Laryngoscope

Can voice disorders matter as much as life‐threatening comorbidities to patients’ general health?

03-12-2019 – Elliana Kirsh DeVore, Thomas L. Carroll, Bernard Rosner, Jennifer J. Shin

Objective
National initiatives and funding agencies may deprioritize voice disorders relative to conditions such as malignancy, pulmonary, or cardiac disease. It is unknown whether the impact of voice problems is outweighed by other potentially more serious disease states. Our objective was thus to quantify the extent to which voice contributes to general health status when adjusting for concurrent, more life‐threatening comorbidities.
Methods
Adults (n = 430) presenting to a tertiary care academic center with a primary voice complaint completed the Voice Handicap Index‐10 (VHI‐10) and the Patient‐Reported Outcomes Measurement Information System global health short‐form instrument (PROMIS). Medical comorbidities were categorized via the Deyo modification of the Charlson Comorbidity Index. The influence of voice and comorbid conditions on general health scores was assessed through multivariate ordinal regression. The potential for effect modification was also evaluated.
Results
VHI‐10 mean scores were 11.4 (95% confidence interval CI, 10.5 to 12.4). PROMIS physical and mental health t scores were 49.0 (95% CI, 48.0 to 49.9) and 51.6 (95% CI, 50.6 to 52.5), respectively. Global and social item scores were 3.4 (95% CI, 3.3 to 3.5) and 3.7 (95% CI, 3.6 to 3.8), respectively. The most prevalent comorbid conditions were pulmonary disease, malignancy, and connective tissue disorders. In all analyses, voice handicap was a significant predictor of general health, even when adjusting for comorbid conditions (VHI‐10 β = −1.349, P < 0.001 for physical health; β = −1.278, P < 0.001 for mental health; β = −1.691, P < 0.001 for social health; β = −0.956, P < 0.001 for the global overview item).
Conclusion
In the observed population, voice health has a significant, multi‐dimensional impact on general health, which is not subsumed by the presence of comorbidities.
Level of Evidence4 Laryngoscope, 2019

Vocal Fold Reconstruction Using an Autologous Pedicled Fat Flap in a Rabbit Model

29-11-2019 – Seungwon Lee, Sangwoo Seon, Kinam Park, Junsun Ryu

Journal Article

Objectives/Hypothesis
We evaluated the efficacy of a vocal fold reconstruction technique using a vascularized autologous pedicled fat (PEFA) flap in a rabbit model of vocal fold paralysis.
Study Design
Animal model.
Methods
The study included 30 male New Zealand White rabbits; 20 received vocal fold reconstructions (PEFA group) and 10 served as normal controls (control group). The right recurrent laryngeal nerve was resected, and simultaneous PEFA flap reconstruction was performed. The PEFA flap, including a pre‐epiglottic fat and thyroid perichondrium, was elevated and implanted through a window at the inferior border of the thyroid cartilage. Histological and high‐speed video analyses of vocal fold vibration were performed 1 month after PEFA reconstruction. The maximum amplitude of vocal fold vibration and the dynamic glottal gap were used to assess vocal fold vibration.
Results
The histological findings showed that the lamina propria ratio (lamina propria pixels/total vocal fold pixels) and the total number of vocal fold pixels were similar between the PEFA and control groups. Vocal fold vibration analyses indicated that the maximum amplitude differences in the vibration were slightly lower in the PEFA group. However, the dynamic glottal gap of the vocal fold was not significantly different between the PEFA group and the control group.
Conclusions
The PEFA flap vocal fold reconstruction technique maintained the vocal fold area without a significant reduction in vocal fold vibration in a rabbit model.
Level of Evidence
NALaryngoscope, 2019

A Randomized Trial of Comparing a Combination of Montelukast and Budesonide With Budesonide in Allergic Rhinitis

29-11-2019 – Hui Chen, Luo Zhang, Hongfei Lou, Yang Wang, Feifei Cao, Chengshuo Wang

Journal Article

Objectives/Hypothesis
It is not unequivocally proven whether a combination of an intranasal corticosteroids (INSs) and a cysteinyl leukotriene receptor antagonist has greater efficacy than INSs in the treatment of seasonal allergic rhinitis (SAR).
Study Design
Single‐center, randomized, open‐label study.
Methods
Study subjects included 46 participants with SAR. Participants were randomized to receive budesonide (BD; 256 μg) plus montelukast (MNT; 10 mg) (BD + MNT) or BD alone (256 μg) for 2 weeks. Visual analog scale scores for five major symptoms of SAR, nasal cavity volume (NCV), nasal airway resistance (NAR), and fractional exhaled nitric oxide (Fe
NO) were assessed before and at the end of treatments.
Results
Both treatments significantly improved the five main SAR symptoms from baseline; however, BD + MNT produced significantly greater improvements in nasal blockage and nasal itching compared to BD alone. At baseline, the nasal blockage score was significantly correlated with NCV and NAR (r = −0.473, P = .002 and r = −0.383, P = .013, respectively). After 2 weeks of treatment, BD + MNT significantly improved NCV, but not NAR, to a greater level than BD. The number of patients with Fe
NO concentration ≥ 30 ppb at baseline was significantly decreased after BD + MNT treatment, but not after BD treatment. Similarly, BD + MNT treatment led to a significantly greater decrease in Fe
NO concentration than BD treatment.
Conclusions
BD + MNT treatment may have an overall superior efficacy than BD monotherapy for patients with SAR, especially in improvement of nasal blockage, itching, and subclinical lower airway inflammation. Also, NCV and NAR could be used to assess nasal blockage more accurately.
Level of Evidence1b Laryngoscope, 2019

The generalizability of the clinical assessment score‐15 for pediatric sleep‐disordered breathing

29-11-2019 – Nira A. Goldstein, Norman R. Friedman, Heather C. Nardone, Abdullah Aljasser, Allison B.J. Tobey, Debra Don, Fuad M. Baroody, Derek J. Lam, Steven Goudy, Stacey L. Ishman, Jill M. Arganbright, Cristina Baldassari, J.B.S. Schreinemakers, Todd M. Wine, Nicole J. Ruszkay, Ahmed Alammar, Amber D. Shaffer, Jeffrey A. Koempel, Jeremy Weedon

Journal Article

Objective
The Clinical Assessment Score‐15 (CAS‐15) has been validated as an office‐based assessment for pediatric sleep‐disordered breathing in otherwise healthy children. Our objective was to determine the generalizability of the CAS‐15 in a multi‐institutional fashion.
Methods
Five hundred and thirty children from 13 sites with suspected sleep‐disordered breathing were recruited, and the investigators completed the CAS‐15. Based on decisions made in the course of clinical care, investigators recommended overnight polysomnography, observation, medical therapy, and/or surgery. Two hundred and forty‐seven subjects had a follow‐up CAS‐15.
Results
Mean age was 5.1 (2.6) years; 54.2% were male; 39.1% were white; and 37.0% were African American. Initial mean (standard deviation SD) CAS‐15 was 37.3 (12.7), n = 508. Spearman correlation between the initial CAS‐15 and the initial apnea‐hypopnea index (AHI) was 0.41 (95% confidence interval CI, 0.29, 0.51), n = 212, P < .001. A receiver‐operating characteristic curve predicting positive polysomnography (AHI > 2) had an area under the curve of 0.71 (95% CI, 0.63, 0.80). A score ≥ 32 had a sensitivity of 69.0% (95% CI, 61.7, 75.5), a specificity of 63.4% (95% CI, 47.9, 76.6), a positive predictive value of 88.7% (95% CI, 82.1, 93.1), and a negative predictive value of 32.9% (95% CI, 23.5, 44.0) in predicting positive polysomnography. Among children who underwent surgery, the mean change (SD) score was 30.5 (12.6), n = 201, t = 36.85, P < .001, effect size = 3.1.
Conclusion
This study establishes the generalizability of the CAS‐15 as a useful office tool for the evaluation of pediatric sleep‐disordered breathing.
Level of Evidence2B Laryngoscope, 2019

Paraganglioma of the recurrent laryngeal nerve

29-11-2019 – Nyall R. London, Mark Hopkins, Simon R. Best, Lisa M. Rooper, Carole Fakhry

Case Reports

Paragangliomas of the head and neck are rare, and most frequently benign, slow growing, and nonsecretory. The most frequent locations these tumors arise in the head and neck include the carotid body, jugular bulb, vagus nerve, tympanic branch of the glossopharyngeal nerve, and sympathetic chain. Here we present, to our knowledge, the second reported case of paraganglioma of the recurrent laryngeal nerve. This case is unique given the patient presentation due to ipsilateral vocal fold paralysis, which has not previously been reported, lack of previous surgery, and demonstration of loss of succinate dehydrogenase iron‐sulfur subunit B expression. Laryngoscope, 2019

Intracapsular versus extracapsular dissection tonsillectomy for adults: A systematic review

29-11-2019 – Nikul Amin, Raj Lakhani

Journal Article, Review

Objectives
Tonsillectomy is an extremely common ENT surgical procedure. There is a growing interest in the role of intracapsular dissection tonsillectomy (ICDT) due to reported reduced perioperative complications. We aim to compare the outcomes associated with ICDT versus traditional extracapsular dissection tonsillectomy (ECDT) in the adult population.
Methods
Systematic review of all randomized controlled trials (RCTs) comparing ICDT and ECDT for all indications in the adult population. Electronic searches performed through CENTRAL, PubMed, Ovid EMBASE, Web of Science, Clinical
Trials.gov, and WHO ICTRP. Review Manager 5.3 (Rev
Man 2014) was used to carry out the meta‐analysis.
Results
Nine RCTs were included with a total of 11 reports with mean age of 23.9 years including 181 patients who received ICDT compared to 176 patients receiving ECDT. We found statistically significant reduced postoperative pain and analgesia requirement as well as a reduced rate of secondary postoperative bleeding in patients undergoing ICDT versus ECDT. There appears to be no significant difference in controlling recurrent tonsillitis between the ICDT and ECDT groups.
Conclusion
Across the recorded outcomes we noted no clear benefit to performing ECDT over ICDT and evidence suggests high patient satisfaction with ICDT. Laryngoscope, 2019

Main branch of ACN‐to‐RLN for management of laryngospasm due to unilateral vocal cord paralysis

29-11-2019 – Wei Wang, Jianxiong Sun, Haihong Tang, Yingna Gao, Shicai Chen, Meng Li, Hongliang Zheng

