mar Arribas, Rosa Hernández, Isabel López, Jorge Basterra

Journal Article

Cost burden and resource utilization in patients with chronic rhinosinusitis and nasal polyps

16-08-2019 – Neil Bhattacharyya, Sara Villeneuve, Vijay N. Joish, Caroline Amand, Leda Mannent, Nikhil Amin, Paul Rowe, Jaman Maroni, Laurent Eckert, Tony Yang, Asif Khan

Journal Article

Objectives/Hypothesis
Establish treatment patterns and economic burden in US patients with chronic rhinosinusitis with nasal polyposis (CRSw
NP) versus without chronic rhinosinusitis (CRS). Determine comparative costs of subgroups with high clinical burden.
Study Design
Observational, retrospective, case‐control study.
Methods
This study matched patients with CRSw
NP to patients without CRS (1:1) using the Truven Health Market
Scan US claims database. Categorical and continuous variables were compared using Mc
Nemar test and paired t test (normal distribution) or Wilcoxon signed rank tests (non‐normal distribution). Within subgroups, χ2 and Wilcoxon or t tests were used (normal distribution).
Results
There were 10,841 patients with CRSw
NP and 10,841 patients without CRS included. Mean age in the CRSw
NP cohort was 45.8 years; 56.2% were male. During follow‐up, patients with CRSw
NP had an increased diagnosis of asthma versus patients without CRS (20.8% vs. 8.1%, respectively; P < .001). Annual incremental costs were $11,507 higher for patients with CRSw
NP versus those without CRS. Costs were higher in subgroups of patients with CRSw
NP undergoing functional endoscopy sinus surgery (FESS), with a comorbid diagnosis of asthma, receiving oral corticosteroids, or macrolides versus the overall CRSw
NP group. Patients with CRSw
NP undergoing FESS had the highest costs of the four subgroups ($26,724, $22,456, $20,695, and $20,990, respectively).
Conclusions
Annual incremental costs were higher among patients with CRSw
NP versus without CRS. Patients with CRSw
NP with high clinical burden had higher overall costs than CRSw
NP patients without.
Level of Evidence
NALaryngoscope, 129:1969–1975, 2019

Cortical networks for speech motor control in unilateral vocal fold paralysis

16-08-2019 – Molly L. Naunheim, Katherine C. Yung, Sarah L. Schneider, Jennifer Henderson‐Sabes, Hardik Kothare, Leighton B. Hinkley, Danielle Mizuiri, David J. Klein, John F. Houde, Srikantan S. Nagarajan, Steven W. Cheung

Journal Article

Objective
To evaluate brain networks for motor control of voice production in patients with treated unilateral vocal fold paralysis (UVFP).
Study Design
Cross‐sectional comparison.
Methods
Nine UVFP patients treated by type I thyroplasty, and 11 control subjects were compared using magnetoencephalographic imaging to measure beta band (12–30 Hz) neural oscillations during voice production with perturbation of pitch feedback. Differences in beta band power relative to baseline were analyzed to identify cortical areas with abnormal activity within the 400 ms perturbation period and 125 ms beyond, for a total of 525 ms.
Results
Whole‐brain task‐induced beta band activation patterns were qualitatively similar in both treated UVFP patients and healthy controls. Central vocal motor control plasticity in UVFP was expressed within constitutive components of central human communication networks identified in healthy controls. Treated UVFP patients exhibited statistically significant enhancement (P < 0.05) in beta band activity following pitch perturbation onset in left auditory cortex to 525 ms, left premotor cortex to 225 ms, and left and right frontal cortex to 525 ms.
Conclusion
This study further corroborates that a peripheral motor impairment of the larynx can affect central cortical networks engaged in auditory feedback processing, vocal motor control, and judgment of voice‐as‐self. Future research to dissect functional relationships among constitutive cortical networks could reveal neurophysiological bases of central contributions to voice production impairment in UVFP. Those novel insights would motivate innovative treatments to improve voice production and reduce misalignment of voice‐quality judgment between clinicians and patients.
Level of Evidence3b
Laryngoscope, 129:2125–2130, 2019

“Epidemiology and resource utilization of ludwigs angina ED visits in the United States 2006–2014”

16-08-2019 – Jamiela A. McDonnough, Deawodi A. Ladzekpo, Iasson Yi, William R. Bond, Gezzer Ortega, Adedoyin O. Kalejaiye

Journal Article

Objectives
Ludwigs angina is a potentially lethal submandibular space infection. We aim to describe the epidemiological characteristics of Ludwigs angina patients presenting to the emergency department (ED) and to examine outcomes and resource utilization to determine their burden on ED and hospitals.
Methods
Using the Nationwide Emergency Department Sample database, a nationally representative all‐payer database, we retrospectively reviewed all ED visits between 2006 and 2014 for patients admitted with a primary diagnosis of Ludwigs angina (International Classification of Diseases, Ninth Revision, 528.3). We collected information including demographics, ED and inpatient charges, airway interventions, length of stay, and mortality.
Results
A total of 5,855 patients met our inclusion criteria. In our study population, the mean age was 44.5 years, with 54% males and 46% females. There were 75% insured and 25% uninsured. Overall median ED charges were $1,352 and median inpatient charges were $18,017.54, with a median length of stay of 3 days. As part of their management, 47.2% of the patients received a surgical drainage procedure, 3.3% required a surgical airway, and 4.6% required a nonsurgical airway. The overall mortality rate was 0.3%.
Conclusion
Ludwigs angina remains a rare and potentially life‐threatening condition. The mortality rate appears to be decreased from previous historical accounts, with airway intervention remaining a significant part of management.
Level of Evidence3Laryngoscope, 129:2041–2044, 2019

Using word clouds to Re‐envision letters of recommendation for residency applicants

16-08-2019 – Sinehan B. Bayrak, Jennifer A. Villwock, Mark R. Villwock, Alexander G. Chiu, Kevin J. Sykes

Journal Article

Objectives/Hypothesis
To develop a “word cloud”–based visual letter of recommendation (VLOR) and to evaluate its efficiency in discerning applicant quality compared to narrative letters of recommendation (NLORs).
Study Design
Cross‐sectional cohort study.
Methods
NLORs for 48 otolaryngology residency applicants interviewed from the 2016 application cycle were identified and mined for descriptive terms to generate a word cloud, referred to as a VLOR. Eight individuals reviewed and rated a total of 187 blinded NLORs and 48 VLORs on a four‐point scale (negative to exceptional). Median VLOR and NLOR scores and the time to review for each candidate were compared using the Wilcoxon signed rank test.
Results
It took significantly more time to review the NLORs in comparison to the VLORs (67 seconds, interquartile range IQR: 41–98 seconds vs. 17 seconds, IQR: 11–26 seconds, P < .001). There was no significant difference between median scores for VLORs and NLORs (P = .136). Review time and score correlated positively for VLORs and was statistically significant (ρ = 0.459, P = .001), indicating that more time spent reviewing equates to higher scores. The same relationship appeared with NLORs, but was not statistically significant (ρ = 0.276, P = .058).
Conclusions
VLORs are a novel and efficient additive tool for screening candidates for otolaryngology residency interview slots. Their scores do not significantly vary from NLOR scores and are significantly faster to evaluate.
Level of Evidence2b
Laryngoscope, 129:2026–2030, 2019

Smartphone capture of flexible laryngoscopy: Optics, subsite visualization, and patient satisfaction

16-08-2019 – Sarah E. Maurrasse, Theresa W. Schwanke, Abtin Tabaee

Journal Article

Objective
To determine whether a smartphone adaptor can record laryngoscopic videos of adequate quality for clinical diagnosis and communication among otolaryngologists and assess the impact of recorded exams on patient satisfaction.
Methods
Twenty adult inpatients undergoing flexible laryngoscopy in a tertiary care medical center were prospectively enrolled. Each subjects larynx was visualized with the standard laryngoscope eyepiece and with an attached mobile phone adaptor with video recording capabilities. A 5‐point Likert scale was used by the resident performing the scope to grade the adaptor and eyepiece exams. The same scale was used by an offsite otolaryngology attending to grade the adaptor video. Patients were shown the video, and a satisfaction survey was administered.
Results
In all patients, the adaptor was easy to use and required minimal setup. Ninety percent of patients reported an increase in satisfaction after watching the video of their exam. The eyepiece was superior to the adaptor in resolution, focus, color fidelity, brightness, and optical fluidity (P < 0.05). The video recording was deemed sufficient for clinical assessment in 90% of cases. The offsite reviewer determined that there would be “little” (15%) or “no value” (65%) in repeating the scope exam in the majority of patients. The laryngeal subsites were equally visible with the eyepiece and the adaptor (“full view,” 85%–100%).
Conclusion
Laryngoscopy videos recorded by a portable smartphone adaptor are sufficient for clinical evaluation in the majority of cases. This technology may improve patient satisfaction and communication among clinicians.
Level of Evidence4Laryngoscope, 129:2147–2152, 2019

Optimal timing of endoscopic sinus surgery for odontogenic sinusitis

16-08-2019 – John R. Craig, Christopher I. McHugh, Zachary H. Griggs, Edward I. Peterson

Journal Article

Objectives
Odontogenic sinusitis (ODS) is more common than historically reported, and management recommendations are limited in the literature. Although ODS case series have shown successful outcomes with dental treatment and endoscopic sinus surgery (ESS), no studies have considered the optimal timing of these treatments. The purpose of this study was to analyze times to ODS resolution after primary dental treatment and ESS based on symptom, 22‐item sinonasal outcome test (SNOT‐22), and endoscopic outcomes.
Study Design
Prospective cohort study.
Methods
Thirty‐seven symptomatic ODS patients who failed medical management were offered primary dental treatment or ESS. Eleven patients selected primary dental treatment, and 26 patients selected ESS. The following variables were collected prospectively at every office visit before and after dental treatment or ESS: SNOT‐22, presence or absence of cardinal sinusitis symptoms, and presence or absence of middle meatal endoscopy findings (edema, polyps, purulence). Times to resolution of these clinical variables were analyzed with t test, chi‐square test, Fisher exact test, Mc
Nemar test, and Kaplan‐Meier survival analysis.
Results
Patients in the dental treatment and ESS groups showed no significant differences in preoperative sinusitis disease burdens based on symptoms, SNOT‐22, endoscopy, and computed tomography. The ESS group experienced faster and more significant improvement in nearly all symptom, SNOT‐22, and endoscopic outcomes.
Conclusions
For symptomatic ODS, primary ESS resulted in faster resolution of SNOT‐22, sinusitis symptoms, and endoscopic findings in ODS patients compared with primary dental treatment. ESS can be considered first‐line therapy for symptomatic ODS, followed by dental treatment when necessary.
Level of Evidence2b
Laryngoscope, 129:1976–1983, 2019

Vocal motor control and central auditory impairments in unilateral vocal fold paralysis

16-08-2019 – Molly L. Naunheim, Katherine C. Yung, Sarah L. Schneider, Jennifer Henderson‐Sabes, Hardik Kothare, Danielle Mizuiri, David J. Klein, John F. Houde, Srikantan S. Nagarajan, Steven W. Cheung

Journal Article

Objectives
To evaluate differences in vocal motor control and central auditory processing between treated unilateral vocal fold paralysis (UVFP) and healthy control cohorts.
Study Design
Cross‐sectional.
Methods
Ten UVFP study patients treated by type I thyroplasty with stable voices were compared to 12 control subjects for vocal motor control using a pitch perturbation response task and central auditory processing performance using a battery of complex sound intelligibility assays that included adverse temporal and noise conditions. Standard clinical evaluations of voice production and peripheral audiometric sensitivity were performed.
Results
Vocal motor control was impaired in treated UVFP. The UVFP cohort exhibited a 32.5% reduction in the instantaneous, subconscious compensatory response to pitch feedback perturbation in the interval between 150 ms and 550 ms following onset (P < 0.0001, linear mixed effects model). This impairment cannot simply be ascribed to vocal motor capacity insufficiency in the UVFP cohort because both cohorts demonstrated comparable functional capacity to perform the vocal motor task. The UVFP cohort also showed greater propensity for central auditory processing impairment (P < 0.05), notably for temporal compression and added noise challenges.
Conclusion
Combined central vocal motor control and auditory processing impairments in treated UVFP highlight reciprocal interdependency of sensory and motor systems. This pilot study suggests that peripheral motor impairment of the larynx can degrade central auditory processing, which in turn may contribute to vocal motor control impairment. A more complete restoration communicative function in UVFP will require deeper understanding of sensory, motor, and sensorimotor aspects of the human communication loop.
Level of Evidence3b
Laryngoscope, 129:2112–2117, 2019

Subacute acrolein exposure to rat larynx in vivo

16-08-2019 – Xinxin Liu, Abigail C. Durkes, William Schrock, Wei Zheng, M. Preeti Sivasankar

Journal Article

Objectives/Hypothesis
Inhaled pollutants can contact vocal fold tissue and induce detrimental voice changes. Acrolein is a pollutant in cigarette smoke and can also be inhaled during the combustion of fossil fuels, animal fats, and plastics in the environment. However, the vocal fold pathological changes induced by acrolein and the underlying inflammatory pathways are not well understood. These biologic data are needed to understand why voice problems may result from pollutant exposure.
Study Design
In vivo prospective design with experimental and control groups.
Methods
Sprague‐Dawley male rats (N = 36) were exposed to acrolein (3 ppm) or filtered air (control) through a whole‐body exposure system for 5 hours/day, for 5 days/week, over 4 weeks. Histopathological changes, presence of edema, expression of proinflammatory cytokines and markers, and the phosphorylation of nuclear factor kappa‐light‐chain‐enhancer of activated B cells (NF‐κB) were investigated.
Results
Histological evaluation and quantification demonstrated that subacute acrolein exposure induced significant vocal fold edema. Acrolein exposure also induced epithelial sloughing and cell death. Quantitative polymerase chain reaction showed a significant upregulation of genes encoding interferon regulatory factor and chitinase‐3‐like protein 3. Western blot revealed a 76.8% increase in phosphorylation of NF‐κB P65 after subacute acrolein exposure.
Conclusions
These findings suggest that 4‐week exposures to 3 ppm acrolein induce vocal fold inflammation manifested as edema, related to the activation of NF‐κB signaling. The edema may underlie the voice changes reported in speakers exposed to pollutants.
Level of Evidence
NALaryngoscope, 129:E313–E317, 2019

Depth of invasion alone as a prognostic factor in low‐risk early‐stage oral cavity carcinoma

16-08-2019 – Margaret M. Kozak, Jennifer Shah, Michelle Chen, Kurt Schaberg, Rie von Eyben, Jie Jane Chen, Timothy Bui, Christina Kong, Michael Kaplan, Vasu Divi, Wendy Hara

Journal Article

Objectives
To evaluate the significance of increasing depth of invasion (DOI) as the sole risk factor for recurrence in patients with low‐risk early‐stage oral cavity squamous cell carcinoma (OCSCC).
Methods
We retrospectively reviewed 560 patients with OCSCC treated at our institution between 2003 and 2013. Patients were included if they had low‐risk early‐stage OCSCC treated with surgical resection ± neck dissection and no adjuvant therapy. Low risk was defined as absence of positive or close margins, lymphovascular invasion, perineural invasion, and positive lymph nodes. Patients with tumor (T)3‐T4 disease were excluded. Pathology specimens were independently re‐reviewed by two board‐certified pathologists to confirm proper measurement of DOI. Kaplan‐Meier and Cox proportional hazards regression analyses were performed to identify factors predictive for recurrence as well as progression‐free survival (PFS) and overall survival (OS).
Results
A total of 126 patients with low‐risk early‐stage T1‐2N0 OCSCC were included. Median follow‐up time was 42.5 months and median DOI was 4 mm. There was no significant difference in incidence of local (P = 0.95), regional (P = 0.81), or distant recurrence (P = 0.96) among patients with DOI < 4 mm versus ≥4 mm. On multivariable analysis, DOI was significant for both PFS (P = 0.03) and OS (P = 0.002).
Conclusion
In this study, we show that in the absence of other high‐risk pathologic features, DOI ≥ 4 mm does not portend for increased incidence of local, regional, or distant relapse in patients treated with surgery alone; however, increasing DOI is a marker for worse PFS and OS in patients with low‐risk, early‐stage OCSCC.
Level of Evidence4Laryngoscope, 129:2082–2086, 2019

Association of household income and education with prevalence of hearing impairment in Japan

16-08-2019 – Junpei Fukui, Chinatsu Nobutoh, Masahiro Okada, Daiki Takagi, Keiko Tanaka, Hidenori Senba, Masato Teraoka, Hiroyuki Yamada, Bunzo Matsuura, Naohito Hato, Yoshihiro Miyake

Journal Article

Objectives/Hypothesis
Epidemiological information regarding the relationship between household income and education and hearing impairment (HI) is limited. The present cross‐sectional study investigated this issue in Japan.
Study Design
Cross‐sectional investigation.
Methods
Study subjects were 371 men and 639 women aged 36 to 84 years. A self‐administered questionnaire was used. Audiological assessment was performed by pure‐tone audiometry. HI was defined as present in subjects who did not respond to a pure‐tone average of >25 d
B HL in the better hearing ear according to the World Health Organization standard. Adjustment was made for age, smoking status, alcohol consumption, hypertension, dyslipidemia, diabetes mellitus, and body mass index.
Results
The prevalence of HI was 31.5% in 371 men and 20.8% in 639 women. In men, a slight inverted J‐shaped association was observed between household income and HI, compared with a household income of <3 million yen per year. A household income of 3 to 5 million yen, but not of 5 million yen or more, was independently inversely associated with the prevalence of HI; the prevalence ratio for 3 to 5million yen was 0.73 (95% confidence interval: 0.54‐0.999). After adjustment for confounding factors, no relationship was found between household income and the prevalence of HI in women. There were no associations between educational level and the prevalence of HI in either men or women in the multivariate model.
Conclusions
Our results suggest that medium, but not high, household income may be associated with a lower prevalence of HI only in men.
Level of Evidence2b
Laryngoscope, 129:2153–2157, 2019

Temporoparietal frey syndrome: An uncommon variant of a common syndrome

16-08-2019 – C. Burton Wood, James L. Netterville

Journal Article

Objectives/Hypothesis
To describe a previously unreported variant of Frey syndrome. Gustatory sweating is a common complication of parotidectomy and typically directly overlies the surgical site or parotid bed. In some instances, the sweating may occur beyond the parotid bed or involve tissue that was undisturbed during the procedure.
Study Design
Retrospective case series.
Methods
All cases of temporoparietal Frey syndrome in a single surgeons experience were reviewed.
Results
Seven patients were found to have temporoparietal Frey syndrome. Three patients had concomitant first bite syndrome. Three patients had some form of reconstruction at time of surgery. The mean time to onset of symptoms was 11.5 months, with a range of 7 to 21 months. Four patients did not require any treatment for their symptoms, but two patients required intradermal Botox injections for symptomatic relief.
Discussion
This study describes a previously unreported variant of Frey syndrome with symptoms occurring distal to the parotid gland. This likely develops either by regeneration of severed postganglionic fibers into sympathetic targets distally along the course of the auriculotemporal nerve or by regeneration into fibers of the sympathetic plexus traveling along the superficial temporal artery.
Level of Evidence
Laryngoscope, 129:2071–2075, 2019

Comparative assessment of drug‐induced sleep endoscopy scoring systems in pediatric sleep apnea

