Laryngoscope

Voice and Swallowing Outcomes Following Airway Reconstruction in Adults: A Systematic Review

13-01-2020 – Gemma M. Clunie, Justin W. G. Roe, Caroline Alexander, Gurpreet Sandhu, Alison McGregor

Objectives
Laryngotracheal stenosis is a rare condition characterized by upper airway narrowing. Reconstructive surgical treatment aims to manage the area of stenosis to improve dyspnea and can impact voice and swallowing function. This article critically evaluates the literature about voice and swallowing outcomes in adults with laryngotracheal stenosis who undergo reconstructive surgery.
Study Design
Systematic review.
Methods
Six databases were searched for articles referring to voice and swallowing outcome measures following reconstruction procedures in adults with laryngotracheal stenosis. Screening was completed using predefined inclusion/exclusion criteria.
Results
A total of 143 abstracts were reviewed, with 67 articles selected for full‐text review. Twenty studies met the inclusion criteria. Data extraction was completed with the Strengthening Reporting of Observational Studies in Epidemiology checklist with Oxford Centre for Evidence‐Based Medicine Level of Evidence used to indicate quality. Risk of bias was assessed using the Risk of Bias Assessment Tool for Non‐Randomized Studies. All studies scored a high risk of bias in at least one of the domains. Selection and timing of outcome measures was heterogenous, and there was limited information provided about rationale or reliability.
Conclusions
The literature acknowledges the importance of voice and swallowing outcomes following airway reconstruction. Studies show correlation between reconstructive surgery and deterioration in vocal function; there are no consistent data about swallowing outcomes. The lack of a core outcome measures set for adults with laryngotracheal stenosis limits the findings of this review. Further research is needed to establish clear criteria for robust and clinically relevant outcome measurement. Laryngoscope, 2020

Facial Nerve Branching Patterns Vary With Vascular Anomalies

11-01-2020 – Lingga Adidharma, Randall A. Bly, Hailey A. Theeuwen, Robert N. Holdefer, Jefferson Slimp, Greg A. Kinney, Vicente Martinez, Kathryn B. Whitlock, Jonathan A. Perkins

Journal Article

Objectives
At our institution, in vivo facial nerve mapping (FNM) is used during vascular anomaly (VAN) surgeries involving the facial nerve (FN) to create an FN map and prevent injury. During mapping, FN anatomy seemed to vary with VAN type. This study aimed to characterize FN branching patterns compared to published FN anatomy and VAN type.
Study Design
Retrospective study of surgically relevant facial nerve anatomy.
Methods
VAN patients (n = 67) with FN mapping between 2005 and 2018 were identified. Results included VAN type, FN relationship to VAN, FNM image with branch pattern, and surgical approach. A Fisher exact test compared FN relationships and surgical approach between VAN pathology, and FN branching types to published anatomical studies. MATLAB quantified FN branching with Euclidean distances and angles. Principal component analysis (PCA) and hierarchical cluster analysis (HCA) analyzed quantitative FN patterns amongst VAN types.
Results
VANs included were hemangioma, venous malformation, lymphatic malformation, and arteriovenous malformation (n = 17, 13, 25, and 3, respectively). VAN FN patterns differed from described FN anatomy (P < .001). PCA and HCA in MATLAB‐quantified FN branching demonstrated no patterns associated with VAN pathology (P = .80 and P = .91, one‐way analysis of variance for principle component 1 (PC1) and priniciple component 2 (PC2), respectively). FN branches were usually adherent to hemangioma or venous malformation as compared to coursing through lymphatic malformation (both P = .01, Fisher exact).
Conclusions
FN branching patterns identified through electrical stimulation differ from cadaveric dissection determined FN anatomy. This reflects the high sensitivity of neurophysiologic testing in detecting small distal FN branches. Elongated FN branches traveling through lymphatic malformation may be related to abnormal nerve patterning in these malformations.
Level of Evidence
NA Laryngoscope, 2020

The Usefulness of the Thyroid Imaging Reporting and Data System in Determining Thyroid Malignancy

11-01-2020 – Michael Xie, Michael K. Gupta, Stuart D. Archibald, B. Stanley Jackson, James Edward Massey (Ted) Young, Han Zhang

Journal Article

Objectives/Hypothesis
To determine the effect of a modified Thyroid Imaging and Reporting Data System (TIRADS) in predicting malignancy in surgically treated nodules.
Study Design
Retrospective review.
Methods
This study was carried out at a tertiary care center from July 2016 to July 2017. Patients were included if they had a thyroid nodule that had an ultrasound assessment with subsequent fine‐needle aspiration biopsy (FNAB) as well as surgical resection. Patients were excluded if they had previous head and neck surgery. Patients were stratified into those who had a formal modified TIRADS report by the radiologist versus those who had an ultrasound report without TIRADS reporting. FNAB results were reported as per Bethesda Thyroid Cytology Criteria, and the final pathology report was nominalized as malignant or benign.
Results
One hundred twenty‐four consecutive patients who met the inclusion criteria listed above were included within the study. Thirty one patients (25%) had a modified TIRADS report from the radiologist, whereas 93 patients (75%) did not. There was no statistical significance between the two groups in terms of: gender (P = .24), age (P = .77), FNAB results (P = .95), final surgical pathology (P = .90), or incidental findings of malignancy (P = .09). Comparative analysis showed no statistically significant difference between the two groups in terms of the concordance of FNAB and a final pathological diagnosis of malignancy (P = .91).
Conclusions
Despite the known diagnostic utility of the TIRADS in relation to FNAB results and its widespread use, this study shows that the overall detection of malignancy is not statistically different in those who received a modified TIRADS report.
Level of Evidence3Laryngoscope, 2020

Emerging Trends in Nasal Surgery: What Is the Impact of a Bioabsorbable Nasal Implant?

10-01-2020 – Marshall Ge, Jee‐hong Kim, Bozena Wrobel, Stephanie Shintani Smith, Amit Kochhar, Elisabeth H. Ference

Journal Article

Background
A bioabsorbable nasal valve implant (NVI) was introduced in 2016 as a minimally invasive solution to nasal valve collapse. Historically the introduction of less invasive procedures performable in‐office has resulted in an increase in volume. Our objective is to evaluate this trend as it relates to nasal vestibular repair, and its impact on healthcare utilization.
Methods
We interrogated the Medicare Part B national database for nasal vestibular repair (CPT code: 30465), Unlisted nasal procedure (30999) and septoplasty (30520) from 2010 to 2017. Septoplasty was used as a surrogate for overall nasal procedural rate. Linear regression modeling was used to examine the changes in reported vestibular repair rate adjusting for septoplasty rate.
Results
In the Medicare population, the rate of septoplasty was stable from 2010 to 2017, increasing from 26,962 to 30,194 at an annual rate of 1.5%. Coding for unlisted nasal procedure increased from 272 to 333 at an adjusted annual rate of 1.1% over this time period. Coding for nasal vestibular repair increased from 2026 to 5331 over this interval at an adjusted annual rate of 0.9% from 2010 to 2016 but significantly increased to 5% between 2016 to 2017 (P < .0001).
Conclusion
The reported volume of nasal vestibular repair increased significantly in the year following Food and Drug Administration approval of NVIs. In the absence of a corresponding increase in septoplasty, this temporal relationship suggests that the introduction of NVIs impacted the utilization of this procedural code.
Level of Evidence
N/ALaryngoscope, 2020

Validation and multidimensional analysis of the japanese penn acoustic neuroma quality‐of‐life scale

10-01-2020 – Takanori Nishiyama, Naoki Oishi, Takashi Kojima, Kento Kasuya, Masaru Noguchi, Toru Ishikawa, Makoto Hosoya, Kaoru Ogawa

Journal Article

Objectives
In the management of vestibular schwannoma (VS), patient‐perceived outcomes should be given as much attention as physician‐reported objective outcomes. Concomitant symptoms can be annoying for sufferers, lowering quality of life (QoL). However, it is difficult to determine the degree to which these symptoms lower QoL using only objective measures. The Penn Acoustic Neuroma Quality of Life Scale (PANQOL) is a validated disease‐specific questionnaire commonly used to assess QoL in VS patients. It was developed and published in English. In this study, we translated the PANQOL questionnaire into Japanese and validated its reliability and utility. We also evaluated patient factors that could influence PANQOL scores.
Study Design
Cross‐sectional study.
Methods
Seventy‐two VS patients monitored conservatively were included in this study. They were assessed using the Japanese versions of PANQOL (PANQOL‐J) and questionnaires about specific symptoms related to VS. The PANQOL questionnaire was translated into Japanese according to the accepted standards. The reliability and utility of the PANQOL‐J questionnaire, as well as the relationship with VS‐specific symptoms, were statistically analyzed.
Results
The mean total score was 78.7. Almost all of its domains had good internal consistency. Most PANQOL‐J domains were related to those of the Short Form‐36, with the exception of facial dysfunction domain. Scores of all PANQOL‐J domains were comparable to scores of other questionnaires related to the VS‐specific symptoms. Our analyses indicated tinnitus or facial palsy might affect the PANQOL‐J total score.
Conclusions
We confirmed the validity of the Japanese version of PANQOL questionnaire and its reliability and utility in the management of VS symptoms concerning facial function.
Level of Evidence4 Laryngoscope, 2020

Thyroid Cartilage Cysts, A Rare Entity Causing Dysphonia

09-01-2020 – Froukje J. Verdam, Hans Mahieu

Case Reports

Five cases are presented with a strained voice quality due to a unique underlying cause: thyroid cartilage cysts. Laryngoscopy and radiological images show antero‐medial displacement of both vestibular and vocal fold(s). Swelling in the ala of the thyroid cartilage results in a pear‐shaped lumen. These cysts were marsupialized with CO2 laser, fluid emerged, and histological biopsies confirmed cartilaginous cysts. Postoperatively, all cases report largely reduced or completely resolved vocal complaints, with a consistent follow‐up of 2 years. Together with previous publications, an overview of 17 cases is presented, to enhance awareness that thyroid cartilage cysts can cause a strained voice quality. Laryngoscope, 2020

In reference to Inclusion of the first cervical nerve does not influence outcomes in upper airway stimulation for treatment of obstructive sleep apnea

08-01-2020 – Clemens Heiser, Benedikt Hofauer

Letter

Do Laryngologists and General Otolaryngologists Manage Laryngopharyngeal Reflux Differently?

08-01-2020 – Jerome R. Lechien, Jacqueline Allen, Francois Mouawad, Tareck Ayad, Maria Rosaria Barillari, Kathy Huet, Lise Crevier‐Buchman, Stéphane Hans, Petros D. Karkos, Young‐Gyu Eun, Francois Bobin, Sven Saussez, Lee M. Akst

Journal Article

Objective
To investigate current practices of laryngologists and non‐laryngologists in management of Laryngopharyngeal Reflux (LPR).
Methods
An online survey was sent to members of otolaryngology societies about LPR, and subgroup analysis was performed between laryngologists and non‐laryngologists. This survey was conducted by the LPR Study Group of Young Otolaryngologists of the International Federation of Otolaryngological Societies.
Results
A total of 535 otolaryngologists completed the survey. Among them, 127 were laryngologists and 408 were non‐laryngologists. Collectively, symptoms most commonly attributed to LPR are cough after lying down/meal, throat clearing, and acid brash; most common findings are thought to be arytenoid erythema and posterior commissure hypertrophy. Respectively, 12.5% and 5% of non‐laryngologists and laryngologists believe that ≥50% of LPR patients suffer from heartburn (P = .010). Non‐laryngologists are more aware about some extra‐laryngeal findings associated with LPR (eg, pharyngeal erythema) than laryngologists. Neither laryngologists nor non‐laryngologists associated development of benign lesions of the vocal folds with reflux. The management of LPR substantially differs between groups, with laryngologists indicating increased awareness of (impedance)‐p
H monitoring as well as the prevalence and treatment of nonacid/mixed LPR. Conversely, non‐laryngologists are much more likely to include gastroenterology referral in their management of presumed LPR. Respectively, 44.8% and 27.6% of non‐laryngologists and laryngologists believe themselves not sufficiently knowledgeable about LPR.
Conclusions
Significant differences exist between laryngologists and non‐laryngologists in diagnosis and treatment of LPR. Overall only one‐third of responders believe themselves to be sufficiently educated about LPR.
Level of Evidence4 Laryngoscope, 2020

Effect of margin status and pathological grade in treatment of sinonasal mucoepidermoid carcinoma

08-01-2020 – Samuel R. Auger, Tirth Patel, Ashwin Ganti, Anish Raman, Aryan Shay, Hannah N. Kuhar, Edward C. Kuan, Peter Papagiannopoulos, Pete S. Batra, Bobby A. Tajudeen

Journal Article

Objectives
The purpose of this study was to investigate the association of demographic factors, grade, margin status, and treatment modalities for overall survival in patients with sinonasal mucoepidermoid carcinoma (SNMEC).
Study Design
Retrospective database review.
Methods
The National Cancer Database was queried for patients of all ages with SNMEC between 2004 and 2015. Univariate Kaplan‐Meier and multivariate Cox regression analyses were performed to evaluate the association of suspected prognostic factors with overall survival. Subgroup analysis by margin status and grade was performed.
Results
A total of 239 patients with SNMEC were included in the analysis. The 5‐year overall survival was 63.6%. Prognostic factors associated with decreased survival include age over 70 years (P = .027), sphenoid primary site (P = .002), and advanced‐stage malignancy (P = .024). Improved survival was associated with surgery achieving negative margins (P = .001). Adjuvant radiation was associated with improved survival (hazard ratio HR = 0.25, P = .015) in the negative‐margin group but was not found to be a statistically significant factor in the positive‐margin group (HR = 0.66, P = .509).
Conclusions
This investigation is the largest to date to analyze the association of treatment modalities with overall survival in SNMEC and subgroup analysis by histopathologic grade and surgical margin status of treatment outcomes. Surgery remains the mainstay of treatment in patients with SNMEC. However, administration of radiation may confer survival benefit to patients with negative margins.
Level of Evidence4 Laryngoscope, 2020

Surgical intervention for exercise‐induced laryngeal obstruction: A UK perspective

08-01-2020 – Bamidele Famokunwa, Guri Sandhu, James H. Hull

Journal Article

Objectives
Exercise‐induced laryngeal obstruction (EILO) is a prevalent cause of exertional breathlessness and wheeze in young individuals. Typically diagnosed using the continuous laryngoscopy during exercise (CLE) test, treatment is largely based on breathing retraining promoting improved laryngeal function. In some cases, these techniques fail to alleviate symptoms, and surgical intervention with supraglottoplasty can be valuable in the supraglottic form of EILO. Globally, there is currently limited experience utilizing a surgical approach to EILO, and data regarding the optimum surgical technique and published outcomes and complication rates are thus limited.
Study Design
Retrospective observational case series.
Methods
In this report, we describe our experience as the only UK center undertaking supraglottoplasty for EILO. We report the surgical outcome of 19 patients (n = 16 female), mean age, 29.6 ± 13.1 years, referred for surgery with moderate to severe supraglottic EILO. Follow‐up clinic ± CLE was performed within 4 months (median = 6 weeks), and CLE scores were evaluated before and following surgery.
Results
We found a beneficial effect of surgery on supraglottic CLE scores (median score reducing from 3/3 to 1/3 postoperatively P < .05 overall) with 79% (n = 15) of patients reporting an improvement in their exercise capacity. One patient developed an apparent increased tendency for glottic‐level EILO following surgery; however, no voice‐ or swallowing‐related complications were encountered.
Conclusions
This study is the first to report the UK experience, surgical technique, and outcome for EILO surgery. The findings indicate that EILO surgery appears to be a safe and effective option for individuals with moderate to severe supraglottic‐type EILO who have failed initial conservative treatment.
Level of Evidence5 Laryngoscope, 2020

Analysis of Abdominal Dermal‐Fat Grafting to Repair Parotidectomy Defects: An 18‐Year Cohort Study

07-01-2020 – Nelson R. Gruszczynski, Barrett J. Anderies BSE, Jacob K. Dey, Daniel L. Price, Eric J. Moore, Jeffrey R. Janus

Journal Article

Objectives
To assess the outcomes of abdominal dermal‐fat grafting following superficial and total parotidectomy.
Methods
A retrospective chart review of parotidectomy patients was performed. Patients were divided into four groups based on surgical extent and grafting status: superficial parotidectomy (SP), superficial parotidectomy with grafting (SPg), total parotidectomy (TP), and total parotidectomy with grafting (TPg). Complication rates and operative times were then compared between surgically matched groups (SP vs. SPg, TP vs. TPg). Complications included graft necrosis, gustatory sweating, first‐bite syndrome, infection, hematoma, sialocele, and seroma. Data was analyzed via chi‐square and two‐sample t testing, logistic regression, and one‐way analysis of variance.
Results
The cohort consisted of 330 patients: 106 SP (32.12%), 61 SPg (18.48%), 82 TP (24.85%), and 81 TPg (24.55%). No donor site complications occurred. TPg resulted in seven graft necroses (8.64%), and 22 reported gustatory sweating (27.20% vs. 10 TP patients (12.2%), P = 0.016); SPg resulted in two necroses (3.28%). There were no other statistically significant differences in complication rates. Graft recipients receiving adjuvant radiation were more likely to develop necrosis (odds ratio OR 4.60, 95% confidence interval CI, 1.16–18.27, P = .0194). Patients who developed gustatory sweating were 8.38 years younger (95% CI 2.66–14.10, P = 0.002, follow‐up time > 48 days). Grafting did not increase operative times (TP/TPg: mean = 275.91/263.65 minutes, standard error of the mean = 41.96/33.75, P = 0.822).
Conclusion
An abdominal dermal‐fat graft is an excellent reconstructive choice for a parotidectomy defect and is not associated with increased complication rates or prolonged operative time.
Level of Evidence4 Laryngoscope, 2020

Functional Electrical Stimulation for Presbyphonia: A Prospective Randomized Trial

07-01-2020 – Markus Gugatschka, Marlies Feiner, Winfried Mayr, Andrea Groselj‐Strele, Katharina Eberhard, Claus Gerstenberger

Journal Article

Objectives
The aim of this prospective study was to examine the effects of transcutaneous functional electrical stimulation (FES) in a group of elderly women with presbyphonia.
Study Design
Prospective randomized study.
Methods
Fourteen participants were enrolled prospectively and attributed randomly to two different treatment groups, where one group (n = 7) received 8 weeks of training (5 days a week), whereas the other group (n = 7) received 4 weeks of ineffective stimulation, followed by 4 weeks of effective training. Stimulation protocols were established during baseline examination and confirmed with endoscopy to ensure a glottal reaction. Numerous acoustical, vocal, patient‐centered, and respiratory parameters were obtained at several time points.
Results
Neither 4 weeks nor 8 weeks of functional electrical transcutaneous stimulation led to changes of vocal, acoustical, or respiratory parameters, apart from patient‐centered items (Voice Handicap Index 12, Voice‐Related Quality of Life), which improved over time. However, there were no differences between the two arms for both items.
Conclusions
Transcutaneous FES over 4 weeks and 8 weeks did not lead to significantly improved objective voice and acoustical parameters, which could be caused by the fact that the muscles of interest cannot be targeted specifically enough. However, we found a significant improvement of subjective voice perception and voice‐related quality of life in both groups. We explain this finding with an observer‐expectancy effect secondary to the very time‐consuming and elaborate study procedures.
Level of Evidence1b Laryngoscope, 2020

Flexible versus rigid laryngoscopy: A randomized crossover study comparing patient experience

06-01-2020 – “Bhavishya S. Clark, William Z. Gao, Caitlin Bertelsen, Janet S. Choi, Shoffel‐Havakuk Hagit, Lindsay S. Reder, Edie R. Hapner, Michael M. Johns, Karla ODell”

Journal Article

Objectives
To compare flexible distal‐chip laryngoscopy (FDL) versus rigid telescopic laryngoscopy (RTL) in regard to examinees pain level, comfort, satisfaction, and preference, and to evaluate the clinicians assessment of the examinees experience with both exam types.
Study Design
Randomized crossover study.
Methods
Twenty‐three normal adult subjects were recruited to undergo both FDL and RTL; the initial exam type was randomized. Subjects and clinicians completed corresponding questionnaires after each exam. Differences in participant characteristics and questionnaire scores between the two exam types were assessed via Pearson χ2 and paired t tests, respectively.
Results
Overall, participants reported that FDL was more uncomfortable than RTL (4.22 vs. 2.91, P = .003) and scored higher on the pain scale for FDL compared to RTL (2.91 vs. 1.70, P = .006). However, there was no significant difference in number of participants who preferred FDL versus RTL (10 43% vs. 13 57%). Poor correlation was seen between clinicians assessment of participants discomfort and actual reported discomfort for FDL (2.70 vs. 4.22, P = .001).
Conclusions
Subjects undergoing FDL experience greater discomfort and pain compared to RTL, but do not demonstrate a differential preference of exam. Overall, clinicians underestimate the discomfort of patients undergoing FDL, but participants maintain high satisfaction with both exams nonetheless.
Level of Evidence1 Laryngoscope, 2020

“A Modern Case Sheds Light on a Classical Enigma: Beethovens Deafness”

06-01-2020 – Davide Brotto, Renato Fellin, Flavia Sorrentino, Flavia Gheller, Patrizia Trevisi, Roberto Bovo