Journal Article

Objectives/Hypothesis
This study explored the feasibility and efficiency of main branch of ansa cervicalis nerve (ACN)‐to‐recurrent laryngeal nerve (RLN) anastomosis for management of paroxysmal laryngospasm due to unilateral vocal cord paralysis (UVCP).
Methods
Thirteen patients who underwent main branch of ACN‐to‐RLN anastomosis for management of paroxysmal laryngospasm due to UVCP were enrolled in the present study. Multidimensional assessments, including videostroboscopy, voice assessment, and laryngeal electromyography (LEMG), were performed preoperatively and postoperatively.
Results
This series was limited to UVCP with iatrogenic causes, including thyroidectomy, cervical spine surgery, and thoracic surgery. After main branch of ACN‐to‐RLN anastomosis, all cases showed significant airway improvement, and laryngospasm was completely abolished in 92.3% (12 of 13) of cases. Videostroboscopy showed that the bulging and paradoxical adduction of the affected vocal cord during a sniff were abolished immediately after operation, and there was no significant difference in vocal fold position or glottal closure before versus after the operation. LEMG showed that the postoperative recruitment and amplitude of voluntary motor unit potential in the affected thyroarytenoid muscle during a sniff were significantly decreased compared to preoperative values, and postoperative recruitment showed significant improvement during phonation compared to that preoperatively. Voice assessment showed that there were no significant differences in overall grade, roughness, breathiness, jitter (local), shimmer (local), noise‐to‐harmonics ratio, or maximum phonation time after the operation compared to the preoperative values.
Conclusions
Main branch of ACN‐to‐RLN anastomosis could have long‐lasting efficacy in the management of paroxysmal laryngospasm due to UVCP, with no apparent compromise of voice quality.
Level of Evidence4 Laryngoscope, 2019

Robotic Tongue‐Base Resection Combined With Tongue‐Base Suspension for Obstructive Sleep Apnea

29-11-2019 – Murat Turhan, Asli Bostanci

Journal Article

Objectives/Hypothesis
Our primary objective was to evaluate the feasibility, morbidity, and efficacy of transoral robotic surgery (TORS) tongue‐base resection (TBR) combined with tongue‐base suspension (TBS) for obstructive sleep apnea (OSA) with tongue‐base collapse. Our secondary objective included evaluation of factors influencing treatment success.
Study Design
Single‐arm, prospective, observational cohort study.
Methods
Patients were eligible if they had moderate‐to‐severe OSA (apnea hypopnea index AHI > 15) or positional OSA, had a tongue‐base collapse and glossoptosis identified by drug‐induced sleep endoscopy (DISE), and failed continuous positive airway pressure. All patients underwent TORS‐TBR combined with TBS. Additionally, concomitant epiglottoplasty, uvulopalatopharyngoplasty, or expansion pharyngoplasty were performed based on DISE findings.
Results
In total, 64 patients were enrolled in the trial. The mean age was 45.9 years, mean body mass index was 30.5 kg/m2, and mean AHI was 41.7 events/hour. The mean robotic surgical time, total volume of tongue‐base tissue removed, and the length of hospital stay were 21.4 minutes, 15.16 m
L, and 6.5 days, respectively. Postoperatively, almost all polysomnographic metrics improved significantly (AHI = 41.72 vs. 18.82 events/hour, lowest oxygen saturation = 80.43% vs. 85.14%, Epworth Sleepiness Scale = 10.49 vs. 4.09). The procedure provided an overall success rate of 75%, with minor morbidity. All patients experienced varying degrees of temporary lingual edema postoperatively. Tracheotomy was not required for any patient. Although no independent predictor of treatment success was determined, patients with more severe disease tend to exhibit lower response to the treatment.
Conclusions
TORS‐TBR combined with TBS is a feasible, safe, and efficient procedure for OSA with tongue‐base collapse.
Level of Evidence4 Laryngoscope, 2019

Improving thyroid function monitoring in head and neck cancer patients: A quality improvement study

28-11-2019 – Nupur Bhatt, Zahrah Taufique, Emily Kamen, Binhuan Wang, Catherine Concert, Zujun Li, Kenneth Hu, Babak Givi

Journal Article

Objective
To investigate and improve compliance of thyroid function monitoring in head and neck cancer patients who received radiotherapy to the cervical region before and after instituting quality improvement interventions.
Methods
Using the Plan, Do, Study, Act (PDSA) methodology, patients with head and neck malignancies who received radiotherapy to the cervical region from 2013–2015 were identified at a tertiary medical center. The status of the patients’ thyroid monitoring and related characteristics were recorded. A quality improvement project was subsequently implemented by data sharing and providing feedback to practitioners involved in head and neck cancer care and creating a tracking database for all patients who received radiotherapy to the neck. After implementation of these interventions, data was collected on patients meeting the inclusion criteria from 2015–2017.
Results
One hundred fifty‐six patients met criteria pre‐intervention and ninety‐eight patients met criteria post‐intervention. Compliance of thyroid monitoring went up from 34% to 80% after interventions (P < .0001). There was a significant increase in thyroid testing performed by radiation oncologists after interventions from 2% to 21%, while medical oncologists and otolaryngologists remained consistent in their compliance rates.
Conclusion
It is possible to improve compliance with evidence‐based recommendations and improve the quality‐of‐care for head and neck cancer survivors through simple, cost effective interventions.
Level of Evidence2 Laryngoscope, 2019

Preoperative sinus computed tomography scan review checklist

28-11-2019 – Daniel B. Spielman, David A. Gudis

Journal Article

Correlation of sinonasal symptoms with the size and position of nasal septal perforations

27-11-2019 – Grace C. Khong, Samuel C. Leong

Journal Article

Objective
To assess the correlation of sinonasal symptoms and quality of life with size and position of nasal septal perforation (NSP).
Method
This is a prospective observational study in a tertiary referral center involving adult patients presented with NSP. The Sino‐Nasal Outcome Test‐22 (SNOT‐22) and its clinico‐psychometric domains were analyzed, including additional NSP‐specific symptoms (nasal crusting, epistaxis, and whistling noise during nasal breathing). The size of NSP was measured radiologically by calculating the area in cm2 and anteroposterior (AP) diameter. Position of perforation was determined clinically by distance from columella to the anterior edge of the perforation.
Results
Forty patients were included in this study (22 males). The most common etiology of NSP was iatrogenic. The mean SNOT‐22 score was 50.8 (standard deviation 23.8), and mean NSP size was 3.0 cm2. No statistical correlation was observed between the total SNOT‐22 score with either position or size of NSP. As for NSP‐specific symptoms, there was a statistically significant negative correlation with the size of perforation (A‐P diameter) (r = −0.34, P = 0.03) and position of the perforation (r = −0.49, P = 0.0016), suggesting that these symptoms improved with posterior and larger perforations.
Conclusion
Reported SNOT‐22 scores were comparable to patients with recalcitrant chronic rhinosinusitis, although the scores did not correlate with size and position of NSP. Sinonasal symptoms typically observed in NSP improved with more posteriorly placed and larger sized perforations. This study provides an insight into the quality‐of‐life impact of NSP and affirms the clinical observation that anterior NSP are more symptomatic.
Level of Evidence4Laryngoscope, 2019

Surgical outcomes and complications of septal extension graft supported by 3D printed polycaprolactone plate

27-11-2019 – Sung Hyun Kim, Ji Yun Choi

Journal Article

Background
Tip plasty using a septal extension graft (SEG) is useful in the Asian population. However, complications such as decreased tip projection, infection, or deviation are noted post‐surgery, and additional support using an SEG is often necessary. We aimed to transplant an additional 3D printed polycaprolactone (PCL) graft to the tip plasty using the SEG to reinforce the SEG.
Methods
The study included 43 patients (20 males and 23 females; mean age, 28.7 years; range, 17–58 years) who received rhinoplasties using the SEG method combined with a 3D printed PCL graft from November 2016 to August 2017. The mean observation period was 14.8 months (range, 12–20 months).
Results
Twenty‐six patients rated their satisfaction level as excellent, 13 rated good, 3 rated fair, and 1 rated poor. In total, 28 patients did not exhibit tip drooping at the 1‐year follow‐up; 13 patients demonstrated mild to moderate tip drooping, and 2 patients demonstrated severe tip drooping. Thirty‐one patients demonstrated “stiffness” of the nasal tip, of which 11 patients reported discomfort, and 20 patients reported none; two patients demonstrated deviation of the tip.
Conclusion
Although the 3D‐printed PCL graft provided support, biocompatibility, and manipulability, care is required to prevent complications.
Level of Evidence4 Laryngoscope, 2019

The impact of resident involvement on tonsillectomy outcomes and surgical time

27-11-2019 – Brittany A. Leader, Nathan D. Wiebracht, Jareen Meinzen‐Derr, Stacey L. Ishman

Objective
Posttonsillectomy hemorrhage can be life‐threatening, so we investigated whether patients are at increased risk with an inexperienced surgeon. There is scant information on how surgical experience affects outcomes in pediatric tonsillectomy. We hypothesized that supervised residents would have longer operative times but no difference in complication rates compared to attending surgeons.
Study Design
Retrospective case series of children who underwent tonsillectomy from July 2014 to April 2017 at a tertiary pediatric medical center.
Methods
We assessed outcomes and operative times, based on the primary surgeons level of training, for children (14 months to 22 years) who underwent tonsillectomy.
Results
A total of 7,606 children were included (mean age 7.0 ± 4.1 years, 51% female) with a mean body mass index (BMI) of 18.6 ± 5.48 kg/m2; 76% were white; and 13% were black. Residents assisted with tonsillectomy in 43% of cases. The readmission rate (5%–6%) was not different (P = 0.48) by level of experience. Similarly, return to the operating room for control of hemorrhage (3.3%–3.5%) did not differ by level of experience (P = 0.95). The median procedure time for adenotonsillectomy was shortest for attendings (9 minutes), followed by fellows (13 minutes), and residents (14 minutes, P < 0.0001). Among residents, time for adenotonsillectomy decreased significantly with each increasing year of training (P < 0.0001) from postgraduate year (PGY) 1 (17 minutes), to PGY2 (15 minutes), to PGY3 (14 minutes), and to PGY4 (12.5 minutes).
Conclusion
Attending surgeons completed tonsillectomy more quickly, and operative times decreased with increasing experience level. However, there was no difference in readmission or postoperative hemorrhage rates between residents and attending surgeons.
Level of Evidence4 Laryngoscope, 2019

Clinical characteristics and treatment‐associated survival of head and neck Ewing sarcoma

27-11-2019 – Sina J. Torabi, Said Izreig, David A. Kasle, Liliya Benchetrit, Parsa P. Salehi, Benjamin L. Judson