16-08-2019 – Joseph Tejan, Melecio Medina, Seckin O. Ulualp

Journal Article

Objectives/Hypothesis
A wide variety of drug‐induced sleep endoscopy (DISE) scoring systems has been used to evaluate sites of upper airway obstruction in children and adults; however, a universally accepted DISE scoring system dedicated to children has not been developed. We evaluated the utility of DISE scoring systems in the assessment of obstructive sleep apnea (OSA) using a single cohort of pediatric patients.
Study Design
Retrospective chart review.
Methods
The medical records of surgically naïve–healthy children with OSA who had undergone DISE were reviewed. Information about demographics, past medical history, and severity of OSA were obtained. A literature review was conducted to identify DISE scoring systems used in children with OSA. Recordings of DISE were analyzed without knowledge of patient information and severity of OSA. The effect of age, obesity, severity of OSA, and oxygen nadir on DISE score was assessed.
Results
Sixty‐eight patients (46 male, 22 female, age range: 19 months–18 years) were included. Forty‐three patients were obese and 25 were nonobese. The severity of OSA was mild in 12 patients, moderate in 13 patients, and severe in 43 patients. DISE scoring systems did not document differences among the groups of patients with mild OSA, moderate OSA, and severe OSA (P > .05). DISE scores were not different among the studied age and weight categories (P > .05).
Conclusions
The DISE scoring systems did not show differences in DISE scores in surgically naïve–healthy children with varying age, weight, and OSA severity categories. Our findings provide preliminary evidence for the need of a universally applicable pediatric DISE scoring system for OSA.
Level of Evidence4Laryngoscope, 129:2195–2198, 2019

Factors associated with epiglottic petiole prolapse repositioning success

16-08-2019 – Mathieu Bergeron, Alessandro de Alarcon, Catherine K Hart, Michael J. Rutter

Journal Article

Objective
Epiglottic petiole prolapse is an overlooked entity that could lead to supraglottic airway obstruction for patients with complex airway history. Classical symptoms include exercise intolerance, obstructive sleep apnea, and difficulty with decannulation. The goal of this project was to evaluate the factors associated with epiglottic petiole repositioning success.
Methods
Retrospective case series of patients with a complex history of airway reconstruction evaluated by the aerodigestive team at a tertiary pediatric hospital from May 2003 to August 2017. All patients underwent repositioning for petiole prolapse.
Results
We had a total of 59 patients (14 females, 23.7%) with complex airway anomalies with petiole prolapse noted during a microlaryngoscopy and bronchoscopy. Mean age was 12.9 ± 6.1 year old (range 1.3–35.9). Patients had a history of 2.2 (1–5) open airway surgeries, and 51 of 58 (87.9%) of them had a prior complete laryngofissure. Laryngotracheoplasty and petiole repositioning were performed as a double‐stage surgery for 54 of 58 (91.5%) patients. Epiglottic petiole prolapse was persistent in 20 patients (33.9%) and became symptomatic for 14 of them (23.7%). The main preventive factor of petiole prolapse recurrence was pre‐epiglottic fat debulking at the time of the repositioning, with an odds ratio of 0.06 (95% confidence interval 0.007–0.6, P = 0.01). Stent placement, longer duration of stent placement, and double‐stage procedure also increased the likelihood of success (all P < 0.05).
Conclusion
Patients with petiole prolapse have a history of complete laryngofissure and multiple open airway surgeries. Pre‐epiglottic fat debulking and longer stent placement at the time of the repositioning surgery appear to significantly increase the long‐term success rate.
Level of Evidence4Laryngoscope, 129:1984–1988, 2019

Trends in female leadership at high‐profile otolaryngology journals, 1997–2017

16-08-2019 – Jamie R. Litvack, Elizabeth H. Wick, Mark E. Whipple

Journal Article

Objectives
To determine the proportion and relative advancement of women in leadership positions at high‐impact otolaryngology journals.
Methods
Nine clinical otolaryngology journals were selected based on high impact factor and subspecialty representation (journal impact factor, 2016: 1.16–2.95). The proportion of women editorial board members associate and/or section editors, and/or editor‐in‐chief was measured from 1997 to 2017. Comparisons were made to the proportion of women otolaryngology faculty at U.
S. medical schools in 2017.
Results
From 1997 to 2017, female editorial board membership increased from 7.2% (range: 0.0%–12.8%) to 17.7% (range: 10.9%–38.9%) (P = 0.0001). In 2017, the proportion of female editorial board members was significantly less than the proportion of female academic otolaryngology faculty (17.7% vs. 27.7%, P = 0.0001), and there was threefold variation between journals. From 1997 to 2017, the proportion of female associate and/or section editors increased from 9.3% (range: 0.0–27.3) to 20.9% (range: 5.3% to 45.5%) (P = 0.09). In 2017, the proportion of female associate and/or section editors was not significantly different than the proportion of female associate or full professor academic otolaryngology faculty (20.9% vs. 19.5%, P = 0.73), but there was ninefold variation between journals.
Conclusion
Women were underrepresented on eight of nine otolaryngology editorial boards but appropriately represented at the associate and/or section editorship level. There was remarkable variation in representation at individual journals, which may provide future opportunities to examine best practices. Disparity exists in leadership at the most senior level of these high‐profile otolaryngology journals: none had women editor‐in‐chiefs.
Level of Evidence
NALaryngoscope, 129:2031–2035, 2019

Surgery of the major salivary glands and its impact on salivary flow—A review

16-08-2019 – Marc Burghartz, Stephan Hackenberg, Christian Sittel, Rudolf Hagen

Journal Article

Objective
The aim of this study was to bring attention to a rather unnoted side effect of salivary gland surgery–reduced salivary flow.
Methods
A systematic PubMed, Cochrane Library, LIVIVO, and Embase databases search was performed to identify relevant articles.
Results
Eight studies matched the inclusion criteria. All studies described an association between salivary gland surgery and reduced salivary flow. In five of the eight studies, patients reported on xerostomia after salivary gland surgery.
Conclusions
Head and neck surgeons should inform their patients more accurately about reduced salivary flow and possible xerostomia after salivary gland surgery, and focus more on conservative strategies and minimally invasive techniques.
Laryngoscope, 129:2053–2058, 2019

Long‐term neurological morbidity following endoscopic transnasal resection of juvenile angiofibroma

16-08-2019 – Davide Mattavelli, Vittorio Rampinelli, Marco Ferrari, Alberto Schreiber, Bruno Guarneri, Piero Nicolai

Objectives/Hypothesis
Although transnasal endoscopic resection (TER) of juvenile angiofibroma (JA) is unquestionably less invasive than traditional external approaches, several endonasal and neurovascular structures are sacrificed during the procedure. The aim of this study was to evaluate long‐term neurological morbidity and related quality of life following TER of JA.
Study Design
Retrospective cohort study.
Methods
All patients who underwent TER for JA at the Unit of Otorhinolaryngology–Head and Neck Surgery of the University of Brescia from 1994 to 2016 were contacted to know their availability to undergo a battery of tests aimed to assess lacrimal secretion (Schirmer test), impairment of sensitive nerves (electrophysiological threshold test), and impact on quality of life of tearing reduction and sensitivity impairment with the Ocular Surface Disease Index (OSDI) and visual analogue scale (VAS) (0–10), respectively.
Results
Thirteen patients were included. Mean follow‐up was 77 months (range, 19–156 months). The median Schirmer test value was 5.5 mm and 28.5 mm for the treated and untreated sides, respectively (P = .003). Analysis of sensitivity revealed significant impairment only in the hard palate. The mean OSDI score was 6.8 (normal). The mean values of the VAS scores for hard palate, buccal mucosa, gum, and premaxillary skin were 1.7, 1.7, 1.2, and 2.3, respectively.
Conclusions
TER for JA can result in objective reduction of lacrimal secretion and sensitivity impairment; nevertheless, their impact on quality of life is negligible. The predictable neurological morbidity of TER should be discussed during preoperative counseling.
Level of Evidence4Laryngoscope, 129:2184–2188, 2019

Neuroprotective factors and incident hearing impairment in the epidemiology of hearing loss study

16-08-2019 – Adam J. Paulsen, Karen J. Cruickshanks, Alex Pinto, Carla R. Schubert, Dayna S. Dalton, Mary E. Fischer, Barbara E.K. Klein, Ronald Klein, Michael Y. Tsai, Ted S. Tweed

Journal Article

Objective
Hearing impairment (HI) is common in aging adults. Aldosterone, insulin‐like growth factor (IGF1), and brain‐derived neurotrophic factor (BDNF) have been identified as potentially protective of hearing. The present study aims to investigate these relationships.
Methods
The Epidemiology of Hearing Loss Study is a longitudinal population‐based study of aging in Beaver Dam, Wisconsin, that began in 1993. Baseline for the present investigation is the 1998 to 2000 phase. Follow‐up exams occurred approximately every 5 years, with the most recent occurring from 2013 to 2016. Hearing was measured by pure‐tone audiometry. HI was defined as a pure tone average (PTA) > 25 decibels hearing level in either ear. Change in PTA was the difference between follow‐up examinations and baseline. Baseline serum samples were used to measure biomarkers in 2017. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated to assess the effect of biomarker levels in the lowest quintile (Q1) versus the highest (Q5) on incident HI and PTA change.
Results
There were 1,088 participants (69.3% women) at risk of HI included in analyses. The mean baseline age was 63.8 years (standard deviation = 7.0). The 16‐year incidence of HI was 54.9% and was higher in men (61.1%) than women (52.1%). In age‐ and sex‐adjusted models, aldosterone (HR = 1.06, 95% CI = 0.82–1.37), IGF1 (HR = 0.92, 95% CI = 0.71–1.19), and BDNF (HR = 0.86, 95% CI = 0.66–1.12) levels were not associated with risk of HI. PTA change was similarly not affected by biomarker levels.
Conclusion
Aldosterone, IGF1, and BDNF were not associated with decreased risk of age‐related hearing loss in this study.
Level of Evidence2b
Laryngoscope, 129:2178–2183, 2019

Postoperative pain and analgesic requirements after septoplasty and rhinoplasty

16-08-2019 – Anthony P. Sclafani, Matthew Kim, Klaus Kjaer, Ashutosh Kacker, Abtin Tabaee

Journal Article

Objectives/Hypothesis
To assess and define the level of pain after rhinoplasty and septoplasty and to better define the strength and quantity of postoperative opioids needed.
Study Design
Prospective outcomes research.
Methods
Two groups of patients were enrolled. One group underwent septoplasty with/without turbinate reduction and the other group underwent functional and/or cosmetic rhinoplasty (with/without septoplasty). Patients completed a 15‐day log (daily, beginning on the day of surgery) to record the analgesics used and the daily maximal level of pain using a visual analog scale. Level of pain, number of days of moderate or severe pain, total number of opioid pills used, and total morphine milligram equivalents (MMEs) of opioid used were assessed.
Results
Pain after septoplasty and rhinoplasty was generally mild. Average pain was moderate through postoperative day (POD) 2 after rhinoplasty and only on POD 0 after septoplasty. There was no statistically significant difference between the two groups in terms of number of opioid tablets consumed or total MMEs used. Patients undergoing rhinoplasty consumed more acetaminophen than septoplasty‐only patients (7471 ± 1009 vs. 2781 ± 585, P = .0112). Ninety percent of patients would have received adequate analgesia with as few as 11 opioid tablets. All patients had excess opioid at the end of the study period.
Conclusions
Both septoplasty and rhinoplasty are associated with mostly mild pain, and postoperative opioid requirements are quite low. Surgeons can reliably reduce opioid prescription after septoplasty and rhinoplasty to as few as 11 tablets. Reducing opioid prescribing will not adversely affect the patient but will reduce the availability of opioids for misuse or diversion.
Level of Evidence2c
Laryngoscope, 129:2020–2025, 2019

Chronic opioid use in patients undergoing treatment for oropharyngeal cancer

16-08-2019 – Natalie Silver, Justin Dourado, Kathryn Hitchcock, Amy Fullerton, Kristianna Fredenburg, Peter Dziegielewski, Deepa Danan, Patrick Tighe, Chris Morris, Robert Amdur, William Mendenhall, Roger B. Fillingim

Journal Article

Objectives/Hypothesis
Head and neck cancer pain is a prevalent problem, and the current opioid crisis has highlighted concerns raised in chronic pain management. This study assessed the characteristics of opioid use in patients undergoing treatment for oropharynx cancer and identified risk factors associated with chronic opioid use.
Study Design
Retrospective cohort study.
Methods
A study was conducted of 198 eligible patients who underwent radiotherapy as part of their treatment for oropharynx cancer at a single institution from 2012 to 2017. p16/human papillomavirus (HPV) status was determined by pathology report review. Opioid use was recorded. Statistical analysis was performed to assess risk factors for chronic opioid use and effect on overall survival.
Results
The average age was 62 years, and the mean follow‐up was 38 months. Eighty‐three percent of patients had stage III/IV disease, and 73% received chemoradiotherapy. Sixty‐nine percent were HPV/p16 positive. Fifty‐seven (29%) patients had preexisting chronic pain conditions. Chronic opioid use was observed in 53% of the patients. Age ≤ 62 years (P < .0001), history of depression (P = .0356), p16 negative status (P = .0097), opioid use at pretreatment visit (P = .0021), and presence of a preexisting chronic pain condition at time of diagnosis (P = .0181) were associated with chronic opioid use using univariate analysis. On multivariate analysis, T stage and anxiety/depression were associated with chronic opioid use. Overall survival was worse for patients who had chronic opioid use, but was not significant when recurrence was taken into consideration.
Conclusions
More than 50% of the patients treated for oropharynx squamous cell carcinoma in this cohort were chronic opioid users after treatment. Identifying patients at greatest risk for chronic opioid use prior to treatment may help with long‐term pain management in this patient population.
Level of Evidence4Laryngoscope, 129:2087–2093, 2019

Laryngeal manifestations of cranial nerve IX/X compression at the brainstem

16-08-2019 – Robert J. Taylor, Stephen R. Lowe, Nic Ellis, Evan Abdullah, Sunil Patel, Lucinda A. Halstead

Journal Article

Objective
We report an association between lower cranial nerve (CN IX/X) vascular compression at the brainstem with laryngeal symptoms utilizing a stepwise algorithm that systematically evaluates and eliminates all other common etiologies. Our experiences with retromastoid craniectomy with lower cranial nerve (LCN) decompression versus non‐neurosurgical treatments are detailed.
Study Design
Retrospective chart review at a tertiary care academic medical center with follow‐up telephone survey.
Methods
Baseline demographics, clinical characteristics, quality‐of‐life surveys, and treatment outcomes were recorded for patients with laryngeal symptoms associated with LCN compression at the brainstem.
Results
Forty‐nine patients demonstrated LCN compression at the brainstem on imaging and presented with chief complaints of dysphonia (25 of 49, 51%), chronic cough (19 of 49, 39%), dysphoric breathing (3 of 49, 6%), and dysphagia (2 of 49, 4%). Poor initial scores were noted for Voice‐Related Quality of Life (V‐RQOL), Reflux Symptom Index, and Glottal Closure Index. Twenty‐four patients underwent LCN decompression, of which 21 of 24 (88%) reported partial, near‐complete, or complete improvement. Major perioperative complications occurred in four of 24 patients (17%). Patients who had undergone decompression were more likely to obtain complete/near‐complete symptom resolution (10 of 24 patients, 42%) compared to those undergoing conservative treatments (2 of 25 patients, 8%) (P = 0.02). V‐RQOL scores improved more in surgical patients mean change score, 33.0 (standard deviation SD, 31.2) than nonsurgical patients (mean change score 9.6, SD 20.9) (P = 0.03) (mean follow‐up 3.0 years, SD 2.0).
Conclusion
Lower cranial nerve compression at the brainstem should be considered when all other etiologies are excluded. Retromastoid craniectomy with LCN decompression demonstrates an acceptable safety profile.
Level of Evidence4Laryngoscope, 129:2105–2111, 2019

Hybrid supracricoid partial laryngectomy with cricohyoidoepiglottopexy via transoral robotic surgery

16-08-2019 – Meijin Nakayama, F. Christopher Holsinger, Ryan K. Orosco

Journal Article

Objectives/Hypothesis
To describe a hybrid supracricoid partial laryngectomy with cricohyoidoepiglottopexy (hybrid SCPL‐CHEP) combining limited transcervical and transoral robotic approaches.
Study Design
Preclinical cadaveric study.
Methods
Using six human cadavers in a series of three preclinical laboratories (July 2016–February 2018), we developed a novel hybrid technique for SCPL‐CHEP. A flexible single‐port robotic surgical system was utilized for the transoral aspects of the procedure.
Results
Detailed procedural steps are defined: 1) transoral: mucosal incisions under direct visualization of the laryngopharynx (tumor resection); 2) transcervical: incision and mobilization of the larynx and pexis; and 3) transoral: mucosal closure. Hybrid SCPL‐CHEP was technically feasible and allowed for complete transoral mucosal reconstruction. We discuss potential clinical significance of adding this TORS approach to conventional open SCPL‐CHEP.
Conclusions
This hybrid technique for SCPL‐CHEP provides two main advantages over the standard technique: direct visualization during tumor resection prior to laryngotomy and full closure of the laryngopharynx defect. These technical refinements might facilitate postoperative recovery and in turn make this larynx preservation procedure more accessible to patients and surgeons. A clinical trial evaluating the efficacy of hybrid SCPL‐CHEP appears warranted to validate these observations.
Level of Evidence
NALaryngoscope, 129:2065–2070, 2019

Laryngeal distribution of adult‐onset recurrent respiratory papillomatosis: A longitudinal study

16-08-2019 – Lizbeth Hu, Peter A. Benedict, David Garber, Binhuan Wang, Milan R. Amin, Ryan C. Branski

Journal Article

Objectives/Hypothesis
To describe recurrence patterns in patients with recurrent respiratory papillomatosis (RRP) following surgical intervention.
Study Design
Single‐center, retrospective, longitudinal case series.
Methods
Initial and follow‐up laryngoscopic examinations of seven previously untreated adult‐onset RRP patients were reviewed. Patients were followed longitudinally for periods ranging from 3 months to 7 years. Lesion locations were recorded using a twenty‐one region laryngeal schematic, and maps were generated to illustrate the distribution of disease before and after cold‐knife or potassium‐titanyl‐phosphate laser intervention. Univariate and multivariate analyses were employed to examine variables affecting recurrence patterns.
Results
Across all patients, a statistically significant correlation between initial distribution and primary recurrence was observed. Seventy‐five percent of new lesions were adjacent to regions with preexisting disease; 83% of new glottic lesions were adjacent to preexisting glottic lesions, and 66% of supraglottic lesions were adjacent to preexisting supraglottic regions. No statistically significant differences in recurrence rate were observed across sites.
Conclusions
In previously untreated patients with adult‐onset recurrent respiratory papillomatosis, lesions tended to recur either in the same regions or regions adjacent to those affected at the time of initial surgery.
Level of Evidence4Laryngoscope, 129:1993–1997, 2019

Investigation of surgical adhesives for vocal fold wound closure

16-08-2019 – Lei Xi Chen, Maxence Coulombe, Francois Barthelat, Almoaidbellah Rammal, Luc Mongeau, Karen Kost

Journal Article

Objectives
Surgical adhesives are increasingly used for vocal fold microsurgery to assist wound closure and reduce the risks of scar formation. Currently used vocal fold adhesives such as fibrin glue, however, have thus far not been found to promote wound closure or reduce scarring. The objectives of this study were to investigate the mechanical strength and the cytotoxicity of three commercially available adhesives (Glubran 2, GEM, Viareggio, Italy; Bio
Glue, Cryo
Life, Kennesaw, GA; and Tisseel, Baxter Healthcare, Deerfield, IL) for vocal fold wound closure.
Methods
Shear and tension tests were performed on 150 porcine larynges. The cytotoxicity of the adhesives to immortalized human vocal fold fibroblasts was investigated using neutral red uptake assays.
Results
The average shear adhesive strength for Tisseel, Bio
Glue, and Glubran 2 was 13.86 ± 5.03 kilopascal (k
Pa), 40.92 ± 17.94 k
Pa, and 68.79 ± 13.29 k
Pa, respectively. The tensile adhesive strength for Tisseel, Bio
Glue, and Glubran 2 was 10.70 ± 6.42 k
Pa, 34.27 ± 12.59 k
Pa, and 46.67 ± 12.13 k
Pa, respectively. The vocal fold cell viabilities in extracts of Tisseel, Bio
Glue, and Glubran 2 were 99.27%, 43.05%, and 1.79%, respectively.
Conclusion
There was a clear tradeoff between adhesive strength and toxicity. The maximum failure strength in shear or tension of the three surgical adhesives ranked from strongest to the weakest was: 1) Glubran 2, 2) Bio
Glue, and 3) Tisseel. Tisseel was found to be the least toxic of the three adhesives, whereas Glubran 2 was the most toxic.
Level of Evidence
NALaryngoscope, 129:2139–2146, 2019