Journal Article

Two hundred and fifty years have passed since the birth of Ludwig van Beethoven, and the enigma about his hearing loss and overall health status seems to be not completely solved. However, the admission to the hospital of a 64‐year‐old woman in 2018 with symptoms extremely similar to those experienced by the great composer may add further evidence to a theory previously underestimated. The health issues of the modern patient were found to be due to chronic lead intoxication. The lead was released during daily cooking using a ceramic‐coated frying pan with worn surface that poisoned her breakfast most probably for years.
Abdominal pain, asthenia, and hearing loss affecting the high frequencies with a many impact on speech intelligibility tormented the patient, as they had Beethoven.
An extensive review of the music and medical literature was performed, as well as re‐examination of manuscripts, correspondence, and autopsy reports of the famous composer; and great similarities have been found. The soundness of the most‐cited classical theories about Beethovens hearing loss will be discussed. After close scrutiny of the theories, our analysis points toward a progressive sensorineural hearing loss due to lead intoxication as the most probable cause of not only Beethovens hypoacusis but his overall health status as well. Laryngoscope, 2020

Inhibition of glutaminase to reverse fibrosis in iatrogenic laryngotracheal stenosis

06-01-2020 – Hsiu‐Wen Tsai, Kevin M. Motz, Dacheng Ding, Ioan Lina, Michael K. Murphy, Dimitri Benner, Michael Feeley, Jody Hooper, Alexander T. Hillel

Journal Article

Objectives/Hypothesis
Glutamine metabolism is a critical energy source for iatrogenic laryngotracheal stenosis (i
LTS) scar fibroblasts, and glutaminase (GLS) is an essential enzyme converting glutamine to glutamate. We hypothesize that the GLS‐specific inhibitor BPTES will block glutaminolysis and reduce i
LTS scar fibroblast proliferation, collagen deposition, and fibroblast metabolism in vitro.
Study Design
Test‐tube Lab Research.
Methods
Immunohistochemistry of a cricotracheal resection (n = 1) and a normal airway specimen (n = 1) were assessed for GLS expression. GLS expression was assessed in brush biopsies of subglottic/tracheal fibrosis and normal airway from patients with i
LTS (n = 6). Fibroblasts were isolated and cultured from biopsies of subglottic/tracheal fibrosis (n = 6). Fibroblast were treated with BPTES and BPTES + dimethyl α‐ketoglutarate (DMK), an analogue of the downstream product of GLS. Fibroblast proliferation, gene expression, protein production, and metabolism were assessed in all treatment conditions and compared to control.
Results
GLS was overexpressed in brush biopsies of i
LTS scar specimens (P = .029) compared to normal controls. In vitro, BPTES inhibited i
LTS scar fibroblast proliferation (P = .007), collagen I (Col I) (P < .0001), collagen III (P = .004), and α‐smooth muscle actin (P = .0025) gene expression and protein production (P = .031). Metabolic analysis demonstrated that BPTES reduced glycolytic reserve (P = .007) but had no effects on mitochondrial oxidative phosphorylation. DMK rescued BPTES inhibition of Col I gene expression (P = .0018) and protein production (P = .021).
Conclusions
GLS is overexpressed in i
LTS scar. Blockage of GLS with BPTES significantly inhibits i
LTS scar fibroblasts proliferation and function, demonstrating a critical role for GLS in i
LTS. Targeting GLS to inhibit glutaminolysis may be a successful strategy to reverse scar formation in the airway.
Level of Evidence
NALaryngoscope, 2020

Tegmen attenuation in patients with idiopathic intracranial hypertension is progressive

03-01-2020 – Ophir Handzel, Adi Brenner‐Ullman, Dana Niry, Uri Neuman, Oren Cavel, Oron Yahav, Dan M. Fliss, Omer J. Ungar

Journal Article

Objectives
To prove that temporal bone tegmen attenuation in patients with idiopathic intracranial hypertension (IIH) is progressive.
Study Design
Retrospective blind study at a tertiary academic medical center.
Methods
Enrolled were medical records of patients with IIH that included at least two sequential computed tomography (CT) scans. The vertical distances between the floor of the middle fossa to the superior and lateral semicircular canals (SSC and LSC, respectively), to the scutum and minimal squama thickness were measured. The same measurements were made in scans of control subjects. The impact of demographics and metabolic variables including opening lumbar puncture (LP) pressure were evaluated.
Results
Twenty medical records were enrolled. Median age at diagnosis was 21 years; 16 were females. The median body mass index (BMI) was 32 kg/m2. Initial LP pressure was 195 mm cerebrospinal fluid (CSF). The median time interval between CT scans was 58 months. A median attenuation of 0.35 mm and 0.25 mm over the right and left LSC and of 0.5 mm and 0.3 mm over the right and left scutum, was found, respectively. The thicknesses of the SSC and squama remained stable. No attenuation was present in controls. The opening pressure on initial LP (median 195 mm CSF), was positively correlated with the degree of tegmen attenuation, but the age at diagnosis and BMI were not.
Conclusions
Tegmen attenuation may be progressive in patients with idiopathic increased intracranial pressure and correlated with the opening pressure on LP. Tegmen defects and CSF leak should be looked for in these patients.
Level of Evidence4 Laryngoscope, 2020

Apoptosis signaling molecules as treatment targets in head and neck squamous cell carcinoma

02-01-2020 – Thomas J. Ow, Carlos Thomas, Cory D. Fulcher, Jianhong Chen, Andrea López, Denis E. Reyna, Michael B. Prystowsky, Richard V. Smith, Bradley A. Schiff, Gregory Rosenblatt, Thomas J. Belbin, Thomas M. Harris, Geoffrey C. Childs, Nicole Kawachi, Nicolas F. Schlecht, Evripidis Gavathiotis

Journal Article

Objectives
To evaluate BCL‐2 family signaling molecules in head and neck squamous cell carcinoma (HNSCC) and examine the ability of therapeutic agents with variable mechanisms of action to induce apoptosis in HNSCC cells.
Methodsmessenger ribonculeic acid (m
RNA) expression of BAK, BAX, B‐cell lymphoma (Bcl‐2), BCL2 Like 1 (BCL2L1), and MCL1 were measured in The Cancer Genome Atlas (TCGA) head and neck cancer dataset, as well as in a dataset from a cohort at Montefiore Medical Center (MMC). Protein expression was similarly evaluated in a panel of HNSCC cell lines (HN30, HN31, HN5, MDA686LN, UMSCC47). Cell viability and Annexin V assays were used to assess the efficacy and apoptotic potential of a variety of agents (ABT‐263 navitoclax, A‐1210477, and bortezomib.
Results
Expression of BAK, BAX, BCL2L1, and MCL1 were each significantly higher than expression of BCL2 in the TCGA and MMC datasets. Protein expression demonstrated the same pattern of expression when examined in HNSCC cell lines. Treatment with combined ABT‐263 (navitoclax)/A‐1210477 or with bortezomib demonstrated apoptosis responses that approached or exceeded treatment with staurospaurine control.
Conclusion
HNSCC cells rely on inhibition of apoptosis via BCL‐x
L and MCL‐1 overexpression, and induction of apoptosis remains a potential therapeutic option as long as strategies overcome redundant anti‐apoptotic signals.
Level of Evidence
NALaryngoscope, 2020

Reconstructive and prosthodontic outcomes after multiple palatomaxillary reconstructions

30-12-2019 – Kayvon F. Sharif, John R. Sims, Lauren E. Yue, Fred M. Baik, Kimberly J. Kiplagat, Daniel Buchbinder, Devin J. Okay, Raymond L. Chai, Mark L. Urken

Journal Article

Objective
A subset of patients who undergo major palatomaxillary reconstruction do not initially achieve their intended oncologic and/or reconstructive goals and require additional surgery. We aim to detail the unique management considerations in this patient population.
Methods
We performed a retrospective review of patients who underwent palatomaxillary reconstruction by the senior author (m.l.u.) between 1998 and 2016.
Results
Twenty‐one patients required multiple reconstructions. The median time to second reconstruction was 17 months. The most common reason for a second reconstruction was for recurrent disease (10 of 21), followed by functional/aesthetic reasons (7 of 21) and osteoradionecrosis (4 of 21). Four patients went on to have a third reconstruction, and two underwent a fourth. A total of 27 reconstructions were performed, consisting of 20 soft tissue free flaps, four vascularized bone free flaps, and three locoregional flaps.
Conclusion
This patient cohort represents unique oncologic and reconstructive challenges. With long‐term follow‐up, multiple reconstructions may be required to optimize oncologic and functional/aesthetic outcomes. This is the first series of its kind that details the reasons for, as well as the outcomes of, patients who required multiple reconstructive procedures following initial palatomaxillary reconstruction.
Level of Evidence2BLaryngoscope, 2019

Predicting the Number of Fibular Segments to Reconstruct Mandibular Defects

30-12-2019 – Yotam Shkedy, Joel Howlett, Edward Wang, Jennifer Ongko, J. Scott Durham, Eitan Prisman

Journal Article

Objectives
Several classification schemes have been proposed to categorize mandibular defects following surgical resection; however, there is a paucity of data to guide an optimal reconstruction. This study examines the feasibility of using a geometric algorithm to simplify and determine the optimal reconstruction for a given mandibular defect. This algorithm is then applied to three different mandible defect classification schemes to correlate the defect type and number of bony segments required for reconstruction.
Methods
Computed tomography (CT) scans of 48 mandibles were decomposed into curvilinear representations and analyzed using the Ramer‐Douglas‐Peucker algorithm. In total, 720 mandibular defects were created and subsequently analyzed utilizing three commonly referenced classification systems. For each defect, the number of bony segments required to reconstruct each defect was computed.
Results
A wide variance in the number of segments needed for optimal reconstruction was observed across existing classifications. A six‐segment total mandible reconstruction best reconstituted mandibular form in all 48 mandibles.
Conclusion
Defect classification schemes are not adaptable to predicting the number of fibula segments required for a given defect. Additionally, cephalometric templates may not be applicable in all clinical settings. The Ramer‐Douglas‐Peucker algorithm is well suited for providing case‐specific predictions of reconstruction plans in a reproducible manner.
Level of Evidence
IV Laryngoscope, 2019

Mode of action of carboplatin via activating p53/miR‐145 axis in head and neck cancers

30-12-2019 – Ahsen Kilic, Neslisah Barlak, Fatma Sanli, Abdulmelik Aytatli, Ozel Capik, Omer F. Karatas

Journal Article

Objectives
In this study, we aimed at investigating the expressions of mi
R‐145 and its well‐characterized direct targets on carboplatin treatment.
Study Design
Laboratory study.
Methods
The effect of carboplatin and mi
R‐145 on the proliferative capacity of head and neck squamous cell carcinoma cells was evaluated using Cell Viability Detection Kit‐8. Expressions of mi
R‐145 and its targets were evaluated using quantitative real‐time polymerase chain reaction on carboplatin treatment and p53 inhibition. Western blot was used to measure the levels of p53 and its acetylated versions in cells treated with carboplatin and/or pifithrin‐α.
Results
We demonstrated that carboplatin induced the expression of mi
R‐145 in a dose‐dependent manner and suppressed the expressions of mi
R‐145 direct targets. In addition, we showed that inhibition of p53 by pifithrin‐α in carboplatin‐treated cells reduced mi
R‐145 expression and reversed the suppression of mi
R‐145 direct targets.
Conclusions
Considering all these findings together, one of the proposed mechanisms of carboplatin to kill cells might be the induction of mi
R‐145 and deregulation of its targets in parallel, via p53 activation, which happens through carboplatins DNA‐damaging property. To the best of our knowledge, these findings are the first to reveal the relationship between carboplatin and mi
R‐145 in cancer cells.
Level of Evidence
NALaryngoscope, 2019

Development of a Modern Pediatric Airway Reference Tool

30-12-2019 – John P. Dahl, Steven Coppess, Evan J. Propst, Adam Snoap, Sanjay R. Parikh, Andrew F. Inglis, Robin T. Cotton, Kaalan Johnson

Journal Article

Progressive Scalp Thinning Over Mesh Cranioplasty and the Role of Lipotransfer

28-12-2019 – Weitao Wang, Aurora Vincent, Arash Bahrami, Tom Shokri, Jared Inman, Yadranko Ducic

Journal Article

Objectives
To evaluate the role of lipotransfer in progressive scalp thinning following titanium mesh cranioplasty.
Methods
Retrospective review of single surgeon, single tertiary referral experience of all patients who underwent mesh cranioplasty. Patient demographics, prior radiotherapy, frequency and timing of scalp thinning, and treatment course data were obtained.
Results
A total of 144 patients were included, 77 male and 67 female with mean ages 58.2 and 54.8, respectively. One hundred four patients (72%) developed mesh exposure or impending exposure requiring reconstruction. Fifty‐six patients (54%) with scalp thinning were treated with lipotransfer, 40 of which were salvaged and the remainder of these patients definitively managed with cranioplasty and reconstruction. Prior radiotherapy was found to be associated with higher rates of mesh exposure (P = .0028), but not predictive of response to lipotransfer.
Conclusion
Lipotransfer is a useful technique in managing moderate scalp thinning following mesh cranioplasty. Mesh exposure or severe thinning require definitive cranioplasty and reconstruction.
Level of Evidence
IVLaryngoscope, 2019

The use and cost‐effectiveness of intraoperative navigation in pediatric sinus surgery

26-12-2019 – Nandini Govil, Amber D. Shaffer, Amanda L. Stapleton

Journal Article

Objectives/Hypothesis
There are consensus statements about when to use intraoperative navigation (IN) in adult sinus surgery. However, no corresponding guidelines exist for pediatrics. Our objectives included: 1) assess the demographic and operative factors associated with IN use and 2) calculate the cost‐effectiveness of IN use.
Study Design
Retrospective chart review.
Methods
One hundred nineteen pediatric patients undergoing sinus surgery between 2003 and 2016 were reviewed. Demographic and surgical factors were collected from medical records. Costs associated with use of IN were gathered from billing records.
Results
Of the 119 patients, 60 underwent sinus surgery with navigation (w
IN) and 59 underwent surgery without navigation (s
IN). Children in the w
IN group had more complex surgeries with more sinuses opened (P = .008). Individual attending surgeon and presence of trainee were associated with increased use of IN (P < .001 for both). IN resulted in a median of 31.5 minutes longer surgical time (P < .001). IN had an incremental cost/effectiveness ratio (ICER) of $22,378 for each year without revision surgery for patients with acute disease. However, for patients with chronic disease, the probability of undergoing a second surgery was the same between w
IN and s
IN groups, and navigation was not cost‐effective (ICER of −$3,583).
Conclusions
IN use did not decrease complications or rates of revision surgery. It was used primarily as an educational tool or to increase confidence in intraoperative identification of landmarks. However, the use of IN added surgical time and was not cost‐effective. Further research must be completed to determine when IN is indicated in pediatric sinus surgery.
Level of Evidence4Laryngoscope, 2019

The Utility and Feasibility of Extending Beyond Traditional Patient Descriptions in Daily Practice

26-12-2019 – Jennifer J. Shin, Thomas L. Carroll, Anthony A. Prince, Adam B. Landman

Journal Article

Objectives/Hypothesis
Institutional and national programs have endorsed the use of validated instruments in daily practice, but their utility for frontline clinicians is unknown. Our first objective was thus to determine if routinely obtained patient descriptions accurately predict disease‐specific validated instrument results. Our second objective was to assess the feasibility of deploying an electronic system to obtain and document patient‐reported descriptions of health status.
Study Design
Prospective assessment of consecutive eligible ambulatory care patients.
Methods
For the first objective, patients presenting with the same chief complaint at consecutive visits provided concurrent routine symptom descriptions and validated instrument responses. To determine whether patients’ routine descriptions predicted scores from disease‐specific instruments, receiver operator characteristic (ROC) curves, sensitivity/specificity, Spearman ρ correlation, and regression models were utilized. For the second objective, feasibility assessment focused on percent with successful response capture, time to questionnaire completion, and impact on physician time needed to obtain and document patient histories.
Results
For the first objective, among patients with hearing loss, eustachian tube dysfunction, nasal obstruction, and chronic rhinosinusitis, the areas under the ROC curves were 0.38 to 0.83. Spearman ρ coefficients were 0.25 to 0.46. Sensitivity and specificity ranged from 15.9% to 87.8%, with correct classification in 42.3% to 55.2% of cases. For the second objective, there was a 91% completion rate. Completion times were 7:18 to 12:37 for new patients and 3:23 to 6:41 for established patients. Physician time savings were estimated at 11 minutes per patient.
Conclusions
Using validated instruments and electronic data collection systems in daily practice has practical and clinical implications. These topics warrant further study.
Level of Evidence2c Laryngoscope, 2019

Does 3D volumetric analysis predict the reach of endoscopically harvested buccal fat pad flap

26-12-2019 – Somasundaram Subramaniam, Matias Gomez, Guillermo Maza, Daniel M. Prevedello, Ricardo L. Carrau

Journal Article

Objectives
To determine if the volume of buccal fat, ascertained by computed tomography (CT) scanning, would correspond to surface area and reach (length and width) of the flap intraoperatively to aid in the reconstruction of selected skull base defects.
Methods
Cadaveric study of five specimens, 10 sides. Methods CT imaging and evaluation using the Osirix 9 software (Pixmeo; Bernex, Switzerland). of cadaveric heads to calculate the volume of the buccal fat bilaterally. The flap was then harvested endoscopically. Measurements were taken. Two heads were also dissected via a transfacial approach.
Results
The volume of the buccal fat pad (BFP) as well as the maximum length and width of the endoscopically harvested flap were documented. There was a positive correlation shown between the calculated volume of the BFP based on CT imaging and the dissected length and width of the flap (Pearson correlation, r = 0.83 and r = 0.80, respectively). The transfacial dissection demonstrated the lobes of the BFP well, showing that most of the endoscopic mobilization of the BFP was limited to the posterior lobe, in particular to the temporalis and pterygoid components, with minimal displacement of the superficial components. This minimized the risk of visibly hollowing the buccal fullness.
Conclusion
Preoperative calculation of the CT‐based volume of the BFP correlates positively with the intraoperative maximum reach of the flap for both length and width. Whereas the volume may be lower in some instances, the BFP would still have adequate reach to provide coverage for the lower and mid‐clival region in most patients.
Level of Evidence
NA.
Laryngoscope, 2019

Relationship of Overall Cardiovascular Health and Hearing Loss in The Jackson Heart Study Population

26-12-2019 – “Steven A. Curti, Joseph A. DeGruy, Christopher Spankovich, Charles E. Bishop, Dan Su, Karen Valle, Emily OBrien, Yuan‐I Min, John M. Schweinfurth”

Journal Article

Objectives
To evaluate the relationships among the overall cardiovascular health scoring tool, Lifes Simple 7 (LS7), and hearing in an African‐American cardiovascular study cohort.
Methods
Using the Jackson Heart Studys cohort of African Americans, the relationships between the LS7 scoring metric and hearing of 1314 individuals were assessed. Standard audiometric data was collected and hearing loss was defined as a four‐frequency average of 500, 1000, 2000, and 4000 Hz greater than 25 d
BHL (PTA4). Measures of reported tinnitus and dizziness were also collected. The LS7 scoring tool, which consists of seven individual categories (abstinence from smoking, body mass index, physical activity, healthy diet, total cholesterol <200 mg/d
L, normotension, and absence of diabetes mellitus), was used as measure of overall cardiovascular health. Each category of the LS7 was broken down into poor, intermediate, and ideal subgroups as in accordance with the American Heart Association Strategic Planning Task Force and Statistics Committee. Unadjusted and adjusted gamma regression and logistic regression models were constructed for determining relationships between LS7 and hearing loss.
Results
Higher total LS7 scores (per 1‐unit increase) were associated with lower PTA4 in gamma regression analyses (RR = 0.942, 95% CI, 0.926–0.958, P < .001). This held true even after adjustments for age, sex, education, and history of noise exposure. Using logistic regression analyses to compare LS7 scores to presence of hearing loss, tinnitus, and vertigo; only hearing loss showed a statically significant relationship after adjustments for age, sex, education, and history of noise exposure.
Conclusions
This study shows a significant, graded association between higher lifes simple seven scores and lower incidence of hearing loss.
Level of Evidence2b. Laryngoscope, 2019

Gastroesophageal reflux in laryngopharyngeal reflux patients: Clinical features and therapeutic response

26-12-2019 – Jerome R. Lechien, Francois Bobin, Vinciane Muls, Pierre Eisendrath, Mihaela Horoi, Marie‐Paule Thill, Didier Dequanter, Jean‐Pierre Durdurez, Alexandra Rodriguez, Sven Saussez

Journal Article

Objective
To investigate the clinical features and the therapeutic response of laryngopharyngeal reflux (LPR) patients with or without gastroesophageal reflux disease (GERD).
Methods
Patients with LPR symptoms were enrolled from three European Hospitals. The diagnosis of LPR and GERD was made through impedance‐p
H monitoring (MII‐p
H). A gastrointestinal endoscopy was realized in patients with digestive complaints or ≥60 years old. The 3‐ to 6‐month treatment was based on the association of diet, pantoprazole, alginate, and magaldrate regarding the MII‐p
H characteristics. Reflux Symptom Score (RSS) and Reflux Sign Assessment (RSA) were used to evaluate the clinical evolution throughout treatment. The gastrointestinal endoscopy findings, clinical features, and therapeutic response were compared between patients with LPR and GERD (LPR/GERD) and patients with LPR.
Results
One hundred and eleven LPR patients were included, 54 being LPR/GERD. LPR/GERD patients had a higher number of proximal reflux episodes compared with LPR patients. The prevalence of esophagitis, hernia hiatal, and lower esophageal sphincter insufficiency did not differ between groups. The presence of GERD was strongly associated with acid LPR. Patients without GERD had a higher proportion of nonacid and mixed LPR compared with LPR/GERD patients. The pre‐ to posttreatment evolutions of RSS and RSA were quite similar in both groups, with the exception of the 3‐ to 6‐month improvement of digestive symptoms, which was better in LPR/GERD group. The therapeutic success rates were 79.6% and 77.2% in GERD/LPR and LPR group, respectively.
Conclusion
GERD is predictive of acid LPR. The clinical evolution and the therapeutic response rates were quite similar in both groups.
Level of Evidence4 Laryngoscope, 2019