Journal Article

Objectives
Ewing sarcoma of the head and neck (ESHN) is a rare malignancy for which limited data exists. Herein we examine anatomic distribution of ESHN, demographic characteristics, and multi‐modal therapy as potential determinants in the overall survival (OS) of patients with ESHN.
Methods
A retrospective study of the National Cancer Database (NCDB) from 2004–2016 was performed. A multivariate Cox regression and univariate Kaplan‐Meier survival analyses were conducted.
Results
We identified 284 patients with ESHN eligible for demographic analysis and 223 for survival analysis. Approximately half (50.3%) of patients with ESHN were under the age of 18. Pediatric patients (<18) were less likely to present with distant metastases (≤8.0% vs. 9.5–19.0%, P = .006) and more likely to present with osseous disease (90.2% vs. 75.2%, P = .001) than adults. Adult age (HR: 2.727, 95% CI, 1.381–5.384, P = .004) and distant metastatic disease at the time of presentation (HR: 8.161, 95% CI, 2.922–22.790, P < .001) were independently associated with worse OS. The addition of local therapy (either surgery, radiotherapy, or both) to chemotherapy was not associated with improved survival when compared to treatment with chemotherapy alone.
Conclusion
Predictors of OS in patients with ESHN included age < 18 years and non‐metastatic disease at the time of diagnosis. Tumor site of origin (osseous vs. extraosseous primary) or the addition of local therapy to chemotherapy had no impact on OS. Our analysis suggests that chemotherapy serves as the primary modality in treating ESHN, while further study of this rare malignancy is required to discern the utility of combined systemic and local therapy. Laryngoscope, 2019

Opioid Prescribing and Use in Ambulatory Otolaryngology

27-11-2019 – Liese C. C. Pruitt, Geoffrey C. Casazza, C. Ian Newberry, Ryan Cardon, Alexander Ramirez, Paul R. Krakovitz, Jeremy D. Meier, David E. Skarda

Journal Article

Objectives
The objective of this study was to evaluate surgeon‐prescribing patterns and opioid use for patients undergoing common otolaryngology surgeries. We hypothesized that there was little consistency across surgeons in prescribing patterns and that surgeons prescribed significantly more opioids than consumed by patients.
Methods
E‐mail–based surveys were sent to all postoperative patients across a 23‐hospital system. The survey assessed quantity of opioids consumed postoperatively, patient‐reported pain control, and methods of opioid disposal. We compared patient‐reported opioid consumption to opioids prescribed based on data in the electronic data warehouse.
Results
There was wide variation in prescribing between providers both in the quantity and type of opioids prescribed. Patients used significantly less opioids than they were prescribed (10 vs. 30 tablets, P < 0.001) for both opioid‐exposed and opioid‐naïve patients. More than 75% of patients had excess opioids remaining.
Conclusion
Opioids are consistently overprescribed following ambulatory head and neck surgery. Otolaryngologists have an important role in the setting of the national opioid epidemic and should be involved in efforts to reduce excess opioids in their community.
Level of Evidence4 Laryngoscope, 2019

Impact of obesity and obstructive sleep apnea in lateral skull base cerebrospinal fluid leak repair

27-11-2019 – “Kristen L. Yancey, Nauman F. Manzoor, Patrick D. Kelly, Robert J. Yawn, Matthew OMalley, Alejandro Rivas, David S. Haynes, Marc L. Bennett”

Journal Article

Objective
To investigate the prevalence and impact of obstructive sleep apnea (OSA) and obesity in lateral skull base cerebrospinal fluid leak repair (LSBR) of various etiologies.
Methods
Retrospective case review at a tertiary skull base center was conducted of consecutive adults undergoing LSBR via transmastoid, middle cranial fossa, or combined approach between 2013–2018. The following data were collected: demographics, comorbidities, radiology and intraoperative findings, and surgical outcomes including complications and need for revision surgery or shunt placement. Patients with incomplete data or leaks following skull base surgery, trauma or chronic ear disease were excluded.
Results
Ninety‐four patients (67.4% female, mean age 53.5 ± 12.9 years) underwent repair forspontaneous (s
CSFL, 44%) and other etiology (ns
CSFL) leaks. ns
CSFL served as a comparisongroup consisting of leaks status‐post lateral skull base surgery, temporal bone fractures, andchronic ear disease. Class III obesity (P = .02), OSA (P = .03), and imaging findings of empty sella (OR = 3.32, P = .02), and skull base thinning including contralateral tegmen thinning (31%, OR = 4.3, P = .02), arachnoid granulations (26%, OR = 4.35, P = .02), and superior canal dehiscence (15.8%, OR = 8.57, P = .04) were more common in s
CSFL. Four patients (4.2%) required surgical revision for recurrence, and another four (4.2%) resolved with shunting. Evidence of elevated intracranial hypertension was present in nine patients with s
CSF leaks and was predictive of need for revision or shunt procedures (P < .01).
Conclusion
Obesity, OSA, and imaging consistent with elevated intracranial pressures were more common among patients with s
CSFL. Elevated intracranial pressure predicted outcomes following multilayer repair of spontaneous CSF leaks
Level of Evidence4Laryngoscope, 2019

Risk assessment of hypertension in carotid body surgeries: A NSQIP analysis

27-11-2019 – Emaad Siddiqui, Aakash Shah, Ashok Para, Soly Baredes, Richard Chan Woo Park

Journal Article

Objectives
Carotid body tumors (CBT) are rare paragangliomas of the carotid body at the carotid bifurcation. The purpose of this study was to determine the effect of hypertension on outcomes in carotid body tumor surgery.
Study Design
A retrospective database review.
Methods
Data on carotid body resections performed from 2005 to 2014 were drawn from the American College of Surgeons’ National Surgical Quality Improvement database. Two groups were created based on the presence of preoperative hypertension. These groups were analyzed for demographics, comorbidities, and postoperative complications using bivariate and multivariate methods.
Results
Of the 452 patients included in the analysis, 49.3% had hypertension. Those with hypertension were significantly more likely to have additional comorbidities, which were controlled for by multivariate analysis to focus on hypertension. These hypertensive patients also had significantly longer hospital stays. Multivariate analysis showed that patients with hypertension undergoing carotid body resections had increased risk for overall medical complications but did not have increased risk for postoperative surgical complications or specific medical complications
Conclusion
This statistically robust study revealed that hypertension does not independently increase a patients risk for specific postoperative surgical complications following a carotid body tumor resection. However, hypertension increases the risk for postoperative medical complications and longer hospital stays. It is notable that almost half of all CBT patients have hypertension, and these hypertensives patients are significantly more likely to carry additional comorbid conditions that may have an adverse effect on outcomes including overall medical complications.
Level of Evidence
NA Laryngoscope, 2019

Interdisciplinary integration of nursing and psychiatry (INaP) for the treatment of dizziness

26-11-2019 – Philip Gerretsen, Parita Shah, Anastasia Logotheti, Mohamed Attia, Thushanthi Balakumar, Shaleen Sulway, Paul Ranalli, Wanda A. Dillon, David D. Pothier, John A. Rutka

Journal Article

Objectives
The traditional medical care model of “assess and refer” requires revamping to address the multifaceted needs of patients with chronic dizziness and imbalance by adopting an interdisciplinary approach to care that integrates nursing and psychiatry (INa
P). We aim to present a novel interdisciplinary approach that incorporates INa
P in the care of patients with chronic dizziness and imbalance.
Methods
Presentation of an interdisciplinary model of care that incorporates INa
P provided at the Toronto General Hospital in Toronto, Canada.
Results
Interdisciplinary care incorporating INa
P, which includes the provision of support from an interdisciplinary health care team (ie, neurotologist, neurologist, psychiatrist, physiotherapist, and nurse clinician), psychoeducation about the interaction between chronic dizziness and psychiatric comorbidities, and ongoing access to medical and psychosocial assessment and intervention, addresses the physical and emotional aspects of patients’ experience with chronic dizziness.
Conclusions
The novel comprehensive interdisciplinary approach incorporating INa
P may be more effective than interdisciplinary care without INa
P in improving clinical outcomes in patients with chronic dizziness. In the subsequent study, we present data comparing patients treated for chronic dizziness and imbalance with and without the integration of INa
P in an interdisciplinary setting.
Level of Evidence5 Laryngoscope, 2019

Interdisciplinary integration of nursing and psychiatry (INaP) improves dizziness‐related disability

26-11-2019 – Philip Gerretsen, Parita Shah, Anastasia Logotheti, Mohamed Attia, Thushanthi Balakumar, Shaleen Sulway, Paul Ranalli, Wanda A. Dillon, David D. Pothier, John A. Rutka

Journal Article

Objectives/Hypothesis
The traditional medical care model of “assess and refer” in a sequential fashion fails to recognize the complexities that arise due to overlapping physical and psychiatric comorbidities experienced by patients with chronic dizziness or imbalance, thus resulting in inadequate treatment outcomes. We aimed to evaluate the impact of a novel interdisciplinary approach to care that integrates nursing and psychiatry (INa
P) on dizziness‐related disability.
Study Design
Retrospective cohort study.
Methods
We compared the change in clinical assessment scores (i.e., Dizziness Handicap Inventory DHI, Dizziness Catastrophizing Scale) at approximately 8 months follow‐up between those who did (INa
P+) and did not receive INa
P (INa
P−). Data from 229 patients with dizziness or imbalance referred to an interdisciplinary neurotology clinic in Toronto, Ontario, Canada were acquired from August 2012 to December 2016 and January 2011 to December 2013 for the INa
P+ and INa
P− groups, respectively.
Results
A mean group difference in the percentage change in DHI scores was found, with greater reductions in dizziness‐related disability in the INa
P+ group (n = 121) versus the INa
P− group (n = 108). This remained significant after controlling for age, gender, baseline illness severity, and duration between baseline and follow‐up visits.
Conclusions
The novel interdisciplinary approach of incorporating INa
P appears to be more effective than interdisciplinary care without INa
P in reducing dizziness‐related disability in patients with chronic dizziness or imbalance. Clinical settings should consider the addition of INa
P to achieve better patient outcomes. Future studies are required to test the hypothesis that INa
P is more efficient and cost‐effective than the traditional model of care.
Level of Evidence3 Laryngoscope, 2019

Does salivary function decrease in proportion to radioiodine dose?