Tra2β silencing suppresses cell proliferation in laryngeal squamous cell carcinoma via inhibiting PI3K/AKT signaling

16-08-2019 – Hao‐Sheng Ni, Song‐Qun Hu, Xi Chen, Yi‐Fei Liu, Ting‐Ting Ni, Lei Cheng

Journal Article

Objectives/Hypothesis
Transformer‐2 protein homolog beta (Tra2β) generally plays an important role in various human cancers, but its role and the underlying mechanisms in laryngeal squamous cell carcinoma (LSCC) remained unknown. So this study aimed to assess the clinical significance and regulatory mechanisms of Tra2β in LSCC.
Study Design
Laboratory analysis.
Methods
Expression of Tra2β was compared in human LSCC tissue samples and paired adjacent normal tissue samples. The in vitro effects of Tra2β expression in Hep‐2 cells on their proliferation, invasion, and migration were assessed by CCK‐8 assays, Matrigel invasion, and transwell migration assays. In addition, the effects of downregulation of Tra2β on the activation of PI3K/AKT signaling pathway were measured using Western blot analysis. The effect of Tra2β on the growth of tumors was detected in the Hep‐2–injected xenograft models in vivo.
Results
Reverse‐transcription quantitative polymerase chain reaction analysis and immunochemistry analysis indicated that the increased expression of Tra2β in LSCC was significantly associated with poor differentiation, lymph node metastasis, and advanced clinical stage. In vitro knockdown of Tra2β caused a significant decrease in the proliferation, invasion, and migration of Hep‐2 cells. Tra2β silencing decreased the expression of Bcl‐2 but increased Bax and Caspase‐3 both in m
RNA and protein levels. Furthermore, knockdown of Tra2β eliminated the suppressive effects of activation of PI3K/AKT signaling. In vivo knockdown of Tra2β significantly inhibited the tumor growth of Hep‐2–injected xenograft mice.
Conclusions
The results of the present study demonstrated that knockdown of Tra2β inhibits the proliferation and invasion of LSCC cells, at least partly via inhibiting PI3K/AKT signaling.
Level of Evidence
NALaryngoscope, 129:E318–E328, 2019

Preclinical assessment of resorbable silk splints for the treatment of pediatric tracheomalacia

16-08-2019 – Meghan McGill, Nikhila Raol, Kevin S. Gipson, Sarah N. Bowe, Jackson Fulk‐Logan, Anahita Nourmahnad, Joon Yong Chung, Michael J. Whalen, David L. Kaplan, Christopher J. Hartnick

Journal Article

Objective
Tracheomalacia is characterized by weakness of the tracheal wall resulting in dynamic airway collapse during respiration; severe cases often require surgical intervention. Off‐label external splinting with degradable implants has been reported in humans; however, there remains a need to develop splints with tunable mechanical properties and degradation profiles for the pediatric population. The objective of this pilot study is to assess the safety and efficacy of silk fibroin‐based splints in a clinically relevant preclinical model of tracheomalacia.
Methods
Silk splints were evaluated in a surgically induced model of severe tracheomalacia in N = 3 New Zealand white rabbits for 17, 24, and 31 days. An image‐based assay was developed to quantify the dynamic change in airway area during spontaneous respiration, and histopathology was used to study the surrounding tissue response.
Results
The average change in area in the native trachea was 23% during spontaneous respiration; surgically induced tracheomalacia resulted in a significant increase to 86% (P < 0.001). The average change in airway area after splint placement was reduced at all terminal time points (17, 24, and 31 days postimplantation), indicating a clinical improvement, and was not statistically different than the native trachea. Histopathology showed a localized inflammatory reaction characterized by neutrophils, eosinophils, and mononuclear cells, with early signs suggestive of fibrosis at the splint and tissue interface.
Conclusion
This pilot study indicates that silk fibroin splints are well tolerated and efficacious in a rabbit model of severe tracheomalacia, with marked reduction in airway collapse following implantation and good tolerability over the studied time course.
Level of Evidence
NALaryngoscope, 129:2189–2194, 2019

Patient‐reported versus physiologic swallowing outcomes in patients with head and neck cancer after chemoradiation

16-08-2019 – Elliana Kirsh, Matthew Naunheim, Allison Holman, Rachel Kammer, Mark Varvares, Tessa Goldsmith

Journal Article

Objective
The primary objective of this project was to retrospectively investigate the relationship between patient‐reported and physiologic swallowing measures after chemoradiation therapy for head neck cancer (HNC).
Methods
Adult patients who underwent chemoradiation therapy for HNC and presented for videofluoroscopic swallow study were reviewed retrospectively. Surgically treated patients were excluded. Patient perception of swallowing‐related outcomes was assessed via the MD Anderson Dysphagia Inventory (MDADI) on the same day that physiologic measures of swallow function were obtained. Using vidoefluoroscopic data, the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale yielded measures of safety (DIGEST‐S: penetration/aspiration) and efficiency (DIGEST‐E: residue). Statistical analysis for correlation coefficients was performed.
Results
Thirty patients met the inclusion criteria. The oropharynx was the most commonly affected site (70.0%), followed by the larynx (16.7%). The median radiation dose was 72 grays (Gy), and participants were assessed a mean of 4.6 (range 0–12) years following completion of treatment. There was no correlation between the MDADI and the DIGEST‐E score (Pearson rho = −0.045, P = 0.812), DIGEST‐S score (Pearson rho = 0.075, P = 0.695), or summary DIGEST grade (Pearson rho = 0.046, P = 0.810). MDADI scores did not change significantly with increasing time since radiation (P = 0.375), whereas the DIGEST‐E scores, DIGEST‐S score, and summary DIGEST grades worsened over time (P = 0.007, P = 0.002, and P = 0.0005, respectively).
Conclusion
Assessment of swallowing physiology showed that function worsened after chemoradiation therapy, but this did not correlate with patient‐reported quality‐of‐life measures. Reduced patient awareness of swallow dysfunction years after completion of chemoradiation has implications for management of dysphagia in the face of physiologic decline.
Level of Evidence4Laryngoscope, 129:2059–2064, 2019

Outcomes of transmastoid resurfacing for superior canal dehiscence using a cartilage overlay technique

16-08-2019 – Ayham Al Afif, Robert Farmer, Manohar Bance

Journal Article

Objective
Superior semicircular canal dehiscence is a well‐described syndrome with potentially debilitating symptoms. We report on the audiologic and long‐term symptom outcomes of 10 patients (12 ears) undergoing a cartilage overlay transmastoid resurfacing technique.
Methods
Retrospective chart review and cross‐sectional outcomes recall survey were used. A mailed questionnaire quantifying the effect of surgery on symptom severity and patient satisfaction were used. Nonlinear regression curves of pre‐/postoperative air and bone pure‐tone audiometric data were used to evaluate postoperative changes in hearing. Surgical failure was defined as requiring revision surgery, and rates were estimated over time using a Kaplan‐Meier analysis.
Results
Most patients reported improved symptoms postoperatively and were satisfied overall with the surgical outcomes. However, four of 12 ears (33%) had a second (revision) surgery before achieving these results. Postoperatively, hearing through air and bone conduction tended to decrease at frequencies greater than 2500 Hz. The chance of avoiding a re‐operation at 36 months (and up to 120 months) was estimated to be 57.1% (95% confidence interval confidence interval: 100%, 32.6%). The most common surgical complication was intraoperative cerebrospinal fluid (CSF) leak, encountered exclusively during dural elevation, seen in four of 12 ears (33%).
Conclusion
Although subjectively successful at reducing symptoms, in our small sample this surgical approach did not provide a long‐term stable repair and was frequently associated with intraoperative CSF leak. Offering transmastoid resurfacing to patients should involve a detailed discussion on the potential for revision surgery and risks of diminished hearing and CSF leak.
Level of Evidence4Laryngoscope, 129:2164–2169, 2019

Evaluation of spin in the abstracts of otolaryngology randomized controlled trials

16-08-2019 – Craig M. Cooper, Harrison M. Gray, Andrew E. Ross, Tom A. Hamilton, Jaye Bea Downs, Cole Wayant, Matt Vassar

Journal Article

Objective
Spin, the misrepresentation and distortion of research findings, has been shown to affect clinical decision making. Spin has been found in randomized controlled trials (RCTs) published in various fields of medicine, but no study has tested for the presence of spin in otolaryngology RCTs. The purpose of this study is to evaluate the abstracts of RCTs found in the otolaryngology literature for spin.
Methods
In this cross‐sectional analysis, we analyzed the abstracts of RCTs for spin using a pilot‐tested form. Double data extraction was performed by two blinded authors, and discrepancies were resolved using mutual discussion.
Results
Out of the 534 PubMed citations retrieved by our search string, 162 parallel‐group RCTs with clearly defined primary and secondary endpoints were identified. Further analysis identified 47 trials with nonsignificant primary outcomes, which were then evaluated for spin. Spin was identified in 33 of the 47 (70%) abstracts. Spin was found in the results sections of 25 (53%) of the included abstracts and was found in the conclusion section of 27 (57%) of the abstracts. Spin was not present in the titles of any of the included studies.
Conclusion
Spin was common in our sample of otolaryngology RCTs. Spin may potentially create false impressions about the true validity of a drug or intervention. Further research needs to test for potential clinical implications of spin in the otolaryngology literature.
Level of Evidence
NALaryngoscope, 129:2036–2040, 2019

Taste disorders are partly genetically determined: Role of the TAS2R38 gene, a pilot study

16-08-2019 – Melania Melis, Lisa Grzeschuchna, Giorgia Sollai, Thomas Hummel, Iole Tomassini Barbarossa

Journal Article

Objectives/Hypothesis
Taste sensitivity varies greatly among individuals influencing eating behavior and health, consequently the disorders of this sense can affect the quality of life. The ability to perceive the bitter of thiourea compounds, such as phenylthiocarbamide (PTC), has been largely reported as a marker of the general taste sensitivity, food preferences, and health. PTC sensitivity is mediated by the TAS2R38 receptor and its genetic common variants. We study the role of the TAS2R38 receptor in taste disorders with the aim of understanding if these can be genetically determined.
Study Design
Prospective cohort study.
Methods
Differences in the PTC responsiveness between the patients cohort and healthy controls were assessed. All subjects received standardized tests for smell and taste function and were genotyped for the TAS2R38 gene.
Results
PAV/PAV homozygous patients gave high PTC ratings, whereas PAV/AVI genotypes reported lower values, which are similar to those determined in AVI/AVI or rare genotypes. In addition, the patients cohort did not meet the Hardy‐Weinberg equilibrium at the TAS2R38 locus, showing a very low frequency of subjects carrying the PAV/AVI diplotype. Independently, in healthy controls who were in equilibrium at the locus, PAV/PAV homozygous and heterozygous rated PTC bitterness higher compared to AVI/AVI or rare genotypes.
Conclusions
Our findings, by showing that an only taster haplotype (PAV) is not sufficient to evoke high responses of TAS2R38 receptor in patients with taste disorders, suggest that the genetic constitution may represent a risk factor for the development of taste disorders.
Level of Evidence2c
Laryngoscope, 129:E307–E312, 2019

Oral tongue squamous cell carcinoma survival as stratified by age and sex: A surveillance, epidemiology, and end results analysis

16-08-2019 – Laith Mukdad, Thomas E. Heineman, Jose Alonso, Karam W. Badran, Edward C. Kuan, Maie A. St. John

Journal Article

Objectives/Hypothesis
To utilize the Surveillance, Epidemiology, and End Results (SEER) database to elucidate differences in predictors of survival in oral tongue squamous cell carcinoma (OTSCC) as stratified by age and sex.
Study Design
Retrospective, population‐based database analysis.
Methods
The SEER registry was utilized to calculate survival trends for patients with OTSCC between 1973 and 2012. Patient data were then stratified by age (≤40 years vs. >40 years) and sex, then analyzed with respect to race, stage, grade, and treatment modalities. Overall survival (OS) and disease‐specific survival (DSS) were calculated and compared.
Results
There were 16,423 cases of OTSCC identified, with 526 and 706 young female and male patients, respectively. Young female patients had improved OS and DSS as compared to young male patients (75% vs. 67% at 5 years), which is better than older patients (P < .001). Younger patients were more likely to receive surgery (P < .001) and combination surgery and radiation (P < .001) as compared to older patients. On multivariate analysis, tumor stage was uniformly associated with worse OS and DSS (P < .05), with surgery predicting improved OS and DSS in all groups except young females (P < .05). Higher tumor grade predicted worse OS and DSS in older patients, but not younger patients (P < .05).
Conclusions
OTSCC appears to present with relatively heterogeneous characteristics across different age groups and sexes. Despite the rising incidence of OTSCC in young individuals, our study demonstrates that young patients have improved survival rates compared to older patients.
Level of Evidence
NALaryngoscope, 129:2076–2081, 2019

Expert sampling of VR simulator metrics for automated assessment of mastoidectomy performance

16-08-2019 – Steven Arild Wuyts Andersen, Peter Trier Mikkelsen, Mads Sølvsten Sørensen

Journal Article

Objective
Often the assessment of mastoidectomy performance requires time‐consuming manual rating. Virtual reality (VR) simulators offer potentially useful automated assessment and feedback but should be supported by validity evidence. We aimed to investigate simulator metrics for automated assessment based on the expert performance approach, comparison with an established assessment tool, and the consequences of standard setting.
Methods
The performances of 11 experienced otosurgeons and 37 otorhinolaryngology residents. Participants performed three mastoidectomies in the Visible Ear Simulator. Nine residents contributed additional data on repeated practice in the simulator. One hundred and twenty‐nine different performance metrics were collected by the simulator and final‐product files were saved. These final products were analyzed using a modified Welling Scale by two blinded raters.
Results
Seventeen metrics could discriminate between resident and experienced surgeons’ performances. These metrics mainly expressed various aspects of efficiency: Experts demonstrated more goal‐directed behavior and less hesitancy, used less time, and selected large and sharp burrs more often. The combined metrics‐based score (MBS) demonstrated significant discriminative ability between experienced surgeons and residents with a mean difference of 16.4% (95% confidence interval 12.6–20.2, P << 0.001). A pass/fail score of 83.6% was established. The MBS correlated poorly with the final‐product score but excellently with the final‐product score per time.
Conclusion
The MBS mainly reflected efficiency components of the mastoidectomy procedure, and although it could have some uses in self‐directed training, it fails to measure and encourage safe routines. Supplemental approaches and feedback are therefore required in VR simulation training of mastoidectomy.
Level of Evidence2b
Laryngoscope, 129:2170–2177, 2019

Analysis of neuromonitoring signal loss during retroauricular versus conventional thyroidectomy

16-08-2019 – Myung Jin Ban, Eun Hae Estelle Chang, Dong Yun Lee, Jae Hong Park, Chan Lee, Da Hee Kim, Joo Hyun Kim, Yoon Woo Koh

Journal Article

Objective
Loss of signal (LOS) during intraoperative neuromonitoring (IONM) of robotic or endoscopic thyroidectomy via a retroauricular approach (RAT) and during conventional open thyroidectomy (COT) was investigated to compare the risk of recurrent laryngeal nerve (RLN) injury between the two groups.
Study Design
Original article.
Methods
This is a retrospective case series study performed between May 2014 and September 2016. IONM using the NIM 3.0 system (Medtronic Xomed, Inc., Jacksonville, FL) was used for this study. Pre‐ and postoperative vocal cord functions were assessed using a flexible laryngoscope. LOS types noted intraoperatively and their associations with postoperative vocal cord palsy (VCP) were evaluated. LOS rate and temporary and permanent VCP rates were compared between the two groups. The surgical events associated with LOS were also documented and analyzed in this study.
Results
In total, 153 patients were recruited, and 111 patients were enrolled in the RAT group; the remaining 42 patients were enrolled in the COT group. No statistically significant differences in intraoperative LOS (P = 0.812) and postoperative VCP rates (early, permanent; P = 0.259 and P = 0.577, respectively) between the two groups were observed. IONM accuracy of predicting postoperative VCP was 99.1% in our case series.
Conclusion
On the basis of IONM findings, the risks of injury to RLN were similar between the two groups. Comparison of LOS was an objective method for verifying the novel RAT approach. We applied our IONM protocol and troubleshooting algorithm during RAT with acceptable accuracy, but the international standardized method of IONM is applicable and recommended for reducing false results using vagal nerve stimulation.
Level of Evidence3b
Laryngoscope, 129:2199–2204, 2019

The role of elective neck dissection in patients with adenoid cystic carcinoma of the head and neck

16-08-2019 – Roy Xiao, Rosh K.V. Sethi, Allen L. Feng, Joel B. Fontanarosa, Daniel G. Deschler

Journal Article

Objective
To investigate the frequency and outcomes of elective neck dissection (END) for adenoid cystic carcinoma (ACC) of the head and neck.
Methods
The National Cancer Database was queried for a cohort study of patients with ACC of the major salivary glands, nasal cavity/nasopharynx, hard/soft palate, tongue, floor of mouth, larynx, and oral cavity who underwent primary surgical resection from 2004 to 2014. Multivariable logistic regression was used to identify predictors of END and occult nodal metastasis. Overall survival (OS) was estimated using the Kaplan‐Meier method and modeled with Cox proportional hazards regression.
Results
Among 2,807 patients with ACC treated surgically, 636 (22.7%) underwent END. Patients with ACC of the salivary glands and tongue most frequently underwent END; patients with hard/soft palate (odds ratio OR 0.06, P < 0.001) and nasal cavity/nasopharynx (OR 0.05, P < 0.001) ACC rarely underwent END compared to patients with major salivary gland cancer. Increasing tumor (T) stage (T4 vs. T1, OR 3.02, P < 0.001) was associated with END. Patients with advanced T3 to T4 ACC of the major salivary glands demonstrated extended OS associated with END (5‐year OS 78.1% vs. 70.4%, P = 0.041) on Kaplan‐Meier analysis and with END with adjuvant radiation therapy (hazard ratio 0.55, P = 0.027) using Cox proportional hazards regression. Elective neck dissection for T4 ACC of the salivary glands (21.3%) and tongue (25.5%) most consistently revealed occult nodal metastasis.
Conclusion
Elective neck dissection for ACC of the major salivary glands or tongue is most likely to reveal occult nodal metastasis. Elective neck dissection is associated with extended OS for advanced‐stage ACC of the major salivary glands.
Level of Evidence
NALaryngoscope, 129:2094–2104, 2019

Supraclavicular flap practice patterns and outcomes: A survey of 221 AHNS surgeons

16-08-2019 – Andrew T. Day, Liyang Tang, Kevin Emerick, Urjeet A. Patel, Daniel G. Deschler, Jeremy D. Richmon