Bridging the gap: Using 3D printed polycaprolactone implants to reconstruct circumferential tracheal defects in rabbits

24-12-2019 – David S. Chan, Nathalie Gabra, Ayesha Baig, John J. Manoukian, Sam J. Daniel

Journal Article

Objective1) To assess the feasibility of reconstructing 2‐cm‐long circumferential tracheal defects with a 3D printed polycaprolactone (PCL) implant in rabbits. 2) To evaluate endoscopic, histologic, and functional characteristics of a PCL tracheal implant over time.
Methods
Ten New Zealand rabbits were included in this study. A 2‐cm‐long 3D printed PCL tracheal implant was created. All rabbits underwent surgical excision of a 2‐cm‐long cm segment of cervical trachea, which was reconstructed with the implant. Rabbits were sacrificed at the following time points: 0, 4, 5, 6, and 7 weeks postoperatively. At these time points, a rigid bronchoscopy was performed, and blinded evaluators calculated the percentage of airway stenosis. The tracheas were then harvested and prepared for histologic analysis.
Results
All rabbits survived to their date of sacrifice except for one. Rabbits were euthanized between 0 to 54 days postoperatively with a median of 30 days. All rabbits developed significant granulation tissue with an average percentage stenosis of 92.3% ± 6.1%. On histology, granulation was present with extensive neovascularization and mixed inflammatory cells. There was re‐epithelialization present on the luminal surface of the PCL implant near the anastomoses but absent at the center of the implant.
Conclusion
This study demonstrates that our 2‐cm‐long 3D printed PCL tracheal implant can be used to reconstruct a tracheal defect of equivalent size in a New Zealand rabbit model in the short term. However, significant granulation tissue formation limits long‐term survival. Further research is warranted to limit the granulation tissue overgrowth.
Level of Evidence
NALaryngoscope, 2019

LncRNA miR143HG suppresses miR‐21 through methylation to inhibit cell invasion and migration

24-12-2019 – Wu Xun, Wei Cen, Yu Dahai, Wei Huaqing, Su Jiping, Guo Mengzhu, Meng Ning

Journal Article

Objective
This study aimed to investigate the role of lnc
RNA mi
R143HG in laryngeal squamous cell carcinoma (LSCC).
Methods
Quantitative polymerase chain reaction (PCR) and paired t test were used to measure and compare expression levels of mi
R143HG and mi
R‐21 in LSCC and nontumor tissues. To analyze the interactions between mi
R143HG and mi
R‐21, UM‐SCC‐17A cells were transfected mi
R143HG expression vector or mi
R‐21 mimic. The effects of mi
R143HG and mi
R‐21 overexpression on UM‐SCC‐17A cell invasion and migration were analyzed by transwell assays.
Results
We found that mi
R143HG was downregulated in LSCC and inversely correlated with mi
R‐21. In LSCC cells, mi
R143HG overexpression led to the downregulated expression of mi
R‐21, whereas mi
R‐21 overexpression failed to affect mi
R143HG. Methylation‐specific PCR results showed that mi
R143HG overexpression led to increased methylation of mi
R‐21. Low expression levels of mi
R143HG were correlated with poor survival. Overexpression of mi
R143HG led to decreased, whereas mi
R‐21 overexpression resulted in increased rate of LSCC cell migration and invasion. In addition, mi
R‐21 overexpression led to reduced effects of mi
R143HG on cell invasion and migration.
Conclusion
Therefore, mi
R143HG suppresses mi
R‐21 via methylation to regulate cell behaviors in LSCC.
Level of Evidence
NALaryngoscope, 2019

Spatial Motion of Arytenoid Cartilage Using Dynamic Computed Tomography Combined with Euler Angles

24-12-2019 – Yanli Ma, Huijing Bao, Xi Wang, Xi Chen, Zheyi Zhang, Jinan Wang, Peiyun Zhuang, Jack J. Jiang, Azure Wilson, Chenxu Wu

Journal Article

Objective
To investigate the feasibility of dynamic computed tomography in recording and describing the spatial motion characteristics of the arytenoid cartilage.
Methods
Dynamic computed tomography recorded the real‐time motion trajectory of the arytenoid cartilage during inspiration and phonation. A stationary coordinate system was established with the cricoid cartilage as a reference and a motion coordinate system was established using the movement of the arytenoid cartilage. The Euler angles of the arytenoid cartilage movement were calculated by transformation of the two coordinate systems, and the spatial motion characteristics of the arytenoid cartilage were quantitatively studied.
Results
Displacement of the cricoid cartilage was primarily inferior during inspiration. During phonation, the displacement was mainly superior. When the glottis closed, the superior displacement was about 5–8 mm within 0.56 s. During inspiration, the arytenoid cartilage was displaced superiorly approximately 1–2 mm each 0.56 s. The rotation angle was subtle with slight rotation around the XYZ axis, with a range of 5–10 degrees. During phonation, the displacement of the arytenoid cartilage was mainly inferior (about 4–6 mm), anterior (about 2–4 mm) and medial (about 1–2 mm). The motion of the arytenoid cartilage mainly consisted of medial rolling, and there was an alternating movement of anterior‐posterior tilting. The arytenoid cartilage rolled medially (about 20–40 degrees within 0.56 s), accompanied by anterior‐posterior tilting (about 15–20 degrees within 0.56 s).
Conclusion
Dynamic computed tomography recordings of arytenoid cartilage movement can be combined with Euler transformations as a tool to study the spatial characteristics of laryngeal structures during phonation.
Level of Evidence4 Laryngoscope, 2019

Role of epstein‐barr virus in the severity of recurrent respiratory papillomatosis

20-12-2019 – Victor Costa, Vivian Narana El‐Achkar, Patrícia Pimentel Barros, Jorge Esquiche León, Alfredo Ribeiro‐Silva, Román Carlos, Shirley Shizue Nagata Pignatari, Silvaneide Ferreira, Barbara Pereira Mello, Laura Sichero, Luisa Lina Villa, Estela Kaminagakura

Journal Article

Objective
The objective was to investigate the prevalence of the Epstein‐Barr virus (EBV) and its association with human papilloma virus (HPV) detection, clinicopathological features, and the severity of recurrent respiratory papillomatosis (RRP).
Methods
Cases of juvenile recurrent respiratory papillomatosis (JRRP) (n = 36) and adult recurrent respiratory papillomatosis (ARRP) (n = 44) were collected retrospectively and subdivided into low‐ and high‐risk severity groups based on the Derkay score. We performed HPV detection and genotyping using a reverse hybridization protocol and investigated the presence of EBV by polymerase chain reaction (PCR) and in situ hybridization. CD21 levels were accessed by immunohistochemistry.
Results
All samples were HPV‐positive, including 49 cases of HPV 6, 26 cases of HPV 11, four cases of HPV 6 and 11 coinfections, and one case of HPV 16. EBV‐DNA was detected in nine samples by PCR, although none of the cases were positive by means of in situ hybridization. CD21 immunoexpression was not statistically associated with any of the variables analyzed. HPV 6 detection was significantly higher in ARRP cases (P = 0.03), whereas HPV 11 was more prevalent in JRRP cases (P = 0.02) and was even more prevalent in JRRP cases of greater severity (Derkay laryngoscopic scale ≥20) (P = 0.04).
Conclusion
The presence of EBV does not seem to play an important role in the progression/severity of RRP.
Level of Evidence4 Laryngoscope, 2019

Endoscopic Fluorescence‐Guided Surgery for Sinonasal Cancer Using an Antibody‐Dye Conjugate

19-12-2019 – Zachary P. Hart, Naoki Nishio, Giri Krishnan, Guolan Lu, Quan Zhou, Shayan Fakurnejad, Peter John Wormald, Nynke S. Berg, Eben L. Rosenthal, Fred M. Baik

Journal Article

Objective
Endoscopic resection of sinonasal squamous cell carcinoma has become the standard of care, but challenges remain in obtaining clear resection margins. The current study evaluated the feasibility of endoscopic fluorescence‐guided surgery (FGS) to improve surgical resection in a human sinus surgical model.
Methods
A fluorescence endoscope optimized for near‐infrared (NIR) fluorescence detection was evaluated in a phantom study. Various endoscope diameters (4 and 10 mm) and viewing angles (0, 30, and 45 degrees) were evaluated to determine the sensitivity of the system for IRDye800CW detection at various working distances (1–5 cm). Endoscopic FGS was then validated in a three‐dimensional human sinus surgical model to which squamous cell tumors derived from mice were inserted. Mice had received intravenous panitumumab‐IRDye800CW and upon fluorescence‐guided tumor resection, mean fluorescence intensity (MFI) and tumor‐to‐background ratio (TBR) were calculated in in situ and ex vivo settings.
Results
A significantly higher fluorescence intensity was found when using the 10‐mm diameter endoscope compared to the 4mm diameter endoscope (P < .001). No significant difference in MFI was found among the viewing angles of the 4‐mm diameter endoscope. Using the human sinus model, the highest MFI and TBR were obtained at a 1‐cm working distance compared to longer working distances.
Conclusion
We demonstrate that clinically acceptable TBRs were obtained with several working distances to discriminate tumor tissue from adjacent normal tissue in a human sinus model, and that endoscopic FGS may have great potential in identifying residual tumor tissue regions during surgery. Laryngoscope, 2019

Laryngeal adductor reflex hyperexcitability may predict permanent vocal fold paralysis

19-12-2019 – Catherine F. Sinclair, Maria J. Téllez, M. Angeles Sánchez Roldán, Sedat Ulkatan

Case Reports

Laryngeal adductor reflex–continuous intraoperative neuromonitoring (LAR‐CIONM) is a novel method of continuous intraoperative neuromonitoring. In contrast to other vagal nerve monitoring techniques, which elicit a laryngeal compound muscle action potential, LAR‐CIONM elicits a laryngeal reflex response (LAR). In 300 nerves at risk monitored with LAR‐CIONM, two patients have had postoperative permanent vocal fold immobility (VFI). Both patients exhibited a significant LAR amplitude increase prior to complete loss of signal. No other patients have exhibited LAR hyperexcitability. If confirmed in a larger sample, this represents the first time that a vagal intraoperative neuromonitoring technique can distinguish transient from permanent VFI, which could improve patient outcomes. Laryngoscope, 2019

“The Utility of Flexible Esophagoscopy During Open Hypopharyngeal (Zenkers) Diverticulum Surgery”

19-12-2019 – Rebecca J. Howell, Luke W. Edelmayer, Gregory N. Postma

Journal Article

Survival in low‐grade and high‐grade sinonasal adenocarcinoma: A national cancer database analysis

17-12-2019 – Aryan Shay, Ashwin Ganti, Anish Raman, Hannah N. Kuhar, Samuel R. Auger, Michael Eggerstedt, Tirth Patel, Edward C. Kuan, Pete S. Batra, Bobby A. Tajudeen

Journal Article

Objectives/Hypothesis
The purpose of this study was to investigate survival differences between low‐grade and high‐grade sinonasal adenocarcinoma (SNAC) by examining demographics, tumor characteristics, and treatment modalities.
Study Design
Retrospective database analysis.
Methods
The National Cancer Database was queried for patients with SNAC between 2004 and 2015. Univariate and multivariate analyses were performed for all cases of SNAC. Subsequent analysis focused on low‐grade (grade 1 and grade 2) and high‐grade (grade 3 and grade 4) SNAC.
Results
A total of 1,288 patients with SNAC were included in the main cohort and divided into low grade (n = 601) and high grade (n = 370). The 5‐year overall survival for all patients, low‐grade, and high‐grade was 54%, 64%, and 38%, respectively. Prognostic factors associated with decreased survival for the main cohort include advanced age (hazard ratio HR: 1.04; 95% confidence interval CI: 1.03‐1.06), Charlson‐Deyo score (HR: 1.37; 95% CI: 1.05‐1.78), grade 2 (HR: 2.21; 95% CI: 1.26‐3.86, grade 3 (HR: 3.67; 95% CI: 2.09‐6.45), and grade 4 (HR: 3.31; 95% CI: 1.38‐7.91). Radiotherapy was associated with improved overall survival for high‐grade SNAC (HR: 0.41; 95% CI: 0.24‐0.70) but not for low‐grade SNAC (HR: 1.05; 95% CI: 0.59‐1.85).
Conclusions
This investigation is the largest to date analyzing the association of treatment modalities with overall survival in SNAC. Surgery remains paramount to treatment, with radiotherapy offering additional survival benefit for high‐grade SNAC. Administration of chemotherapy was not associated with improved survival.
Level of Evidence4 Laryngoscope, 130:E1–E10, 2020

SCUBA Medicine for Otolaryngologists: Part II. Diagnostic, Treatment, and Dive Fitness Recommendations

17-12-2019 – Jonathan R. Mallen, Daniel S. Roberts

Objectives
Challenge current practices and misconceptions in treating recreational SCUBA (Self‐contained underwater breathing apparatus) divers. Differentiate patients who are fit to dive and those with relative and absolute contraindications. Redefine the standard of care for fitness to dive parameters based on the most up‐to‐date evidence.
Methods
We conducted a review of the available medical and diving literature in English, German, Spanish, Italian, Turkish, and French to determine the degree of evidence or lack thereof behind recommendations for treating SCUBA divers. The databases of PubMed, Ovid Medline, and Cochrane library, as well as available textbooks, were queried for relevant data.
Results
Current recommendations regarding fitness to dive are overly prohibitive given the available evidence. Insufficient evidence currently exists to justify the level of certainty with which some recommendations have been made previously. This is particularly true with regard to postsurgical patients, including those who have undergone stapedectomy or skull base repairs. Updated treatment guidelines, particularly those regarding the timely differentiation of barotrauma and decompression sickness, as well as clearance for return to diving following surgery or trauma, are presented herein.
Conclusion
Current guidelines for otorhinolaryngologists governing the diagnosis and treatment of SCUBA divers are lacking and in some instances founded on insufficient evidence. We present an up‐to‐date, comprehensive guide for otorhinolaryngologists to utilize going forward. Laryngoscope, 130:59–64, 2020

Adding Long‐term Value to the Residency Selection and Assessment Process

17-12-2019 – Jennifer A. Villwock, Sarah N. Bowe, Dana Dunleavy, B. Renee Overton, Stephanie Sharma, Mona M. Abaza

The residency selection process is challenging for both applicants and programs. This is particularly true in competitive specialties such as otolaryngology. The importance of noncognitive competencies in successful residents has been well demonstrated in both medicine and surgery. Unfortunately, there is no streamlined or uniform process for incorporating this information into the selection and training of residents. This review provides a summary of innovative approaches in the selection of residents in otolaryngology and the important role these methods and associated data can play in resident selection and training. The goal of these processes is to create a holistic view of potential residents so programs can enhance the development of current residents and boost long‐term success in our specialty. Laryngoscope, 130:65–68, 2020

The role of pepsin in epithelia‐mesenchymal transition in idiopathic subglottic stenosis

17-12-2019 – Alec J. McCann, Tina L. Samuels, Joel H. Blumin, Nikki Johnston

Objectives
Idiopathic subglottic stenosis (i
SGS) is commonly characterized by laryngeal fibrosis thought to arise by epithelia‐mesenchymal transition (EMT) induced by chronic inflammation. Pepsin is a potent inducer of inflammation in the airways during chronic laryngopharyngeal reflux and has been observed in the subglottic mucosa of patients with i
SGS, absent in normal mucosa. The aim of this study was to examine the effect of pepsin on mechanisms of EMT in laryngeal cells with implications for i
SGS.
Study Design
In vitro translational research study.
Methods
Human laryngeal epithelial cell cultures were exposed to 0.1 mg/m
L or 1.0 mg/m
L pepsin at p
H7 for 24 and 48 hours, or media p
H5 ± 0.1 mg/m
L pepsin for 10 minutes and harvested after 24 and 48 hours. EMT marker expression was measured by q
PCR and enzyme‐linked immunosorbent assays. Wound‐healing scratch assay was performed on immortalized human vocal fold fibroblasts pretreated with media p
H5 ± 0.1 mg/m
L pepsin (10 minutes) or continuously treated with media p
H7 ± 0.1 to 1 mg/m
L pepsin for 24 hours.
Results
Pepsin yielded no effect on MMP1, MMP9, FN1, COL1A1, HAS2, or CDH1 gene expression or matrix metalloproteinase‐9 or fibronectin protein expression, either alone or in the presence of weak acid. Pepsin and/or acid produced no effect on fibroblast migration.
Conclusion
Whereas pepsin has been shown to be present in the subglottic mucosa of patients with i
SGS, this in vitro acute exposure investigation does not provide evidence of a direct causal role for development of fibrosis in subglottic epithelial cell cultures.
Levels of Evidence
NA. Laryngoscope, 130:154–158, 2020

“Potts puffy tumor in children: A review of the literature”

17-12-2019 – Petros Koltsidopoulos, Eleni Papageorgiou, Charalampos Skoulakis

Objectives
Potts puffy tumor (PTT) is a frontal subperiosteal abscess associated with underlying frontal osteomyelitis. The purpose of the present study was to assess the rate of intracranial involvement in pediatric and adolescent patients with PPT and to discuss the diagnostic workup and the therapeutic features of this pathology.
Methods
We searched Web of Science, PubMed and MEDLINE from 1998 to 2018. The search focused on papers concerning the diagnostic procedure and therapeutic management of PTT. Statistical techniques were not used.
Results
We included 53 articles that described 92 pediatric and adolescent patients with PPT. The overall rate of intracranial complications was found to be 72%. Most authors used computed tomography for the diagnosis of PTT and its complications, either alone or in combination with magnetic resonance imaging. In 50% of cases, an endoscopic endonasal approach is used for the management of the underlying acute or chronic sinusitis.
Conclusions
On the basis of the available literature, it seems that the incidence rate of intracranial involvement in patients with PPT is quite high. Early diagnosis using the appropriate imaging raise the possibility of good recovery. Concerning the therapy of PTT, endoscopic sinus surgery could be considered as a valuable technique. The vast majority of patients treated appropriately recover without long‐term neurologic complications and sequelae.
Level of Evidence4 Laryngoscope, 130:225–231, 2020

The optimal surgical approach for papillary thyroid carcinoma with pathological n1 metastases: An analysis from the SEER database

17-12-2019 – Tingting Ji, Jun Chen, Jianing Mou, Xin Ni, Yongli Guo, Jie Zhang, Shengcai Wang, Wei Wang, Xin Zhang, Jun Tai

Journal Article

Objectives/Hypothesis
The definition of large‐volume pathologic N1 metastases has been changed in the 2017 version 2 of the National Comprehensive Cancer Network guidelines, leading to a controversy over the optimal surgical approach selection for patients with biopsy‐proven papillary thyroid carcinoma (PTC). The aim of this study was to investigate the therapeutic efficacy of total thyroidectomy (TT) and thyroid lobectomy (TL) for these patients.
Study Design
Retrospective population‐based database analysis.
Methods
A total of 906 consecutive PTC patients with pathologic N1 metastases (>5 involved nodes with metastases ≤5 mm in the largest dimension) were retrieved from the Surveillance, Epidemiology, and End Results database, and divided into two groups (≤2 mm, >2–5 mm) based on the size of the extent of disease. Overall survival (OS) was then compared between patients treated with TT and TL, followed by Cox proportional hazards regression analysis to explore multiple prognostic factors.
Results
OS favored TT compared with TL in patients with more than five involved nodes and metastases >2 to 5 mm in the largest dimension (P < .05). Cox analysis showed that the TL was not an independent factor associated with poorer OS than TT in these patients (P > .05).
Conclusions
TT showed better survival than TL for patients with more than five involved nodes and metastases >2 to 5 mm in the largest dimension. For patients with more than five involved nodes and metastases ≤2 mm in the largest dimension, either TT or TL can be recommended because there was no difference in survival.
Level of Evidence
NA Laryngoscope, 130:269–273, 2020

Topical anesthetic techniques in office‐based laryngeal surgery: A comparison of patient preferences

17-12-2019 – Matthew R. Naunheim, Peak Woo

Objectives
Multiple topical anesthesia techniques exist for office‐based laryngeal surgery. Our objective was to assess patient and surgeon satisfaction for three different techniques.
Study Design
Cohort study.
Methods
All consecutive patients presenting to an outpatient laryngology office for awake surgical procedures were enrolled. Patients were anesthetized with local anesthesia (2 cubic centimeters of 4% lidocaine) in one of three ways: 1) nebulizer, 2) flexible cannula through a channeled laryngoscope, or 3) transtracheal instillation. Demographics, procedure times, and surgeon satisfaction were recorded. A validated 11‐item patient satisfaction questionnaire (Iowa Satisfaction with Anesthesia Survey) was administered after the procedure to calculate an overall satisfaction score (−3worst to 3best). Descriptive and correlative statistics were performed.
Results
One hundred consecutive patients were included (37 females, 73 males), with relatively equal numbers between groups (32 nebulizer, 35 cannula, 33 transtracheal). Seven procedures were aborted (4 nebulizer, 2 cannula, 1 transtracheal) due to movement, anxiety, or technical issues. Three patients did not adequately complete the survey. Of the 90 remaining patients, patient satisfaction was highest with the transtracheal technique (2.04) versus cannula (1.46) or nebulizer (1.45), and this was statistically significant (P = 0.0167). This difference was driven by decreased pain and nausea scores in the transtracheal group. Surgeon satisfaction was lower with nebulizer and higher with transtracheal injection (P = 0.0081). There was a correlation between surgeon satisfaction and patient satisfaction (P < 0.0001).
Conclusion
Transtracheal instillation was favored by both patients and the surgeon. Choice of local anesthetic techniques may impact patient preferences and surgical success. This may serve as a basis for optimizing anesthetic care in office‐based laryngeal surgery.
Level of Evidence4 Laryngoscope, 130:166–170, 2020