25-11-2019 – Ji Won Kim, Jeong Mi Kim, Mi Eun Choi, Seok‐Ki Kim, Young‐Mo Kim, Jeong‐Seok Choi

Journal Article

Objectives
This study was conducted to investigate the dose‐response characteristics of radioiodine on salivary glands and to investigate the mechanism responsible for radioiodine‐induced salivary glands toxicity.
Methods
Twenty‐four mice were divided into six groups: 0, 0.05, 0.10, 0.20, 0.40, and 0.80 m
Ci/20 g mouse, administered orally. Mortalities were noted 12 months after radioiodine administration. Body weights, gland weights, salivary lag times, flow rates, and changes in 99m
Tc pertechnetate were recorded. Histopathological changes and m
RNA expressions were also evaluated, and immunohistochemical analysis and apoptotic assays were performed.
Results
Survival rates, body weights, gland weights, and flow rates decreased, and lag times increased on increasing radioiodine dose. Animals administered radioiodine showed acinar atrophy, striated duct dilations, and lymphocytic infiltration in glands and irregular destruction of epithelial surfaces of tongue. The uptake and excretion of 99m
Tc pertechnetate were impaired by radioiodine. Immunohistochemical analysis showed that numbers of salivary epithelial, myoepithelial, and endothelial cells decreased and that numbers of ductal cells increased with radioiodine dose. Oxidative stress biomarker levels increased; reactive oxygen species scavenger levels decreased; and numbers of apoptotic cells increased in animals exposed to higher radioiodine doses.
Conclusion
These dose‐related, long‐term effects on salivary gland should be taken into account when determining radioiodine doses.
Level of Evidence
NALaryngoscope, 2019

Opioid sparing multimodal analgesia treats pain after head and neck microvascular reconstruction

25-11-2019 – Thomas S. Lee, Lexie L. Wang, Dae Ik Yi, Praveen D. Prasanna, Christopher Kandl

Journal Article

Objective
To compare pain control (opioid consumption and postsurgical pain scores) in head and neck (H&N) free flap reconstruction patients who undergo traditional means of postoperative analgesia including use of opioids versus a novel protocol that includes ketamine and gabapentin.
Methods
Single‐institution retrospective cohort study.
Results
Eighty‐six patients who underwent H&N free flap reconstruction from 2015 to 2018 were included. Forty‐three patients were in the control cohort treated with opioids only, and 43 patients were in the treatment group. There was a statistically significant decrease in opioid consumption in each of the first 5 postoperative days ranging from 80% to 83% in the treatment group. The daily pain scores were significantly lower in the treatment group in the first 2 postoperative days. At the 1‐month postoperative visit, there was no significant difference in pain scores between the groups; however, by the 2‐month visit, the treatment group reported significantly lower pain scores than the control group (P = 0.001). No adverse outcomes of ketamine or gabapentin were experienced.
Conclusion
Ketamine and gabapentin are safe and effective analgesics in H&N free flap surgery that significantly decrease opioid use in the acute postoperative setting and may improve pain control.
Level of Evidence3a
Laryngoscope, 2019

Long‐term complications of palate surgery: A multicenter study of 217 patients

25-11-2019 – Kenny P. Pang, Claudio Vicini, Filippo Montevecchi, Ottavio Piccin, Sudipta Chandra, Hyung C. Yang, Vikas Agrawal, Joseph C. K. Chung, Yiong H. Chan, Scott B. Pang, Kathleen A. Pang, Edward B. Pang, Brian Rotenberg

Journal Article

Objectives/Hypothesis
To investigate long‐term complications of newer reconstructive palate surgery techniques.
Study Design
Retrospective case‐series analysis.
Methods
Retrospective six‐country clinical study of OSA patients who had nose and palate surgery.
Results
There were 217 patients, mean age = 43.9 ± 12.5 years, mean body mass index = 25.9 ± 4.7, mean preoperative apnea‐hypopnea index AHI = 30.5 ± 19.1, follow‐up 41.3 months. A total of 217 palatal procedures were performed, including 50 expansion sphincter pharyngoplasties (ESP), 34 functional expansion pharyngoplasties (FEP), 40 barbed reposition pharyngoplasties (BRP), 64 modified uvulopalatopharyngoplasties (m
UPPP), 11 uvulopalatal flap procedures (UPF), nine suspension pharyngoplasties (SP), eight relocation pharyngoplasties (RP), and one z‐pharyngoplasty (ZPP). Complications included were constant and/or felt twice per week; dry throat (7.8%), throat lump feeling (11.5%), throat phlegm (10.1%), throat scar feeling (3.7%), and difficulty swallowing (0.5%). Of the 17 patients who had a dry throat complaint, two were constant (one SP, one RP), 15 were occasional (10 m
UPPP, three SP, two BRP). Of the 25 patients with the throat lump feeling, four were constant (three RP, one ZPP), 21 were occasional (10 m
UPPP, five SP, five UPF, one BRP). Of the 22 patients with the throat phlegm feeling, four were constant (two SP, two RP), 18 were occasional (10 m
UPPP, four BRP, two FEP, two SP). Of the eight patients with throat scar feeling, eight were occasional (four SP, two m
UPPP, one FEP, one RP), none were constant. One patient had difficulty swallowing (RP procedure). There was no velopharyngeal incompetence, taste disturbance, nor voice change. Highest symptom complaints were m
UPPP, SP, and RP, whereas the lowest symptom complaint was ESP.
Conclusions
Newer palatal techniques have shown to have less long‐term complications compared to the older ablative techniques.
Level of Evidence4Laryngoscope, 2019

Risk factors affecting length of stay in patients with deep neck space infection

25-11-2019 – “Kaitlin July OBrien, Kaitlin R. Snapp, Adam J. Dugan, Philip M. Westgate, Nikita Gupta”

Journal Article

Objectives
Analyze risk factors affecting length of stay (LOS) for patients presenting with deep neck space infections including care by medical versus surgical team.
Methods
This is a retrospective chart review from January 2005 through May 2018 at the University of Kentucky analyzing factors related to deep neck space abscesses. Patients included adults >18 years old admitted for deep neck space infections undergoing surgical intervention. This study compared effects of treatment on a medical versus surgical service on LOS while accounting for patient confounders. Independent variables included age, gender, tobacco use, medical comorbidities, Charlson comorbidity index, American Society of Anesthesiology (ASA) classification, presence of drain, readmissions, and repeat surgical interventions. Univariate and multivariate analysis were performed.
Results
One hundred sixty‐three patients were included in the analysis. LOS was significantly longer for those on medicine services (P < .001). Patients on medicine services had a higher incidence of diabetes (P = .011), higher Charlson comorbidity score (P = .001), and higher incidence of repeat interventions (P = .005). Postoperative LOS remained lower for patients on a surgical service (P = .009) after adjusting for Charlson comorbidity scores. Presence of a drain or tobacco use was not significant between service management (P = .89; P = .63) or LOS (P = .366; P = .225).
Conclusion
Increased postoperative LOS was associated with age, diabetes, ASA class, Charlson comorbidity index, and repeat procedures. Patients on a medicine service had longer LOS and higher comorbidity indices. Patients had shorter hospital stays on surgical services after adjusting for comorbidity indices. Use of a drain or presence of tobacco use did not affect LOS.
Level of Evidence3 Laryngoscope, 2019

Safety and cost of drug‐induced sleep endoscopy outside the operating room

25-11-2019 – Mathieu Bergeron, David R. Lee, Michael A. DeMarcantonio, Ali Kandil, Mohamed A. Mahmoud, Robert J. Fleck, Stacey L. Ishman

Journal Article

Introduction
Drug‐induced sleep endoscopy (DISE) is used to assess site of obstruction for patients in a pharmacologically induced sleep‐like state. It is traditionally performed in the operating room (OR), however, no data exists regarding the feasibility of this intervention outside the OR in children. The objective is to compare the safety of DISE performed in the MRI induction room to those performed in the OR.
Methods
Prospective case‐series of patients undergoing DISE in the MRI induction room (study group) to those assessed in the OR (controls) in a single‐institution pediatric tertiary care center. Consecutive patients undergoing DISE examination for persistent obstructive sleep apnea (OSA) after adenotonsillectomy from September 2016 to September 2017 were included.
Results
Overall, 118 patients (38 study patients, 80 controls) with a mean age of 10.6 years (95% confidence interval CI, 9.3–11.9) underwent DISE; 39.8% (47/118) were female. The most frequent comorbidity was cardiac disease (22.0%, 26/118). The mean obstructive apnea‐hypopnea index was 12.2 events/hour (95% CI, 8.8–15.6) for controls and 13.5 events/hour (95% CI, 8.7–18.3) for study patients (P = .76). No major complication or unplanned admissions occurred in either group. Induction time was similar (12 vs. 13 minutes, P = .7) as was total procedure time (12 vs. 14 minutes, P = .3) for procedures performed in both settings.
Conclusion
There were no significant complications for DISE performed in the OR or the MRI induction room and procedure times were similar. Further assessment of patient outcomes and resource utilization is needed.
Level of Evidence4Laryngoscope, 2019

Prevalence, incidence, and characteristics of dysphagia in those with unilateral vocal fold paralysis

25-11-2019 – Benjamin Schiedermayer, Katherine A. Kendall, Maya Stevens, Zhining Ou, Angela P. Presson, Julie M. Barkmeier‐Kraemer

Journal Article

Objectives/Hypothesis
The purpose of this study was to investigate the impact of dysphagia definition on the incidence and overall prevalence of dysphagia in patients with unilateral vocal fold paralysis (UVP) stratified by etiology.
Study Design
Retrospective medical chart review.
Methods
Data was collected from the records of individuals diagnosed with UVP from 2013 to 2018, including patient demographics, dysphagia questionnaire total scores, clinical evaluation dysphagia symptoms, and instrumental swallow assessment outcomes. The annual incidence and overall prevalence of dysphagia were calculated by etiology as counts and percentages across five operational definitions of dysphagia.
Results
A total of 415 individuals met inclusion criteria for the study. Annual prevalence estimates ranged from 19% to 55%, depending on the definition of dysphagia used. The highest prevalence of dysphagia occurred when defined by symptoms or signs identified by the clinician (55%). The lowest prevalence of dysphagia occurred using a definition of abnormal swallowing function documented during instrumental assessment (19%). Dysphagia questionnaire scores were more frequently abnormal in those with iatrogenic than idiopathic etiology of UVP (adjusted P = 0.014). Rate of instrumental assessment and documentation of aspiration was highest for central UVP etiology (33%). On average, pneumonia was rare (6%) irrespective of UVP etiology.
Conclusion
Up to 55% of patients diagnosed with UVP complained of dysphagia, but only 21% had dysphagia symptoms severe enough to prompt instrumental assessment. Incidence and severity of dysphagia varied depending on UVP etiologic category as well as dysphagia definition. The etiology of UVP may impact dysphagia risk and severity in this population and warrants further investigation.
Level of Evidence
IVLaryngoscope, 2019