Journal Article

Objectives
To describe American Head and Neck Society (AHNS) surgeon supraclavicular flap (SCF) practice patterns and to identify variables associated with SCF complications.
Methods
The design is a cross‐sectional study. An online survey was distributed to 782 AHNS surgeons between November 11, 2016, and December 31, 2016. The primary outcome was frequency of SCF complications. Independent variables included demographics, training, practice patterns, and SCF techniques.
Results
Adequate survey responses were obtained from 221 AHNS surgeons. Among these, 54.3% (n = 120) performed supraclavicular flaps (SCFs). Most surgeons used the SCF for cutaneous (n = 85; 78.7%) or parotid–temporal bone (n = 59; 54.6%) defects. Nearly one‐third (n = 31; 29.8%) of surgeons experienced more than a “few” SCF complications. Surgeons experienced fewer pectoralis major flap (P < 0.001) and radial forearm free flap (P < 0.001) complications compared to SCF complications. Univariate analysis demonstrated no association between surgeons with “few” SCF complications and Doppler use in SCF design (P = 0.90), harvest location (P = 0.51), and pedicle skeletonization (P = 0.25). Multivariable logistic regression revealed that surgeons performing more than 30 SCFs compared to less than or equal to 30 SCFs had a greater odds of having “few” SCF complications (odds ratio 7.1, 95% confidence interval 1.1–43.9, P = 0.04).
Conclusion
A majority of surgeons performing SCFs use the flap to reconstruct cutaneous and parotid–temporal bone defects. The significance of relatively higher SCF complications compared to other routine flaps should be explored further. Surgeon experience with the SCF appears to be significantly associated with SCF success, whereas training characteristics, practice patterns, and technical variations may not be associated with SCF outcomes.
Level of Evidence
NALaryngoscope, 129:2012–2019, 2019

Carcinoma presenting as idiopathic anterior glottic webs: A case series

16-08-2019 – Apoorva T. Ramaswamy, Lisa Tian, Jonathan M. Bock, Adam M. Klein, Michael J. Pitman

Case Reports

An anterior glottic web is an abnormal fusion of the anterior aspect of the membranous vocal folds. Noncongenital glottic webs are usually iatrogenic from intubation or laryngeal surgery. We present six adult patients whose initial in‐office diagnoses were consistent with “idiopathic” benign anterior glottic webs as determined by three laryngologists (a.m.k., j.m.b., m.j.p.). Further evaluation revealed the diagnoses of laryngeal squamous cell carcinoma in all cases. The high risk of malignancy in cases of idiopathic anterior glottic web necessitates biopsy for tissue diagnosis of all such lesions.
Laryngoscope, 129:2118–2120, 2019

Laryngeal reconstruction for recurrent desmoid tumor using three‐dimensional modeling: A unique approach for a rare tumor

16-08-2019 – Lauren F. Tracy, Samip N. Patel, Robert A. Buckmire, Rupali N. Shah

Case Reports

Desmoid tumors are exceedingly rare within the larynx and cause significant morbidity due to their locally aggressive and infiltrative nature. Surgery is the mainstay of treatment with previous reports describing total and near‐total laryngectomy for cure. We present a case of recurrent glottic desmoid tumor managed with hemilaryngectomy and reconstructed with temporoparietal free tissue, rib, and buccal grafts. Three‐dimensional modeling was utilized to optimize aerodigestive function after laryngeal reconstruction.
Laryngoscope, 129:1989–1992, 2019

Otologic considerations in a full face transplant recipient

16-08-2019 – Michael J. Cammarata, Daniel Jethanamest, Eduardo D. Rodriguez

Case Reports

Facial transplantation provides a functional and aesthetic solution to severe facial disfigurement previously unresolved by conventional reconstruction. Few facial allografts have been ear containing; hence, there is limited knowledge of the postoperative otologic considerations. We describe the case of a 44‐year‐old man who underwent transplantation of the total face, eyelids, ears, scalp, and skeletal subunits in 2015 after an extensive thermal injury. We detail the patients transition from osseointegrated prosthetic ears to an ear‐containing facial allograft, and describe the unique surgical approach and challenges encountered. Subsequent bilateral revision meatoplasties were performed, which provided relief from stenosis of the external auditory meatus.
Laryngoscope, 129:2008–2011, 2019

In Response to letter to the editor regarding International Neuromonitoring Study Group Guidelines 2018: Part II: Optimal Recurrent Laryngeal Nerve Management for Invasive Thyroid Cancer—Incorporation of Surgical, Laryngeal, and Neural Electrophysiologic Data

16-08-2019 – Gregory W. Randolph, Dipti Kamani

Letter

In reference to International neuromonitoring study group guidelines 2018: Part II: Optimal recurrent laryngeal nerve management for invasive thyroid cancer—incorporation of surgical, laryngeal, and neural electrophysiologic data

16-08-2019 – Mehmet Haciyanli

Letter

A new editor‐in‐chief for the laryngoscope

16-08-2019 – Michael G. Stewart

Editorial

Does the intracochlear position of an electrode array impact performance?

16-08-2019 – Richard K. Tilton, Marlan R. Hansen

Journal Article

Is primary radiotherapy an acceptable treatment modality for verrucous carcinoma of the larynx?

16-08-2019 – Brent A. Chang, Sanford Katz, Anvesh R. Kompelli, Cherie‐Ann O. Nathan

Journal Article

Masthead

16-08-2019 –

Table of contents

16-08-2019 –

Control of speech and voice in cochlear implant patients

16-08-2019 – Anirudh Gautam, James G. Naples, Steven J. Eliades

Journal Article, Review

Objective
Hearing plays an important role in the learning and production of speech, but the benefits of cochlear implantation for such vocal control are unclear. Here, we present a perspective and review of recent work on the control of speech and voice following cochlear implantation. We further discuss insights provided on the mechanisms of normal vocal control and implications for future rehabilitative approaches.
Data Sources
Peer‐reviewed articles on speech and voice production in cochlear implant patients were identified from PUBMED. Relevant articles were supplemented with selected publications describing normal vocal control mechanisms and behaviors.
Review Methods
Publications that discussed speech and voice outcomes following cochlear implantation were chosen, with a focus on those presenting measurements of specific speech or voice parameters.
Results
Recent studies demonstrate that hearing restoration by cochlear implantation has significant effects on many aspects of voice and speech production. These include changes in vocal pitch and loudness, as well as improved control of both vowels and consonants. Despite these improvements, however, the speech of many implant recipients remains abnormal as compared to normal hearing individuals. Such differences likely result from the impoverished auditory feedback provided by the implant.
Conclusions
Cochlear implants provide valuable insights into the role of hearing in vocal production. Although implants improve vocal production for most patients, there remains considerable room for future study and therapeutic improvement.
Laryngoscope, 129:2158–2163, 2019

Olfactory outcomes after endoscopic skull base surgery: A systematic review and meta‐analysis

16-08-2019 – “Linda X. Yin, Christopher M. Low, Cassandra L. Puccinelli, Erin K. OBrien, Janalee K. Stokken, Kathryn M. Van Abel, Jeffrey R. Janus, Michael J. Link, Jamie J. Van Gompel, Garret Choby”

Journal Article, Review

Objectives
Determine the effect of endoscopic skull base surgery (ESBS) on long‐term olfactory outcomes after surgery.
Methods
An English‐language search was conducted using the Cochrane, MEDLINE, Scopus, and Embase databases from January 2000 to October 2017 for adult patients undergoing ESBS with subjective and objective olfaction outcomes. Two authors independently examined articles to identify those meeting inclusion criteria. Studies examining objective olfactory outcomes after ESBS were included in the meta‐analysis. A random‐effects meta‐analysis of patients undergoing sellar and parasellar ESBS was conducted to compare preoperative and postoperative olfactory outcomes using the University of Pennsylvania Smell Identification Test (UPSIT) and Cross‐Cultural Smell Identification Test (CCSIT).
Results
Among 339 eligible articles, 29 articles met inclusion criteria. Twenty‐five of these focused on sellar and parasellar tumors. Individual articles not meeting criteria for meta‐analysis were qualitatively reported. Meta‐analysis showed there was no difference in preoperative and postoperative olfactory function after sellar and parasellar ESBS based on the UPSIT (five studies, mean difference MD = −1.03; 95% CI: −3.98, 1.93; P = .50) and the CCIST (three studies, MD = −0.77; 95% CI: −3.03, 1.49; P = .50). A pooled overall meta‐analysis revealed similar results (eight studies, effect size = −0.30; 95% CI: −0.79, 0.18; P = .22). However, heterogeneity for all meta‐analyses was high (I2 > 95%, P < .01), suggesting significant variation in the included studies.
Conclusions
Based on published objective olfaction outcomes after sellar and parasellar ESBS, there was no significant difference between preoperative and postoperative olfaction. Further prospective studies using validated objective measures of olfaction are required to improve our understanding on this subject.
Level of Evidence2a
Laryngoscope, 129:1998–2007, 2019

In‐office procedures for the treatment of benign vocal fold lesions in the awake patient: A contemporary review

16-08-2019 – Hagit Shoffel‐Havakuk, Babak Sadoughi, Lucian Sulica, Michael M. Johns

Journal Article, Review

Objectives
To review available information regarding in‐office procedures for benign vocal fold lesions (BVFL).
Methods
PubMed term search on office/awake laryngeal procedures for any of the following specific lesions: Reinkes edema (RE), polyps, nodules, varices, vocal process granuloma, and vocal fold (VF) scar.
Results
In‐office ablative and nonablative laser procedures have been described for BVFL, including RE, polyps, varices, and granuloma. Fiber‐based lasers used include potassium titanyl phosphate, pulsed dye laser, and more recently CO2. In‐office intralesional steroid injection (ISI) for BVFL targets the inflammatory process involved with the lesion and may induce regression of polyps, nodules, RE, and granuloma. Botulinum toxin‐induced “voice rest” has been described as adjunctive treatment for refractory VF nodules or vocal process granuloma. Most in‐office techniques for treating BVFL rely on induction of lesion regression rather than complete lesion removal, as in conventional operative microsurgery. When treating VF scarring, in‐office procedures aim to alter the wound‐healing process; ISI targets the inflammatory phase and angiolytic lasers target the proliferative phase.
Conclusion
In‐office procedures for BVFL apply new technology that can potentially lower risk and cost. Although numerous case series have shown the potential of these procedures, data that thoroughly compares outcomes with those of microlaryngoscopic techniques is needed.
Laryngoscope, 129:2131–2138, 2019

Association between laryngopharyngeal reflux and benign vocal folds lesions: A systematic review.

16-08-2019 – Jerome R. Lechien, Sven Saussez, Andrea Nacci, Maria Rosaria Barillari, Alexandra Rodriguez, Serge D. Le Bon, Lise Crevier‐Buchman, Bernard Harmegnies, Camille Finck, Lee M. Akst

Journal Article, Review

Objectives
To investigate the role of laryngopharyngeal reflux (LPR) in the development of benign lesions of the vocal folds (BLVF).
Methods
PubMed, Cochrane Library, and Scopus were searched by three independent investigators for articles published between January 1990 and November 2018 providing substantial information about the role of LPR in the development of nodules, polyps, cysts, Reinkes edema, and sulcus vocalis. Inclusion, exclusion, diagnostic criteria and clinical outcome evaluation of included studies were analyzed using Preferred Reporting Items for Systematic Reviews and Meta‐Analyses criteria.
Results
Of the 155 relevant publications, 42 studies were included. Thirty‐five were clinical studies and seven were experimental research studying the impact of reflux on vocal fold tissue. Only seven clinical studies utilized objective LPR diagnoses (p
H monitoring), suggesting an association between LPR and the development of nodules, polyps, and Reinkes edema. These studies were characterized by a substantial heterogeneity due to discrepancies in inclusion/exclusion criteria, diagnostic methods, and clinical outcome evaluation. The few basic science studies on this topic support that LPR creates an environment that may predispose to BLVF through changes in defense mechanisms of the vocal folds, cell‐to‐cell dehiscence, inflammatory reaction of the vocal folds, and reaction to phonotrauma.
Conclusions
Caustic mucosal injury from LPR could cause increased susceptibility of the vocal fold mucosa to injury and subsequent formation of nodules, polyps, or Reinkes edema. However, the heterogeneity and the low number of high‐quality studies limit the ability to draw definitive conclusions. Future clinical and experimental studies are needed to better identify the role of reflux in development of BLVF.
Laryngoscope, 129:E329–E341, 2019

Clinical applications of three‐dimensional printing in otolaryngology–head and neck surgery: A systematic review

16-08-2019 – Chris J. Hong, Andreas A. Giannopoulos, Brian Y. Hong, Ian J. Witterick, Jonathan C. Irish, John Lee, Allan Vescan, Dimitrios Mitsouras, Wilfred Dang, Paolo Campisi, John R. de Almeida, Eric Monteiro

Journal Article, Review

Objectives
Medical three‐dimensional (3D) printing, the fabrication of handheld models from medical images, has the potential to become an integral part of otolaryngology–head and neck surgery (Oto‐HNS) with broad impact across its subspecialties. We review the basic principles of this technology and provide a comprehensive summary of reported clinical applications in the field.
Methods
Standard bibliographic databases (MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and The Cochrane Central Registry for Randomized Trials) were searched from their inception to May 2018 for the terms: “3D printing,” “three‐dimensional printing,” “rapid prototyping,” “additive manufacturing,” “computer‐aided design,” “bioprinting,” and “biofabrication” in various combinations with the terms: “ptolaryngology,” “head and neck surgery,” and “otology.” Additional articles were identified from the references of retrieved articles. Only studies describing clinical applications of 3D printing were included.
Results
Of 5,532 records identified through database searching, 87 articles were included for qualitative synthesis. Widespread implementation of 3D printing in Oto‐HNS is still at its infancy. Nonetheless, it is increasingly being utilized across all subspecialties from preoperative planning to design and fabrication of patient‐specific implants and surgical guides. An emerging application considered highly valuable is its use as a teaching tool for medical education and surgical training.
Conclusions
As technology and training standards evolve and as healthcare moves toward personalized medicine, 3D printing is emerging as a key technology in patient care in Oto‐HNS. Treating physicians and surgeons who wish to stay abreast of these developments will benefit from a fundamental understanding of the principles and applications of this technology.
Laryngoscope, 129:2045–2052, 2019

Frailty as a predictor of outcomes in patients undergoing head and neck cancer surgery

16-08-2019 – David P. Goldstein, Michael C. Sklar, John R. de Almeida, Ralph Gilbert, Patrick Gullane, Jonathan Irish, Dale Brown, Kevin Higgins, Danny Enepekides, Wei Xu, Jie Su, Shabbir M.H. Alibhai

Journal Article

Objectives
To evaluate whether frailty and functional measures are predictors of perioperative complications and length of hospital stay (LOS) in patients undergoing head and neck cancer surgery.
Study Design
Prospective study.
Methods
Patients 50 years and older undergoing major head and neck cancer surgery between 2011 and 2015 preoperatively completed Frieds Frailty Index, Barthel Index, Lawton‐Brody questionnaire and Vulnerable Elders Survey‐13. Primary outcome measures were postoperative complications and LOS, which were analyzed using multivariable logistic and linear regression models.
Results
There were 274 patients recruited (105 aged 50–64 and 169 aged 65 and older). Of these, 119, 132, and 23 were defined as non‐frail, pre‐frail, and frail, respectively. Frailty score and functional measures were not predictors of overall complications. In multivariable models, frailty score (odds ratio OR = 1.36; 95% confidence interval CI, 1.04–1.78, P = .025) was a predictor of medical complications and Clavien‐Dindo Grade III and higher complications independent of age and comorbidity. Higher frailty score (β = 1.07; 95% CI, 1.02–1.12, P = .0025) and less independence on the Lawton Brody (β = −0.08; 95% CI, −0.11 to −0.05, P < .001) and Barthel Index (β = −0.12; 95% CI, −0.19 to −0.06, P < .001) were predictors of increased LOS.
Conclusions
Frailty was a predictor of type and severity of complications. Both frailty and measures of independence in activities of daily living were independent predictors of LOS. Frailty and functional assessment can help surgeons identify patients at risk of adverse postoperative outcomes and thus aid in counselling patients as well as identifying patients that may benefit from comprehensive geriatric assessment and targeted interventions.
Level of Evidence
Prognosis study 2b Laryngoscope, 2019

Is a voice‐specific instrument more indicative of stroboscopy results than common clinical queries?

16-08-2019 – Elliana Kirsh DeVore, Thomas L. Carroll, Jennifer J. Shin

Journal Article

Objectives
To determine whether the Voice Handicap Index‐10 (VHI‐10) predicts diagnoses made via laryngoscopy/stroboscopy, as compared to common clinical inquiries about vocal characteristics.
Methods
We prospectively collected data from a cohort of 204 consecutive patients newly presenting for ambulatory laryngology evaluation. Each patient completed the VHI‐10 and 16 concurrent mainstream queries about vocal characteristics such as weakness, breathiness, fatiguability, or inability to shout. Using the objective diagnoses made by laryngoscopy/stroboscopy as a gold standard, the area under the receiver operating characteristic curves (AUC), sensitivity, and specificity were determined.
Results
For unilateral vocal fold paralysis, VHI‐10 scores had an AUC of 0.78 (95% CI, 0.68–0.88) and had better discrimination than 12 common clinical queries. At a threshold score of ≥11, VHI‐10 sensitivity was 0.94; at a threshold of ≥31, specificity was 0.91. For laryngeal stenosis, the VHI‐10 score demonstrated moderate discrimination, with an AUC of 0.79 (95% CI, 0.56–1.00) and higher discrimination than three common clinical queries. At a threshold score of ≥11, VHI‐10 sensitivity was 1.00; at a threshold of ≥31, specificity was 0.89. Both VHI‐10 scores and common clinical queries had low diagnostic ability for vocal fold paresis, laryngopharyngeal reflux (LPR), paradoxical vocal fold motion, and vocal fold scar or atrophy.
Conclusions
The VHI‐10 score is an effective diagnostic indicator of laryngoscopy/stroboscopy findings of vocal fold paralysis and laryngeal stenosis, performing better than multiple mainstream queries about vocal characteristics. VHI‐10 scores and common clinical queries are limited in their ability to indicate paresis, reflux, paradoxical motion, and vocal fold scar or atrophy.
Level of Evidence2c Laryngoscope, 2019

Frontal inverted papillomas: A 25‐year study

16-08-2019 – Cheuk Lun Sham, C. Andrew van Hasselt, Samuel M. W. Chow, Dennis L. Y. Lee, Ryan H. W. Cho, John K. S. Woo, Michael C. F. Tong

Journal Article

Objectives/Hypothesis
This study analyzes the treatment outcomes of frontal inverted papillomas (FIPs) in an attempt to provide guidelines for surgery selection.
Study Design
Retrospective case series.
Methods
The treatment results of 29 FIPs classified into five categories were retrospectively analyzed. The five categories are F1, tumor prolapsed into frontal sinus, tumor origin outside frontal sinus; F2, tumor origin inside frontal sinus, medial to the plane of lamina papyracea; F3, tumor origin inside frontal sinus, lateral to the plane of lamina papyracea; F4, bilateral; and F5, extrasinonasal.
Results
Of the 11 F1 cases, 73% had Draf I and 27% had Draf IIA procedures. There was one (9%) frontal recurrence and one (9%) frontal stenosis. Of the 10 F2 cases, 10% had Draf I, 40% had Draf IIA, 40% had Draf IIB, and 10% had Draf III surgery with a trephination. One patient (10%) had a frontal recurrence. Of the five F3 cases, 40% had Draf IIA surgery, 20% had external frontoethmoidectomy, and 40% had external frontal sinusotomy. The recurrence rate was 60%, and frontal stenosis rate was 60%. The two F4 cases had external frontal sinusotomies and Draf III surgery with no frontal recurrence or stenosis. The patient with the F5 had a frontal recurrence after Draf IIA surgery and external frontoethmoidectomy.
Conclusions
Draf I or IIA surgery is adequate for most F1 tumors, and Draf II surgery is adequate for most F2 tumors. F3 and F4 tumors can be managed initially by Draf III surgery with external frontal sinusotomy added when required. F5 tumors probably require combined surgical approaches.
Level of Evidence4 Laryngoscope, 2019

Anemia and blood transfusion requirements in endoscopic sinus surgery: A propensity‐matched analysis

16-08-2019 – Roman Povolotskiy, Samantha Y. Cerasiello, Sana H. Siddiqui, Soly Baredes, Jean Anderson Eloy, Wayne D. Hsueh

Journal Article

Objective
Massive bleeding requiring blood transfusion is a feared complication of endoscopic sinus surgery (ESS). In an effort to improve healthcare quality and outcomes, research is focused on identifying the risk factors for complications following surgical procedures. Blood transfusions have been linked to increased complication rates, but their role has not been extensively studied in ESS.
Methods
The American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) participant user files 2005 to 2014 were queried for all cases of ESS. Patients were divided into cohorts based on anemia (hematocrit <39.00 in men and <36.00 in women) and hematocrit levels. Univariate analyses and a propensity score‐matching algorithm were employed.
Results
Of 630 cases of ESS, 117 (18.6%) had preexisting anemia. Anemic patients were more likely to be black (19.8% vs. 6.7%, P ≤ 0.001), undergo longer operation times (117.50 minutes ±155.73 vs. 129.85 minutes ±36.03, P = 0.005), have diabetes (28.2% vs. 10.9%, P ≤ 0.001), and have hypertension (46.2% vs. 33.1%, P = 0.010). Following propensity score matching, 109 cases were selected for each cohort, with no significant differences in demographics, comorbidities, operation time, or outpatient status. The anemic cohort was independently associated with an increase in overall postoperative complications (17.4% vs. 7.3%, P = 0.038). Transfusion use was significantly associated with preoperative hematocrit levels <30 (30.0% vs. 4.5%, P = 0.001) and between 30 and 34.99 (13.9% vs. 2.5%, P = 0.011).
Conclusion
Preoperative anemia is a significant predictor of overall complications and bleeding requiring transfusion for patients undergoing ESS. These results highlight the need for careful preoperative assessment and management of anemia in this population.
Level of Evidence
NALaryngoscope, 2019

Should an elective neck dissection be performed for maxillary sinus squamous cell carcinoma?