Voice and swallowing dysfunction in X‐linked dystonia parkinsonism

17-12-2019 – Phillip C. Song, Hoai Le, Patrick Acuna, Jan Kristopher Palentinos De Guzman, Nutan Sharma, Taylor N. Francouer, Marisela E. Dy, Criscely L. Go

Journal Article

Objectives
To systematically characterize and describe voice and swallowing manifestations in patients with X‐linked dystonia parkinsonism (XDP) and correlate with quality‐of‐life (QOL) measures.
Methods
Thirty‐four patients with XDP with communication and swallowing difficulties underwent neurological examination, head and neck examination, nasopharyngoscopy, QOL surveys (Swallowing Quality of Life questionnaire SWAL‐QOL and Voice Handicap Index VHI), and functional endoscopic evaluation of swallowing (FEES) to assess the extent of dysfunction.
Results
All patients showed high rates of lingual, oromandibular, and laryngeal dysfunction, as well as severe QOL changes in swallowing and communication ability. The most common head and neck manifestations of dystonic symptoms were difficulty coordinating the mouth and tongue (79%), uncontrollable tongue thrusting (53%), and jaw opening (35%). Laryngeal symptoms including vocal strain (adductor voice breaks) or stridor (32%), as well as velopharyngeal insufficiency (20%), were also identified. Of the patients with laryngeal symptoms, 18% had respiratory dystonia. Swallowing assessments showed significant abnormalities in oral bolus control and oropharyngeal dysphagia. FEES examinations showed that 87.5% of the study group had penetration or aspiration. QOL scores showed an average VHI of 94.4 (severe dysfunction), and SWAL‐QOL showed an average of 37.7 (severe dysfunction).
Conclusion
Swallowing and voice impairment in XDP is not well characterized and presents a more distinctive phenomenology than other neurological disorders, with a unique set of challenges for treatment. This is the first study to systematically evaluate laryngeal and pharyngeal dysfunction in XDP patients and correlate with QOL measures.
Level of Evidence4 Laryngoscope, 130:171–177, 2020

Cost and efficiency of myringotomy procedures in minor procedure rooms compared to operating rooms

17-12-2019 – Jacob Davidson, Khrystyna Ioanidis, Vanessa Fantillo, Josee Paradis, Julie Strychowsky

Objectives
Minor pediatric surgeries performed in the minor procedure room (MPR) may be more time efficient and less costly compared to those performed in the operating room (OR).
Study Design
Retrospective review.
Methods
This was a retrospective study on cost and efficiency differences of bilateral myringotomy with tube insertions performed in the MPR versus the OR. Charts were reviewed from June 2015 to May 2017. Cost data was based on supply cost and case costing of medical personnel including nurses, aides, and anesthesia assistants.
Results
Two hundred eighteen patients were included in the study. The median age was 2.7 years (range: 0.8–16.7), and there were no differences in gender between locations. One hundred twenty‐three patients had surgery in the MPR (56.4%), and 95 had surgery in the OR (43.6%). The median length of time in the procedure room was 11 minutes shorter for patients who underwent surgery in the MPR (12.0 minutes, range: 3.0–33.0) compared to patients in the OR (23.0 minutes, range: 11.0–52.0; P < .0001). Median hospital stay (2.0 hours vs. 4.3 hours; P < 0.0001) and median patient turnover time (6.0 minutes vs. 14.0 minutes; P < .0001) was shorter in the MPR compared to OR. The total overall cost of a myringotomy with tube insertion, including labor and supply cost, was $189.41 in the MPR compared to $468.56 in the OR, a difference of $279.15 per case.
Conclusion
Bilateral myringotomy with tube insertions are more time and cost‐efficient when performed in the MPR. This study supports the need for increased availability of MPR time for appropriate surgeries.
Level of Evidence3 Laryngoscope, 130:242–246, 2020

Long‐term quality of life after definitive treatment of sinonasal and nasopharyngeal malignancies

17-12-2019 – Matthew A. Tyler, Abdallah S.R. Mohamed, Joshua B. Smith, Jeremy M. Aymard, Clifton D. Fuller, Jack Phan, Steven J. Frank, Renata Ferrarotto, Michael E. Kupferman, Ehab Y. Hanna, Gary B. Gunn, Shirley Y. Su

Objective
To evaluate long‐term global and site‐specific health‐related quality of life (HRQoL) in patients treated for sinonasal and nasopharyngeal malignancies.
Study Design
Cross‐sectional.
Methods
One hundred fourteen patients with sinonasal and nasopharyngeal malignancies received surgery, radiation, systemic chemotherapy, or a combination thereof, with curative intent. Validated global (Euro
Qol‐5D Visual Analogue Scale EQ‐5D VAS) and disease‐specific instruments (MD Anderson Symptom Inventory–Head and Neck MDASI‐HN, Anterior Skull Base Questionnaire ASBQ) were administered to patients who were both free of disease and had completed treatment at least 12 months previously. Associations between instruments, instrument domains, and specific clinical parameters were analyzed.
Results
The median age was 55 years. The mean EQ‐5D VAS, MDASI‐22 composite score, and ASBQ score were 74 (standard deviation SD 21), 48 (SD 36), and 130 (SD 27), respectively. The most frequently reported high‐severity items in MDASI‐HN were dry mouth and difficulty tasting food. The most frequently reported high‐severity items in ASBQ were difficulty with smell and nasal secretions. Advanced Tumor (T) classification was associated with worse overall ASBQ sum score (P = 0.02). ASBQ performance at home and MDASI‐HN drowsy symptom items independently predicted worse global HRQoL as measured by the EQ‐5D VAS (P < 0.001).
Conclusion
Global HRQoL for survivors of sinonasal and nasopharyngeal malignancies after multimodality treatment approximates that of the U.
S. population for the same age group. ASBQ and MDASI‐HN correlate well with global HRQoL outcomes as measured by EQ‐5D VAS. MDASI‐HN and ASBQ elicited unique symptoms, highlighting the complex symptom burden experienced by these patients. Further studies should identify patients predisposed to reduced long‐term QOL.
Level of Evidence3 Laryngoscope, 130:86–93, 2020

Long‐term evaluation of satisfaction and side effects after modified uvulopalatopharyngoplasty

17-12-2019 – Danielle Friberg, Joar Sundman, Nanna Browaldh

Objectives/Hypothesis
We have previously shown that modified uvulopalatopharyngoplasty (UPPP) is effective to treat obstructive sleep apnea (OSA) and that the effect is stable after 24 months. This continuous report includes questionnaires and phone interviews.
Study Design
Prospective intervention study.
Methods
Sixty‐five patients with apnea‐hypopnea index (AHI) score ≥ 15, body mass index <36 kg/m2, and Epworth Sleepiness Scale (ESS) score ≥ 8 underwent modified UPPP after failing nonsurgical treatment. The results from a patient questionnaire at 6 and 24 months after surgery were correlated with age, body mass index, and ESS and AHI scores. Patients reporting side effects and/or regretting the surgery after 24 months were selected for phone interviews 9 years after surgery.
Results
The response rate was 80% and 74% at the 6‐ and 24‐month follow‐ups, respectively. Of those who responded to the questionnaire, 96% and 83% were satisfied after 6 and 24 months, respectively; 98% and 92% recommended the surgery. Side effects (globus, mucus, and voice and swallowing disorders) occurred in 38% and 31%, respectively. Dissatisfaction correlated significantly with high postoperative AHI and ESS scores, but not with occurrence of side effects. Younger subjects had a higher rate of recommendation and lower rate of side effects than did older subjects. Phone interviews after 9 years were responded to by 14 of 16 selected patients, and the responders reported minor or no side effects.
Conclusions
The vast majority of the OSA patients were satisfied 24 months after surgery, even though a third of them were experiencing side effects. Younger patients had fewer side effects than did older patients. Patients with better OSA outcomes were also more satisfied. After 9 years the side effects were no longer problematic.
Level of Evidence2b Laryngoscope, 130:263–268, 2020

Lengthening the nasoseptal flap pedicle with extended dissection into the pterygopalatine fossa

17-12-2019 – Karthik S. Shastri, Luciano Cesar P. C. Leonel, Varun Patel, Marcelo Charles‐Pereira, Tyler J. Kenning, Maria Peris‐Celda, Carlos D. Pinheiro‐Neto

Journal Article

Objectives/Hypothesis
Releasing the nasoseptal flap (NSF) pedicle from the sphenopalatine artery (SPA) foramen may considerably improve flap reach and surface area. Our objectives were quantify increases in pedicle length and NSF reach through extended pedicle dissection into the pterygopalatine fossa (PPF) through cadaveric dissections and present clinical applications.
Study Design
Anatomical study and retrospective clinical cohort study.
Methods
Twelve cadaveric dissections were performed. Following standard NSF harvest, the distance from the anterior edge of the flap to the anterior nasal spine while pulling the flap anteriorly was measured. As dissection into the SPA foramen and PPF continued, similar interval measurements were completed in four stages after release from the SPA foramen, release of the internal maxillary artery (IMAX), and transection of the descending palatine artery (DPA). The extended pedicle dissection technique was performed in seven consecutive patients for a variety of different pathologies.
Results
The mean length of the NSF from the anterior nasal spine and maximum flap reach were 1.91 ± 0.40 cm/9.3 ± 0.39 cm following standard harvest, 2.52 ± 0.61 cm/9.75±1.06 cm following SPA foramen release, 4.93 ± 0.89 cm/12.16 ± 0.54 cm following full IMAX dissection, and 6.18 ± 0.68 cm/13.41 ± 0.75 cm following DPA transection. No flap dehiscence or necrosis was observed in all seven surgical patients.
Conclusions
Extended pedicle dissection of the NSF to the SPA/IMAX markedly improves the potential length and reach of the flap. This technique may provide a feasible option for reconstruction of large anterior skull base and craniocervical junction defects. Seven successful cases are presented here, but further studies with larger series are warranted to validate findings in a clinical setting.
Level of Evidence4 Laryngoscope, 130:18–24, 2020

The spectrum of facial palsy: The MEEI facial palsy photo and video standard set

17-12-2019 – Jacqueline J. Greene, Diego L. Guarin, Joana Tavares, Emily Fortier, Mara Robinson, Joseph Dusseldorp, Olivia Quatela, Nate Jowett, Tessa Hadlock

Journal Article

Objectives
Facial palsy causes variable facial disfigurement ranging from subtle asymmetry to crippling deformity. There is no existing standard database to serve as a resource for facial palsy education and research. We present a standardized set of facial photographs and videos representing the entire spectrum of flaccid and nonflaccid (aberrantly regenerated or synkinetic) facial palsy. To demonstrate the utility of the dataset, we describe the relationship between level of facial function and perceived emotion expression as determined by an automated emotion detection, machine learning‐based algorithm.
Methods
Photographs and videos of patients with both flaccid and nonflaccid facial palsy were prospectively gathered. The degree of facial palsy was quantified using e
FACE, House‐Brackmann, and Sunnybrook scales. Perceived emotion during a standard video of facial movements was determined using an automated, machine learning algorithm.
Results
Sixty participants were enrolled and categorized by e
FACE score across the range of facial function. Patients with complete flaccid facial palsy (e
FACE <60) had a significant loss of perceived joy compared to the nonflaccid and normal groups. Additionally, patients with only moderate flaccid and nonflaccid facial palsy had a significant increase in perceived negative emotion (contempt) when compared to the normal group.
Conclusion
We provide this open‐source database to assist in comparing current and future scales of facial function as well as facilitate comprehensive investigation of the entire spectrum of facial palsy. The automated machine learning‐based algorithm detected negative emotions at moderate levels of facial palsy and suggested a threshold severity of flaccid facial palsy beyond which joy was not perceived.
Level of Evidence
NA Laryngoscope, 130:32–37, 2020

Long‐term outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation

17-12-2019 – Todd T. Kingdom, Henry P. Barham, Vikram D. Durairaj

Journal Article

Objective
A growing body of evidence demonstrates that endonasal endoscopic dacryocystorhinostomy (e
DCR) techniques provide comparable results to conventional external techniques. The purpose of this study was to evaluate long‐term outcomes after powered endoscopic DCR without preservation of mucosal flaps for the management of acquired nasolacrimal duct obstruction performed by a single surgical team.
Methods
A retrospective review was performed of patients with epiphora secondary to acquired nasolacrimal duct obstruction who underwent e
DCR without mucosal flap preservation from May 2003 to April 2013 at a tertiary referral medical center. Main outcome measures were subjective improvement in epiphora and assessment of anatomic patency based on lacrimal irrigation and endoscopic evaluation.
Results
Eighty patients (69 primary and 11 revision) totaling 103 procedures (87 primary, 16 revision) were available for analysis at a mean follow‐up of 28.7 (range 6–114) months. At the most recent follow‐up, 92 of 103 (89.3%) procedures had complete resolution of epiphora, and 10 of 103 procedures achieved mild intermittent epiphora. Complete resolution of epiphora was noted in 93.1% (81 of 87) of primary procedures and 68.8% (11 of 16) of revision procedures. Objective anatomic patency was confirmed in 98% (101 of 103). A revision procedure was required in 5.8% (6 of 103).
Conclusion
Outcomes of powered e
DCR without the preservation of mucosal flaps compare favorably to previously reported results in the literature. These long‐term results suggest that mucosal flap preservation is not required to achieve successful outcomes with e
DCR.
Level of Evidence4 Laryngoscope, 130:12–17, 2020

An evaluation of arytenoid prolapse following laryngotracheal reconstruction

17-12-2019 – Lilun Li, Kaelan Black, Michelle White, George Zalzal, Diego Preciado

Objectives/Hypothesis
Laryngotracheal reconstruction (LTR) is a collection of procedures used to treat pediatric laryngotracheal stenosis. Arytenoid prolapse is a potential postoperative complication that may lead to upper airway obstruction. This study investigates the incidence, risk factors, and need for surgical intervention for post‐LTR arytenoid prolapse.
Study Design
Retrospective chart review.
Methods
The charts of 107 patients who underwent a total of 119 LTR procedures between 2005 and 2018 at a tertiary free‐standing childrens hospital were reviewed.
Results
The incidence of post‐LTR arytenoid prolapse was 7.6%. Age, glottic involvement, tracheostomy status, vocal cord paralysis, and balloon dilation had no effect on arytenoid prolapse development. Sixteen percent of procedures performed in children <8 kg resulted in arytenoid prolapse, versus 4.5% of procedures performed in children >8 kg (P = .036). One hundred percent 100% of patients with post‐LTR arytenoid prolapse had placement of a posterior graft. Multivariate analysis confirmed both weight <8 kg and posterior graft use to be significantly associated with arytenoid prolapse (P = .027 and .039, respectively). Three of the nine patients with arytenoid prolapse were symptomatic and weighed <8 kg at time of surgery. One required voice therapy; two required surgical intervention.
Conclusions
The incidence of arytenoid prolapse is 7.6% following LTR. Patients undergoing posterior graft LTR or weigh <8 kg at time of surgery are more likely to develop arytenoid prolapse. Children <8 kg at time of surgery who develop arytenoid prolapse are more likely to be symptomatic and require further intervention. These findings are valuable for preoperative risk assessment of pediatric laryngotracheal stenosis management.
Level of Evidence4 Laryngoscope, 130:247–251, 2020

SCUBA Medicine for otolaryngologists: Part I. Diving into SCUBA physiology and injury prevention

17-12-2019 – Jonathan R. Mallen, Daniel S. Roberts

Objectives
Introduce pertinent self‐contained underwater breathing apparatus (SCUBA) physiology and corresponding terminology. Appreciate the scope of diving and related otolaryngological injury. Illustrate pathophysiologic mechanisms for diving injuries. Summarize strategies for ear, paranasal sinus, and lung barotrauma prevention, including medical optimization and autoinsufflation techniques.
Methods
We conducted a review of the available medical and diving literature in English, German, Spanish, Italian Turkish, and French to determine the degree of evidence or lack thereof behind recommendations for treating SCUBA divers. The databases of PubMed, Ovid Medline, and the Cochrane library, as well available textbooks, were queried for relevant data.
Results
Divers are subjected to large pressure gradients within the first few meters of descent. This can lead to gas embolism formation as well as barotrauma secondary to gas expansion/compression in potential closed spaces such as the middle ear, paranasal sinuses, and lungs. Physicians can minimize the risk of injury by counseling patients regarding proper equalization and descent/ascent techniques, and optimizing sinonasal and eustachian tube function. The use of decongestants is controversial.
Conclusions
Diving is an increasingly popular sport with predominantly otolaryngologic manifestations of injury and disease. Treating SCUBA divers requires a firm understanding of how physiology is altered underwater. This review presents the relevant background information using illustrations to understand the environmental forces acting on divers and how to prevent injury. Laryngoscope, 130:52–58, 2020

The impact of cricothyroid involvement on adductor recovery in unilateral vocal fold paralysis

17-12-2019 – Tuan‐Jen Fang, Hsiu‐Feng Chuang, Hui‐Chen Chiang, Yu‐Cheng Pei

Objectives/Hypothesis
Wide variation in postinjury functional recovery is a hallmark of unilateral vocal fold paralysis (UVFP), ranging from zero to full recovery. The present study examined the impact of cricothyroid (CT) muscle involvement on recovery using quantitative laryngeal electromyography (LEMG) of the thyroarytenoid–lateral cricoarytenoid (TA‐LCA) muscle complex at multiple times postinjury.
Study Design
Prospective cohort study in a medical center.
Methods
Eighty‐one patients with UVFP (37 males and 44 females) received an initial assessment of quantitative LEMG, stroboscope, acoustic voice analysis and 36‐Item Short Form Survey quality‐of‐life questionnaire at 3 to 6 months after UVFP onset and a follow‐up assessment at 12 months after UVFP onset.
Results
The initial and follow‐up assessments were performed at 4.3 ± 1.9 and 12.5 ± 1.3 months after UVFP onset, respectively. The peak turn frequency of the TA‐LCA muscle complex on the lesion side was improved at the follow‐up (470 ± 294 Hz) compared with the initial assessment (300 ± 204 Hz) (P < .001). Patients were also divided into two groups with (n = 27) and without (n = 54) CT involvement, respectively. TA‐LCA muscle complex turn frequency improved in patients without CT involvement (from 277 ± 198 to 511 ± 301 Hz; P < .001), but not in those with CT involvement (from 345 ± 211 to 386 ± 265 Hz; P = .46). Seventy‐one of all patients received early intervention with intracordal hyaluronate injection, showing similar therapeutic effects in those with and without CT involvement.
Conclusions
Acute UVFP with combined TA‐LCA muscle complex and CT muscle involvement has a poor prognosis, with poorer recovery of TA‐LCA muscle complex recruitment. Early interventions should be considered in patients with UVFP with CT involvement.
Level of Evidence2 Laryngoscope, 130:139–145, 2020

A retrospective analysis of 1,717 paranasal sinus fungus ball cases from 2008 to 2017

17-12-2019 – Xin Liu, Chengyao Liu, Hongzheng Wei, Shuai He, Shouxiang Dong, Bing Zhou, Luo Zhang, Yunchuan Li

Journal Article

Objectives/Hypothesis
To analyze the epidemiological characteristics, clinical features, and the outcomes of histopathology and microbiology for fungus ball (FB) in the last 10 years in our department.
Study Design
Database review.
Methods
In total, 1,717 cases of FB were reviewed from the case database of Beijing Tongren Hospital (between 2008 and 2017). Epidemiologic data, clinical manifestations, histopathology, and microbiology were analyzed.
Results
In the past 10 years, there has been a significant increase in patients with FB presenting at our department (P < .05). The mean age of patients with paranasal sinus FB was 54 years, and 67% of patients were female (1,156/1,717). The average age and female predominance were consistent with previous reports. In total, 1,626 cases (94.7%) were unilateral, and the most common location was the maxillary sinus (76.6%). Aspergillus spp. (72.8%) was the most abundant fungal species in our study. The direct smear positive rate was 68.6%, and the fungal culture rate was 22.6%. All cases were treated with functional endoscopic sinus surgery, with a very low rate of postoperative complications and reoperation (20/1,717).
Conclusions
Histopathological and microbiological analyses are essential for the diagnosis of FB. Surgery is the most effective method of treatment. Direct smear after surgery is not necessary. Oral or topical antimycotic treatments are not recommended after surgery or during the perioperative period.
Level of Evidence4 Laryngoscope, 130:75–79, 2020

Sentinel lymph node biopsy for high‐risk cutaneous squamous cell carcinoma of the head and neck

17-12-2019 – Michael P. Wu, Rosh K. V. Sethi, Kevin S. Emerick

Objectives/Hypothesis
To describe outcomes of a single institution experience with sentinel lymph node biopsy (SLNB) for high‐risk cutaneous squamous cell carcinoma of the head and neck.
Study Design
Retrospective case series.
Methods
Chart review was performed for patients who presented with clinically node negative cutaneous squamous cell carcinoma of the head and neck between December 2007 and May 2018. Patients who met high‐risk criteria underwent SLNB and excision, with or without adjuvant therapy. Patients who underwent prior neck dissection were excluded. The main outcomes were SLNB result, lymph node spread, recurrence‐free survival, disease‐specific survival, and overall survival.
Results
Eighty‐three patients underwent successful SLNB, and one patient underwent selective neck dissection for intraoperatively identified occult lymph node metastasis. Five patients (6%) had a sentinel node positive for tumor, of whom 4/5 received further treatment (neck dissection, radiation, and/or systemic therapy) with no further recurrence at the time of last follow‐up. SLNB had a negative predictive value of 95% to 100%. Recurrent tumor at presentation, tumor arising from an area of chronic inflammation, and immunosuppression were significantly associated with increased risk of subsequent recurrence, with a mean follow‐up of 19.9 months.
Conclusions
SLNB can be used to identify regional lymph node metastases in cutaneous squamous cell carcinoma of the head and neck with a high negative predictive value (95%–100%). Factors associated with recurrence were tumor being locally recurrent at presentation, arising from an area of chronic inflammation, and immunosuppression.
Level of Evidence4 Laryngoscope, 130:108–114, 2020