Piezosurgery versus conventional osteotomy in rhinoplasty: A systematic review and meta‐analysis

22-11-2019 – Ahmad A. Mirza, Talal A. Alandejani, Ahmed A. Al‐Sayed

Journal Article, Review

Objective
Piezosurgery, used in different otolaryngology procedures, was a breakthrough in surgery. We systematically reviewed the differences in outcomes after lateral nasal osteotomy with peizosurgery and conventional osteotome and quantified the differences through a meta‐analysis.
Methods
Medline, Embase, and Cochrane library databases were selected to search for randomized clinical trials (RCTs) published before January 2019 that detailed differences between piezosurgery and conventional osteotomy. The key search terms included “rhinoplasty” and “piezosurgery.” Only RCTs in English with patients >18 years who underwent lateral osteotomy by percutaneous or internal approaches were included. PRISMA guidelines were followed in data extraction and study inclusion. Two independent reviewers assessed the relevance of the studies. The point of estimate in the meta‐analysis was the standardized mean difference and was pooled with the random‐effect model. The measured outcomes were ecchymosis, edema, postoperative pain, and duration of surgery.
Results
Six RCTs that met our criteria were enrolled for meta‐analysis. Piezosurgery demonstrated significantly lower edema (SMD = ‐0.75; 95% CI, ‐1.26, ‐0.24) and ecchymosis scores (SMD = ‐0.85; 95% CI, ‐1.49, ‐0.20) on postoperative days (POD) 2 or 3 than conventional surgery. They were also significantly lower with piezosurgery than conventional surgery on POD 7 (SMD = ‐0.64; 95% CI, ‐1.21, ‐0.06; and SMD = ‐0.64; 95% CI, ‐1.14, ‐0.14, respectively). Two studies that estimated the degree of pain showed that after piezosurgery, patients experienced lesser pain than after conventional surgery. The mean difference was ‐0.73 (95% CI, ‐1.06, ‐0.39).
Conclusions
Piezosurgery causes less ecchymosis, edema, and pain than conventional osteotomy, without extending the duration of surgery. Laryngoscope, 2019

Thirty‐Day Readmission and Prolonged Length of Stay in Malignant Otitis Externa

22-11-2019 – Zachary G. Schwam, Rocco Ferrandino, Vivian Z. Kaul, George B. Wanna, Maura K. Cosetti

Journal Article

Objectives
To determine independent risk factors for 30‐day readmission, prolonged length of stay (PLOS), and discharge to a rehabilitation facility for those with malignant otitis externa.
Methods
Retrospective cohort study of patients hospitalized with malignant otitis externa (International Classification of Diseases, 9th edition, code 380.14) in the Nationwide Readmissions Database (2013–2014). Overall and disease‐specific complication and mortality data were analyzed using chi‐squared and multivariate analysis.
Results
There were 1267 cases of malignant otitis externa extracted. A PLOS of ≥8 days (90th percentile) was found in 14.2% (n = 180) of patients, and 13.7% (n = 174) were discharged to a facility. Patients were readmitted within 30 days at a rate of 12.5% (n = 159). The overall rates of uncomplicated and complicated diabetes were found to be 42.1% and 17.8%, respectively. Factors independently associated with PLOS included undergoing a surgical procedure (odds ratio OR 2.08, P < .001), and having central nervous system complications (OR 3.21, P < .001). Independent risk factors for disposition to a facility included nutritional deficiency (OR 1.91, P = .029), PLOS (OR 4.61, P < .001), and age 65–79 years (OR 6.57, P = .001). Readmission was independently linked to PLOS (OR 3.14, P < .001). Diabetes was not an independent risk factor for any outcome.
Conclusions
Thirty‐day readmission, PLOS, and ultimate discharge to a rehabilitation facility were common and closely intertwined. Despite the classic association between diabetes and malignant otitis externa, diabetes was not an independent risk factor for any of our outcomes.
Level of Evidence4 Laryngoscope, 2019

Efficacy and safety of steroid‐impregnated implants following sinus surgery: A meta‐analysis

22-11-2019 – Wanpeng Li, Hanyu Lu, Huan Wang, Xicai Sun, Dehui Wang

Journal Article

Objectives
The purpose of this meta‐analysis was to discuss the efficacy and safety of bioabsorbable steroid‐impregnated implants following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) patients.
Methods
PubMed, Cochrane, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials were comprehensively searched for studies comparing the experimental group (bioabsorbable steroid‐impregnated implants) with the control group (bioabsorbable nonsteroid‐impregnated implants). Lund‐Kennedy scores, Perioperative Sinus Endoscopy (POSE) scores, polyp change, significant adhesion, middle turbinate lateralization, and adverse events were extracted from the final eligible studies. Rev
Man 5.3 software was used to analyze the data.
Results
Eight randomized controlled trials were included in our analysis. The experimental group showed no significant differences from the control group in Lund‐Kennedy scores (weighted mean difference (WMD) −0.40; 95% confidence interval confidence interval (CI) −1.05 to −0.62; P = 0.23). The experimental group had lower POSE scores compared with the control group, and there was a significant difference (WMD −1.88; 95% CI −2.32 to −1.43, P < 0.00001). The pooled results also demonstrated significant differences in polyp change, significant adhesion, and middle turbinate lateralization between the two groups. In addition, there was no significant difference with respect to adverse events between the two groups (odds ratio (OR) 0.38; 95% CI: 0.07 to 2.03; P = 0.26).
Conclusion
Bioabsorbable steroid‐impregnated implants following ESS are effective in improving the endoscopic appearance of the healing process, and the safety profile appears to be favorable for the treatment of CRS patients.
Level of Evidence1A Laryngoscope, 2019

Reducing Surgical Site Infections During Otolaryngology Surgical Missions

22-11-2019 – Glenn Isaacson, Winifred Doyle, Deborah Summer

Journal Article

Objectives
To determine what measures an otolaryngology–head and neck surgery team might adopt to decrease the incidence of surgical site infection (SSI) on a short‐term surgical mission. Despite concerns about safety and efficacy, short‐term surgical missions remain the predominant structure for humanitarian surgical care in low‐ and middle‐income countries (LMIC). Hospitals in high‐income countries strive to improve surgical outcomes through implementation of World Health Organization (WHO) safe surgery guidelines. Reduction of SSI risk is a key part of this effort.
Methods
Literature review and practical experience.
Results
WHO recommendations for reducing SSI are based largely on research done in the North America and Europe. LMIC populations are younger; comorbidities are fewer; infectious disease and trauma are prevalent; and delays in access to care are common. SSI are much more frequent in resource‐limited settings. Recommendations regarding preoperative assessment, operating room environment, instrument sterilization, surgical antibiotic prophylaxis, surgical site preparation, gloving, draping, and postsurgical care are reviewed in the context of a surgical mission at a typical LMIC government hospital.
Conclusion
Many of the WHO guidelines on reduction of SSI are logical and applicable to the short‐term surgical missions; others may need to be modified. Careful prospective data collection and clinical trials are needed to learn which interventions are valid and which should be changed.
Level of Evidence5 Laryngoscope, 2019

Association of insurance type with time course of care in head and neck cancer management

22-11-2019 – Kyohei Itamura, Niels Kokot, Uttam Sinha, Mark Swanson

Journal Article

Objectives/Hypothesis
To determine differences in time course of care based on major insurance types for patients with head and neck squamous cell carcinoma (HNSCC).
Study Design
Retrospective cohort study.
Methods
Retrospective study of Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Medicare patients with biopsy‐proven diagnosis of HNSCC referred to an academic tertiary center for tumor resection and adjuvant therapy. In addition to patient demographic information and tumor characteristics, duration of chief complaint and the following time points were collected: biopsy by referring physician, first specialty surgeon clinic appointment, surgery, and adjuvant radiation start and stop dates.
Results
There was a statistically significant increase in time interval for HMO (n = 32) patients from chief complaint to biopsy (P = .003), biopsy to first specialty surgeon clinic appointment (P < .001), and surgery to start of adjuvant radiation (P < .001) compared to that of Medicare (n = 31) and PPO (n = 41) patients. Adjuvant radiation was initiated ≤6 weeks after surgery in 22% of HMO (mean duration of 59 ± 17 days), 48% of Medicare (44 ± 13 days), and 61% of PPO (41 ± 12 days) patients.
Conclusions
Compared to PPO and Medicare patients, HMO patients begin adjuvant radiation after surgery later and experience treatment delays in transitions of care between provider types and with referrals to specialists. Delaying radiation after 6 weeks of surgery is a known prognostic factor, with insurance type playing a possible role. Further investigation is required to identify insurance type as an independent risk factor of delayed access to care for HNSCC.
Level of Evidence4 Laryngoscope, 2019

Margins in Sinonasal Squamous Cell Carcinoma: Predictors, Outcomes, and the Endoscopic Approach

22-11-2019 – Sina J. Torabi, Todd Spock, Bruno Cardoso, Janet Chao, Elliot Morse, R. Peter Manes, Benjamin L. Judson

Journal Article

Objectives
To identify factors associated with positive margins following surgical management of sinonasal squamous cell carcinoma (SNSCC), especially with regard to endoscopic treatment.
Methods
In a retrospective analysis of adult patients with clinically staged tumor (T)1 to T4a SNSCC within the National Cancer Database (NCDB) from 2004 to 2014, factors were associated with positive margins using multivariable binary logistic regression. Cases from 2010 to 2014 had surgical approach (open vs. endoscopic) available and were analyzed in a subgroup to assess the association of surgical approach with margin status. The association of margin status with overall survival (OS) and additional therapy administration was also assessed.
Results
We identified 2,968 cases, of which 807 (27.2%) had positive margins. On multivariable analysis, factors associated with positive margins included higher T stage (T4a vs. T1: odds ratio OR 2.768 95% CI 2.143–3.577), less differentiated tumors (poorly differentiated vs. well differentiated: OR 1.403 95% CI 1.060–1.856), and tumors in the ethmoid sinus (vs. nasal cavity; OR 1.889 95% CI 1.305–2.734). Cases treated at higher volume facilities (HVFs) were associated with a lower likelihood of positive margins (OR 0.716 95% CI 0.582–0.881). Positive margins were associated with decreased OS (hazard ratio 1.672 95% CI 1.464–1.908) and an increased rate of additional therapy (OR 1.966 95% confidence interval 1.597–2.421). An endoscopic approach was not associated with an increased likelihood of obtaining positive margins (vs. open; OR 1.151 0.903–1.651).
Conclusion
Positive margins were less likely when performed at HVFs and more likely in the ethmoid sinus than other subsites. Importantly, there was no association between positive margins and surgical approach. Endoscopic surgery may offer a safe, less invasive alternative to open surgery for select patients.
Level of Evidence
NALaryngoscope, 2019