16-08-2019 – Michael H. Berger, Bobby A. Tajudeen, Maie A. St. John, Tjoson Tjoa, Edward C. Kuan

Journal Article

Pharyngeal‐sparing radiation for head and neck carcinoma of unknown primary following TORS assisted work‐up

14-08-2019 – “Amardeep S. Grewal, Karthik Rajasekaran, Steven B. Cannady, Ara A. Chalian, Alireza F. Ghiam, Alexander Lin, Virginia LiVolsi, John N. Lukens, Nandita Mitra, Kathleen T. Montone, Jason G. Newman, Bert W. OMalley, Christopher H. Rassekh, Gregory S. Weinstein, Samuel Swisher‐McClure”

Journal Article

Objective
In patients with head and neck carcinoma of unknown primary (HNCUP;p
T0) following TORS‐assisted workup, we have adopted a pharyngeal‐sparing radiation therapy (PSRT) approach targeting only the at‐risk neck and omitting treatment of the pharynx. We report outcomes following PSRT, and compare to institutional historical control subjects who received pharyngeal‐targeted RT (PRT).
Methods
Between 2009 and 2018, 172 patients underwent TORS‐assisted endoscopy as part of their workup for HNCUP. Following TORS, 54 patients had p
T0 disease, of which 45 received RT. Forty‐nine percent received PSRT and 51% received PRT.
Results
No statistically significant differences existed between the PSRT and PRT groups with respect to overall nodal distribution, p16 positivity (55% vs. 43%, P = .12), neck dissection rates (77% vs. 65%, P = .51), and administration of chemotherapy (55% vs. 65%, P = .55). Median follow‐up for PSRT and PRT groups were 24 and 28 months, respectively (P = .04). Two‐year RFS was 86% and 74% for PSRT and PRT patients, respectively (log‐rank P = .30). Three and six patients recurred after PSRT and PRT, respectively. Two‐year OS for PSRT and PRT patients was 91% and 74%, respectively (log‐rank P = .31). Compared to PRT, PSRT was associated with statistically significantly less: grade 2+ mucositis (18% vs. 91%, P < .01), new opioid requirement (27% vs. 91%, P < .01), mean weight loss during RT (6.2 lbs vs. 17.4 lbs, P < .01), feeding tube placement during RT (5% vs. 43%, P < .01), and treatment‐related unplanned hospitalizations (9% vs. 39%, P = .04).
Conclusion
Following TORS‐assisted management of patients with p
T0 HNCUP, we observed reduced toxicity following PSRT compared to PRT without apparent compromise of disease cure.
Level of Evidence
Level 3 evidence, retrospective review comparing cases and controls
Laryngoscope, 2019

Preoperative biopsy in parotid malignancies: Variation in use and impact on surgical margins

14-08-2019 – Liliya Benchetrit, Sina J. Torabi, Elliot Morse, Saral Mehra, Rahmatullah Rahmati, Heather A. Osborn, Benjamin L. Judson

Journal Article

Objectives
Determine rate of preoperative biopsy in parotid malignancies, identify factors associated with its use, and its association with surgical margins.
Study Design
Retrospective cohort.
Setting
Commission on Cancer–Accredited Institutions.
Subjects and Methods
We included 5533 patients treated surgically for a parotid malignancy 2004–2014 in the National Cancer Database. Chi‐squared tests, univariable, and multivariable logistic regressions were used to evaluate predictors of preoperative biopsy (defined as needle, aspiration, or incisional), and associate biopsy with surgical margins.
Results
Preoperative biopsy was utilized in 26.0% of patients. Biopsy was more likely in patients >60 years (odds ratio OR: 1.19, P = .035), advanced clinical T stage (vs. T1,T2 OR: 1.23, P = .009; T3 OR: 1.26, P = .026; T4A OR: 2.05, P < .001), advanced clinical N stage (vs. N0, N1: OR: 1.39, P = .013; N2/3: OR: 1.63, P < .001), in academic centers (OR: 1.18, P < .024), and in higher volume centers (vs. low, medium OR: 1.28, P = .002; high OR: 2.16, P < .001). Biopsy use increased over time (vs. 2004–2006, 2007–2010 OR: 1.20, P = .047; 2011–2014 OR: 1.39, P < .001). Biopsy was associated with a reduced risk of positive margins in patients with clinical T1 stage (OR: 0.70, P = .012), and younger than 61 (OR: 0.79, P = .036).
Conclusion
The national rate of preoperative biopsy in parotid malignancy is low at 26.0%, but has increased over time. Preoperative biopsy is associated with a reduced risk of positive margins in younger patients and those with early clinical stage, suggesting its increased use may improve surgical outcomes and decrease reoperation or adjuvant therapy in these subgroups of patients.
Level of Evidence3 Laryngoscope, 2019

Beyond Depth of Invasion: Adverse Pathologic Tumor Features in Early Oral Tongue Squamous Cell Carcinoma

14-08-2019 – Andrew R. Larson, Jacquelyn Kemmer, Eric Formeister, Ivan El‐Sayed, Patrick Ha, Jonathan George, William Ryan, Emily Chan, Chase Heaton

Journal Article

Objective
In small (≤2 cm) oral tongue squamous cell carcinoma (OTSCC), we sought to clarify the contribution of pathologic features including perineural invasion (PNI), lymphovascular invasion (LVI), and worst pattern of invasion‐5 (WPOI‐5) to clinical outcomes relative to tumor depth of invasion (DOI) of > or ≤ 4 mm.
Methods
Cases of ≤2 cm OTSCC treated surgically between 2000 and 2017 at an academic cancer center were reviewed, with retrospective pathologic slide review of DOI, LVI, PNI, and WPOI‐5. Primary outcome measures included occult nodal positivity, 2‐year locoregional recurrence (LRR), disease‐specific survival (DSS), and overall survival (OS).
Results
One hundred tumors were included in analyses; 50 had DOI ≤ 4 mm, while 50 had DOI > 4 mm. When DOI was ≤4 mm, the presence of PNI, LVI, or WPOI‐5 was not associated with higher rates of occult cervical metastasis, LRR, or OS. When DOI was >4 mm, there was no difference in rates of occult cervical metastasis or LRR with each feature. On multivariate analysis, only the presence of two or more adverse features was associated with higher LRR (OR 5.7, P = .01) and worse DSS (HR 6.5, P = .02).
Conclusion
The rate of occult cervical metastases in small (≤2 cm) OTSCC when DOI is ≤4 mm is very low even when PNI, LVI, or WPOI‐5 is present, and 2‐year LRR is no different. When DOI is >4 mm, the strongest predictor of recurrence and survival on multivariate analysis is the presence of two or more features in the tumor.
Level of Evidence4 Laryngoscope, 2019

Computed tomography performance in predicting extranodal extension in HPV‐positive oropharynx cancer

14-08-2019 – Farhoud Faraji, Nafi Aygun, Stephanie F. Coquia, Christine G. Gourin, Marietta Tan, Lisa M. Rooper, David W. Eisele, Carole Fakhry

Journal Article

Objectives
To evaluate the performance characteristics of seven predetermined imaging features on pretreatment computed tomography (CT) in identifying extranodal extension (ENE) in cervical lymph node metastases from human papillomavirus‐positive oropharyngeal carcinoma (HPV‐OPC).
Study Design
Retrospective study.
Methods
Seventy‐three patients with HPV‐OPC who underwent primary surgery and cervical lymph node dissection were included. Preoperative contrast‐enhanced CT (cCT) imaging was evaluated by two radiologists blinded to pathological results. Each cCT was scored for seven imaging features of interest: 1) indistinct capsular contours, 2) irregular nodal margins, 3) perinodal fat stranding, 4) perinodal fat planes, 5) nodal necrosis, 6) intranodal cysts, and 7) nodal matting. Logistic regression was employed to determine radiologist‐specific odds ratios (OR) of predicting ENE for each imaging feature and radiologist‐specific receiver operating characteristics (sensitivity Sn, specificity Sp, area under the curve AUC, positive predictive value PPV, negative predictive value NPV) for each imaging feature.
Results
Thirty‐two (44%) patients had ENE‐positive lymph nodes. The presence of irregular margins (ORA = 12.3, 95% confidence interval CIA = 2.3–65.9; ORB = 7.0, 95% CIB = 1.4–36.3) and absence of perinodal fat plane (ORA = 6.8, 95% CIA = 2.0–23.3; ORB = 14.2, 95% CIB = 1.7–120.5) were significantly associated with ENE for each radiologist. Irregular nodal margin status was most specific for ENE (Sn
A = 45%, Sp
A = 94%, AUCA = 69%, PPVA = 82%, NPVA = 73%; Sn
B = 28%, Sp
B = 95%, AUCB = 61%, PPVB = 80%, NPVB = 64%). Absence of perinodal fat plane was most sensitive for ENE (Sn
A = 87%, Sp
A = 50%, AUCA = 69%, PPVA = 59%, NPVA = 62%; Sn
B = 96%, Sp
B = 34%, AUCB = 65%, PPVB = 53%, NPVB = 63%).
Conclusions
Of the seven imaging features hypothesized to be associated with ENE‐status, the presence of irregular nodal margins and absence of perinodal fat plane were the most specific and sensitive features, respectively.
Level of Evidence4 Laryngoscope, 2019

Comorbidity burden and nonclinical factors associated with sinonasal cancer all‐cause mortality

14-08-2019 – Premal B. Desai, Aleksandr R. Bukatko, Matthew C. Simpson, Eric Adjei Boakye, Jason W. Greenberg, Greg M. Ward, Ronald J. Walker, Jastin L. Antisdel, Nosayaba Osazuwa Peters

Journal Article

Objective
To describe comorbidity burden and nonclinical factors associated with all‐cause mortality of sinonasal cancer in the United States.
Methods
The National Cancer Database (2004–2013) was queried for adult cases of sinonasal cancer (n = 10,518). Outcome of interest was all‐cause mortality. Independent variables included comorbidity score and nonclinical factors such as age, gender, race, facility type, distance to facility, insurance, and income. Survival analysis was conducted via multivariable extended Cox regression with Heaviside adjustments.
Results
Patients were mostly (79%), male (61%), and mean age of diagnosis was 63.5 years. Approximately one in five patients (18.7%) had a major comorbid condition (Charlson‐Deyo score ≥ 1) at diagnosis. After adjusting for clinical factors, increasing comorbidity score was associated with a corresponding increase in hazard of mortality (a
HR comorbidity score of 1 = 1.25; 95% CI, 1.16, 1.35), (a
HR score of 2+ = 1.61; 95%, CI 1.41, 1.83). Hazard of mortality was also associated with being male (a
HR = 1.11; 95% CI, 1.04, 1.17); black (a
HR = 1.13, 95% CI, 1.03, 1.24); uninsured (a
HR = 1.45; 95% CI, 1.25, 1.68) or on Medicaid (a
HR = 1.50; 95% CI, 1.33, 1.69); residence in zip codes with lower median income quartile (a
HR < $30,000 = 1.17; 95% CI, 1.06, 1.29); and treatment at community cancer programs (a
HR = 1.14, 95% CI 1.01, 1.28).
Conclusion
Comorbid disease is associated with all‐cause sinonasal cancer mortality, and after accounting for known clinical factors, significant differences in mortality persist based on disparity‐driven, nonclinical factors.
Level of Evidence
NA Laryngoscope, 2019

Effect of medical comorbidities on treatment regimen and survival in T3/T4 laryngeal cancer

13-08-2019 – Craig Bollig, Jumah Ahmad, Laura Dooley

Journal Article

Objective
Investigate the impact of medical comorbidities on treatment regimen and overall survival (OS) in patients with locally advanced laryngeal cancer.
Study Design
Retrospective Review of the National Cancer Database (NCDB).
Methods
The NCDB was queried for patients with T3 and T4 laryngeal cancer. Comorbidity scores were calculated from the Charlson‐Deyo comorbidity index (CDCI). Univariate and multivariate analyses explored the association of CDCI scores on treatment regimen and OS.
Results14,053 patients were analyzed. 65% of patients had a CDCI score of 0, whereas 25%, 7%, and 3% had CDCI score of 1, 2, and ≥3, respectively. As patients’ CDCI increased, they became more likely to receive treatment options other than a laryngectomy or chemoradiation therapy (CRT) (P < 0.0001). Patients with CDCI ≥1 were more likely have a laryngectomy than those with CDCI 0 (P < 0.0001). In patients with T3 tumors, OS did not differ between those receiving CRT versus laryngectomy with any CDCI score. In patients with T4 tumors, laryngectomy was associated with improved OS compared to CRT across all CDCI scores except CDCI ≥3.
Conclusion
Our results support the current national guidelines with a recommendation for CRT or TL for T3 tumors and a preference for TL for T4 tumors. These outcomes are generally consistent in patients as their CDCI scores increases.
Level of Evidence
NALaryngoscope, 2019

Obesity May Not Affect Outcomes of Transoral Robotic Thyroidectomy: Subset Analysis of 304 Patients

13-08-2019 – Dora Kai Chun Tai, Hoon Yub Kim, Dawon Park, Jiyoung You, Hong Kyu Kim, Jonathan O Russell, Ralph Tufano

Journal Article

Objectives/Hypothesis
Obesity is an increasing health concern worldwide. It has been associated with perioperative complications that could affect patient outcomes. Our aim was to compare surgical outcomes in obese and nonobese patients after transoral robotic thyroid (TORT) surgery.
Study Design
Retrospective cohort study.
Methods
A total of 304 consecutive patients who underwent TORT between January 2012 to December 2017 were included in the study. Patients were divided into two groups according to their body mass index (BMI): BMI < 30 kg/m2 and BMI ≥30 kg/m2. Patient demographics, operative extent, pathological data, surgical outcomes, and postoperative complications were included and analyzed. A χ2 test was used to compare categorical variables, and a Student t test was used to compare changes of continuous variables between groups. Statistical significance was conferred by a two‐tailed P value of ≤.05.
Results
There were 290 patients in the non‐obese group and 14 patients in the obese group. There was no statistically significant difference between the two groups in terms of patient demographics, operative procedure, or pathological characteristics. The only statistically significant difference was for lymph node dissection (P = .012); however, for both groups, unilateral central node dissection was the most common procedure. There was also no statistically significant difference found for operative time, length of stay, pain score, or postoperative complications including TORT‐specific complications such as oral commissure tear and general complications such as recurrent nerve injury.
Conclusions
This initial experience shows that TORT appears to be a safe and feasible option for obese patients pursuing scarless thyroid surgery.
Level of Evidence
NALaryngoscope, 2019

The safety and efficacy of open bedside tracheotomy: A retrospective analysis of 1000 patients

12-08-2019 – David Z. Liao, Vikas Mehta, Corin M. Kinkhabwala, Daniel Li, Sarah Palsen, Bradley A. Schiff

Journal Article

Objectives
To evaluate the safety/efficacy of performing open bedside tracheotomy (OBT) in intensive care unit (ICU) patients and identify predictive factors for outcomes.
Methods
This is a retrospective cohort study. We identified 1000 consecutive patients undergoing OBT at a single university hospital starting from August 1, 2007. Complication rate, 30‐day mortality, decannulation rate, time to surgery (TTS) from initial consult, and ICU length of stay were analyzed. Multivariate analysis was performed to identify predictors of complication rate, 30‐day mortality, and decannulation rate.
Results
Mean TTS was 1.80 days. Major complication rate was 1%. No intraoperative deaths were caused by tracheotomy although two deaths resulted from late tracheotomy‐related complications. Thirty‐day mortality was 26.6%. The only significant predictor for overall complications was mild chronic hepatitis (OR = 2.355). Predictors for 30‐day mortality included platelet count <50,000 (OR = 2.125) and vasopressor use (OR = 3.51). Each additional year of age was associated with decreased decannulation rate (OR = 0.972).
Conclusions
This study demonstrates the safety and efficacy of starting an OBT program in a highly comorbid population without strict selection criteria. Safety of OBT was supported by minimal major complication rates and no intraoperative tracheotomy‐related deaths in our cohort. These complication rates were comparable to, or lower than, published studies of open and percutaneous techniques. Predictive factors for decannulation, complication, and mortality were identified to help determine which patients would benefit from OBT.
Level of Evidence4 Laryngoscope, 2019

Navy diver with recurrent facial nerve baroparesis treated with eustachian tube balloon dilation

10-08-2019 – Edward R. Utz, Sean R. Wise

Case Reports

Facial nerve baroparesis is a rare complication of middle ear barotrauma reported almost exclusively in overpressure events related to diving and flying. Until the development of Eustachian tube balloon dilation, no diving compatible options existed to effectively and safely prevent recurrence. We present a case of a U.
S. Navy diver with a history of repeated ipsilateral facial nerve paresis that occurred during diving. The patient underwent Eustachian tube balloon dilation of the affected side. Following surgery, the patient completed a recompression chamber simulated dive that allowed the patient to return to diving. The patient has been symptom‐free for 12 months following dilation. Laryngoscope, 2019

Perforator‐based propeller flap for fibula free flap donor site repair: A novel surgical technique

10-08-2019 – Patrick F. Morgan, Joshua D. Hornig, Suhael R. Momin, William G. Albergotti, Robert M. Brody, Evan M. Graboyes

Journal Article

Efficacy of a silicone plug for patulous eustachian tube: A prospective, multicenter case series

10-08-2019 – Ryoukichi Ikeda, Takeshi Oshima, Kunihiro Mizuta, Maki Arai, Shiori Endo, Ryoji Hirai, Koji Ikeda, Satoki Kadota, Yuki Otsuka, Takuhiro Yamaguchi, Tetsuaki Kawase, Toshimitsu Kobayashi