Oncologic outcomes after surgery for locally aggressive basal cell carcinoma of the head and neck

17-12-2019 – Amarbir S. Gill, Vinay R. Nittur, Michael G. Moore, D. Gregory Farwell, Arnaud F. Bewley

Objective
Although basal cell carcinoma (BCC) is the most common skin cancer, locally aggressive BCC of the head and neck is rare and not well studied.
Study Design
Retrospective review of patients who underwent primary surgical resection of locally aggressive head and neck BCC at a single tertiary academic center.
Results
Eighty‐seven patients with 98 tumors demonstrated a 5‐year Kaplan‐Meier estimated recurrence‐free survival of 64.5%, overall survival of 83.3%, and disease‐specific survival of 98.3%. Intraoperative positive frozen section margin was a strong independent predictor of local recurrence (hazard ratio 6.88, P = 0.038) and was more likely to occur in tumors previously treated with radiation (odds ratio 6.47 = 0.05).
Conclusion
Locally aggressive BCCs of the head and neck have high rates of local recurrence but low disease‐specific mortality when treated with primary surgery and selected use of adjuvant therapy. Intraoperative positive frozen section margin is a strong independent predictor of local recurrence and is more likely in tumors that were previously treated with radiation therapy.
Level of Evidence4 Laryngoscope, 130:115–119, 2020

Mesenchymal stromal cells modulate tissue repair responses within the injured vocal fold

17-12-2019 – Srinivasa Rao Nagubothu, Rachael V. Sugars, Nikolce Tudzarovski, Anton Törnqvist Andrén, Matteo Bottai, Lindsay C. Davies, Stellan Hertegård, Katarina Le Blanc

Objectives/Hypothesis
This study aimed to determine whether local injection of human mesenchymal stromal cells (MSC) could modulate the early inflammatory response within injured vocal folds (VFs) to promote wound‐healing processes.
Study Design
Experimental xenograft model.
Methods
VF injury was surgically induced by bilateral resection of the lamina propria of rabbits, and MSC were immediately injected into the injured area of both VFs. Animals were sacrificed on days 2, 4, and 24. Histological analyses were performed by hematoxylin and eosin, Massons Trichrome, and elastin staining. Cell death was visualized by terminal deoxynucleotidyl transferase d
UTP nick end labeling (TUNEL), and the M2 macrophage marker, CD163, detected by immunohistochemistry. Persistence of injected MSC was evaluated by fluorescent in situ hybridization (FISH). Quantitative polymerase chain reaction was performed on the contralateral VF.
Results
Histological examination at days 2 and 4 indicated that MSC were able to reduce tissue inflammation, with gene expression analysis confirming a significant reduction of proinflammatory markers, interleukin (IL)‐1β, and IL‐8. FISH demonstrated low‐level persistence of injected MSC at both time points, and TUNEL confirmed localized cell death at the injury site. Increased levels of CD163+ anti‐inflammatory macrophages indicated a change in the immune milieu, supporting wound resolution. Evidence of a more organized collagen matrix suggests that MSC may enhance the production of a functional repair tissue after injury, despite their low‐level persistence within the tissue.
Conclusions
This study demonstrates that MSC are able to positively modulate the early wound‐healing response through resolution of the inflammatory phase and promotion of tissue repair.
Level of Evidence
NA Laryngoscope, 130:E21–E29, 2020

Single, high‐dose local injection of bFGF improves thyroarytenoid muscle atrophy after paralysis

17-12-2019 – Takao Goto, Rumi Ueha, Taku Sato, Yoko Fujimaki, Takaharu Nito, Tatsuya Yamasoba

Objectives/Hypothesis
Unilateral vocal fold paralysis (UVFP) induces hoarseness due to progressive atrophy of the denervated thyroarytenoid (TA) muscle. Therefore, treatments aimed at regenerating the atrophied TA muscle are required. Basic fibroblast growth factor (b
FGF) is involved in muscle development and regeneration. This study aimed to elucidate the effects of b
FGF injection on atrophied TA muscle.
Study Design
Animal research.
Methods
A recurrent laryngeal nerve–paralysis rat model was established, and low‐ (200 ng) or high‐dose (2,000 ng) b
FGF or saline (control) was injected into the TA muscle 28 days later. The larynges were excised on day 1, 3, 7, 14, and 28 after treatment. The cross‐sectional area of the TA muscle in normal and paralyzed sides was compared, and the Ki67‐positive (Ki67+) dividing cells, paired box 7–positive (Pax7+) satellite cells (SCs), and myogenic differentiation–positive (Myo
D+) myoblasts were counted.
Results
The TA muscle area of animals administered high‐dose b
FGF increased with time and was significantly larger than that of the saline‐injected controls 28 days after treatment (P < .05). The counts of Ki67+ and Pax7+ cells were the highest on day 1, whereas the Myo
D+ myoblast count was highest on day 7. These results suggest that b
FGF administration into the denervated TA muscles compensated for the atrophied TA muscles by inducing proliferation of SCs and their differentiation to myoblasts.
Conclusions
A single injection of high‐dose b
FGF augmented regeneration and differentiation of the atrophied TA muscle by enhancing proliferation and differentiation of muscle SCs, suggesting its possible clinical application in humans with UVFP.
Level of Evidence
NA Laryngoscope, 130:159–165, 2020

Preoperative characteristics of over 1,300 functional septorhinoplasty patients

17-12-2019 – Natalie Justicz, Shekhar K. Gadkaree, Jennifer C. Fuller, Joseph J. Locascio, Robin W. Lindsay

Journal Article

Objective
To identify characteristics of patients presenting preoperatively for functional septorhinoplasty associated with increased Nasal Obstruction Symptom Evaluation (NOSE) scores.
Study Design
Retrospective analysis of a prospective cohort at a tertiary medical center. Only baseline assessments were analyzed in this cross‐sectional study.
Methods1,338 patients completed baseline nasal evaluation, resulting in 1,034 NOSE scores. Demographics, medical history, surgical history, and physical exam findings were recorded.
Results
The average preoperative NOSE score was 59.8 out of 100 (standard deviation: 24.9). Fifty‐four percent (578 per 1,074) of respondents were female, although sex did not affect baseline NOSE score (P = 0.7). Forty‐five percent (404 per 896) reported prior nasal surgery. History of rhinoplasty was not associated with a difference in baseline NOSE score (P = 0.1924); however, history of septoplasty (P = 0.0390) was associated with an increased baseline NOSE score. Snoring was also both associated with higher baseline NOSE score (P = 0.0003). All 12 septal/nasal valve measurements were associated with higher preoperative NOSE score, whereas the internal nasal valve narrowing variables retained significance in multivariate analysis (left: P = .0490; right: P = .0077).
Conclusion
Patients presenting for nasal airway obstruction were evaluated. Sex was not associated with difference in NOSE score. History of septoplasty was associated with higher baseline NOSE score, as were snoring and internal nasal valve narrowing at rest.
Level of Evidence2C Laryngoscope, 130:25–31, 2020

Positive airway pressure ventilation and complications in pediatric tracheocutaneous fistula repair

17-12-2019 – Joshua D. Smith, Marc C. Thorne, Aaron L. Thatcher

Objectives
Surgical repair of persistent tracheocutaneous fistula in children may be complicated by tracheal air leak with resultant subcutaneous emphysema, pneumomediastinum, and/or pneumothorax. We first sought to identify clinical risk factors for postoperative complications after primary repair of persistent tracheocutaneous fistula in children. Second, the type and frequency of complications in patients administered positive airway pressure ventilation (e.g., bag‐valve mask ventilation, continuous positive airway pressure CPAP, or bilevel positive airway pressure Bi
PAP) postoperatively was determined and compared to a control population.
Methods
This was a retrospective investigation of all pediatric patients (n = 108) undergoing surgical repair of persistent tracheocutaneous fistula from January 2000 and April 2016 at a tertiary, academic referral center. Type and frequency of postoperative complications were compared among patients who were administered positive airway pressure ventilation postoperatively versus those who were not.
Results
Of 108 pediatric patients, complications after tracheocutaneous fistula repair occurred in 22 (20.4%) patients. These included symptoms of respiratory distress requiring intervention (e.g., supplemental O2, racemic epinephrine, intubation), subcutaneous emphysema, pneumomediastinum and/or pneumothorax, bleeding, wound infection, and readmission. Frequency of all postoperative complications was significantly higher in patients administered positive airway pressure ventilation versus those who were not (50.0% vs. 16.7%, P = 0.015), as were rates of subcutaneous emphysema, pneumomediastinum, and/or pneumothorax (33.3% vs. 4.2%, P = 0.005).
Conclusion
Positive airway pressure ventilation after primary repair of persistent tracheocutaneous fistula in children may increase risk of serious respiratory complications. In practice, we advocate for avoidance of bag‐valve mask ventilation and caution when utilizing CPAP or Bi
PAP postoperatively in these patients.
Level of Evidence4 Laryngoscope, 130:E30–E34, 2020

Validating peritonsillar abscess drainage rates using the Pediatric hospital information system data

17-12-2019 – Allison G. Chisholm, Benjamin D. Little, Romaine F. Johnson

Objectives
To evaluate the accuracy of the Childrens Hospital Associations Pediatric Health Information System (PHIS) registry data in determining surgical drainage rates as compared to a chart review on the same cohort of children with diagnosis of peritonsillar abscess.
Study Design
Retrospective analysis.
Methods
Our analysis included 200 children, ages 2 to 17 years, treated for a peritonsillar abscess from 2011 to 2016. The primary outcome was to determine the sensitivity, specificity, predictive values, receiver operating characteristics (ROC), and likelihood ratios of surgical drainage rates comparing the PHIS database to manual chart review of the same patients.
Results
One hundred and fifteen (58%) children underwent drainage by chart review, whereas 87 (44%) had a drainage procedure by PHIS data. Age was a significant predictor of abscess drainage by chart review (age coefficient = 0.10; standard error = 0.04; 2 = 5.8; P = 0.02; odds ratio = 1.1; 95% confidence interval CI = 1.01–1.19). When using the chart review as the reference value for surgical drainage, the PHIS data had a sensitivity of 76% and 100% specificity. The positive and negative predictive values were 100% and 75%, respectively. The ROC area was 0.88 (95% CI, 84 to 92). Cases that lacked a clear procedure note composed the false negative cases in the PHIS.
Conclusion
At our institution, the PHIS Administrative data was adequate at predicting surgical drainage of the peritonsillar abscess when compared to chart review.
Level of Evidence4 Laryngoscope, 130:238–241, 2020

Patterns of Radiotherapy Use and Outcomes in Head and Neck Soft‐Tissue Sarcoma in a National Cohort

17-12-2019 – Joseph K. Kim, Nipun Verma, Sean McBride, Nadeem Riaz, Jay O. Boyle, Daniel Spielsinger, Christopher Sabol, Todd Waldenberg, Thomas Brinkman, Kaled Alektiar, Nancy Y. Lee, C. Jillian Tsai

Journal Article

Objectives/Hypothesis
We used the National Cancer Database to identify the patterns of care and prognostic factors in adult patients with head and neck soft‐tissue sarcoma (HNSTS).
Study Design
Retrospective cohort analysis.
Methods
Using the National Cancer Database, we identified patients age ≥ 18 years who were diagnosed with HNSTS between 2004 and 2013. Both χ2 and multivariate logistic regression were used to identify factors associated with radiation therapy (RT) utilization. Kaplan‐Meier methods were used to estimate overall survival (OS) and Cox proportional regression was used to determine significant contributors to OS.
Results
Our final cohort included 1,282 patients (682 treated with surgery only, 199 treated with RT only, and 401 treated with surgery and RT). Patients with younger age, poor tumor grade, rhabdomyosarcoma histology, and chemotherapy treatment were more likely to receive RT alone without surgery. Among the 1,083 surgical patients, RT utilization was associated with positive margins (odds ratio OR: 2.18, 95% confidence interval CI: 1.36‐3.48), poor grade (OR: 2.92, 95% CI: 1.95‐4.38), and chemotherapy use (OR: 1.78, 95% CI: 1.15‐2.76). Radiotherapy utilization among surgical patients was not affected by demographic factors (age, sex, or ethnicity) or treatment institution (academic or community). For surgical patients, poor grade, large tumor size, and rhabdomyosarcoma histology were associated with worse OS on multivariate analysis.
Conclusions
In this analysis of HNSTS, younger patients with poor tumor grade and rhabdomyosarcoma histology were more likely to receive RT without surgery. Among surgical patients, adjuvant RT was more likely to be used for positive margins and poor grade, with no demographic disparities identified. Poor grade and rhabdomyosarcoma histology were negative prognostic factors for surgical patients.
Level of Evidence
NA Laryngoscope, 130:120–127, 2020

Dexmedetomidine versus propofol at different sedation depths during drug‐induced sleep endoscopy: A randomized trial

17-12-2019 – Tonsy V. Padiyara, Sandeep Bansal, Divya Jain, Suman Arora, Komal Gandhi

Objectives/Hypothesis
The aim of this study was to compare the effect of dexmedetomidine and propofol on airway dynamics, cardiorespiratory system, and emergence following drug‐induced sleep endoscopy (DISE).
Study Design
Prospective, randomized, single‐blinded study.
Methods
Sixty patients age 18 to 65 years in American Society of Anesthesiologists physical status groups 1 and 2 scheduled to undergo DISE were randomly allocated to either Group P (N = 30; receiving propofol infusion at 50–150 μg/kg/min) or Group D (N = 30; receiving dexmedetomidine bolus of 1 μg/kg followed by infusion at 0.5–1.0 μg/kg/hr). DISE was done at light sleep and deep sleep. Airway obstruction at tongue base was recorded as primary outcome. Airway obstruction at velum, oropharyngeal lateral wall, and epiglottis level during light and deep sedation, hemodynamic and respiratory parameters, time to attain sufficient sedation, time for emergence from sedation, and any adverse events during DISE with the two study drugs were recorded as secondary outcomes.
Results
There was a greater degree of obstruction at the tongue base level (P = 0.001) and Oropharynx level (P = 0.017) in Group P compared with Group D during deep sedation. Increase in airway obstruction from light to deep sleep was seen with propofol at the oropharynx (P = 0.0185) and tongue base (P = 0.0108) levels. Two patients (6.6%) in Group D and 10 patients (33.3%) in Group P showed oxygen saturation below the minimum oxygen saturation recorded during polysomnography. Time to open eyes to call after stopping sedation was significantly less in Group P (P = 0.005).
Conclusions
Dexmedetomidine shows a lesser degree of airway collapse and higher oxygen saturation levels at greater sedation depth during DISE. Propofol has a faster onset and emergence from sedation.
Level of Evidence1b Laryngoscope, 130:257–262, 2020

Surgical Outcomes in Idiopathic Recurrent Facial Nerve Paralysis: A Rare Clinical Entity

17-12-2019 – Christopher Blake Sullivan, Daniel Q. Sun, Vivian L. Zhu, Marlan R. Hansen, Bruce J. Gantz

Objective
To evaluate the postoperative facial nerve dysfunction, audiometric outcomes, and long‐term quality‐of‐life outcomes of patients with idiopathic recurrent facial nerve paralysis (RFP) after middle cranial fossa (MCF) microsurgical decompression.
Methods
Retrospective chart analysis of 11 (mean age 37.0 years, range 5 to 67) patients at an academic tertiary referral center who underwent MCF facial nerve decompression. Data analysis included evaluation of pre‐ and postoperative House‐Brackmann (HB) score, pre‐ and postoperative pure‐tone average (PTA), pre‐and postoperative word recognition scores (WRS), and postoperative Facial Clinimetric Evaluation survey.
Results
Mean number of preoperative facial paralysis episodes was 3.5 (range 2 to 6), and preoperative HB score was 4.5 (range 1 to 6). Postoperatively, 0 patients had further episodes of facial nerve paralysis at an average of 6.5 years (range 0.1 to 17.6) (P = 0.005), and the average postoperative HB score was 2.1 (range 1 to 3) (P = 0.011). Postoperative audiometry was stably maintained as assessed with PTA and WRS scores.
Conclusion
Microsurgical facial nerve decompression for idiopathic RFP may be a reliable therapeutic modality to prophylactically decrease the number of facial nerve paralysis episodes and may also help to improve facial nerve functional status.
Level of Evidence4 Laryngoscope, 130:200–205, 2020

Hydroxyapatite cement cranioplasty for translabyrinthine surgery: A single institution experience

17-12-2019 – Alexander L. Luryi, Christopher A. Schutt, Elias Michaelides, John F. Kveton

Objective
To assess complication rates in hydroxyapatite cement (HAC) cranioplasty for translabyrinthine acoustic surgery compared with historical controls.
Methods
Retrospective chart review of patients undergoing de novo translabyrinthine surgery with HAC cranioplasty without concurrent adipose tissue graft or additional material between 2010 and 2017 at a tertiary otology center.
Results
Fifty‐two patients underwent HAC cranioplasty during the study period. The average length of follow‐up was 30.5 months. HAC cranioplasty was associated with acceptable rates of cerebrospinal fluid leak (3.8%), wound or intracranial infection (5.8%), need for unplanned revision surgery (9.6%), and all complications (15.3%). All complications occurred within 5 months of surgery. No delayed wound infections or implant extrusions occurred.
Conclusion
HAC cranioplasty has an acceptable complication profile for translabyrinthine surgery and is a viable alternative to abdominal fat grafting without associated donor site morbidity.
Level of Evidence4 Laryngoscope, 130:206–211, 2020

Histoanatomical structures of laryngeal atresia: Functional considerations

17-12-2019 – Pierre Fayoux, Louise Devisme

Objective
To study the histoanatomical structure of laryngeal atresia with a focus on the laryngeal functional components in order to evaluate the functional prognosis of laryngeal atresia repair.
Methods
Twenty‐one consecutives cases of laryngeal atresia were diagnosed at our institution between 2009 and 2016. Morphological analysis by macroscopic exam during autopsy was performed in 19 cases. Histological study of the larynx included hematoxylin and eosin staining and protein S100 immunostaining. Our analysis focused on the vocal folds, structures of the lamina propria, cricoarytenoid joints, muscles, and innervation. For each case, associated malformations were classified into two groups: severe and moderate.
Results
Antenatal diagnosis was suspected because of congenital high airway obstruction syndrome in nine cases (37%).
Associated malformations were present in 19 cases (90%), including severe malformations in 12 cases (57%). Atresia involved the cricoid in all cases, with a residual lumen in only one case and the glottis in 18 cases. Separation between the cricoid and arytenoid cartilages was observed in all cases. Fusion of the vocal process of the arytenoids in the midline was present in 13 cases.
According to the gestational age, posterior maculae flavae (MF) were present in 17 of 19 cases, with abnormal structure and median fusion in 13 cases. Anterior MF were present in nine of 18 cases, with fusion on the midline in five cases.
Intrinsic abductors and adductors muscles were identifiable in all cases, with fusion of thyroarytenoids muscles in the midline in 18 cases. Both recurrent laryngeal nerves were observed in all cases.
Conclusion
Laryngeal atresia is generally associated with other malformations, with a high risk of fatal outcomes. We observed that the functional structures of the glottic plane were present in most cases, with the exception of MF, which were frequently abnormal.
Level of Evidence4 Laryngoscope, 130:252–256, 2020

Predictors of swallow function after transoral surgery for locally advanced oropharyngeal cancer

17-12-2019 – Jennifer H. Gross, Melanie Townsend, Helena Y. Hong, Emily Miller, Dorina Kallogjeri, Joseph Zenga, Patrik Pipkorn, Ryan S. Jackson, Bruce Haughey, Jason T. Rich

Journal Article

Objective
Transoral surgery (TOS) for oropharyngeal carcinoma (OPC) is steadily becoming more routine. Expected posttreatment swallow function is a critical consideration for preoperative counseling. The objective of this study was to identify predictors of swallow dysfunction following TOS for advanced tumor (T)‐stage (T3‐T4) OPC.
Methods
A retrospective review from 1997 to 2016 at a single institution was performed. Eighty‐two patients who underwent primary transoral resection of locally advanced OPCs with at least 1 year of postoperative follow‐up were included.
The primary outcome measure was swallow function, as measured by the Functional Outcomes Swallowing Scale (FOSS) at 1 year postoperatively. Operative reports were reviewed, and the extent of resection and type of reconstruction were documented. Conjunctive consolidation was then performed to incorporate multiple variables and their impact on swallow function into a clinically meaningful classification system.
Results
Fifty‐six patients (68%) had acceptable swallowing at 1 year. T4 tumor stage and receipt of adjuvant chemoradiation therapy (CRT) were strongly associated with poor swallowing but did not reach statistical significance. Only base of tongue (BOT) resection ≥50% (odds ratio OR 3.19, 95% confidence interval CI 1.21–8.43) and older age (OR 1.06, 95% CI 1.00–1.12) were significantly associated. Utilizing T‐stage, adjuvant CRT, and BOT resection, a conjunctive consolidation was performed to develop a classification system for swallow dysfunction at 1 year.
Conclusion
This study provides risk stratification for swallow function at 1 year following primary transoral resection of locally advanced OPCs. BOT resection ≥50%, especially when coupled with T4 tumor stage or adjuvant CRT, was associated with poor long‐term swallow outcomes.
Level of Evidence3 Laryngoscope, 130:94–100, 2020