Lack of additive benefit of oral steroids on short‐term postoperative outcomes in nasal polyposis

22-11-2019 – Claudio Arancibia, Cristóbal Langdon, Joaquim Mullol, Isam Alobid

Journal Article

Objectives
There is a lack of evidence concerning the efficacy of oral corticosteroids (OCS) as a postoperative treatment for patients with chronic rhinosinusitis with nasal polyps (CRSw
NP). The objective of our study was to determine the short‐term additive benefit of postoperative OCS in CRSw
NP patients.
Methods
We prospectively randomized CRSw
NP patients who were treated by endoscopic sinus surgery. All patients were resistant to maximum medical treatment according to European position paper on rhinosinusitis and nasal polyps 2012 guidelines. Treatment group received postoperative OCS in descending doses plus nasal douching over a period of 4 weeks, whereas the control group received only nasal douching. The efficacy of OCS was determined by a total 5 item symptoms score (T5SS), polyp size score, Barcelona Smell Test 24 and Medical Outcome Study Short Form‐36 questionnaire for quality of life (QoL).
Results
Of the 70 enrolled patients, 35 were in the treatment group and 35 in the control group. After 4 weeks of follow‐up, patients from both groups improved in T5SS, QoL, endoscopic findings (except for crusts that increased in both) and sense of smell, without significant differences between OCS and control groups.
Conclusion
Postoperative OCS as an add‐on treatment for CRSw
NP patients does not improve sinonasal and QoL outcomes; thus, they should not be routinely recommended.
Level of Evidence
Ib Laryngoscope, 2019

Otopathology in Kleefstra Syndrome: A Case Report

21-11-2019 – Tadao Okayasu, Alicia M. Quesnel, Katherine L. Reinshagen, Joseph B. Nadol

Case Reports

Kleefstra syndrome is a rare neurogenetic disorder caused by a subtelomeric 9q34.3 deletion or by an intragenic mutation of the euchromatin histone methyl transferase 1 gene (EHMT1). Approximately 20% to 30% of individuals have hearing loss. The left temporal bone of one subject with hearing loss was studied using light microscopy. There were several abnormalities including dysostosis of the stapes without fixation, enlarged vestibular aqueduct, anomalies of the organ of Corti in the basal turn, cyst formation in the stria vascularis, and dysmorphia of the cochlear modiolus and the vestibular labyrinth. This is the first published description of the otopathology in Kleefstra syndrome. Laryngoscope, 2019

Significance of sleep stability using cardiopulmonary coupling in sleep disordered breathing

21-11-2019 – Min Young Seo, Sun Jin Hwang, Kuk Jin Nam, Seung Hoon Lee

Journal Article

Objectives
The aim of this study was to assess the sleep quality and sleep stability according to the severity of obstructive sleep apnea (OSA) by using questionnaires and cardiopulmonary coupling (CPC) analysis.
Methods
Two hundred and twenty‐one adults were evaluated using subjective sleep questionnaires, CPC parameters, and respiratory parameters measured during full‐night polysomnography. We measured the differences in the CPC parameters of each OSA group and the correlation between the apnea–hypopnea index (AHI) and CPC parameters.
Results
AHI and CPC parameters were not associated with sleep questionnaires. AHI is negatively correlated with high frequency coupling (HFC, r = −0.725, P < 0.001) and very low frequency coupling (VLFC, r = −0.475, P < 0.001), but it is positively correlated with low frequency coupling (LFC, r = 0.786, P < 0.001) and narrow‐ and broadband‐elevated low frequency coupling (e‐LFCNB and e‐LFCBB; r = 0.522, P < 0.001 and r = 0.668, P < 0.001, respectively). We also found similar results regarding the correlation between the arousal index and CPC parameters. In addition, there were significant differences in HFC, LFC, VLFC, e‐LFCNB, and e‐LFCBB (all P < 0.001) between the severe OSA group and all other groups.
Conclusion
We found that CPC parameters significantly correlated with AHI. In addition, sleep stability‐related parameters differ significantly based on OSA severity, and apneic parameters in the severe OSA group are significantly different from those in the other groups.
Level of Evidence4 Laryngoscope, 2019

Meta‐analysis does not support routine traditional nuclear medicine studies for malignant otitis

21-11-2019 – Wiliam James Moss, Andrey Finegersh, Ajay Narayanan, Jason Ying Kuen Chan

Journal Article, Review

Objectives
The role of traditional nuclear medicine studies in the management of malignant otitis externa (MOE) is unclear and there are ongoing debates regarding their diagnostic value. The authors perform a systematic review and meta‐analysis to assess the sensitivity and specificity of traditional nuclear medicine studies in the diagnosis of MOE.
Methods
In accordance with PRISMA guidelines, a query of the Medline, Embase, Web of Science, and Cochrane databases was undertaken. The primary outcomes of interest were the sensitivity and specificity of traditional nuclear medicine studies to detect MOE.
Results
Of the initial 1317 hits from the four databases, 20 articles with a combined 608 patients were ultimately included in the review. The pooled sensitivities for Technetium‐99 and Gallium‐67 were 85.1% (95% CI, 72.0–98.1%) and 71.2% (95% CI, 55.1–87.3%) respectively. The available evidence suggested poor specificity of these modalities, but was insufficient for meta‐analysis. Neither modality was shown to be effective in the assessment of disease resolution.
Conclusion
The sensitivities of Technetium‐99 and Gallium‐67 to detect MOE are less favorable than was initially thought. Given this finding and their poor specificity, lack of anatomic resolution, unproven ability to detect disease resolution and variable availability, this review does not support the routine use of these studies in the management of MOE.
Level of Evidence
N/ALaryngoscope, 2019

Table of contents

20-11-2019 –

Masthead

20-11-2019 –

The Alberta Reconstructive Technique: An Occlusion‐Driven and Digitally Based Jaw Reconstruction

20-11-2019 – “Hadi Seikaly, Sherif Idris, Richelle Chuka, Caroline Jeffery, Agnieszka Dzioba, Fawaz Makki, Heather Logan, Daniel A. OConnell, Jeffrey Harris, Kal Ansari, Vincent Biron, David Cote, Martin Osswald, Suresh Nayar, John Wolfaardt”

Journal Article

Objectives/Hypothesis
The free flap reconstructive protocols of the jaws have been refined over the years and presently are based on bone‐driven approaches that generally use the lower border of the mandible or the anterior surface of the maxilla as the templates for reconstruction because these contours are deemed important to the eventual cosmetic outcomes of patients. The ultimate goal of functional jaw reconstruction, however, is the reconstruction of the dental occlusion and oral rehabilitation. The purpose of the present study was to evaluate the Alberta reconstructive technique (ART), which is a new approach of occlusion‐driven jaw reconstruction with digitally planned immediate osseointegrated implant installation.
Study Design
Prospective cohort study.
Methods
This research study considers the ARTs safety, effectiveness, accuracy, timeliness of reconstruction, aesthetic appeal, and cost‐effectiveness in comparison with the standard bone‐driven and delayed osseointegrated implant installation (BDD) protocol.
Results
The ART procedures were as safe and more effective at achieving full occlusal reconstruction and oral rehabilitation. The ART cohort of patients achieved oral rehabilitation in 21.4 month as compared to 73.1 months for the BDD cohort. There were no differences in the aesthetic appeal the two groups. The ART cost an average of $22,004 less than BDD and we calculated the quality adjusted life years gain to be between 2.14 and 4.04 in favour of ART.
Conclusions
The ART is a good option for patients with jaw defects. It provides a safe, effective, accurate, aesthetic, and cost‐effective reconstruction that restores form and function in a timely manner.
Level of Evidence2b Laryngoscope, 129:S1–S14, 2019

Tracheostomy in bilateral neck dissection: Comparison of three tracheostomy scoring systems

20-11-2019 – Stefan Janik, Faris F. Brkic, Stefan Grasl, Meinhard Königswieser, Peter Franz, Boban M. Erovic

Journal Article

Objectives
To evaluate whether elective tracheostomy is justified after tumor resection and bilateral neck dissection (ND) and whether application of tracheostomy scoring systems is reliable for planning of postoperative airway management.
Study Design
Retrospective cohort study.
Methods
We retrospectively assessed airway management in 160 patients with head and neck squamous cell carcinomas. Additionally, we applied and analyzed the 1) Cameron, 2) TRACHY, and 3) CASST tracheostomy scoring systems on the tracheostomy recommendations.
Results
Elective tracheostomies were performed in 51.3% of our patients, particularly in T3 to T4 tumors, cases with free flap reconstruction, and concurrent procedures. Among patients undergoing concurrent procedures, those who received tracheostomy showed significantly longer inpatient stays (27.8 ± 30.0 days vs. 13.3 ± 6.6 days; P < 0.001). Tracheostomy recommendation coincides with the performance of bilateral ND in 28.6% (CASST), 60.0% (Cameron), and 75.0% (TRACHY) of the cases, respectively. By applying corresponding criteria, tracheostomy would be recommended in 2.5% (CASST), 76.9% (Cameron), and 84.4% (TRACHY) of our cases. Bleeding episodes were the most common complication occurring in 10 patients (6.3%), but tracheostomy scores did not significantly differ between bleeders and nonbleeders.
Conclusion
Bilateral ND on its own is not a reliable predictor for elective tracheostomy. Furthermore, given the significant heterogeneity of currently available scoring systems, they prove inadequate for decision making and predictive modeling of tracheostomy placement.
Level of Evidence4 Laryngoscope, 2019

Tonsillar surface swab bacterial culture results differ from those of the tonsillar core in recurrent tonsillitis

20-11-2019 – Amy Dickinson, Hanna Kankaanpää, Suvi Silén, Seppo Meri, Aaro Haapaniemi, Jukka Ylikoski, Antti Mäkitie

Journal Article

Objectives/Hypothesis
We aimed to determine whether there was a difference between core and surface bacteriology of Finnish adults with recurrent or chronic tonsillitis to understand whether a surface swab is worthwhile and which bacteria are involved.
Study Design
Case series.
Methods
Uninflamed tonsillar surface swabs and core biopsies were taken prior to and during surgery, respectively, in 103 patients aged 16 to 66 years undergoing tonsillectomy for recurrent or chronic tonsillitis. The Mc
Nemar test was used to determine differences between the surface and core in the most prevalent bacterial species.
Results
Twenty‐seven bacterial species were isolated in addition to normal flora and were more commonly found in the core (1.11 surface and 4.75 core bacteria isolated per patient). Viridans group streptococci were the most commonly detected bacteria, found in 88% of the patients, mainly in the core. The bacteria in general were mainly isolated from the core. Of the 10 most prevalent bacteria, only group C β‐hemolytic streptococci showed no difference between detection from core and surface swabs. Other bacteria found mainly in the core include Prevotella melaninogenica, Staphylococcus aureus, and fusobacteria.
Conclusions
There is discord between the surface and core bacteria. A different population of bacteria exists in the core, especially anaerobic bacteria, suggesting that a core sample may be useful in evaluating recurrent and chronic tonsillitis.
Level of Evidence4 Laryngoscope, 2019