Journal Article

Objectives/Hypothesis
To report the efficacy and safety of transtympanic plugging of the eustachian tube (ET) using a silicone plug (Kobayashi plug) for chronic patulous ET (PET).
Study Design
Prospective and multicenter trial conducted in which 30 PET patients were resistant to at least 6 months of conservative treatment.
Methods
The efficacy and safety of 28 and 27 patients, respectively, were analyzed. All patients fulfilled inclusion and exclusion criteria. The primary end point used the patulous eustachian tube handicap inventory‐10 (PHI‐10), and the secondary end point used ET function tests such as sonotubometry, tubo‐tympano‐aerodynamic‐graphy, and respiratory movement of the tympanic membrane and auscultation of voice sounds transmitted from the nose through the ET to the external auditory canal at 3months after surgery.
Results
PHI‐10 scores were 34.4 ± 4.2, 6.4 ± 9, and 5.7 ± 8.6 at screening, and 3 and 6 months after surgery. Twenty‐three cases (82.1%, 95% confidence interval: 63.1%–93.9%) were judged as successes. There were five cases (17.2%) of middle ear effusion, four cases (13.8%) of tympanic membrane perforation, and one case of tinnitus due to surgery to remove the plug. No severe or life‐threatening complications were found.
Conclusions
This study revealed the efficacy and safety of silicone plug insertion for severe PET patients.
Level of Evidence2 Laryngoscope, 2019

Heparin therapy as adjuvant treatment for profound idiopathic sudden sensorineural hearing loss

09-08-2019 – Junsuk Kim, Jinuk Jeong, Ryun Ha, Woongsang Sunwoo

Journal Article

Objectives/Hypothesis
This study aimed to provide evidence of whether unfractionated heparin used as adjuvant therapy in conjunction with systemic corticosteroid therapy improves hearing recovery in patients with profound idiopathic sudden sensorineural hearing loss (ISSNHL), and to compare the effect of this treatment with those of additional intratympanic corticosteroid therapy.
Study Design
Retrospective chart review.
Methods
Eighty‐seven patients with profound ISSNHL (≥90 d
B) and who had been admitted at a tertiary referral center between 2010 and 2018 were retrospectively reviewed, 67 patients for additional intratympanic corticosteroid injection (ITSI) (ITSI group) and 21 for adjuvant heparin therapy (heparin group). Hearing recovery was evaluated by grade assessment according to the American Academy of Otolaryngology–Head and Neck Surgery criteria.
Results
Of the patients in the heparin group, 42.8% recovered serviceable hearing, which was significantly higher than the recovery rates (19.7%) of those in the ITSI group. Particularly, in patients with pretreatment hearing level of 90 to 100 d
B, adjuvant heparin therapy enhanced therapeutic effects with a significant hearing recovery rate of 80%. However, in patients with initial hearing level >100 d
B, the rates of significant hearing recovery in the two groups were roughly equal and remained unsatisfactory (8.1% in the ITSI group and 9.1% in the heparin group).
Conclusions
The results of this study suggest that the treatment of profound ISSNHL with adjuvant heparin therapy, in combination with systemic steroid therapy, results in higher hearing recovery rates when compared to combined local and systemic corticosteroid therapy, without serious complications.
Level of Evidence3b Laryngoscope, 2019

Multifactorial analysis of local control and survival in patients with early glottic cancer

09-08-2019 – Tsutomu Nomura, Junichi Ishikawa, Masafumi Ohki, Atsushi Ohata, Ryuichiro Araki, Sigeru Kikuchi

Journal Article

Objectives
The purpose of this study is to determine the effects of various prognostic factors for early glottic cancer patients who underwent radiotherapy.
Methods
We retrospectively reviewed the all patients who were treated at our hospital for early glottic squamous cell carcinoma from 2004 to 2016. Data included patients age, sex, T classification, tumor size, pathological grade, anterior commissure involvement, subglottic extension, laryngeal ventricle involvement, and restriction of vocal cord movement.
Results
There were 74 patients with T1 tumors and 31 with T2 tumors. Recurrence was found in four patients with T1 and eight patients with T2. There were 99 males and six females enrolled, and the mean age was 67.5 ± 9.2 years for T1a, 67.3 ± 11.2 years for T1b, and 67.4 ± 7.9 years for T2. One patient with recurrence after 1 month was thought to have a residual tumor. The 5‐year overall survival (OS) rate and the 5‐year disease‐specific survival (DSS) rate for T1–T2 patients were both 100%. The rate of larynx preservation was 94.6% for T1 and 74.2% for T2. A univariate analysis showed that the effective factors were age, T, size, SE. A multivariate logistic regression analysis showed that age influenced the recurrence status. Size is also suspected to be a prognostic factor.
Conclusions
This study revealed that the effective factors were age, T, size, and SE.
Level of Evidence4 Laryngoscope, 2019

Microflap dissection with a cotton ball self‐retraction technique in treating vocal cysts

09-08-2019 – Hong Geun Ahn, Jae Yeup Jung, Hong‐Shik Choi, Joo Hyun Kim

Journal Article

The natural progression of low‐frequency hearing loss in patients who meet hybrid implant system candidacy criteria

08-08-2019 – Masahiro Okada, Amy Quinkert, Kevin H. Franck, D. Bradley Welling

Journal Article

Objectives/Hypothesis
To investigate the natural progression of hearing loss in patients with high‐frequency hearing loss whose audiograms met the criteria for a hybrid cochlear implant (CI).
Study Design
Retrospective database review.
Methods
We retrospectively identified patients who met the criteria for a hybrid CI from our audiometric database. We also recorded the etiology of hearing loss in each patient and excluded patients with retrocochlear etiologies, those age <6 years, duration of observation <1 year, or those with a mixed or conductive hearing loss. We calculated the pre‐CI progression of residual low‐frequency (LF) hearing level in decibels per year and investigated the risk factor of the progression of hearing loss.
Results
A total of 1,083 ears of 944 patients were included in this study. The average rate of hearing loss progression for all etiologies was 1.70 ± 0.10 d
B/yr at an average of 250 Hz, 500 Hz, and 1 k
Hz in the affected ear(s). The progression of hearing loss was 5.0 ± 0.93 d
B/yr in patients with Menieres disease and 3.5 ± 0.76 d
B/yr in those with autoimmune disease, both of which were significantly faster than progression rates in other etiologies. In patients with idiopathic, genetic/hereditary, and congenital hearing loss, the progression of hearing loss was 1.46 ± 0.10 d
B/yr. Patients with steeply sloping hearing loss experienced significantly faster progression in the ipsilateral ear compared to patients with another audiometric type.
Conclusions
It is suggested that Menieres disease, autoimmune‐mediated inner ear disease, and steeply sloping hearing loss in the ipsilateral ear are risk factors for faster progression of residual LF hearing level.
Level of Evidence4 Laryngoscope, 2019

Does Thyroid Gland Preserving Total Laryngectomy Affect Oncological Control in Laryngeal Carcinoma?

08-08-2019 – Jessica K. McGuire, Gerrit Viljoen, John Rocke, Siobhan Fitzpatrick, Sameera Dalvie, Johannes J. Fagan

Journal Article

Introduction
Thyroid lobectomy is recommended with total laryngectomy in the National Comprehensive Cancer Network guidelines. However, it is associated with a 32% to 89% risk of hypothyroidism, which is a problem for patients without access to thyroid hormone monitoring and replacement. A number of studies have reported a low incidence of thyroid gland involvement and recommended preserving the thyroid gland in favorable cases. Yet there are no studies that report whether thyroid preserving laryngectomy for laryngeal cancer adversely affects oncologic outcomes compared to patients who have undergone thyroid lobectomy.
Objectives
To determine whether patients who underwent thyroid gland preserving laryngectomy had higher local recurrence rates or poorer disease‐free survival.
Method
A retrospective folder review of patients who underwent a total laryngectomy over a 12‐year period was conducted. Local recurrence and disease‐free survival were determined for patients who had both their thyroid lobes preserved and compared with those who had a thyroid lobectomy.
Results
Sixty‐nine patients had thyroid preserving laryngectomy and 73 patients had a thyroid lobectomy. The duration of follow‐up was 18 to 132 months (median, 30; IQR, 30). There was no significant difference in local recurrence rates (P = .76) or survival curves between the two groups.
Conclusion
Thyroid preserving laryngectomy in selected patients with advanced laryngeal carcinoma does not increase local recurrence rates, nor does it negatively affect disease‐free survival. Thyroid preservation is appropriate when intraoperative inspection of the larynx shows no extralaryngeal extension or when paratracheal nodal metastases are not a concern.
Level of Evidence
Level 4 Laryngoscope, 2019

Voice‐Related Quality of Life Increases With a Talking Tracheostomy Tube: A Randomized Controlled Trial

06-08-2019 – Vinciya Pandian, Therese Cole, Dana Kilonsky, Kate Holden, David J. Feller‐Kopman, Roy Brower, Marek Mirski

Journal Article

Objective
The primary objective of our study was to determine the quality of life (QOL) using a talking tracheostomy tube.
Methods
Randomized clinical trial (NCT2018562). Adult intensive care unit patients who were mechanically ventilated, awake, alert, attempting to communicate, English‐speaking, and could not tolerate one‐way speaking valve were included. Intervention comprised a Blue Line Ultra Suctionaid (BLUSA) talking tracheostomy tube (Smiths Medical, Dublin, OH, US). Outcome measures included QOL scores measured using Quality of Life in Mechanically Ventilated Patients (QOL‐MV) and Voice‐Related Quality of Life (V‐RQOL), Speech Intelligibility Test (SIT) scores, independence, and satisfaction.
Results
The change in V‐RQOL scores from pre‐ to postintervention was higher among patients using a BLUSA (Smiths Medical) compared to those who did not (P = 0.001). The QOL‐MV scores from pre‐ to postintervention were significantly higher among patients who used a BLUSA (Smiths Medical) compared to patients who did not use BLUSA (Smiths Medical) or a one‐way speaking valve (P = 0.04). SIT scores decreased by 6.4 points for each 1‐point increase in their Sequential Organ Failure Assessment scores (P = 0.04). The overall QOL‐MV scores correlated moderately with the overall V‐RQOL scores (correlation coefficient = 0.59). Cronbach alpha score for overall QOL‐MV was 0.71. Seventy‐three percent of the 22 intervention patients reported the ability to use the BLUSA (Smiths Medical) with some level of independence, whereas 41% reported some level of satisfaction with the use of BLUSA (Smiths Medical). The lengths of stay was longer in the intervention group.
Conclusion
Our study suggests that BLUSA (Smiths Medical) talking tracheostomy tube improves patient‐reported QOL in mechanically ventilated patients with a tracheostomy who cannot tolerate cuff deflation.
Level of Evidence
I Laryngoscope, 2019

Correlation Between Peak Nasal Flow Reversibility and Mucociliary Clearance in Allergic Rhinitis

06-08-2019 – Virat Kirtsreesakul, Jitanong Leelapong, Suwalee Ruttanaphol

Journal Article

Objectives/Hypothesis
Reversibility of nasal airflow after decongestion measured by rhinomanometry is associated with the severity of allergic inflammation. Peak nasal flow is a simpler alternative method for assessing nasal patency. The aim of this study was to evaluate the correlation between changes in peak nasal expiratory and inspiratory flows (PNEFs and PNIFs) after decongestion and nasal mucociliary clearance times (NMCCTs).
Study Design
Single‐center, prospective cross‐sectional study.
Methods
One hundred one allergic rhinitis patients were enrolled. Nasal symptoms and NMCCTs were assessed. PNEF and PNIF were performed before and after decongestion. Correlations between changes in PNEF and PNIF after decongestion and NMCCTs were analyzed. One‐half the standard deviation of baseline peak nasal flows was used to estimate the minimal clinically important differences (MCIDs) and discriminate between patients with reversible mucosa and with irreversible mucosa.
Results
PNEF showed more peak flow improvements after decongestion compared to PNIF. Changes in PNEF had better negative correlations with NMCCTs than PNIF (ρ = −0.49, P < .001 and ρ = −0.34, P < .001, respectively). The MCID values of the PNEF and PNIF were 27.93 and 19.74, respectively. In comparisons of NMCCTs between patients with or without MCID of peak nasal flow after decongestion, PNEF had better discrimination ability compared to PNIF (P = .003 and P = .026, respectively).
Conclusions
The limitation of reversibility as measured by peak nasal flows could indirectly point to the affection of mucosal inflammation as indicated by NMCCTs. PNEF is more sensitive to assess peak flow changes after decongestion than PNIF.
Level of Evidence2 Laryngoscope, 2019

The health utility of mild and severe dysphonia

05-08-2019 – Elliana K. DeVore, Mark G. Shrime, Eve Wittenberg, Ramon A. Franco, Phillip C. Song, Matthew R. Naunheim

Journal Article

Objectives/Hypothesis
The impact of disease states can be measured using health state utilities, which are values that reflect economic preferences for health outcomes. Utilities for dysphonia have not been studied using direct methods. The objective of this project was to establish the baseline health utilities of mild and severe dysphonia from a societal perspective.
Study Design
Direct utility elicitation survey.
Methods
Four health states (monocular blindness, binocular blindness, mild dysphonia, and severe dysphonia) were evaluated by a convenience sample of adults recruited from the general public with three computer‐aided estimation techniques (visual analog scale VAS, standard gamble SG, and time trade‐off TTO). Standardized descriptions and voice recordings from multiple dysphonic patients were employed. Perfect health was defined as a utility of 1, with death 0. Analysis of variance with post hoc pairwise comparison was used to calculate significant differences between health states.
Results
Three hundred participants were surveyed, and 225 (75.0%) responses met quality thresholds. Severe dysphonia (VAS = 48.3, SG = 0.810, TTO = 0.798) was valued significantly worse than monocular blindness (VAS = 56.2, SG = 0.834, TTO = 0.839) on the VAS (P < .001) and equivalent on SG and TTO; it was preferred over binocular blindness (VAS = 25.7, SG = 0.631, TTO = 0.622; P < .001) with all methods. Mild dysphonia evaluated favorably with all methods to the other health states (VAS = 78.5, SG = 0.902, TTO = 0.908; P < .001).
Conclusions
Voice disorders may have a measurable impact on utility, with severe dysphonia valued equivalently to monocular blindness. Mild dysphonia has a utility decrement from perfect health. These estimates are critical for quality‐of‐life assessment and could be used to assess cost‐effectiveness of treatments for voice disorders.
Level of Evidence
NALaryngoscope, 2019

The utility of intraoperative navigation of the temporal bone for otolaryngology resident training

05-08-2019 – Zachary G. Schwam, Vivian Z. Kaul, Maura K. Cosetti, George B. Wanna

Journal Article

Objectives
To determine whether image guidance improves dissection quality among residents in the temporal bone lab and to gauge their reactions to its use.
Methods
Prospective cohort study of nine otolaryngology residents who dissected cadaveric temporal bones with and without image guidance in the temporal bone laboratory. Quality of dissection was measured with the Welling scale. A survey was administered assessing their interactions with the navigation system.
Results
There was no significant difference in quality of dissection for the majority of structures or number of major errors with use of image guidance. Dissection quality of the tegmen (4.67 vs. 5.67, P = .034) and sinodural angle (0.83 vs. 1.56, P = .005) was superior in the non‐navigation specimens. The majority of residents reported increased confidence with locating several critical anatomic structures and found the system intuitive to use. Nearly all thought it would be helpful in revision cases or for aural atresia.
Conclusion
Image guidance did not improve quality of temporal bone dissection or number of major errors in this cohort of residents, but the majority found it intuitive and increased confidence in finding several structures. Navigation systems may play an important adjunctive role in resident education and further work is required to determine its optimal use.
Level of Evidence
NALaryngoscope, 2019

The suction‐assisted endoscopic suture technique: A simple method for endotracheal suturing

02-08-2019 – Steven J. Charous, Edward Westfall

Journal Article

Background
Silicone stents are commonly employed to treat subglottic stenosis. A frequent complication is the tendency of stents to migrate. As such, various techniques to secure stents have been developed over the years, none of which have gained large popularity. We present a novel, low‐cost, and easy‐to‐perform technique herein.
Objectives
To describe a novel surgical technique to secure silicone stents and prevent migration for management of subglottic stenosis.
Materials and Methods
After standard excision and dilation of stenotic portions in the subglottic or trachea. A silicone stent is introduced in a standard fashion. To secure the stent, an 18‐G needle loaded with braided suture is inserted through skin, trachea, and stent. Endoscopic visualization then permits the surgeon to grasp the suture with forceps. A separate transcutaneous puncture site is performed with an 18‐G needle attached to a 10‐cc syringe (plunger removed) and blue tip suction within the empty syringe, creating an airtight suctioning tool. The grasped suture is gently introduced into the eye of the needle and quickly travels into the 10‐cc syringe with suction assist, leaving both extracorporeal ends of the suture to tie.
Results
This stitch has been employed on seven occasions on four patients. There have been no episodes of stent migration. A laboratory model found the 18‐G needle and braided 3‐0 suture performed optimally.
Conclusions
We present a novel surgical technique to secure silicone stents in management subglottic or tracheal stenosis.
Level of Evidence
Level 4 Laryngoscope, 2019

Vocal cord function during recurrent laryngeal nerve injury assessed by accelerometry and EMG

02-08-2019 – Geir Olav Dahle, Erling Johan Setså, Øyvind Sverre Svendsen, Lodve Stangeland, John‐Helge Heimdal, Bård Henriksen, Paul Husby, Katrin Brauckhoff

Journal Article

Objective
Gradual impairment of nerve conduction is expected to be tightly associated with simultaneous gradual loss of vocal cord contractility, related to the fact that injured axons are connected to a defined number of muscle cells. In clinical studies, there is a time gap between observed adverse electromyographic (EMG) changes and examination of vocal cord function. This study evaluates the impact of intraoperative EMG changes on synchronous vocal cord contractility by simultaneous use of continuous intraoperative neuromonitoring (C‐IONM) and accelerometry for registration of actual vocal cord function at a given change of EMG amplitude.
Methods
EMG was obtained following vagus nerve stimulation by use of C‐IONM. A vocal cord accelerometer probe that could be attached to the vocal cords was developed based on a LIS3DH ultra low‐power high performance three axis linear accelerometer (STMicroelectronics, Geneva, Switzerland). Accelerometer data were registered continuously together with EMG data during traction injury of the recurrent laryngeal nerve (RLN) until an amplitude depression ≤100 μV.
Results
Six RLN from four immature domestic pigs were studied. Vocal cord contractility assessed by vocal cord accelerometry decreased in parallel with EMG amplitude, with significant correlations ranging from 0.707 to 0.968.
Conclusion
Decrease of EMG amplitude during traction injury to the RLN injury is closely associated with a parallel drop in vocal cord contractility.
Level of Evidence
NA Laryngoscope, 2019

Response to Glucocorticosteroids Predicts Olfactory Outcome After ESS in Chronic Rhinosinusitis

02-08-2019 – Vasyl Bogdanov, Ute Walliczek‐Dworschak, Katherine L. Whitcroft, Basile N. Landis, Thomas Hummel

Journal Article

Objectives
Olfaction is frequently impaired in chronic rhinosinusitis with nasal polyps (CRSw
NP) and often improves after endoscopic sinus surgery (ESS). Data about dynamics of olfactory changes after ESS are lacking, and little information is available concerning whether preoperatively administered glucocorticosteroids predict postoperative olfaction. Therefore, the aim of this study was to examine dynamics of olfaction after ESS in relation to the effect of preoperative administration of glucocorticosteroids in CRSw
NP.
Methods
This prospective study included 52 CRSw
NP patients (30 men, 22 women, mean age 54 ± 14 years) divided into a control group (n = 31) subjected to ESS without preoperative steroids and a treatment group (n = 21) receiving orally administered glucocorticosteroids preoperatively.
Self‐ratings of olfaction and olfactory testing using the extended Sniffin’ Sticks test battery (threshold, discrimination and identification TDI score) were performed. Olfaction was measured preoperatively; after termination of glucocorticosteroid treatment (only treatment group); and 2 weeks, 1 month, and 3 months postoperatively.
Results
After glucocorticosteroids, TDI score significantly improved in 57% of patients, and olfactory function remained unchanged in 43%. In addition, improvement in TDI score after steroids and 3 months postoperatively were significantly correlated (r = 0.66, P = 0.01). Patients whose olfaction did not improve after glucocorticosteroids did not benefit from surgery. Regarding postoperative olfactory dynamics, TDI score reached its maximum 1 month postoperatively and decreased again approximately 3 months after surgery.
Conclusion
Glucocorticosteroids improved olfaction in CRSw
NP comparable to surgery. In addition, changes in relation to steroids predicted olfactory outcome postoperatively. Regarding the olfactory dynamics, it could be demonstrated that olfactory function increased 1 month after surgery and decreased 3 months postoperatively.
Level of Evidence2 Laryngoscope, 2019