A nomogram to predict osteoradionecrosis in oral cancer after marginal mandibulectomy and radiotherapy

17-12-2019 – Levent Renda, Tsung‐You Tsai, Jung‐Ju Huang, Ran Ito, Wei‐Chuan Hsieh, Huang‐Kai Kao, Shao‐Yu Hung, Yenlin Huang, Yu‐Chen Huang, Yu‐Liang Chang, Ming‐Huei Cheng, Kai‐Ping Chang

Objective
There is no useful tool to clinically predict the occurrence of osteoradionecrosis (ORN) of the mandible quantitatively. The aim was to investigate the risk factors, including different modalities of radiotherapy, for developing mandibular ORN in patients undergoing marginal mandibulectomy and postoperative radiotherapy.
Methods
Between January 2006 and December 2012, 167 subjects who underwent marginal mandibulectomy and postoperative radiotherapy with different modalities were enrolled. The association of ORN with mandibular bone measurements and patient variables was analyzed, and a nomogram was established.
Results
Fifteen (8.98%) of the 167 patients developed ORN during the follow‐up period, and ORN was significantly associated with diabetes mellitus (DM), body mass index (BMI), remaining bone height, remaining bone height to original bone height ratio, resected bone height to original bone height ratio, and mandibular dose (P: < 0.001, 0.004, 0.042, 0.018, 0.010, 0.020, respectively). Interestingly, the risk of ORN had no significant difference between conformal and intensity modulation radiation therapy (P = 0.407). Multivariate analysis revealed that DM and resected bone height to original bone height ratio ≥ 50% were independent risk factors for postoperative ORN. A nomogram consisting of BMI, DM, resected bone height to original bone height ratio, mandibulotomy, and mandibular dose for predicting the ORN‐free probability was established; and the c‐index of the nomogram for ORN status was 0.803.
Conclusion
A nomogram based on the risk factors was plotted to strengthen the prediction of ORN quantitatively. Surgeons should be more discrete regarding the treatment plan for patients with higher probability of ORN.
Level of Evidence3b Laryngoscope, 130:101–107, 2020

Temporal bone carcinoma: Treatment patterns and survival

17-12-2019 – Kristen L. Seligman, Daniel Q. Sun, Patrick P. Ten Eyck, Nathan M. Schularick, Marlan R. Hansen

Objectives/Hypothesis
Carcinomas of the temporal bone are rare, and appropriate treatment, staging, and survival data are limited. This study evaluates clinical characteristics and survival rates for patients with temporal bone carcinoma treated with resection at a single tertiary‐care institution, with a focus on the outcomes of patients with locally advanced disease including skull base and/or dural invasion.
Study Design
Retrospective chart review.
Methods
Demographic, tumor‐specific, and survival data were collected for patients with primary carcinomas of the external auditory canal with involvement of the temporal bone from 2003 to 2015. All patients were staged according to the modified Pittsburgh system. Kaplan‐Meier and logistic regression analysis were used to calculate factor‐specific survival outcomes.
Results
Sixty‐seven patients met inclusion criteria; 85% were male. There were 43 squamous cell carcinomas (64%) and 24 basal cell carcinomas (BCCs) (36%). Tumor stage was 24 (36%) T2, 12 (18%) T3, and 31 (46%) T4 tumors; 53% had recurrent disease. Surgical management included 49 lateral temporal bone resections and 18 subtotal temporal bone resections. Kaplan‐Meier analyses revealed more favorable 5‐year survival rates associated with BCC histology (P = .01), lateral temporal bone resection compared to subtotal temporal bone resection (P < .01), lack of immunocompromise (P = .04), and absence of perineural/lymphovascular invasion (P = .01). Multivariate regression analysis did not yield statistically significant results.
Conclusions
Factors predictive of more favorable survival include lack of immunocompromise, BCC histology, absence of perineural/lymphovascular invasion, and disease extent amenable to lateral temporal bone resection. Dural invasion is not an absolute contraindication to surgery, with a subset of patients surviving >5 years.
Level of Evidence3 Laryngoscope, 130:E11–E20, 2020

Treatment delays in surgically managed sinonasal cancer and association with survival

17-12-2019 – Alexander N. Goel, Jivianne T. Lee, Marilene B. Wang, Jeffrey D. Suh

Objective
To characterize treatment delays in sinonasal cancer managed with surgery and adjuvant radiation and determine the associated impact on survival.
Study Design
Retrospective cohort study.
Methods
We identified adults in the National Cancer Database treated for sinonasal squamous cell carcinoma with definitive surgery followed by adjuvant radiation from 2004 to 2014. We then examined intervals of diagnosis to surgery (DTS), surgery to radiation (SRT), and radiation duration (RTD). Next, we performed recursive partitioning analysis (RPA) to identify thresholds for these treatment intervals that estimated the greatest differences in survival. We determined the association of treatment delay with overall survival using Cox proportional hazards regression.
Results
Among 2,267 patients included, median durations of DTS, SRT, and RTD were 32, 49, and 47 days, respectively. Predictors of treatment delay included care transitions, black race, and Medicare insurance. We identified thresholds of 26, 64, and 51 days for DTS, SRT, and RTD, respectively, as estimating the largest survival differences. Delays in SRT (hazard ratio HR 1.20; 95% confidence interval CI, 1.03–1.40), and RTD (HR, 1.27; 95% CI, 1.10–1.46) beyond these thresholds independently predicted mortality. Delay in DTS beyond the RPA‐derived threshold was not significantly associated with mortality after adjusting for other covariates.
Conclusion
Delays in SRT and RTD intervals are associated with decreased overall survival. Median durations may serve as national benchmarks. Treatment delays could be considered quality indicators for sinonasal cancer treated with surgery and adjuvant radiation.
Level of Evidence
NA Laryngoscope, 130:2–11, 2020

Evidence of a microbial etiology for sialoliths

17-12-2019 – W. K. Kao, Richard A. Chole, M. Allison Ogden

Objectives
Sialolithiasis is the primary etiology for parotid and submandibular swelling, potentially resulting in discomfort, bacterial infections, and hospitalization. The etiology of sialolith formation is unknown. Currently, the proposed etiologies range from inflammation, coalescence of organic molecules, sialomicrolith formation, p
H changes, and biofilm formation. In this study, we performed a descriptive analysis of images obtained through electron microscopy of sialoliths. Based on our findings and descriptive analysis, we hypothesize that sialolith formation is likely multifactorial and begins with biofilm formation. Biofilm formation then triggers a host immune response, and it is the interaction of biofilm with host immune cells and calcium nanoparticles that forms the nidus and creates a favorable environment for calcium precipitation.
Methods
Sialoliths were extracted from patients and imaged under light and scanning electron microscopy. Specimens for light microscopy were prepared using a diamond saw. Specimens for electron microscopy were freeze‐fractured, thus providing an undisturbed view of the core of the sialolith.
Results
We were able to identify clear evidence of biofilm caves at the core of each sialolith. These biofilm caves were complex with the presence of bacteria and dehydrated extrapolysaccharide matrix, host cells (immune cells, platelets and erythrocytes), and calcium nanoparticles.
Conclusion
The etiology of sialolith formation is likely multifactorial. We propose that biofilm formation within a single salivary gland or duct leads to local ductal injury, which results in the influx of host immune cells that interact with the biofilm and calcium nanoparticles, creating a scaffold upon which further calcium deposition can occur.
Level of Evidence
NA Laryngoscope, 130:69–74, 2020

A Call for Universal Acceptance of the Milan System for Reporting Salivary Gland Cytopathology

17-12-2019 – Eric Barbarite, Sidharth V. Puram, Adeeb Derakhshan, Esther D. Rossi, William C. Faquin, Mark A. Varvares

Objectives
The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) established a standardized, tiered reporting system for salivary gland fine‐needle aspiration (FNA) that has gained international acceptance among cytologists. Our goal was to review the key features of the MSRSGC to familiarize the surgical community with this system and its application to the FNA evaluation of salivary gland masses.
Methods
A comprehensive review of the MSRSGC and its application in clinical practice.
Results
The MSRSGC consists of six major diagnostic categories: 1) nondiagnostic, 2) non‐neoplastic, 3) atypia of undetermined significance, 4) neoplasm (benign or salivary gland neoplasm of uncertain malignant potential), 5) suspicious for malignancy, and 6) malignant. Each diagnostic category is associated with an implied risk of malignancy with implications for clinical management.
Conclusions
The MSRSGC is similar to the system used for reporting thyroid FNA, which is familiar to most otolaryngologists and head and neck surgeons. As this reporting system continues to gain popularity among pathologists, widespread understanding by surgeons will be important to standardize communication and classification of salivary gland cytopathology to improve clinical care. Laryngoscope, 130:80–85, 2020

A contemporary review of machine learning in otolaryngology–head and neck surgery

17-12-2019 – Matthew G. Crowson, Jonathan Ranisau, Antoine Eskander, Aaron Babier, Bin Xu, Russel R. Kahmke, Joseph M. Chen, Timothy C. Y. Chan

One of the key challenges with big data is leveraging the complex network of information to yield useful clinical insights. The confluence of massive amounts of health data and a desire to make inferences and insights on these data has produced a substantial amount of interest in machine‐learning analytic methods. There has been a drastic increase in the otolaryngology literature volume describing novel applications of machine learning within the past 5 years. In this timely contemporary review, we provide an overview of popular machine‐learning techniques, and review recent machine‐learning applications in otolaryngology–head and neck surgery including neurotology, head and neck oncology, laryngology, and rhinology. Investigators have realized significant success in validated models with model sensitivities and specificities approaching 100%. Challenges remain in the implementation of machine‐learning algorithms. This may be in part the unfamiliarity of these techniques to clinician leaders on the front lines of patient care. Spreading awareness and confidence in machine learning will follow with further validation and proof‐of‐value analyses that demonstrate model performance superiority over established methods. We are poised to see a greater influx of machine‐learning applications to clinical problems in otolaryngology–head and neck surgery, and it is prudent for providers to understand the potential benefits and limitations of these technologies. Laryngoscope, 130:45–51, 2020

Evaluating the impact of adenotonsillectomy for pediatric sleep‐disordered breathing on parental sleep

17-12-2019 – Hannah Ernst, Agnieszka Dzioba, Jordan Glicksman, Josee Paradis, Brian Rotenberg, Julie Strychowsky

Objectives/Hypothesis
To evaluate the impact of adenotonsillectomy for pediatric sleep‐disordered breathing (SDB) on parental sleep quality, daytime sleepiness, and child quality of life.
Study Design
Prospective cohort study.
Methods
Pediatric patients aged 2 to 10 years with SDB and suspected obstructive sleep apnea (OSA) requiring adenotonsillectomy were identified at a single tertiary‐care pediatric otolaryngology hospital. Parental daytime sleepiness and quality of sleep were evaluated pre‐ and postoperatively using the Epworth Sleepiness Scale (ESS) and Pittsburg Sleep Quality Index (PSQI), respectively. Child quality of life, in the context of suspected OSA, was evaluated by the Obstructive Sleep Apnea Quality of Life Survey (OSA‐18), pre‐ and postoperatively. Paired‐samples t tests were conducted to analyze data.
Results
Forty‐seven patients with a mean (standard deviation SD) age of 4.9 (2.2) years, participated. Mean (SD) parental age was 35.5 (4.6) years. Statistically significant decreases of 2.1 points were observed between preoperative and postoperative parental mean global ESS (P = .007; 95% confidence interval CI: 0.6‐3.6) and mean total PSQI (P = .001; 95% CI: 0.9‐3.1) scores. A statistically significant improvement (41.6 points) was observed between preoperative and postoperative on mean OSA‐18 scores (P < .0001; 95% CI: 35.7‐47.6).
Conclusions
Adenotonsillectomy performed in the pediatric population for SDB, with suspected OSA, can positively impact parental daytime sleepiness and sleep quality in addition to pediatric quality of life.
Level of Evidence2 Laryngoscope, 130:232–237, 2020

Enhancements to The Laryngoscope

17-12-2019 – Samuel H. Selesnick

Editorial

Masthead

17-12-2019 –

Table of contents

17-12-2019 –

The evidence‐based preoperative assessment for the otolaryngologist

17-12-2019 – Christopher Nickel, Daniel Segarra, Tapan Padhya, Matthew Mifsud

There is a narrow window of opportunity between surgical scheduling and the operative date to optimize patients for an elective surgical procedure. Traditionally, preoperative care has involved extended routine testing batteries with intermittent referrals for medical clearance. These traditions are costly, inefficient, and yield no clear reduction in perioperative morbidity and mortality. Evidence, which has evolved over the past decade, suggests that optimal preoperative care requires a patient‐centric, personalized, and often multidisciplinary approach. We present an up‐to‐date overview of this literature with a focus on the otolaryngologic surgical population. An algorithmic approach to preoperative patient assessment is also proposed in hopes of both optimizing patient outcome and streamlining routine clinical workflow. Laryngoscope, 130:38–44, 2020

Clinical Guidelines in Pediatric Hearing Loss: Systemic Review Using the Appraisal of Guidelines for Research and Evaluation II Instrument

17-12-2019 – Pratik Kanabur, Caleb Hubbard, Anita Jeyakumar

Objectives
Despite the importance, impact, and prevalence of pediatric hearing loss (HL), there are very few published clinical practice guidelines (CPG) supporting the evaluation and management of pediatric patients with HL. Our objective was to appraise existing CPGs to ensure safe and effective practices.
Methods
A literature search was conducted in PubMed, Google Scholar, EBSCO, as well as a manual Google search. Three independent assessors using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument evaluated CPGs related to HL in children. Standardized domain scores were calculated for each guideline.
Results
A total of four guidelines met the inclusion criteria and were appraised. Scope and purpose achieved a high median score of 83%. Stakeholder involvement, clarity of presentation, and editorial independence achieved intermediate scores of 67%, 54%, and 50%, respectively. The areas that required most improvement and achieved low scores were rigor of development and applicability, with scores of 22% and 38%, respectively. Based on the AGREE II measures, the four guidelines had domain scores less than 60% for each domain, and without modification no guideline could be recommended.
Conclusions
Based on the AGREE II, the qualities of CPGs for pediatric HL have several shortcomings, and the need for a comprehensive CPG remains. Rigor of development and applicability present the greatest opportunities for improvement of these CPGs. Laryngoscope, 130:212–216, 2020

Comparison of balance outcomes according to treatment modality of vestibular schwannoma

17-12-2019 – Gaeun Kim, Timothy E. Hullar, Jae‐Hyun Seo

Objectives
We sought to compare balance outcomes according to treatment modality of vestibular schwannoma (VS) via a meta‐analysis that divided measuring tools of balance outcomes into three categories based on type.
Methods
A comprehensive review of the literature from January 1966 to September 2017 was performed, looking for studies about long‐term balance outcomes after microsurgery (MS), radiotherapy (RT), or observation for VS. A comprehensive meta‐analysis was used to analyze effect sizes, explore possible causes of heterogeneity, and check publication bias with a funnel plot and Eggers regression.
Results
Among 633 references, 34 were included in the meta‐analysis. Perceived dizziness improvement rate was significantly higher in the MS group than in the RT group (odds ratio OR: 1.61; 95% confidence interval CI: 1.08 to 2.40; P < .05, I2 = 4.18, but no significant difference was observed between the two groups with regard to validated dizziness questionnaire score (standardized mean difference: 0.04; 95% CI: −0.36 to 0.44; P = .84, I2 = 69.61) or dizziness or disequilibrium‐related symptom incidence rate (OR: 0.91; 95% CI: 0.50 to 1.68; P = .77, I2 = 0). In a subanalysis conducted within the groups after intervention, the MS group demonstrated a lower vertigo incidence rate (P < .001), and the RT group experienced a significant reduction in validated dizziness questionnaire score (P < .05).
Conclusions
Our results indicate that MS should be considered at least equal to RT in regard to resolving long‐term dizziness and improving balance outcomes. Furthermore, well‐designed studies are necessary to predict balance outcomes after VS treatment and to choose from among possible treatment options.
Level of Evidence2a Laryngoscope, 130:178–189, 2020

Surgical margins in oral cavity squamous cell carcinoma: Current practices and future directions

17-12-2019 – Joshua J. Kain, Andrew C. Birkeland, Neha Udayakumar, Anthony B. Morlandt, Todd M. Stevens, William R. Carroll, Eben L. Rosenthal, Jason M. Warram

Journal Article, Review

Objective
To discuss the current available techniques for intraoperative margin assessment in the surgical treatment of oral squamous cell carcinoma (OSCC) through a review of the available literature.
Methods
A systematic review was undertaken of the available English literature between 2008 through 2018 regarding surgical margins in OCSS. A total of 893 relevant articles were returned; 144 met criteria for review; and 64 articles were included.
Results
In this review, we discuss the data surrounding the use of frozen section in OCSS. Additionally, alternative techniques for margin assessment are discussed, including Mohs, molecular analysis, nonfluorescent dyes, fluorescent dyes, autofluorescent imaging, narrow‐band imaging, optical coherence tomography, confocal microscopy, high‐resolution microendoscopy, and spectroscopy. For each technique, particular emphasis is placed on the local recurrence, disease‐free survival, and overall survival rates when available.
Conclusion
This review provides support for the practice of specimen‐driven margin assessment when using frozen section analysis to improve the utility of the results. Finally, several alternatives for intraoperative margin assessment currently under investigation, including pathologic, wide‐field imaging and narrow‐field imaging techniques, are presented. We aim to fuel further investigation into methods for margin assessment that will improve survival for patients with OSCC through a critical analysis of the available techniques.
Level of Evidence
NA Laryngoscope, 130:128–138, 2020

Perioperative analgesia for patients undergoing otologic surgery: An evidence‐based review

17-12-2019 – Hilary T. Campbell, Brian T. Yuhan, Brendan Smith, Emily Misch, Peter F. Svider, Anna A. Pashkova, Anthony Sheyn, Yu‐Lan M. Ying, Andrew P. Johnson

Journal Article, Review

Objectives/Hypothesis
Opioid misuse and diversion is a major concern, with a negative impact on both the individual and society. The objective of this study was to perform an evidence‐based systematic review of the efficacy of perioperative analgesic regimens following otologic surgery.
Methods
Embase, Cochrane Library, and PubMed/MEDLINE databases (January 1, 1947 to June 30, 2018) were searched for studies investigating pain management in otologic surgeries. All studies were assessed for quality and bias using the Cochrane bias tool. Patient demographics, type of surgery, medication class, dose, administration characteristics, pain scores, and adverse events were reported.
Results
Twenty‐three studies encompassing 1,842 patients met inclusion criteria. In 21.4% of studies, an overall reduction in pain scores was reported when the treatment group included more than one analgesic. Nausea and vomiting were the most common adverse events across all medication types (10.2%), with local anesthetic patients experiencing these side effects most frequently (38.0%). Perioperative acetaminophen was reported to have the fewest adverse drug reactions overall (6.1%), but did not reduce pain scores as much as other modalities, such as nonsteroidal anti‐inflammatory drugs (NSAIDs) or combination analgesics.
Conclusions
There is evidence that combination analgesics, such as acetaminophen plus codeine, provide superior pain relief to monotherapy analgesics in the perioperative pain management of otologic surgeries. NSAIDs, α‐agonists, and nerve blocks may also be viable single‐therapy options. Further prospective randomized controlled trials into perioperative analgesia for patients undergoing otologic surgery may be helpful in establishing a definitive consensus. Laryngoscope, 130:190–199, 2020

Tracheo‐innominate fistula in children: A systematic review of literature

17-12-2019 – Daniel J. Lee, Weining Yang, Evan J. Propst, Steven D. Rosenblatt, Anne Hseu, Nikolaus E. Wolter

Objective
Tracheo‐innominate fistula (TIF) is a rare but fatal complication of tracheotomy. To date, there is a paucity of literature regarding pediatric TIFs. The objectives of this study were to conduct a systematic review of literature on pediatric TIF following tracheotomy and describe three demonstrative cases from our institutional experience.
Methods
We conducted a systematic review using MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and CINAHL. All studies with pediatric patients (under 18 years of age) who developed TIF following tracheotomy were included.
Results
Fifty‐four publications met inclusion criteria, reporting on 77 cases. The most common indication for tracheotomy was prolonged intubation and the need for ventilatory support (38.6%), with neurological comorbidities being the most common indication (72.7%). The mean time to TIF was 395.7 days (95% confidence interval, 225.9–565.5). Fifty‐four patients (70.1%) presented with massive hemorrhage, whereas 18 patients (23.3%) presented with a sentinel bleeding event. The most common diagnostic interventions were computed tomography scan with or without contrast and bronchoscopy (55.8%). A substantial number of patients did not have any investigations (41.6%). Surgical management occurred in 70.1% of patients. Mortality was 38.6% in reported cases with variable follow‐up periods.
Conclusion
TIF may occur in long‐term tracheostomy‐dependent children, contrary to the conventionally described 3‐week postoperative period. The mortality may not be as high as previously reported with timely intervention. Our results are limited by inherent risks of bias. Further research including well‐designed cohort studies are needed to guide an evidence‐based approach to TIF.
Level of Evidence
NA Laryngoscope, 130:217–224, 2020

Health utility of rhinectomy, surgical nasal reconstruction, and prosthetic rehabilitation

17-12-2019 – Callum Faris, Alyssa Heiser, Olivia Quatela, Matthew Jackson, Oren Tessler, Nate Jowett, Linda N. Lee