Predictors of eustachian tube dysfunction improvement and normalization after endoscopic sinus surgery

20-11-2019 – Thomas S. Higgins, Zachary J. Cappello, Arthur W. Wu, Jonathan Y. Ting, Raj Sindwani

Journal Article

Objective
Studies have demonstrated improvement in Eustachian tube dysfunction (ETD) symptomatology after functional endoscopic sinus surgery (FESS); however, factors associated with ETD symptom alteration have not been elucidated. This study evaluated factors associated with improvement and normalization of ETD symptoms after FESS.
Methods
A case‐control study was performed of FESS patients who had clinically significant ETD symptoms based on the Eustachian Tube Dysfunction Questionnaire‐7 (ETDQ‐7 ≥ 2.1) without middle ear effusion (MEE) preoperatively. Study patients were identified as those with a normalized ETDQ‐7 at 2 months postoperatively. Controls were patients whose ETDQ‐7 did not normalize at 2 months. Demographics, surgery characteristics, chronic rhinosinusitis phenotype, Lund‐Mackay score, temporomandibular joint dysfunction (TMJD), preoperative ETDQ‐7 and SNOT‐22 scores, and tympanograms were analyzed. Univariate and multivariate analyses were performed comparing study cases and controls.
Results
Data were collected on 165 patients, with 46% patients having clinically significant preoperative ETD and 60 patients meeting final study inclusion/exclusion criteria. FESS was associated with both SNOT‐22 and ETDQ‐7 improvement (P < 0.001). Nasal polyposis was associated with a higher probability of ETDQ‐7 normalization (OR 4.429, P = 0.035). Factors associated with failure of ETDQ‐7 normalization included TMJD (OR 0.086, P < 0.001, 95% CI 0.019–0.391) and high preoperative ETDQ‐7 (OR 0.140, P = 0.006, 95% CI 0.032–0.613).
Conclusion
In patients with clinically significant ETD symptoms without MEE, FESS was associated with ETDQ‐7 improvement. Nasal polyposis was associated with an increased probability of normalization of ETD symptoms postoperatively, whereas TMJD had a negative association.
Level of Evidence3b Laryngoscope, 2019

Clinical predictors of descending necrotizing mediastinitis after deep neck infections

20-11-2019 – Akari Kimura, Shunsuke Miyamoto, Taku Yamashita

Journal Article

Objectives/Hypothesis
To identify the clinical predictors of descending necrotizing mediastinitis (DNM) secondary to deep neck infections (DNIs) before treatment.
Study Design
Retrospective case series.
Methods
We reviewed 73 patients with DNIs who had been treated with external drainage at our institute between April 2009 and March 2019. We divided these patients into either a DNI group without mediastinitis (n = 55) or a DNM group secondary to DNI (n = 18). We collected clinical data and compared them between the groups, conducting univariate and multiple logistic regression analysis to identify the predictors of DNM.
Results
We identified age, C‐reactive protein (CRP), neutrophil percentage, lymphocyte percentage, neutrophil to lymphocyte ratio (NLR), presence of comorbidities, presence of gas, and abscess extension below the hyoid bone as statistically significant by univariate analysis. Moreover, multiple logistic regression analysis showed that age ≥55 years, NLR ≥13, and CRP ≥30 mg/d
L were statistically significant.
Conclusions
We identified age ≥55, NLR ≥13, and CRP ≥30 before DNI treatment as clinical predictors of a DNM complication.
Level of Evidence4 Laryngoscope, 2019

Risk of thyroid cancer after therapeutic irradiation in adult patients: An Age‐Based surveillance, epidemiology, and end results analysis

20-11-2019 – Shraddha M. Dalwadi, Clark Dorman, Sarah B. Fisher, Mark Bonnen, Elizabeth Grubbs, Michelle S. Ludwig

Journal Article

Objectives/Hypothesis
One risk of radiation therapy exposure (XRTe) is second primary thyroid cancer (SPTC). Previous reports examined this in children, but no population‐based studies have explored XRTe and SPTC across all ages or stratified by histological subtypes.
Study Design
Database study.
Methods
We report patient characteristics of a Surveillance, Epidemiology, and End Results (SEER) dataset of SPTC (n = 4,669) using χ2 and t tests. Odds ratio (OR) for SPTC was determined based on age, histology, and XRTe compared to expected values in the SEER database. Kaplan‐Meier survival and Cox proportional hazard ratios were reported to determine factors influencing latent survival (LS; time from initial diagnosis to SPTC) and overall survival in univariate and multivariate models.
Results
Extrathyroid extension and node status based on XRTe were similar (P = .684 and P = .776, respectively). XRTe patients were more likely to have smaller tumors (17.6 vs. 19.3 mm, P = .007). XRTe patients were diagnosed with SPTC at younger ages (59.8 vs. 62.7 years, P < .001) without a difference in LS (7.45 vs. 7.50 years, P = .426). Patients aged 1 to 14 years and 15 to 29 years at diagnosis of first cancer are at higher risk of SPTC after XRTe (OR = 1.89, P = .005 and OR = 2.35, P = .001, respectively), unlike patients age 30 to 44 years and 45+ years (OR = 1.03, P = .823 and OR = 0.97, P = .624, respectively). This difference is not present for follicular and medullary SPTC.
Conclusions
Patients aged 30+ years receiving radiation therapy (XRT) do not have an increased risk of SPTC. Deliberation is necessary in recommending, planning, and delivering XRT to minimize risk of subsequent malignancy in younger patients.
Level of Evidence
NALaryngoscope, 2019

Diffusion Kurtosis Imaging and Intravoxel Incoherent Motion in Differentiating Nasal Malignancies

20-11-2019 – Zebin Xiao, Zuohua Tang, Chunquan Zheng, Jianfeng Luo, Keqing Zhao, Zhongshuai Zhang

Journal Article

Objectives/Hypothesis
To evaluate the usefulness of diffusion kurtosis imaging (DKI) and intravoxel incoherent motion (IVIM) in the differentiation of sinonasal malignant tumors (SNMTs) with different histological types.
Study Design
Retrospective observational and diagnostic study.
Methods
Sixty‐five patients with SNMTs who underwent DKI and IVIM were enrolled in this retrospective study, including 27 squamous cell carcinomas (SCCs), 13 olfactory neuroblastomas (ONBs), 14 malignant melanomas (MMs) and 11 lymphomas. The kurtosis (K) and diffusion coefficient (Dk) from DKI and the pure diffusion coefficient (D), pseudodiffusion coefficient (D*), perfusion fraction (f), and the product of D* and f (f∙D*) from IVIM were measured. Kruskal‐Wallis and Dunn multiple comparison tests with Bonferroni correction, receiver operating characteristic curve, and logistic regression analyses were used for statistical analysis.
Results
Lymphomas demonstrated the highest K values but lowest Dk, D, D*, f, and f∙D* values among these four malignant tumors. ONBs exhibited high K values and MMs had highest D*, f, and f∙D* values. The cutoff value of ≤0.887 × 10−3 mm2/sec for f∙D* provided a sensitivity, specificity, and an accuracy of 100%, 98.1%, and 98.5%, respectively, for differentiating lymphomas from the other three entities. The combination of f∙D* and D values showed a sensitivity of 92.9% and a specificity of 92.5% for the discrimination of MMs from ONBs and SCCs. The K value was useful for differentiating ONBs from SCCs, with a threshold value of 0.942 (sensitivity, 84.6%; specificity, 63.0%).
Conclusions
The combined use of DKI and IVIM is helpful for differentiating among four histological types of SNMTs.
Level of Evidence3 Laryngoscope, 2019

Table of contents

20-11-2019 –

Masthead

20-11-2019 –

The Structure of The Laryngoscope is Changing: A New Associate Editor and A New Section Editor

20-11-2019 –

Editorial

In‐Office Injection Pharyngoplasty for Velopharyngeal Insufficiency After Oropharyngeal Cancer Treatment

20-11-2019 – “Karla ODell, John Hubanks”

Journal Article

Intraoperative mapping and monitoring of sensory vagal fibers during vagal schwannoma resection

20-11-2019 – Catherine F. Sinclair, Maria J. Téllez, M. Angeles Sánchez Roldán, Mark Urken, Sedat Ulkatan

Case Reports

Vagal schwannomas are rare, benign tumors. Intermittent intraoperative neuromonitoring via selective stimulation of splayed motor fibers running on the schwannoma surface to elicit a compound muscle action potential has been previously reported as a method of preserving vagal motor fibers. In this case report, vagal sensory fibers are mapped and continuously monitored intraoperatively during high vagus schwannoma resection using the laryngeal adductor reflex (LAR). Mapping of nerve fibers on the schwannoma surface enabled identification of sensory fibers. Continuous LAR monitoring during schwannoma subcapsular microsurgical dissection enabled sensory (and motor) vagal fibers to be monitored in real time with excellent postoperative functional outcomes.
Laryngoscope, 129:E434–E436, 2019

The impact of repetitive hyperbaric exposure during SCUBA diving on cochlear implants

20-11-2019 – Justin M. Hintze, Lina Geyer, Conall W. Fitzgerald, Cristina Simoes Franklin, Fergal Glynn, Laura Viani, Peter Walshe

Journal Article

Objectives/Hypothesis
Complications during or after cochlear implantation are relatively rare. They occur more frequently in patients who partake in activities that can potentially lead to local trauma. No formal recommendations exist for participation in self‐contained underwater breathing apparatus (SCUBA) activities. We describe three patients with a combined five cochlear implants and extensive diving experience, the largest case series to date, and highlight some of the difficulties faced. We also review the literature on previously described SCUBA‐diving patients with cochlear implants.
Study Design
Retrospective case series and literature review.
Methods
A review of the known SCUBA divers in the National Hearing Implant and Research Centre in Ireland was conducted, and a review of the literature was carried out using PubMed and Google Scholar.
Results
Of the three SCUBA divers with cochlear implants, two required reimplantation, the first due to nonauditory stimulation, and the second due to extrusion of the electrode through the tympanic membrane following repetitive SCUBA dives. The third patient remains without complications after 80 dives.
Conclusions
Patients with cochlear implants can have complications relating to the implant itself, with device failure a theoretical risk. The cochleostomy can lead to perilymphatic extravasation, as well as inner ear barotrauma, decompression sickness, and formation of air bubbles along the electrode. A combination of deafness, vestibulopathy with abrupt perilymph leak, and loss of proprioception can lead to disorientation and blue dome syndrome. Based on our experience with cochlear implants in SCUBA divers, along with those reported in the literature, we recommend caution in patients with cochlear implants who SCUBA dive regularly and strict adherence to the recommended safety limits.
Level of Evidence: 4 129:2760–2764, 2019