Nitrous oxide anesthetic versus total intravenous anesthesia for functional endoscopic sinus surgery

01-08-2019 – Benjamin J. Heller, Samuel DeMaria, Erick Mendoza, Jaime Hyman, Alfred M.C. Iloreta, Hung‐Mo Lin, Satish Govindaraj, Adam I. Levine

Journal Article

Background
Functional endoscopic sinus surgery is a common procedure for sinonasal disease, frequently performed in the outpatient setting. General anesthesia maintained with total intravenous anesthesia (TIVA) with propofol has been shown to give superior surgical conditions compared to inhaled anesthetics. This study evaluated the effects of TIVA versus a predominantly nitrous oxide (N2O)–based anesthetic with a low‐dose propofol and remifentanil infusion on sinus surgery.
Methods
Patients were randomized to either a N2O‐based (nitrous oxide with propofol and remifentanil) or TIVA (propofol and remifentanil without nitrous oxide) group. The surgeon was blinded to the anesthetic technique. Surgical field grading was performed in real time by the otolaryngologist every 15 minutes with the Boezaart grading system.
Results
There were no statistically significant differences between the Boezaart scores, duration of surgery, or estimated blood loss between the two anesthetic techniques. However, the use of N2O provided a statistically significant, 38% reduction in time from surgery end to extubation. The TIVA group had significantly decreased mean and median pain scores in the post‐anesthesia care unit (PACU). There was no difference in the rate of postoperative nausea and vomiting between the two groups.
Conclusion
A N2O‐based anesthetic for functional endoscopic sinus surgery provides similar intraoperative and postoperative conditions when compared to TIVA, while being superior in terms of time to extubation. Although the TIVA group had significantly decreased pain scores, this did not lead to a decrease in pain medicine received in the PACU, and there was no difference between groups in time to discharge.
Level of Evidence1b
Laryngoscope, 2019

A 10‐year study of the etiopathogenesis of cysts with a study of seromucinous glands in vocal folds

01-08-2019 – Nupur Kapoor Nerurkar, Trishna Chitnis, Vani Krishana Gupta, Girish Muzumdar, Keyuri Patel, Pritha Bhuiyan

Journal Article

Objective
An increasing number of vocal fold cysts excised, as compared to polyps, over the last decade led us to review these cases. We found a statistically significant increase in cysts excised as compared to polyps, over the latter 5‐year period (2013–2017). This prompted us to analyze possible factors responsible for this increase. We also performed a histological study of the normative distribution pattern of seromucinous glands in the apparently normal vocal folds.
Methods
A retrospective review of all cysts and polyps excised over a 10‐year period was performed. Patient demographics, air‐pollution levels, videostroboscopic findings and histologic analysis of pathology were reviewed. Findings were compared between the initial and latter 5‐year period of all cysts excised. The second part of the study entailed a histological study of the presence and distribution pattern of seromucinous glands in 40 apparently normal fresh frozen cadaver vocal folds.
Results
There was a statistically significant (P = .035) increase of mucous retention cysts excised as compared to polyps over the latter 5‐year period. Decreased laryngeal hydration was a significant associated finding in cysts excised over the decade as compared to polyps. Striking zone lesions, suggestive of vocal abuse, were seen in a majority of patients of both polyps and cysts excised over the decade. Air pollution had significantly increased in India over the latter 5‐year period. Vocal fold histology in cadavers revealed a presence of seromucinous glands in 32.50% (13/40) with 25.00% (10/40) present in the Superficial Lamina Propria (SLP).
Conclusion
Decreased laryngeal hydration, vocal abuse and mucous glands present in the SLP may be predisposing factors towards mucous retention cyst formation. An increase in number of these cysts excised over the latter 5‐year period was seen as was increased air pollution.
Level of Evidence3b for the first part of study and NA for the second part of the study
Laryngoscope, 2019

Locally advanced epithelial sinonasal tumors: The impact of multimodal approach

01-08-2019 – Ester Orlandi, Stefano Cavalieri, Roberta Granata, Piero Nicolai, Paolo Castelnuovo, Cesare Piazza, Alberto Schreiber, Mario Turri‐Zanoni, Pasquale Quattrone, Rosalba Miceli, Gabriele Infante, Fausto Sessa, Carla Facco, Giuseppina Calareso, Nicola Alessandro Iacovelli, Davide Mattavelli, Alberto Paderno, Carlo Resteghini, Laura Deborah Locati, Lisa Licitra, Paolo Bossi

Journal Article

Objective
Outcomes of locally advanced epithelial sinonasal cancers remain unsatisfactory; moreover, only limited and heterogeneous data exist on prognostic factors.
Methods
We reviewed all consecutive patients with American Joint Committee Cancer stage III to IV epithelial sinonasal cancers treated with platinum‐based induction chemotherapy (IC) followed by locoregional treatment between 1996 and 2015.
Results
We identified 69 patients treated with a multimodal approach (IC, surgery, radiotherapy). Overall, 44 patients recurred (64%). Of those, 19 patients received salvage surgery, but only four remained disease‐free. Median overall survival (OS) was 62.5 months. Sinonasal neuroendocrine and small cell histotypes (P = 0.0085), neuroendocrine differentiation (P = 0.006), and lack of response to IC (P = 0.03) were associated with worse OS. In patients who recurred, median OS was 13 months since recurrence. Survival was longer in patients submitted to salvage surgery (44%) than in those receiving chemotherapy alone at recurrence (29.5 vs. 4.6 months). Patients with a clinical benefit after palliative chemotherapy had a longer median OS than those with disease progression (29.2 vs. 4.4 months; P < 0.0001).
Conclusion
Globally, the prognosis of locally advanced epithelial sinonasal cancers is dismal, with worse outcomes for neuroendocrine lesions. In the recurrent setting, feasibility of salvage surgery and clinical benefit from palliative chemotherapy are associated with longer OS. A multimodal treatment strategy with IC seems to offer improved OS when compared with other retrospective series not employing such a therapeutic tool.
Level of Evidence4Laryngoscope, 2019

Histological characteristics of intra‐temporal facial nerve paralysis in temporal bone malignancies

01-08-2019 – Omer J. Ungar, Joseph B. Nadol, William C. Faquin, John P. Carey, Ophir Handzel, Felipe Santos

Journal Article

Objective
To describe the histopathologic findings and clinical presentation of intra‐temporal facial nerve invasion in primary and metastatic malignancies of the human temporal bone (TB).
Materials and Methods
Retrospective analysis of all medical records of patients diagnosed with peripheral facial nerve palsy (PFn
P) of a malignant origin was performed. Temporal bones underwent standard processing for histologic examination. Hematoxylin and eosin (H&E)–stained slides were examined by light microscopy. The histologic findings were compared to premortem clinical data.
Results
Eighteen TBs were identified in 16 patients. The male to female ratio was 9:7. The median (range) age of death was 56.5 years (27 months to 75 years). The median time interval from facial nerve injury to death was 5.5 months. There were 11 carcinomas and seven sarcomas identified. Primary TB malignancies were identified in seven TBs (39%), and the rest (11 TBs, 61%) were of metastatic origin. Complete facial nerve paralysis (House‐Brackmann HB grade VI), was the most common clinical presentation affecting nine patients (10 TBs, 56%). Neural involvement was multifocal in nature (16 of 18 TBs, 89%). The most commonly involved cranial nerve (CN) VII segment was the meatal segment (13 TBs, 72%), followed by the labyrinthine, tympanic, and vertical segments (nine, eight, and six TBs, respectively).
Conclusion
PFn
P can be the result of local, regional, or distant malignancy, and is associated with poor survival. The facial nerve can serve as a route of tumor progression intracranially. Whereas every segment of CNV II can be violated by tumors, not all PFn
P are related to direct tumor invasion.
Level of Evidence4Laryngoscope, 2019

Adapting Electromagnetic Navigation System for Transoral Robotic‐Assisted Skull Base Surgery

01-08-2019 – Raymond K. Tsang, Joseph C.K. Chung

Journal Article

An ex vivo porcine model of the anterior glottoplasty for voice feminization surgery

31-07-2019 – Matthew L. Rohlfing, Jacob E. Kuperstock, Daniel Friedman, Jeffrey H. Spiegel

Journal Article

Objective
Perceived gender identity is correctly assigned when a combination of physical and vocal attributes become congruent. Several voice feminization procedures have gained popularity, but current evidence of their impact on vocal feminization is limited to case series. This study establishes an ex vivo porcine phonatory model to evaluate the ideal extent of anterior glottic web formation in relation to frequency elevation and airway patency.
Methods
Six fresh porcine larynges were obtained and fitted with arytenoid adduction sutures. Compressed air was passed through the larynges, and the vocal folds were adducted to induce phonation. Vocal fold length, posterior glottic width, fundamental frequency, and sound pressure intensity were measured as the vocal folds were progressively shortened as per the anterior glottic web surgical technique.
Results
The average fundamental frequency prior to web formation was 109.7 Hz. The maximum frequency achieved after web formation was 403.7 Hz, and the web proportions varied from 11.8% to 61.0% of the length of the membranous vocal folds. The glottic cross‐sectional area showed an expected inverse linear relationship to the length of the glottic web. Creation of an anterior glottic web caused consistent elevation of pitch, but there was a gradual plateau of effect with increased length of the web.
Conclusion
The ex vivo porcine larynx is demonstrated as an effective, available, and low‐cost model for further study of vocal pitch elevation surgical techniques. We demonstrate that in addition to progressively reducing the cross‐sectional area of the airway, additional benefit from increased web length is limited.
Level of Evidence
NALaryngoscope, 2019

Awake thyroidectomy

30-07-2019 – Thorsen W. Haugen, Luke N. Andera, Archie B. LaMadrid

Journal Article

Objective
In this article, we present a series of 28 patients who underwent thyroid surgery using local anesthesia. We describe our technique, report outcomes, and assess how well the procedure was tolerated from a patient perspective.
Methods
Three surgeons performed awake thyroidectomies and recorded data, including the patients age and gender, surgery being performed, operative time, weight of the surgical specimen, quantity and type of local anesthetic used, additional medications, patient‐reported pain assessment, and any complications.
Results
Twenty‐seven of 28 patients (96%) successfully underwent awake thyroidectomy. One patient had to be converted to general anesthesia due to airway concerns. There were no complications; however, one patient had a panic attack. Based on a 0 to 10 scaled pain score, the average amount of pain reported was 3.4. The amount of pain the patient reported was significantly dependent on the amount of experience the operating surgeon had with this technique. Seventy‐one percent of patients tolerated surgery with local anesthesia only and did not require additional medications.
Conclusion
Awake thyroidectomy is a well‐tolerated and safe procedure in appropriately selected patients, with many potential benefits over general anesthesia. In most cases, only local anesthesia is required. Increased experience with this technique may be associated with increased patient comfort.
Level of Evidence4 Laryngoscope, 2019

Injection laryngoplasty as adjunct treatment method for muscle tension dysphonia: Preliminary findings

30-07-2019 – Daniel Novakovic, Duong Duy Nguyen, Antonia Chacon, Catherine Madill

Journal Article

Objectives
This study examined the effectiveness of injection laryngoplasty (IL) in muscle tension dysphonia (MTD) patients who did not fully respond to voice therapy. It was hypothesized that IL would improve voice quality and voice‐related quality of life measures in MTD.
Methods
A retrospective review was conducted on 37 patients with a primary diagnosis of MTD who underwent IL following a suboptimal response to voice therapy (mean age = 43.0 years; standard deviation SD = 13.4; range = 23 to 71). Outcome measures included laryngoscopic signs of supraglottic constriction, Voice Handicap Index‐10 (VHI‐10) scores, maximal phonation time, vowel fundamental frequency (F0), standard deviation of F0 (F0SD), harmonics‐to‐noise ratio (HNR), and smoothed cepstral peak prominence. These were compared between baseline and within 3 months following the IL procedure.
Results
There was significant decrease in supraglottic constriction. Mean (SD) of VHI‐10 scores decreased from 25.4 (5.7) at baseline to 15.3 (9.3) following IL. This improvement in VHI‐10 was observed in patients with and without baseline glottal insufficiency (GI). Mean (SD) of HNR (decibels) increased from 21.1 (5.4) at baseline to 22.8 (4.3) after IL. Only patients with GI demonstrated a significant improvement in HNR from baseline to post‐IL. No statistically significant differences in other acoustic measures were observed.
Conclusions
IL resulted in positive changes in voice‐related quality of life in MTD patients with and without GI. Acoustically, only those with GI demonstrated an increase in HNR following IL. Further studies are needed to examine the effects of IL in MTD.
Level of Evidence4 Laryngoscope, 2019

Inducible laryngeal obstruction: Endoscopic quantitative analysis of glottic aperture

30-07-2019 – Paulo Henrique Peitl Gregorio, Juliana Teixeira Gomes, Roberto Rodrigues, Marcia Jacomelli, Ellen Samara Santos, Marcelo Gervilla Gregorio

Journal Article

Objectives
Using a method developed for this study, the objective was to perform a quantitative analysis of glottic aperture during the respiratory cycle in subjects suspected of having inducible laryngeal obstruction (ILO) and to compare results to healthy individuals. Correlations between glottic aperture and spirometric parameters were assessed.
Methods
Subjects with high clinical suspicion of ILO and atypical inspiratory findings in spirometry had the images of their laryngoscopy displayed alongside a respiratory flow chart and both were recorded simultaneously. This method allowed detailed analysis of the glottic aperture by measuring the angle of the anterior commissure during inspiration and expiration. Healthy volunteers who performed the same tests and agreed to provide data to this study were used as a control group.
Results
All 15 subjects with ILO and 16 healthy participants were evaluated successfully using the proposed method. Measures of the anterior commissure angle in the ILO versus control group were significantly different in all observed parameters and just three ILO subjects had an anterior commissure closure greater than 50% during the respiratory cycle. Inspired volume (FIF50) and mid‐vital capacity ratio (FEF50/FIF50) had a significant correlation with glottic aperture parameters when considering the evaluation of the subjects all together.
Conclusion
The proposed method provided precise and quantitative analysis of glottic aperture during the respiratory cycle thus indicating that the usage of equipment that allows for such assessment should be encouraged. Also, the threshold of vocal cords closure accepted as indicative of ILO should be reconsidered, especially during the intercritical period of the disease.
Level of Evidence4 Laryngoscope, 2019

Increased prevalence of neural monitoring during thyroidectomy: Global surgical survey

30-07-2019 – Allen L. Feng, Sidharth V. Puram, Michael C. Singer, Rahul Modi, Dipti Kamani, Gregory W. Randolph

Journal Article

Objective
To investigate intraoperative nerve monitoring (IONM) use among thyroid surgeons.
Methods
A 25‐question survey was used to assess attitudes regarding IONM use. Surveys were sent to surgeons registered to the American Academy of Otolaryngology–Head and Neck Surgery, International Association of Endocrine Surgeons, and American Head and Neck Society.
Results
Among 1,015 respondents, 83% reported using IONM (65.1% always using IONM and 18.1% reporting selective use). For selective users, a majority reported using IONM for reoperative cases (95.1%) and in cases with preoperative vocal cord paralysis (59.8%). When comparing location, there was a significant difference in IONM implementation (P < 0.001), with 70.4% of North American responders using it ubiquitously compared to 27.4% of non‐North American responders. Preoperative laryngeal exam was performed more universally by North American surgeons and more selectively by non‐North American surgeons (P < 0.001). Other attitudes toward their implementation and the postoperative laryngeal exam were similar. Surgeons ≤45 years of age and those with ≤15 years of practice used IONM more than their peers (P < 0.001). Thyroid surgery volume, fellowship training, and type of practice had no bearing on IONM use.
Conclusion
The prevalence of IONM in thyroid and parathyroid surgeries has increased significantly over the past decade, with 83% of surgeons using IONM in some or all cases. Although IONM use may be more ubiquitous in North America, attitudes toward its implementation and pre‐ and postoperative laryngeal exams are fairly uniform. IONM use is more prevalent among younger surgeons, whereas its use has no correlation with thyroid surgery volume or type of practice.
Level of Evidence4 Laryngoscope, 2019

Optimizing international otolaryngology service trips: Perceptions from learners versus volunteers

30-07-2019 – Cameron P. Worden, Elizabeth D. Stephenson, Brent A. Senior

Journal Article

Objectives/Hypothesis
Optimizing value of medical service trips (MSTs) requires alignment of the services provided with the needs and desires of hosts. Our aim was to understand which MST services Vietnamese otolaryngologists find most beneficial and contrast to those believed most important by volunteers.
Study Design
Cross‐sectional survey.
Methods
Otolaryngologists from a tertiary care institution travel to Vietnam yearly. In March 2018, surveys were distributed to Vietnamese otolaryngology faculty, residents, and US otolaryngology volunteers. The value of 11 MST‐provided services were graded on a five‐point Likert scale. Services included observing US otolaryngology volunteers perform surgery, US otolaryngology volunteer lectures, paper/electronic lecture material, instrument donation, minifellowships in the United States, among others. Respondents also voted for the single most important service. Responses were analyzed via Kruskal‐Wallis analysis of variance and Wilcoxon rank sum test.
Results
A total of 153 survey responses were recorded. There were 52% respondents who identified as male and 39% as female. The highest‐valued services by Vietnamese otolaryngologists were didactic lectures given by US otolaryngology volunteers (4.6/5 ± 0.6), and reviewing cases with US otolaryngology volunteers in the clinic (4.4/5 ± 0.9). The least important services were instrument donation and seeing US otolaryngology volunteers assist with surgery (≤4.1/5). The highest‐value services perceived by US otolaryngology volunteers were reviewing cases in the clinic and sponsoring minifellowships (4.9 ± 0.4). Vietnamese faculty perceived the single most important service to be US volunteer lectures (20/74 votes), whereas Vietnamese residents perceived minifellowships to be most important (13/34 votes)Conclusions
Vietnamese otolaryngologists desire an education‐focused relationship with US otolaryngology volunteers, with didactic lectures and sponsored US fellowships having the highest value and performance of surgeries having less value.
Level of Evidence4 Laryngoscope, 2019

Predictive value of the ACS NSQIP calculator for head and neck reconstruction free tissue transfer

30-07-2019 – William Tierney, Janki Shah, Kate Clancy, Maxwell Y. Lee, Peter J. Ciolek, Michael A. Fritz, Eric D. Lamarre

Journal Article

Background
Predictive models to forecast the likelihood of specific outcomes after surgical intervention allow informed shared decision‐making by surgeons and patients. Previous studies have suggested that existing general surgical risk calculators poorly forecast head and neck surgical outcomes. However, no large study has addressed this question while subdividing subjects by surgery performed.
Objectives
To determine the accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator in estimating length of hospital stay and risk of postoperative complications after free tissue transfer surgery.
Study Design
A retrospective chart review of patients at one institution was performed using Current Procedural Terminology codes for anterolateral thigh (ALT) flap, fibula free flap (FFF), and radial forearm free flap (RFFF) reconstruction. Output data from the ACS NSQIP surgical risk calculator were compared with the observed rates in our patients.
Methods
Incidences of cardiac complications, pneumonia, venous thromboembolism, return to the operating room, and discharge to skilled nursing facility (SNF) were compared to predicted incidences. Length of stay was also compared to the predicted length of stay.
Results
Three hundred thirty‐six free flap reconstructions with 197 ALT flaps, 85 RFFFs, and 54 FFFFs were included. Brier scores were calculated using ACS NSQIP forecast and actual incidences. No Brier score was <0.01 for the entire sample or any subgroup, which indicates that the NSQIP risk calculator does not accurately forecast outcomes after free tissue reconstruction.
Conclusion
The ACS NSQIP failed to accurately forecast postoperative outcomes after head and neck free flap reconstruction for the entire sample or subgroup analyses.
Level of Evidence4 Laryngoscope, 2019