Journal Article

Objectives
Advanced nasal malignancies may require rhinectomy, which can have profound psychosocial impacts. Rhinectomy defects can be rehabilitated through surgery or prosthetics. We seek to understand the health utility of the rhinectomy defect, surgical, and prosthetic reconstruction, which have not been previously studied.
Study Design
Prospective clinical study
Methods
Adult naïve observers (n = 273) ranked the utility of five randomized health states (monocular blindness, binocular blindness, post‐rhinectomy nasal defect, postsurgical reconstruction, and post‐prosthetic rehabilitation). Health utilities were measured using visual analogue scale (VAS), standard gamble (SG), and time trade‐off (TTO). One‐way analysis of variance (ANOVA) with post hoc Scheffes test and the independent samples T‐test for a priori comparisons were performed. Multiple linear regression was performed using participant demographics as independent predictors of utility scores.
Results
Health utilities (VAS, SG, TTO) were reported as follows (mean ± SD): monocular blindness (0.71 ± 0.21, 0.84 ± 0.20, 0.85 ± 0.19), binocular blindness (0.48 ± 0.25, 0.68 ± 0.28, 0.63 ± 0.28), post‐rhinectomy nasal defect (0.59 ± 0.24, 0.74 ± 0.24, 0.74 ± 0.24), postsurgical reconstruction (0.88 ± 0.16, 0.90 ± 0.18, 0.89 ± 0.13), and post‐prosthetic rehabilitation (0.67 ± 0.22, 0.80 ± 0.23, 0.82 ± 0.20). Both surgical reconstruction (P < .001) and prosthetic rehabilitation (P < .001) significantly improved health utility. SG and TTO utility scores were inversely associated with observer age (P < .001) and participants who identified themselves as non‐Caucasians (P < .05) in post‐rhinectomy nasal defect, post‐nasal surgical reconstruction, and post‐nasal prosthetic rehabilitation health states, while higher levels of education were directly associated with SG scores (P < .05), respectively.
Conclusion
This is the first study to demonstrate the significant negative impact of the rhinectomy nasal defect on health utility. Rehabilitation by surgical or prosthetic techniques significantly increases health utility as rated by naïve observers. Laryngoscope, 2019

Appropriate medical management of chronic rhinosinusitis reduces use of antibiotics and oral corticosteroids

17-12-2019 – Marlene M. Speth, Katie M. Phillips, Lloyd P. Hoehle, David S. Caradonna, Stacey T. Gray, Ahmad R. Sedaghat

Journal Article

Objectives/Hypothesis
Antibiotics and oral corticosteroids are used in the treatment of acute exacerbations of chronic rhinosinusitis (AECRS) and reflect poor disease control. We sought to characterize utilization of these systemic medications after appropriate medical management of chronic rhinosinusitis (CRS).
Study Design
Prospective observational study.
Methods
One hundred fifty patients undergoing medical management for CRS were studied. Data were collected at enrollment and follow‐up 3 to 12 months later. All patients were asked to report the number of CRS‐related antibiotics and oral corticosteroids used in the last 3 months. CRS symptom burden was measured using the 22‐item Sino‐Nasal Outcome Test (SNOT‐22). Associations were sought between CRS‐related antibiotics and oral corticosteroids use at follow‐up compared to enrollment.
Results
From enrollment to follow‐up, the mean number of CRS‐related antibiotics courses used decreased by 0.2 courses (95% confidence interval CI: 0.1–0.4, P = .012), and the mean number of CRS‐related oral corticosteroid courses used also decreased by 0.2 courses (95% CI: 0.1–0.3, P = .029). The number of CRS‐related antibiotics used at follow‐up was associated with CRS‐related antibiotic use at enrollment (adjusted rate ratio RR = 1.58, 95% CI: 1.17–2.13, P = .003). The number of CRS‐related oral corticosteroids used at follow‐up was associated with reported CRS‐related oral corticosteroid use at enrollment (adjusted RR = 3.20, 95% CI: 1.69–6.07, P < .001). SNOT‐22 results at enrollment were also not predictive of future systemic medication use.
Conclusions
Appropriate medical management of CRS is associated with decreased use of oral antibiotics and corticosteroids. Previous utilization of antibiotics and oral corticosteroids for CRS is associated with future use of these medications.
Level of Evidence2c Laryngoscope, 2019

Outcomes of carotid‐sparing IMRT for T1 glottic cancer: Comparison with conventional radiation

17-12-2019 – Abdallah S.R. Mohamed, Blaine D. Smith, Joshua B. Smith, Parag Sevak, Jessica S. Malek, Aasheesh Kanwar, Theodora Browne, G. Brandon Gunn, Adam S. Garden, Steven J. Frank, William H. Morrison, Jack Phan, Mark Zafereo, Heath Skinner, Stephen Y. Lai, Katherine A. Hutcheson, Jan S. Lewin, Amy E. Hessel, Apurva A. Thekdi, Randal S. Weber, Clifton D. Fuller, David I. Rosenthal

Objectives
We aim to report oncologic outcomes after conventional radiotherapy (Con
RT) using opposed lateral beams and intensity‐modulated radiation therapy (IMRT) for tumor (T)1 nodal (N)0 T1 N0 glottic squamous cell carcinoma.
Study Design
Retrospective case‐control study.
Methods
We retrospectively reviewed demographic, disease, and treatment characteristics for patients treated at our institution during 2000 to 2013.
Results
One hundred fifty‐three patients (71%) were treated using Con
RT and 62 (29%) using IMRT. The median follow‐up for all patients was 68 months. There was no statistically significant difference in 5‐year local control between patients with T1a versus T1b disease (94% vs. 89%, respectively, P = 0.5). Three‐year locoregional control for patients treated with Con
RT was 94% compared to 97% with IMRT (P = 0.4). Three‐year overall survival (OS) for patients treated with Con
RT was 92.5% compared with 100% with IMRT (P = 0.1). Twelve of 14 patients with local recurrence underwent salvage surgery with 5‐year ultimate locoregional control of 98.5% and 97.1% in the Con
RT and IMRT cohorts, respectively (P = 0.7). Multivariate analysis showed age < 60 years (P < 0.0001) and pretreatment Eastern Cooperative Oncology Group performance status <2 (P = 0.0022) to be independent correlates of improved OS. Postradiation cerebrovascular events were in four patients in the Con
RT cohort (3%), whereas no patients in the IMRT cohort suffered any events.
Conclusion
Because the oncologic outcomes for patients treated with IMRT were excellent and IMRT allows for carotid sparing, we have transitioned to IMRT as our standard for most patients with T1 glottic cancer.
Level of Evidence3b Laryngoscope, 130:146–153, 2020

Endoscopic Nasopharyngectomy Combined with a Nerve‐sparing Transpterygoid Approach

16-12-2019 – Mathew Geltzeiler, Meghan Turner, Ryan Rimmer, George Zenonos, Andrea Hebert, Carl Snyderman, Paul Gardner, Juan Fernandez‐Miranda, Eric W. Wang

Journal Article

Objectives/Hypothesis
Surgical management of nasopharyngeal tumors has evolved in the endoscopic era. Lateral exposure remains difficult especially near the petrous internal carotid artery and bony Eustachian tube (ET). Our study examines the need to sacrifice the vidian and greater palatine nerves in order to successfully perform en bloc endoscopic nasopharyngectomy.
Methods
Four cadaveric specimens (eight sides) were dissected bilaterally using a binarial, extended, endoscopic endonasal approach (EEA). Nasopharyngectomy was completed including an extended transptyergoid approach for resection of the cartilaginous ET at its junction with the bony ET. Dissection was attempted without sacrifice of the vidian or palatine nerves.
Results
Successful en bloc nasopharyngectomy combined with a nerve‐sparing transpterygoid approach was achieved in all specimens with successful preservation of the palatine and vidian nerves. The approach provided exposure of foramen lacerum, the petrous carotid, foramen spinosum, and foramen ovale as well as all segments of the cartilaginous Eustachian tube, Meckels cave and the parapharyngeal carotid. There was no inadvertent exposure or injury of the internal carotid artery.
Conclusion
Endoscopic nasopharyngectomy combined with a nerve‐sparing transpterygoid approach allows for en bloc resection of the cartilaginous Eustachian tube and nasopharyngeal contents with broad skull base exposure and preservation of the internal carotid artery, vidian and palatine nerves.
Level of Evidence
VI Laryngoscope, 2019

Manifestations of Skull Base IgG4‐Related Disease: A Multi‐Institutional Study

16-12-2019 – John P. Marinelli, Chiara Marvisi, Augusto Vaglio, Pierce A. Peters, Eric M. Dowling, Alessandro A. Palumbo, John I. Lane, Eric N. Appelbaum, Alex D. Sweeney, Matthew L. Carlson

Journal Article

Objective
Ig
G4‐related disease (Ig
G4‐RD) is a recently recognized disease characterized by fibroinflammatory infiltrates rich in Ig
G4+ plasma cells that can present as isolated tumor‐like lesions of the head and neck. The objective of the current study was to describe the cranial base manifestations of Ig
G4‐RD.
Methods
Review of all cases at three tertiary‐referral centers since disease description in 2003.
Results
Eleven patients were identified at a median age at presentation of 58 years (IQR, 38–65; 55% male). Ten (91%) patients had isolated skull base masses without systemic disease. Cranial neuropathies were commonly observed in the abducens (45%), trigeminal (18%), and facial nerves (18%). Lesions frequently involved the cavernous sinus (55%; 6/11) with extension to the petroclival junction in 50% (3/6). Infiltration of the internal auditory canal was present in 27% (3/11) with one case demonstrating erosion of the bony labyrinth. Preliminary clinical diagnoses commonly included nasopharyngeal cancer, pituitary macroadenoma, cholesteatoma, and meningioma / multiple meningioma syndrome. Local biopsy demonstrated >30 Ig
G4‐positive plasma cells per high‐powered field or an Ig
G4:Ig
G ratio greater than 40% in all cases. Rapid and durable clinical improvement was seen in 91% following corticosteroid and rituximab therapy.
Conclusions
Ig
G4‐RD nonspecifically presents as a rare cause of the skull base mass. Often presenting without concomitant systemic disease, local diagnostic biopsies are required. Obtaining adequate tissue specimen is complicated by densely fibrotic cranial base lesions that are frequently in close proximity to critical neurovascular structures. Primary medical therapy with corticosteroids and rituximab is effective in most patients.
Level of Evidence4 Laryngoscope, 2019

Intersegmenter Variability in High‐Speed Laryngoscopy‐Based Glottal Area Waveform Measures

16-12-2019 – Youri Maryn, Monique Verguts, Hannelore Demarsin, Joost Dinther, Pablo Gomez, Patrick Schlegel, Michael Döllinger

Journal Article

Objectives/Hypothesis
High‐speed videoendoscopy (HSV) has potential to objectively quantify vibratory vocal fold characteristics during phonation. Glottal Analysis Tools (GAT) version 2018, developed in Erlangen, Germany, is software for determining various glottal area waveform (GAW) quantities. Before having GAT analyze HSV videos, segmenters have to define glottis manually across videos in a semiautomatic segmentation protocol. Such interventions are hypothesized to induce variability of subsequent GAW measure computation across segmenters and may attenuate GAT measures’ reliability to a certain point. This study explored intersegmenter variability in GATs GAW measures based on semiautomatic image processing.
Study Design
Cohort study of rater reliability.
Methods
In total, 20 HSV videos from normophonic and dysphonic subjects with various laryngeal disorders were selected for this study and segmented by three trained segmenters. They separately segmented glottis areas in the same frame sets of the videos. Upon analysis of GAW, GAT offers 46 measures related to topologic GAW dynamic characteristics, GAW periodicity and perturbation characteristics, and GAW harmonic components. To address GATs reliability, intersegmenter‐based variability in these measures was examined with intraclass correlation coefficient (ICC).
Results
In general, ICC behavior of the 46 GAW measures across three raters was highly acceptable. ICC of one parameter was moderate (0.5 < ICC < 0.75), good for seven parameters (0.75 < ICC < 0.9), and excellent for 38 parameters (0.9 < ICC).
Conclusions
Overall, high ICC values confirm clinical applicability of GAT for objective and quantitative assessment of HSV. Small intersegmenter differences with actual small parameter differences suggest that manual or semiautomatic segmentation in GAT does not noticeably influence clinical assessment outcome. To guarantee the softwares performance, we suggest segmentation training before clinical application.
Level of Evidence2b Laryngoscope, 2019

Proton radiotherapy and treatment delay in head and neck squamous cell carcinoma

14-12-2019 – Michael C. Jin, Jeremy P. Harris, Aaron N. Sabolch, Michael Gensheimer, Quynh‐Thu Le, Beth M. Beadle, Erqi L. Pollom

Journal Article

Objective
For patients with head and neck squamous cell carcinoma (HNSCC), delays in the initiation of radiotherapy (RT) have been closely associated with worse outcomes. We sought to investigate whether RT modality (proton vs. photon) is associated with differences in the time to initiation of RT.
Methods
The National Cancer Database was queried for patients diagnosed with nonmetastatic HNSCC between 2004 and 2015 who received either proton or photon RT as part of their initial treatment. Wilcoxon rank‐sum and chi‐square tests were used to compare continuous and categorical variables, respectively. Multivariable logistic regression was used to determine the association between use of proton RT and delayed RT initiation.
Results
A total of 175,088 patients with HNSCC receiving either photon or proton RT were identified. Patients receiving proton RT were more likely to be white, reside in higher income areas, and have private insurance. Proton RT was associated with delayed RT initiation compared to photon RT (median 59 days vs. 45, P < 0.001). Receipt of proton therapy was independently associated with RT initiation beyond 6 weeks after diagnosis (adjusted OR a
OR, definitive RT = 1.69; 95% confidence interval CI 1.26–2.30) or surgery (a
OR adjuvant RT = 4.08; 95% CI 2.64–6.62). In the context of adjuvant proton RT, increases in treatment delay were associated with worse overall survival (weeks, adjusted hazard ratio = 1.099, 95% CI 1.011–1.194).
Conclusion
Use of proton therapy is associated with delayed RT in both the definitive and adjuvant settings for patients with HNSCC and could be associated with poorer outcomes.
Level of Evidence2b
Laryngoscope, 122:0000–0000, 2019 Laryngoscope, 2019

Acute Exacerbations in Recurrent Acute Rhinosinusitis: Differences in Quality of Life and Endoscopy

14-12-2019 – Daniel M. Beswick, Noel F. Ayoub, Jess C. Mace, Alia Mowery, Peter H. Hwang, Timothy L. Smith

Journal Article

Objectives/Hypothesis
Research surrounding outcome differences for patients with recurrent acute rhinosinusitis (RARS) is scarce. This investigation explored quality of life (QOL) and sinonasal attributes in patients during acute episodes (AEs) and in‐between AEs of RARS.
Study Design
Retrospective outcomes research.
Methods
Data from patients with RARS were collected from two academic institutions between 2009 and 2017 using prospective and retrospective methodology. During clinical presentation, subjects were classified as with or without an AEs using guideline definitions of acute bacterial rhinosinusitis (ABRS). Between‐group differences in 22‐item Sino‐Nasal Outcome Test (SNOT‐22) survey and Lund‐Kennedy (LK) endoscopy scores were assessed.
Results
Four hundred twenty‐three clinical visits from 202 patients were included. Visits during an AE (168/423, 40%) were associated with significantly worse SNOT‐22 total scores compared to between AEs (255/423, 60%; median = 53.0 interquartile range (IQR) = 24.0 vs. 34.0 IQR = 29.5) and all SNOT‐22 subdomain scores (all P < .001). LK scores were available for 167 visits, with 56 (34%) completed during an AE. Compared to visits without an AE, endoscopy findings associated with an AE were less frequently normal (LK score = 0, 45% vs. 62%, P = .031) with worse median LK scores (2.0 IQR = 4.0 vs. 0.0 IQR = 2.0, P = .005).
Conclusions
AEs are associated with significantly worse QOL and mildly worse endoscopic findings. Almost half of visits during AEs had negative endoscopy, identifying a disparity between patient symptoms and objective findings and calling into question alternative or concomitant diagnoses. Diagnostic criteria for ABRS or AEs in RARS do not require objective confirmation of inflammation, presenting a conundrum for clinicians. The potential for overdiagnosis of ABRS and AEs should be considered when determining the risk/benefit ratio of treatments for RARS.
Level of Evidence2c Laryngoscope, 2019

Hypoglossal Nerve Stimulation in Veterans with Obstructive Sleep Apnea

14-12-2019 – Kathleen M. Sarber, Katherine W. Chang, Madison V. Epperson, Meredith E. Tabangin, Mekibib Altaye, Stacey L. Ishman, Reena Dhanda Patil

Journal Article

Objectives
The hypoglossal nerve stimulator (HNS) is an effective treatment for obstructive sleep apnea (OSA) in a relatively healthy subset of the population. Our aim was to determine the efficacy of HNS in a veteran population with a high incidence of chronic disease and mental health disorders. Our secondary aim was to compare subjective outcomes and adherence between veterans with and without mental health disorders.
Methods
We included all patients who underwent HNS at our institution to date. Veterans were divided into two groups based on whether or not they carried a diagnosis of anxiety, depression, and/or post‐traumatic stress disorder. Demographics, comorbidities, previous OSA treatments, adverse events, and adherence to therapy were recorded. Baseline and treatment outcome data were collected and analyzed including polysomnographic parameters, Epworth sleepiness scale score (ESS), and body mass index.
Results
Thirty‐one patients were identified: 93.5% male, median age = 63.0 years. Median apnea hypopnea index (AHI) decreased from 30.0 to 3.0 events/hour (P < .001) and median ESS dropped from 11.0 to 6.5 (P < .001). There was no difference between groups with regard to change in AHI or ESS (P = .31 and .61). Twenty‐six (89.7%) patients achieved surgical success (decrease in AHI > 50% and AHI < 20 events/hour) and 21 (72.4%) had AHI < 5 events/hour. The mean device usage was 5.4 hours/night which was not significantly different between groups (P = .55).
Conclusion
Our cohort exhibited similar declines in AHI and ESS compared to published studies with adequate adherence to HNS. There were no significant differences in ESS or adherence to therapy between veterans with and without mental health disorders.
Level of Evidence4 Laryngoscope, 2019

The submental flap for head and neck reconstruction: Comparison of outcomes to the radial forearm free flap

14-12-2019 – Urjeet A. Patel

Journal Article

Objectives
To compare intraoperative, postoperative, functional, and oncologic outcomes of the submental island pedicled flap (SIPF) to the radial forearm free flap (RFFF).
Study Design
Retrospective review; comparison with statistical analysis.
Methods
A retrospective review was performed on patients at two tertiary care academic hospitals by a single surgeon. Consecutive patients who underwent cancer resection and reconstruction with SIPF or RFFF between 2004 and 2016 were included. Cancer staging, surgical procedure, hospital stay, complications, and functional and oncologic results were extracted.
Results
The study included 146 patients (57 SIPF; 89 RFFF). The most prevalent primary site was oral cavity, with a minority in the oropharynx, paranasal sinuses, or external face. Mean area of the SIPF was smaller at 28 cm2 compared to 48 cm2 for the RFFF. Operative time for SIPF was shorter at 6.5 hours compared to 9 hours for RFFF. Hospital stay was 8.0 days for SIPF patients and 10.0 days for RFFF patients. Multivariate analysis confirmed these differences were significant. Functional outcomes of speech quality and gastrostomy feeding tube dependence were similar between the SIPF and RFFF groups. There was no difference in local recurrence rate for SIPF (16%) and RFFF (19%), and there was no difference in overall recurrence. Kaplan‐Meier curves showed no difference in recurrence between both groups, and multivariate logistic regression demonstrated no association between SIPF and local recurrence.
Conclusion
Operative time and hospital stay are both significantly reduced with the SIPF. Functional and oncologic results are similar with no contraindication to the SIPF. The SIPF is a good first‐line choice for head and neck reconstruction.
Level of Evidence3 Laryngoscope, 2019

Unilateral versus bilateral botulinum toxin injections in adductor spasmodic dysphonia in a large cohort

14-12-2019 – Ishaan Dharia, Steven Bielamowicz

Journal Article

Objectives/Hypothesis
The primary treatment of adductor spasmodic dysphonia is repeated injections of botulinum toxin type A (Botox) into the thyroarytenoid muscles. Dosing can be performed into either one or both thyroarytenoid muscles. The objective of this study was to evaluate the treatment effect and side effect profile across a large number of injections. This study was performed previously in 2002 on 45 patients.
Study Design
Individual cohort study.
Methods
This is retrospective study of all patients with adductor spasmodic dysphonia with and without tremor treated by the senior laryngologist at George Washington University. In the current study, 272 patients (214 females and 58 males) were included in the current analysis. Duration of effects and side effects (vocal weakness and liquid dysphagia) were recorded into a database for each patient after each injection. These data were analyzed using χ2 analysis.
Results
A total of 4,023 injections (2,708 bilateral and 1,315 unilateral) were evaluated in this study. Optimal effect duration (≥3 months) was more commonly seen in the bilaterally injected patients (55%) compared to the unilaterally injected patients (47%) (P = .0001). Optimal side effect duration (≤2 weeks) was better for the unilaterally injected patients (77%) compared to the bilaterally injected patients (73%) (P = .023). Having both optimal effect and side effect in the same injection was more commonly seen in the bilaterally injected patients (36%) compared to the unilaterally injected patients (33%) (P = .0228).
Conclusions
This study shows that bilateral injections of Botox are more effective in producing optimal effect/side effect profiles.
Level of Evidence2b Laryngoscope, 2019

Three‐dimensional analysis of the human pharyngoesophageal sphincter

14-12-2019 – Derrick R. Randall, Daniel J. Cates, E. Brandon Strong, Peter C. Belafsky

Journal Article

Objectives
Dysfunction of the pharyngoesophageal segment (PES) is a common cause of oropharyngeal dysphagia. Surgical dilation of the PES uses cylindrical dilators that expand radially in a circular shape. Animal studies, however, suggest that the PES is kidney‐shaped. The purpose of this investigation was to evaluate the 3D shape of the human PES with a novel casting method.
Methods
A platinum‐cured liquid silicone polymer was infused under pressure into the upper aerodigestive tract of nine fresh human cadavers to construct 3D casts of the maximally distended PES. Cross‐sectional and volumetric analysis were performed using computed tomography and serial sectioning of the models. Canonical variate analysis was used to identify the shape features that best distinguishes the PES from the cervical esophagus.
Results
The mean age of the cadavers was 77.9 (SD ± 10.6) years, with 67% women. Analysis of the casts confirms that the human PES possesses a kidney‐shaped structure at maximal distention, which is discretely different from the adjacent esophagus (P < 0.001). The posterior body of the cricoid cartilage formed the anterior wall of the PES, which provided a rigid structure responsible for preservation of the kidney shape during distention. The diameter of the maximally distended PES at the cricopharyngeus was highly variable (range = 0.86–4.68 cm2; SD = 1.33 cm2).
Conclusion
The data suggest that the human PES is not round and that targeted expansion at the level of the cricopharyngeus with an eccentrically shaped dilator may provide improved distention.
Level of Evidence4 Laryngoscope, 2019

Benefit of postoperative radiotherapy for early tumors with single ipsilateral lymph node metastasis

14-12-2019 – Bernhard G. Weiss, Mahalia Z. Anczykowski, Susanne Flach, Jennifer L. Spiegel, Julia Kitz, Mattis Bertlich, Martin Canis, Mark Jakob, Friedrich Ihler

Journal Article

Objectives/Hypothesis
Indication for postoperative radiotherapy in patients with locally circumscribed tumors (p
T1–p
T2) and a single ipsilateral lymph node metastasis (p
N1) is debatable. The aim of this study was to evaluate the oncological long‐term outcome of patients with p
T1‐p
T2 p
N1 squamous cell carcinoma (SCC) of the oral cavity, the oropharynx, and the hypopharynx without extracapsular spread (ECS) after a margin‐negative surgical resection, who either received or did not receive postoperative (chemo)radiotherapy.
Study Design
Retrospective case series.
Methods
The oncological outcome of patients with p
T1‐p
T2 p
N1 SCC without ECS was evaluated retrospectively. All patients underwent primary tumor resection that included transoral laser microsurgery and neck dissection at an academic tertiary referral center.
Results
Of 65 identified patients treated between 1986 and 2015 (18 oral cavity, 30 oropharynx, 17 hypopharynx), 21 (32%) received postoperative radiotherapy, and 44 (68%) were treated by surgery alone. The group of patients receiving postoperative treatment showed a significantly superior 5‐year disease‐specific (94.4% vs. 73.2%, P = .029) and recurrence‐free survival (85.2% vs. 43.2%, P = .002), as well as a higher local control rate (90.2% vs. 64.9%, P = .042). The overall survival was 71.4% vs. 62.6% (P = .53). The mean follow‐up was 80.7 months.
Conclusions
Patients with locally circumscribed carcinomas and a single ipsilateral ECS‐negative lymph node metastasis seem to benefit from postoperative radiotherapy.
Level of Evidence4 Laryngoscope, 2019

Erratum

12-12-2019 –

The Developmental Origin of the Auricula Revisited

11-12-2019 – Christianne C. A. F. M. Veugen, Frederik G. Dikkers, Bernadette S. Bakker

Journal Article

Objectives/Hypothesis
Congenital auricular anomalies are common. Additionally, the auricle plays an important role in the staging of human embryos. However, little is known about the embryological development of the auricle. The most commonly reproduced developmental theory by His (1885) describes six hillocks; three on the first and three on the second pharyngeal arch. The aim of this study was to assess the validity of this theory by modern techniques and to expand the knowledge of the embryological development and morphology of the auricle.
Study Design22 human embryos from the Carnegie collection between Carnegie stage 13 and 23 (28–60 days) were selected based on their histological quality.
Methods
Histological sections of the selected embryos were examined. Three‐dimensional (3D) reconstructions were prepared. Additionally, literature research was performed.
Results
The hillocks were absent in most stages. Contrary to common knowledge, the auricle is almost entirely innervated by branches of the facial nerve. The branches of the trigeminal nerve only innervate the tragus and the anterior external auditory meatus (EAM). Consequently, this indicates that almost the entire auricle is derived from the second pharyngeal arch, with the exception of the tragus and the anterior EAM.
Conclusions
The 3D reconstructions show the anatomy and development of the auricle to be different from concepts presented in current textbooks. As a consequence, we propose that preauricular sinuses should be classified as first pharyngeal arch anomalies.
Level of Evidence
NALaryngoscope, 2019

What is the optimal management of pediatric nontuberculous mycobacterial cervicofacial lymphadenitis?

11-12-2019 – Jennifer L. Harb, Emily Pascal, Rebecca A. Compton, Andrew R. Scott

Journal Article

The state of diversity based on race, ethnicity, and sex in otolaryngology in 2016

11-12-2019 – Ceisha C. Ukatu, Lauren Welby Berra, Qiwei Wu, Christine Franzese

Journal Article

Objective
To compare the representation of women and racial minorities among otolaryngology residents and faculty to other surgical specialties.
Methods
Information from 2016 regarding female and minority representation among medical school graduates, otolaryngology applicants, otolaryngology residents, otolaryngology faculty and residents, and faculty in other surgical specialties was obtained from the publicly available registries from the American Medical Association and the American Association of Medical Colleges. The data obtained was used to explore the differences between the various stages of training in otolaryngology and to compare the female and minority diversity of otolaryngology residents with residents in other surgical specialties.
Results
Women and African Americans were underrepresented at the resident level compared with their level of representation as medical school graduates. Women were underrepresented in otolaryngology resident applicants (P < .001), but equally represented between otolaryngology residency applicants and residents (P = .582). African Americans were equally represented between medical school graduates and otolaryngology resident applicants (P = .871), but underrepresented in otolaryngology residents (P < .001). Asian Americans and Hispanics were underrepresented among otolaryngology faculty compared with their representation in otolaryngology residency programs (P < .001, P < .001, respectively). Otolaryngology has the lowest percentage of African‐American residents and faculty compared to other surgical specialties. The representation of women in otolaryngology residencies is higher than most surgical specialties but worse than general surgery, integrated plastics, and medical school graduates.
Conclusion
Otolaryngology lags behind other surgical specialties in representation of minorities and women. Continued efforts should be made to increase diversity in the field of otolaryngology, especially in regard to underrepresented minorities.
Level of Evidence3 Laryngoscope, 2019

Passy muir valve tolerance in medically complex infants and children: Are there predictors for success?

11-12-2019 – Laura Brooks, Janet Figueroa, Tracy Edwards, Walter Reeder, Sheila McBrayer, April Landry

Journal Article

Objective
The aim of this study was to investigate if there are predictors for success with Passy Muir Valve (PMV) placement for medically complex pediatric patients.
Methods
Retrospective chart review of 52 pediatric patients with a tracheostomy with or without ventilator dependence who received PMV assessments from October 2017 through October 2018 in intensive care units and acute care units within Childrens Healthcare of Atlanta (Atlanta, GA). Univariate analysis and logistic regression modeling were used to identify factors associated with a successful PMV trial.
Results
Factors found to be associated with a successful PMV trial were as follows: transtracheal pressure measurement, presence of voicing, age of patient >2 years, weight of patient, and ventilator rate.
Conclusion
Medically complex infants and children in the intensive care units and acute care units on or off the ventilator can be considered candidates for PMV use; several factors can be predictive of a successful trial.
Level of Evidence2CLaryngoscope, 2019

Acute airway compromise after recombinant human TSH administration: A case report and review of the literature

10-12-2019 – Eric Dowling, Jan Kasperbauer, John Morris, Semirra Bayan

Case Reports

Radioiodine ablation is a commonly utilized treatment for differentiated thyroid carcinoma. Uptake of radioiodine can be enhanced by pretreatment with thyroid hormone withdrawal or administration of recombinant human thyroid‐stimulating hormone (rh
TSH). rh
TSH is generally well‐tolerated with minimal adverse effects. However, in patients with extensive tumor burden in confined anatomic spaces, rapid enlargement of normal or neoplastic thyroid tissue secondary to rh
TSH administration can result in significant compressive effects. In this report, we describe a case of rapid airway deterioration requiring intubation in a patient with involvement of the thyroid cartilage by papillary thyroid carcinoma.
Laryngoscope, 122:0000–0000, 2019 Laryngoscope, 2019

Development of a microporous annealed particle hydrogel for long‐term vocal fold augmentation

10-12-2019 – Lauren Pruett, Heather Koehn, Teresa Martz, Ian Churnin, Sergio Ferrante, Lisa Salopek, Patrick Cottler, Donald R. Griffin, James J. Daniero

Journal Article

Objectives/Hypothesis
The purpose of this study was to develop and provide evidence of a novel permanent injectable biomaterial for vocal fold augmentation with the potential to treat glottic incompetence by evaluating its performance in two animal models.
Study Design
Animal model.
Methods
Microporous annealed particle (MAP) hydrogel was fabricated using a water‐in‐oil emulsion method and synthetically tuned to match the stiffness modulus of native vocalis muscle. Thirty‐two New Zealand White rabbits were administered unilateral injections of MAP (n = 16), saline (n = 8), and the clinical standard hyaluronic acid (Restylane‐L) (n = 8), and evaluated at day 0, and 6‐week, 4‐month, and 6‐month endpoints. Induced vocal fold vibration was recorded with a high‐speed camera prior to euthanization, with glottic closure and mucosal wave characteristics assessed both quantitatively and qualitatively by an experienced voice clinician. Histologic analysis was performed to assess scaffold permanence, immunogenicity, and vascularization within the scaffold.
Results
Histologic analysis confirmed the MAP gel treatment group maintained its volume without migration for 6 months postimplantation. Immune staining showed minimal to nonexistent immunogenicity over the course of the implant lifetime. Extensive tissue integration and vascularization was observed histologically within the MAP gel group by immunofluorescence staining. Mucosal wave was not impaired by any of the injected materials, including the MAP gel augmentation.
Conclusions
MAP gel is a nonresorbable biostimulatory injectable implant that provides superior tissue integration, stiffness matching, and permanence compared to current injectable implants, with retained biomechanical function, suggesting its potential as a new therapeutic for glottic incompetence.
Level of Evidence
NALaryngoscope, 2019

Prognostic Value of a Family History of Oral Tongue Squamous Cell Carcinoma: A Matched‐Pair Study

10-12-2019 – Meng Cui, Wei Du, Qigen Fang, Liyuan Dai, Jinxing Qi, Ruihua Luo

Journal Article

Objectives/Hypothesis
To analyze the prognostic value of a family cancer history for predicting survival in patients with oral tongue squamous cell carcinoma (SCC).
Study Design
Retrospective case series.
Methods
Each patient with a family history was paired with one patient with sporadic oral tongue SCC without a family history. The primary endpoint was disease‐specific survival (DSS).
Results
In total, 124 patients were enrolled as participants with a family cancer history, and the 5‐year DSS rate was 51%. In the matched group, the 5‐year DSS rate was 40%. The difference was significant (P = .032). In the smoking patients with a family history, the 5‐year DSS rate was 43%. In the smoking patients from the matched group, the 5‐year DSS rate was 17%; the difference was significant (P = .028). In nonsmoking patients with a history of cancer, the 5‐year DSS rate was 51%; in nonsmoking patients in the matched group, the 5‐year DSS rate was 40%; the difference was not significant (P = .141).
Conclusions
A family cancer history is associated with improved DSS in surgically treated oral tongue SCC patients.
Level of Evidence4 Laryngoscope, 2019

“Hearing Preservation and Speech Outcomes After Cochlear Implantation in Menieres Disease”

10-12-2019 – “Maheer M. Masood, Douglas R. Farquhar, Kevin D. Brown, Harold C. Pillsbury, English R. King, Brendan P. OConnell”

Journal Article

Objectives/Hypothesis
To evaluate speech perception outcomes and hearing preservation after cochlear implantation in patients with Menieres disease (MD).
Study Design
Retrospective chart review.
Methods
Fifty‐one adult patients, accounting for a total of 63 implants, with MD treated at a tertiary care center were included in the study. Patients with unaided preoperative air‐conduction thresholds ≤80 d
B at 250 Hz were included in hearing preservation analyses. The primary outcome measure was Consonant‐Nucleus‐Consonant (CNC) score. Hearing preservation was assessed as follows: 1) maintenance of functional hearing, defined as a postoperative unaided air‐conduction threshold ≤80 d
B at 250 Hz and 2) low‐frequency pure‐tone average (LFPTA) shift.
Results
Speech perception scores improved significantly postimplantation; specifically, the CNC mean score was 9% preoperatively and increased to 57% by 1 year postoperatively (P < .001). Eighteen ears were included in hearing preservation analysis; the mean preoperative LFPTA was 65 d
B (standard deviation SD = 10). The mean postoperative LFPTA at activation was 93 d
B (SD = 21), and at 1 year was 102 d
B (SD = 11). Twenty‐seven percent of patients achieved short‐term functional hearing preservation, whereas the longer‐term outcomes were less favorable (11%).
Conclusions
Speech perception scores improve after implantation in patients with MD. Hearing preservation is possible in patients with MD, albeit at lower rates than reported non‐MD populations. Our data suggest that there can be degradation in acoustic hearing over time.
Level of Evidence4 Laryngoscope, 2019

Treatment sequence and survival in locoregionally advanced hypopharyngeal cancer: A surveillance, epidemiology, and end results–based study

10-12-2019 – Colleen G. Hochfelder, Aileen P. McGinn, Vikas Mehta, Enrico Castellucci, Rafi Kabarriti, Thomas J. Ow

Journal Article

Objectives/Hypothesis
The objective of this study was to examine the association between modality of primary treatment and survival among patients with locoregionally advanced hypopharyngeal cancer.
Study Design
Retrospective cohort.
Methods
There were 2,328 adult patients diagnosed with stage III or IV, M0, hypopharyngeal squamous cell carcinoma identified within the Surveillance, Epidemiology and End Results (SEER) registry (years 2004–2015). Patients who received primary chemoradiation (CRT) were compared to those who received surgery with either adjuvant radiation therapy (S + RT), or surgery with adjuvant CRT (S + CRT). The latter primary surgery group (S + Adj) was also analyzed collectively. Overall survival (OS) and disease‐specific survival (DSS) were assessed using Kaplan‐Meier analyses and Cox regression models using a propensity score to adjust for factors associated with treatment allocation.
Results
Median survival was 20 months (interquartile range IQR = 10–45) with CRT and 25 months (IQR = 10–47) with S + Adj (P < .001). S + Adj had higher‐grade cancers and more advanced T staging (P < .001). S + CRT was associated with longer OS (hazard ratio HR = 0.70, 95% confidence interval CI: 0.59‐0.84) and DSS (HR = 0.66, 95% CI: 0.54‐0.82) after adjusting for age, gender, race, subsite, grade, and stage. S + RT was associated with longer DSS than CRT (HR = 0.75, 95% CI: 0.57‐0.99) but not OS (HR = 0.82, 95% CI: 0.66‐1.04). S + Adj was associated with longer DSS in T1/T2 disease (P = .04) and T4 disease (P = .0003), but did not reach significance among patients with T3 disease (P = .06).
Conclusions
Among patients with advanced hypopharyngeal cancer reported in the SEER database, treatment with S + Adj was associated with longer DSS and OS compared to those treated with primary CRT.
Level of Evidence2b Laryngoscope, 2019

Competency‐Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus

10-12-2019 – Evan J. Propst, Nikolaus E. Wolter, Stacey L. Ishman, Karthik Balakrishnan, Ashley R. Deonarain, Deepak Mehta, George Zalzal, Seth M. Pransky, Soham Roy, Charles M. Myer, Michele Torre, Romaine F. Johnson, Jeffrey P. Ludemann, Craig S. Derkay, Robert H. Chun, Paul Hong, David W. Molter, Jeremy D. Prager, Lily H. P. Nguyen, Michael J. Rutter, Charles M. Myer, Karen B. Zur, Douglas R. Sidell, Liane B. Johnson, Robin T. Cotton, Catherine K. Hart, J. Paul Willging, Carlton J. Zdanski, John J. Manoukian, Derek J. Lam, Nancy M. Bauman, Eric A. Gantwerker, Murad Husein, Andrew F. Inglis, Glenn E. Green, Luv Ram Javia, Scott Schraff, Marlene A. Soma, Ellen S. Deutsch, Steven E. Sobol, Jonathan B. Ida, Sukgi Choi, Trina C. Uwiera, Udayan K. Shah, David R. White, Christopher T. Wootten, Hamdy El‐Hakim, Matthew A. Bromwich, Gresham T. Richter, Shyan Vijayasekaran, Marshall E. Smith, Jean‐Philippe Vaccani, Christopher J. Hartnick, Erynne A. Faucett

Journal Article

Objectives/Hypothesis
Create a competency‐based assessment tool for pediatric tracheotomy.
Study Design
Blinded, modified, Delphi consensus process.
Methods
Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as “keep” or “remove,” and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven‐point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items.
Results
The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as “keep,” and 137 comments were incorporated. In the second round, 30 task‐specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task‐Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus.
Conclusions
It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency‐based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure.
Level of Evidence5 Laryngoscope, 2019

African American Otolaryngologists: Current Trends and Factors Influencing Career Choice

09-12-2019 – Erynne A. Faucett, Hillary Newsome, Thomas Chelius, Carrie L. Francis, Dana M. Thompson, Valerie A. Flanary

Journal Article

Objectives1) Identify factors that influence African American physicians to choose a career in otolaryngology; 2) determine the predominant practice setting for African American otolaryngologists who can be role models; and 3) determine if the presence of an African American otolaryngologist in academic setting influences career choice.
Methods
Survey methodology included a 15‐item survey to determine trends in practice and factors that influenced choice of specialty.
Results
The results were reviewed for trends influencing career choice and practice location and stratified by age group. Most African American otolaryngologists are in academic practice and have subspecialty fellowship training. Enjoying medical student clerkship was the most frequently cited reason why African Americans chose otolaryngology as a career regardless of age. Early exposure was a driving factor in those 30 to 40 years old. Receiving mentorship was less influential in career choice for all age groups, but there was a positive association between those who were mentored in training and those who mentor faculty.
Conclusion
The findings suggest the continued need for initiatives to increase African Americans in our specialty. Encouraging early exposure, intentional mentoring of students, and development of African American role models who can be mentors may help increase the number of African American otolaryngologist faculty. This can help our specialty achieve racial parity in a percentage that matches the number of African Americans in the United States workforce.
Level of Evidence5 Laryngoscope, 2019

Endoscopic Versus Microscopic Management of Attic Cholesteatoma: A Randomized Controlled Trial

09-12-2019 – Arindam Das, Sandipta Mitra, Debasish Ghosh, Arunabha Sengupta

Journal Article

Objectives
To compare endoscopic transcanal approach to attic cholesteatoma with conventional microscopic transcanal technique
Methods
Seventy‐eight patients diagnosed with attic cholesteatoma were randomly assigned into two groups—one undergoing endoscopic approach and the other microscopic technique. The two groups were compared in terms of area of exposure, access to hidden areas in terms of Middle Ear Structural Visibility Index (MESVI), intraoperative time, postoperative pain, vertigo, long‐term hearing, and surgical outcomes.
Results
The mean area of exposure in endoscopic atticotomy required was less than that in microscopic group and was found to be statistically significant. The median MESVI for endoscopic group better than that for microscopic group (P < .0001). The mean operating time in endoscopic approach was less than that in case of microscopic approach, with P < .05. The median postoperative pain score in the endoscopic group was less than that in microscopic group (P < .05). No significant difference was found between two groups in terms of vertigo experienced at the end of first week and air‐bone gap closure. When long‐term surgical outcomes were assessed at 1 year, in endoscopic group, one patient had disease recurrence, one cartilage displacement, one perforation, and two had retraction pocket formation. In the microscopic group, two patients had recurrence, four cartilage displacement, one perforation, and five retraction pocket formation.
Conclusion
Endoscopic management of limited attic cholesteatoma has definite advantages over the conventional microscopic approach.
Level of Evidence1 Laryngoscope, 2019

“A comparison of endolymphatic shunt surgery and intratympanic gentamicin for menieres disease”

06-12-2019 – Alec W. Gibson, Il Joon Moon, Justin S. Golub, Jay T. Rubinstein

Journal Article

Objective
To report audiovestibular outcomes following endolymphatic shunt surgery (ELS) and intratympanic gentamicin injections (ITG) in patients with Menieres disease (MD).
Study Design
Retrospective matched cohort study
Methods
Patients with MD refractory to medical management between 2004 and 2017 were reviewed: 44 patients underwent ELS and had outcomes available, while 27 patients underwent ITG and had outcomes available. Mean follow‐up durations for the ELS and ITG groups were 39.1 and 43.3 months, respectively. Twenty‐six patients from the ELS group and 24 patients from the ITG group were then included in a pretreatment hearing‐ and age‐matched analysis. Main outcome measures were successful control of vertigo, pure‐tone average (PTA; 0.5, 1, 2 and 4 k
Hz), word recognition score (WRS), and treatment complications.
Results
A matched analysis showed vertigo control rates of 73.1% in the ELS group and 66.8% in the ITG group, which were not significantly different (P = .760). The change in PTA following treatment was statistically similar between the ELS group (6.2 d
B) and ITG group (4.6 d
B) (P = .521), while the change in WRS for the ELS group (+3.9 %) was significantly more favorable than the ITG group (‐13.6 %) (P = .046). Chronic post‐treatment unsteadiness was reported in 25.0% of the ITG group and was not encountered in the ELS group (P = .009).
Conclusion
ELS provided successful vertigo control at least as well as ITG with a lower incidence of audiovestibular complications.
Level of Evidence4 Laryngoscope, 2019