Management of arteriovenous malformation of the ear: A protocol for resection and reconstruction

29-07-2019 – Marina Vilela Chagas Ferreira, Dov Charles Goldenberg, Vania Kharmandayan, Rolf Gemperli

Journal Article

Objective
Arteriovenous malformations (AVM) of the ear show unique features. Progressive growth or inadequate management of AVMs may lead to bleeding, infection, cartilage exposure, and ultimately loss of structure. Total ear amputation is an alternative; however, due to the structural complexity of the ear, reconstruction is technically challenging. This study presents a treatment algorithm based on a clinical series, with treatment options including resection and immediate and late reconstruction.
Methods
Between 2004 and 2018, 12 patients with auricular AVMs were treated with AVM resection and ear reconstruction at our hospital. Among these 12 patients, seven were women, and patients’ ages ranged between 4 and 34 years. Parameters considered before resection and reconstruction were compromised ear extension (partial, total, or extra‐auricular involvement), thickness (cutaneous and cartilaginous), symptoms (bleeding, infection, ulceration, and/or cartilage exposure), and preoperative embolization. Total resection of AVMs was planned as the first step in all cases, followed by primary closure. AVM resection was categorized into a partial or total procedure, resulting in partial or total ear defects. Reconstruction was categorized as immediate or delayed.
Results
Preoperative embolization was performed in 10 patients. AVMs were totally removed, resulting in seven total ear amputations. In six of these patients, total ear reconstruction was performed 6 months later, and all patients were recurrence‐free. Only one patient did not undergo ear reconstruction. Regrowth was not observed in any reconstructed ear.
Conclusion
Treatment of ear AVMs requires a planned approach to achieve favorable clinical outcomes and for concomitant safe and definitive reconstruction.
Level of Evidence4 Laryngoscope, 2019

The impact of social determinants of health on laryngotracheal stenosis development and outcomes

29-07-2019 – Sabina Dang, Justin R. Shinn, Benjamin R. Campbell, Gaelyn Garrett, Christopher Wootten, Alexander Gelbard

Journal Article

Objectives
The social determinants of health affect a wide range of health outcomes and risks. To date, there have been no studies evaluating the impact of social determinants of health on laryngotracheal stenosis (LTS). We sought to describe the social determinants in a cohort of LTS patients and explore their association with treatment outcome.
Methods
Subjects diagnosed with LTS undergoing surgical procedures between 2013 and 2018 were identified. Matched controls were identified from intensive care unit (ICU) patients who underwent intubation for greater than 24 hours. Medical comorbidities, stenosis characteristics, and patient demographics were abstracted from the clinical record. Tracheostomy at last follow‐up was recorded from the medical record and phone calls. Socioeconomic data was obtained from the American Community Survey.
Results
One hundred twenty‐two cases met inclusion criteria. Cases had significantly lower education compared to Tennessee (P = .009) but similar education rates as ICU controls. Cases had significantly higher body mass index (odds ratio OR: 1.04, P = .035), duration of intubation (OR: 1.21, P < .001), and tobacco use (OR: 1.21, P = .006) in adjusted analysis when compared to controls. Tracheostomy dependence within the case cohort was significantly associated with public insurance (OR: 1.33, P = .016) and chronic obstructive pulmonary disease (OR: 1.34, P = .018) in adjusted analysis.
Conclusion
Intubation practices, medical comorbidities and social determinants of health may influence the development of LTS and tracheostomy dependence after treatment. Identification of at‐risk populations in ICUs may allow for prevention of tracheostomy dependence through the use of early tracheostomy and specialized follow‐up.
Level of Evidence
Level 3, retrospective review comparing cases and controls Laryngoscope, 2019

Slide laryngotracheoplasty for congenital subglottic stenosis in newborns and infants

27-07-2019 – László Rovó, Eszter Erdélyi, Zoltán Tóbiás, Péter Gál, Ilona Szegesdi, Balázs Sztanó, Kishore Sandu, Ádám Bach

Journal Article

Objectives
Subglottic stenosis is the most common laryngeal anomaly necessitating tracheostomy in early childhood. Crico‐ and laryngotracheal resection and laryngotracheal reconstruction—usually with autologous cartilage graft implantation—are the most effective treatments. These surgical techniques are obviously challenging in neonatal age and infancy. However, a reconstructive surgery performed at early age may prevent the sequel of complications.
Methods
The authors present their novel surgical method for congenital subglottic stenosis. Seven infants had inspiratory stridor; two of them had to be intubated and one required tracheostomy. Laryngotracheoscopy, CT or MRI revealed subglottic stenosis: Cotton‐Myer grade II in one, and grade III in six cases. Slide laryngotracheoplasty was performed before 5 months of age (10–130 days), with a follow‐up period of average 36 months (4–80 months). Phoniatry and quality of life questionnaire were used for evaluation of postoperative results.
Results
Slide laryngotracheoplasty in the neonatal age made the temporary tracheostomy unnecessary. All babies remained intubated for 3 to 10 days with an uncuffed tracheal tube. After extubation, no dyspnea or swallowing disorder occurred. A subjective quality of life questionnaire, laryngotracheoscopy, clinical growth charts showed satisfactory functional results.
Conclusions
Single‐stage slide laryngotracheoplasty might be a favorable solution for subglottic stenosis, even in early childhood. In one step, the airway can be maintained without stenting and tracheostomy.
Level of Evidence4Laryngoscope, 2019

Quantifying the use of opioids in the immediate postoperative period after endoscopic sinus surgery

24-07-2019 – Ido Badash, Christopher G. Lui, Kevin Hur, Joseph R. Acevedo, Elisabeth H. Ference, Bozena B. Wrobel

Journal Article

Objectives/Hypothesis
The opioid crisis is a public health emergency. There is limited evidence regarding how much opioid medication is necessary and which patients will require additional pain medication following endoscopic sinus surgery (ESS). The objective of this study was to quantify the use of opioids in the first 24 hours following ESS and determine the risk factors associated with increased need for opioid analgesia.
Study Design
Retrospective chart review.
Methods
A review of opioid‐naïve patients routinely admitted to the hospital following ESS between June 2016 and August 2018 was performed. Opioid consumption was quantified for each patient and converted to a morphine milligram equivalents (MME) dose. Pain intensity scores were also recorded throughout the postoperative period. Sociodemographic characteristics as well as surgical procedures performed were evaluated for impact on MME.
Results
A total of 130 patients (45.4% female) were included for analysis. The mean opioid dose consumed per patient in the first 24 hours following ESS was 24.1 MME, and the mean pain intensity was 2.4/10. Increasing pain scores were strongly associated with increasing MME (R = 0.78, P < .001). Multiple linear regression identified that patients taking antidepressants required an additional 17.2 MME (95% confidence interval CI: 5.5‐28.9, P = .004) in the first 24 hours following ESS, whereas patients undergoing papilloma resection required an additional 16.9 MME (95% CI: 2.5‐31.4, P = .022).
Conclusions
Patients undergoing ESS require different amounts of opioids for pain control in the immediate postoperative period. A history of antidepressant use and inverted papilloma resection during ESS were associated with increased opioid consumption postoperatively.
Level of Evidence4 Laryngoscope, 2019

Is the gender gap closing in otolaryngology subspecialties? An analysis of research productivity

23-07-2019 – Somtochi Okafor, Kathleen Tibbetts, Gopi Shah, Brittny Tillman, Ashley Agan, Ashleigh A. Halderman

Journal Article

Objective
The proportion of women specializing in otolaryngology–head and neck surgery (Oto–HNS) and seeking fellowship training has steadily increased over the last several years. In academic Oto–HNS, gender differences exist in research productivity, scholarly impact, and funding. This study aims to evaluate gender differences in academic productivity between otolaryngologists in early, mid‐, and later careers stages and within various subspecialties.
Methods
Departmental websites for all Oto–HNS residency programs were accessed, and data including gender, academic rank, and fellowship training/subspecialty field was collected. Bibliometric data including h‐index, publication years, number of citations, documents, and coauthors was obtained from the Scopus database. Career groups were defined as early (1–5 years), mid‐ (6–15 years), and later (16+ years). Continuous data was compared using the t test.
Results
Data was collected on 1,754 academic otolaryngologists (412 women, 1,342 men). Overall, men exhibited significantly higher h‐indices, number of documents, citations, and coauthors and actively published for more years compared to women (P < 0.0001 for all variables). Similar trends persisted across all subspecialties. When authors were broken down into career groups, women and men showed similar research productivity across all career groups in the subspecialties of otology, facial plastics, and rhinology; however, in head and neck, laryngology, and pediatrics, women continued to lag behind men.
Conclusion
This study suggests that female otolaryngologists within certain subspecialties are keeping pace with their male counterparts in publication productivity in the early career time frame. This represents a change from prior studies which have shown women to be less productive in the early career period.
Level of Evidence
NALaryngoscope, 2019

Selective stimulation of human intrinsic laryngeal muscles: Analysis in a mathematical three‐dimensional space

23-07-2019 – Michael Broniatowski, Sharon Grundfest‐Broniatowski, Matthew Schiefer, David H. Ludlow, David A. Broniatowski, Harvey M. Tucker

Journal Article

Objectives/Hypothesis
Standard stimulating methods using square waves do not appropriately restore physiological control of individual intrinsic laryngeal muscles (ILMs). To further explore our earlier study of evoked orderly recruitment by quasitrapezoidal (QT) currents, we integrated the contribution of the cricothyroideus (CT) with attention to mutual activation in an additional patient, based on recent studies of appropriate responses via strict recurrent laryngeal nerve (RLN) stimulation.
Study Design
Basic science study.
Methods
The patient received functional electrical stimulation (FES) with QT pulses at 5 Hz, 60 to 2,000 μAmp, 100 to 500 μs pulse width, 0 to 500 μs decay. Ipsilateral electromyography (EMG) responses were calculated using the average maximum amplitude, area under the curve, and the root mean square of the rectified amplitude waveforms. The thyroarytenoideus (TA), posterior cricoarytenoideus (PCA), lateral cricothyroideus (LCA), and the CT were each interrogated via two monopolar electrodes, values were recorded in MATLAB, exported to Excel, and analyzed. Individual and mutual recruitment configurations and activation delays with stimulation were explored using multiple regression and exploration factor analyses.
Results
A total of 868 EMG data points based on 18 trials and up to 11 subtrials were captured from each of the four ILMs. Various combinations of pulse amplitude, pulse width, and exponential decay were found to produce significant (P ≤ .001) individual ILM responses. CT mirrored the LCA, whereas the TA and PCA exhibited separate interactions along shared trajectories in a three‐dimensional space.
Conclusions
FES calibrated to individual and coupled ILMs offers promise for restoring normal and pathological contraction patterns via strict RLN stimulation.
Level of Evidence5 Laryngoscope, 2019

Correlation of salivary and nasal lavage pepsin with MII‐pH testing

22-07-2019 – Miles J. Klimara, Nikki Johnston, Tina L. Samuels, Alexis M. Visotcky, David M. Poetker, Todd A. Loehrl, Joel H. Blumin, Jonathan M. Bock

Journal Article

Objectives
Laryngopharyngeal reflux (LPR) is a common upper airway disease. Salivary pepsin is a proposed marker for LPR; however, the optimal time for collection of specimens for pepsin detection and pepsins presence in the oral and nasal secretions relative to concurrent multichannel intraluminal impedance‐p
H (MII‐p
H) monitoring are unknown.
Study Design
Prospective case‐control study with an experimental design.
Methods
Patients undergoing MII‐p
H testing for evaluation of LPR and asymptomatic control subjects were selected. Nasal lavage and saliva samples were collected in the clinic prior to MII‐p
H probe placement. Additional saliva samples were obtained an hour after each meal and upon waking the following morning. Nasal lavage and salivary pepsin were measured by ELISA.
Results
Twenty‐six patients undergoing MII‐p
H testing and 13 reflux‐free control patients were enrolled. Salivary pepsin was detected in 11 of 26 patients with suspected LPR and 0 of 13 controls. Pepsin was most frequently detected in the specimen provided upon waking at an average concentration of 186.9 ng/m
L. A significant correlation was observed between salivary pepsin in waking samples to MII‐p
H measurements, including reflux bolus duration, and proximal and distal recumbent reflux episodes (P < 0.05). A significant correlation was also observed between salivary pepsin upon waking or sinus lavage and reflux symptom index (P < 0.05).
Conclusion
Pepsin in salivary and nasal lavage samples demonstrated an association with MII‐p
H‐documented LPR. Pepsin detection was most frequent in morning samples, supporting use of morning salivary pepsin levels as a potential noninvasive technique for LPR diagnosis.
Level of Evidence2 Laryngoscope, 2019

In Response to Hemodynamic and Pharmacokinetic Analysis of Oxymetazoline Use During Nasal Surgery in Children

22-07-2019 – Richard S. Cartabuke, Brian J. Anderson, Charles Elmaraghy, Dmitry Tumin, Joseph D. Tobias

Letter

Endoscope‐assisted transoral accessory parotid mass excision: Multicenter prospective observational study

22-07-2019 – Jin Pyeong Kim, Dong Kun Lee, Jeong Hwan Moon, Jun Sun Ryu, Seung Hoon Woo

Journal Article

Objective
Transoral surgery is gaining favor because it has the advantage of leaving no scar after surgery. The aim of this study was to evaluate the technical feasibility and safety of endoscope‐assisted transoral accessory parotid mass excision.
Study Design
Multicenter, prospective, observational study.
Methods
This study was designed as a 7‐year, prospective, multicenter evaluation of endoscope‐assisted transoral accessory parotid mass excision. Clinical outcomes and complications related to the procedures were evaluated in patients.
Results
Twenty patients underwent endoscope‐assisted transoral accessory parotid mass excisions, and 22 patients underwent conventional parotidectomy approach excisions. There was no significant difference with respect to overall demographic characteristics between the groups. However, the operation times were shorter in the transoral approach group (P = 0.001), and cosmetic satisfaction was much better in the transoral group (P < 0.001).
Conclusion
Endoscope‐assisted transoral accessory parotid mass excision is a potentially safe and effective procedure with excellent outcomes.
Level of Evidence2 Laryngoscope, 2019

In reference to hemodynamic and pharmacokinetic analysis of oxymetazoline use during nasal surgery in children

22-07-2019 – Gregory J. Latham

Letter

Understanding nationwide readmissions after parotidectomy

18-07-2019 – Laith Mukdad, Alexander N. Goel, Hassan B. Nasser, Maie A. St. John

Journal Article

Objectives
To evaluate the incidence, causes, risk factors, and costs associated with 30‐day readmissions in parotidectomy patients utilizing the Nationwide Readmissions Database (NRD).
Study Design
Retrospective cohort study.
Methods
We examined the NRD for patients who underwent parotidectomy between 2010 and 2014. Rates, causes, and costs of 30‐day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission.
Results
Among 15,102 included patients, 594 (3.9%) were readmitted within 30 days. The average cost per readmission was $12,502. Infectious (22.7%) and wound (11.2%) complications were the two most common causes of readmission. After controlling for other covariates, significant predictors of readmission included advanced comorbidity (odds ratio OR, 1.61; 95% confidence interval CI, 1.09–2.37), a malignant parotid tumor (OR, 2.37; 95% CI, 1.63–3.43), length of stay ≥2 days (OR, 1.54; 95% CI, 1.09–2.18), and nonroutine discharge destinations (home with care OR, 1.88; 95% CI, 1.27–2.78 and nursing facility OR, 2.69; 95% CI, 1.55–4.67).
Conclusion
In this nationwide database analysis, we found that nearly 4% of all patients undergoing parotidectomy are readmitted within 30 days. Readmissions are commonly due to infections and wound complications. Quality improvement proposals targeting avoidable readmissions should focus on early recognition and prevention of infection and wound complications. Risk factors contributing to readmission include advanced comorbidity, malignant parotid tumor, prolonged index hospitalization, and nonroutine discharge destinations.
Level of Evidence
NA Laryngoscope, 2019

Presurgical induction chemotherapy for squamous cell carcinoma of the tonsil

18-07-2019 – Mark S. Burke, John T. Loree, Saurin R. Popat, Daniel Ford, Jae Kim, Adam R. Szymanowski, Thom R. Loree

Journal Article

Objectives/Hypothesis
The indications for and efficacy of induction chemotherapy in the management of squamous cell carcinoma of the head and neck is controversial. With the advent of human papillomavirus (HPV)–related cancers, survival has improved significantly. Here we present a group of patients with tonsil cancer treated with induction chemotherapy followed by surgery.
Study Design
Retrospective cohort study.
Methods
Thirty‐eight patients with tonsil cancer were treated with induction chemotherapy, consisting of cisplatin and docetaxel, followed by neck dissection and radical tonsillectomy. Twenty‐six patients were HPV+, 28 were nonsmokers or long‐term former smokers, and 28 were T1/T2. Fourteen patients required postoperative chemoradiotherapy (CRT). Median follow‐up time was 4.1 years.
Results
A complete response to induction chemotherapy was achieved in 45% (17) of patients. In total, 76% (29/38) of patients were successfully treated: 53% (20/38) with chemotherapy and surgery alone, and 24% (9/38) required postoperative CRT. Almost 90% (23/26) of HPV+ and half (6/12) of HPV− patients are no evidence of disease (NED). HPV status is a significant prognostic factor (P = .02). Only 38% (5/13) of current smokers were NED compared to 96% (24/25) of nonsmokers (P = .0002). All HPV+ nonsmokers (20/20) were NED at last follow‐up.
Conclusions
In this study, the primary driver of prognosis was smoking status. HPV status and T stage were also important. The prognosis for HPV+ nonsmokers is extremely good; most likely regardless of treatment. Treatment failures have a poor chance of salvage, irrespective of treatment type. With the major exception of HPV− smokers, induction chemotherapy followed by surgery with selective CRT is a viable treatment option for tonsil cancer.
Level of Evidence4 Laryngoscope, 2019

Economic costs of dysphagia among hospitalized patients

17-07-2019 – Jacqui Allen, Monique Greene, Ismael Sabido, Matthew Stretton, Anna Miles

Journal Article

Objectives/Hypothesis
Difficulties swallowing may lead to aspiration pneumonia and death. In a hospital setting where patients are admitted for other causes, we hypothesized that the additional burden of a swallow problem would increase length of stay, rate of pneumonia, cost, readmissions, and morbidity compared to those without dysphagia.
Study Design
Retrospective parallel cohort study.
Methods
A study of patients admitted to the hospital with hip/femur fracture was completed. Two groups were identified and compared: those with a coded diagnosis of dysphagia (n = 165) in addition to hip/femur fracture (HF + D), and a group with hip fracture alone (HF‐D) (n = 2,288) (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification). Number of inpatient days, cost per patient, diagnosis of pneumonia, 30‐day readmission, and mortality rates were compared.
Results
For those in the HF + D group, mean age was 85 years compared to 78 years in the HF‐D group (P < .05); length of stay was 32 days, more than twice that of the HF‐D group (14 days) (P < .05). Mortality within 30 days of admission was significantly higher (18% vs. 4%,respectively) but 30‐day readmission rate was similar (8% vs. 11%, respectively). Rate of aspiration pneumonia was 14 times greater in HF + D (9.7%) compared with HF‐D (0.7%). Average admission cost was NZD$36,913 (HF + D) compared with NZD$22,222 (HF‐D) (P < .05).
Conclusions
Complaint of dysphagia, in addition to hip fracture, increases a patients average admission cost by 60%. It is associated with increased aspiration pneumonia and greater mortality. Dysphagia screening at admission to hospital would allow early identification of swallow compromise and may prevent complications and reduce costs.
Level of Evidence3b Laryngoscope, 2019