Prognostic indicators of survival in sinonasal extranodal natural killer/T‐cell lymphoma

20-11-2019 – Antonios N. Varelas, Ashwin Ganti, Michael Eggerstedt, Bobby A. Tajudeen

Journal Article

Objectives
Extranodal natural killer/T‐cell lymphoma (ENKTL) is a highly aggressive tumor of the sinonasal tract associated with poor overall survival (OS). This study expands upon epidemiologic, prognostic, and treatment factors for OS and disease‐specific survival (DSS), incorporating newly accessible chemotherapy data.
Methods
Retrospective population‐based cohort study performed on cases of sinonasal ENKTL identified through the Surveillance, Epidemiology, and End Results database. Univariate Kaplan‐Meier analysis and subsequent multivariate Cox‐regression analysis were performed to evaluate prognostic and treatment variables for OS and DSS.
Results
Four hundred and sixty cases of sinonasal ENKTL were identified. Five‐year OS and DSS were 46% and 56%, respectively. On multivariate analysis, higher Ann Arbor stage was associated with worse OS (P < 0.001) and DSS (P < 0.001), whereas administration of radiotherapy was associated with improved OS (P < 0.001) and DSS (P = 0.001). Additionally, a higher age at diagnosis was associated with reduced OS (P = 0.024). Chemotherapy was associated with improved OS (P < .01) and DSS (P = .04) for Ann Arbor stage I disease. Surgery was not associated with improved survival.
Conclusion
This represents the first study to investigate the use of chemotherapy for the treatment of sinonasal ENKTL using population‐based analysis. Radiation therapy and chemotherapy significantly improve survival in all Ann Arbor stage patients and early‐stage patients, respectively. Early‐stage disease is significantly associated with improved survival. With no established treatment regimen for sinonasal ENKTL, these findings suggest combination chemoradiation is an effective therapy for prolonged survival, especially in early stages of disease.
Level of Evidence3 Laryngoscope, 129:2675–2680, 2019

Hemodynamic and pharmacokinetic analysis of oxymetazoline use during nasal surgery in children

20-11-2019 – Richard S. Cartabuke, Brian J. Anderson, Charles Elmaraghy, Julie Rice, Dmitry Tumin, Joseph D. Tobias

Journal Article

Objectives/Hypothesis
Oxymetazoline is an α‐adrenergic agonist that is commonly used as a topical hemostatic agent in the operating room during ear, nose, and throat surgery. There are limited data on oxymetazoline pharmacokinetics in children who undergo general anesthesia. We assessed the hemodynamic effects and systemic absorption of topically applied oxymetazoline in children undergoing various nasal procedures.
Study Design
Prospective trial.
Methods
Children ages 2 to 17 years undergoing functional endoscopic sinus surgery, turbinate resection, or adenoidectomy were enrolled. The surgeon placed oxymetazoline‐soaked pledgets (1.5 m
L of 0.05% solution) according to our usual clinical practice. Blood samples for oxymetazoline assay were drawn at 5, 10, 20, 45, 90, and 150 minutes, and hemodynamic data were recorded at 5‐minute intervals. Data analysis included mixed‐effects regression and population pharmacokinetic/pharmacodynamic modeling.
Results
The analysis included 27 patients, age 7 ± 4 years, who received between 2 and 12 pledgets (3–18 m
L) of oxymetazoline. Relative bioavailability compared to the spray formulation was 2.3 (95% confidence interval CI: 1.6‐3.2), with slow absorption from the mucosal surface (absorption half‐life 64 minutes; 95% CI: 44‐90). Mean arterial pressure did not increase with oxymetazoline instillation at the observed oxymetazoline serum concentrations (0.04‐7.6 μg/L).
Conclusions
Despite concerns regarding oxymetazoline administration to mucosal membranes, we found that hemodynamic changes were clinically negligible with our usual clinical use of pledgets soaked in oxymetazoline. Compared to data on oxymetazoline in spray formulation, bioavailability was increased twofold with pledgets, but systemic absorption was very slow, contributing to low serum concentrations and limited hemodynamic effects.
Level of Evidence1b. Laryngoscope, 129:2775–2781, 2019

Thyroid cartilage compression causing stroke

20-11-2019 – William E. Karle, Maria C. Buniel, Helmi L. Lutsep, Bronwyn E. Hamilton, Gary M. Nesbit, Joshua S. Schindler

Case Reports

We describe the diagnostic workup and surgical treatment of a patient presenting with the unique case of vertebral artery (VA) occlusion subsequent to head flexion leading to compression of an aberrant VA by the ipsilateral superior cornu of the thyroid cartilage. Imaging revealed ischemic infarcts as well as the presence of an aberrant right VA, which was compressed by the ipsilateral superior cornu of the thyroid cartilage upon neck flexion. The patient was managed with laryngoplasty involving removal of the right superior cornu of the thyroid cartilage. Laryngoscope, 129:E445–E448, 2019

Office‐based transnasal esophagoscopy biopsies for histological diagnosis of head and neck patients

20-11-2019 – Hassan Mohammed, Marcus Del Pero, Matthew Coates, Liam Masterson, Peter Tassone, Stuart Burrows, Ramez Nassif

Objectives/Hypothesis
To present yield of transnasal esophagoscopy (TNE) biopsies of upper aerodigestive tract (UADT) lesions and define the role of TNE as a safe alternative to rigid endoscopy.
Study Design
Retrospective case series.
Methods
All patients who underwent TNE‐guided biopsies attempted over a 2‐year period were included. Patients were identified using coding records and outpatient diaries. Demographic data were recorded as well as the histological diagnosis and additional histological diagnostic procedures.
Results
During the observation period, 134 TNE‐guided procedures were attempted. The procedure could not be completed in 19 patients. There were 102/115 (89%) patients who did not require further interventions for histological diagnosis of the tumor. The most common biopsied area was the larynx (53), followed by the tongue base (29). The most common malignancy was invasive squamous cell carcinoma in 42/115 (36.5%).
Conclusions
The work presented in this article strongly suggests that TNE‐guided biopsy is a valuable diagnostic tool for patients suspected of having carcinoma of the UADT.
Level of Evidence4 Laryngoscope, 129:2721–2726, 2019

Risk Factors for Multiple Hemorrhages Following Tonsil Surgery in Children

20-11-2019 – Mallory McKeon, Elliana Kirsh, Kosuke Kawai, David Roberson, Karen Watters

Objectives/Hypothesis
Although much is known about the incidence and risk factors for hemorrhage after tonsil surgery, the incidence and factors related to multiple episodes of hemorrhage are not well examined. Our objective was to identify risk factors that may contribute to multiple hemorrhages following tonsil surgery in children.
Study Design
Retrospective chart review.
Methods
A retrospective review was conducted of pediatric patients who experienced one or more hemorrhages following tonsillectomy/tonsillotomy, with or without adenoidectomy, between 2010 and 2016 at a single, tertiary‐care hospital. Risk factors for multiple hemorrhages were examined using a multivariable logistic regression model.
Results
Among the 11,140 patients who underwent tonsil surgery, 452 patients experienced one or more hemorrhages; 32 of these had multiple episodes of hemorrhage (7.1% of all patients with bleeds/0.3% of all patients). Older age (≥12 years: adjusted odds ratio OR: 3.13; 95% confidence interval CI: 1.47‐6.68) and high body mass index for age (≥85th percentile: adjusted OR: 2.26; 95% CI: 1.06‐4.85) were significantly associated with an increased risk of multiple hemorrhages in the multivariable model. Medical comorbidities, indications for surgery, surgical technique, intraoperative blood loss, and perioperative medications were not associated with multiple episodes of bleeding.
Conclusions
Multiple hemorrhages after tonsillectomy/tonsillotomy are uncommon. The risk of a second PTH after an initial episode is 7.1%, almost double the risk of a bleed after the initial tonsil surgery. Age > 12 years and high BMI for age may be associated with increased risk of rebleeding. After an initial bleed, increased surveillance may be warranted, particularly for patients with risk factors.
Level of Evidence4 Laryngoscope, 129:2765–2770, 2019

Wound Complications in Head and Neck Squamous Cell Carcinomas After Anti–PD‐1 Therapy

20-11-2019 – Victoria Hwang, Eduardo Mendez, Laura Q. M. Chow, Neal David Futran, Peter Andersen, Ryan Li, Vasu Divi, Cristina P. Rodriguez

Case Reports

Immune checkpoint inhibitors have demonstrated activity in recurrent/metastatic head and neck squamous cell cancer, but less is known regarding their long‐term sequelae. We describe four patients who, after complete responses to anti–PD‐1 therapy, developed complications requiring surgical intervention. Patient 1 is a 57‐year‐old female whose marked tumor regression exposed some mandibular hardware. Patient 2 is a 39‐year‐old male who developed an ulcerated buccal lesion with exposed mandible. Patient 3 is a 66‐year‐old male with craniofacial osteoradionecrosis. Patient 4 is a 71‐year‐old male who developed an exposed and fractured mandible. All patients successfully underwent surgical intervention and remain disease free. Laryngoscope, 129:E428–E433, 2019

Basaloid nasopharyngeal carcinoma: A population‐based analysis of a rare tumor

20-11-2019 – Aykut A. Unsal, J. Renee Booth, Nicholas A. Rossi, J. Kenneth Byrd, Stilianos E. Kountakis

Objectives
Basaloid nasopharyngeal carcinoma (BNPC) is an extremely rare malignancy with a paucity of cases reported in the literature. This analysis represents the largest cohort of BNPC to date.
Study Design
Retrospective population‐based analysis.
Methods
The Surveillance, Epidemiology, and End Results registry from 2001 to 2015 was utilized to extract a total of 82 cases of BNPC. Data were analyzed for incidence trends, demographic, and tumor characteristics, as well as potential outcome prognosticators.
Results
White male patients between the ages of 40 to 79 years were most commonly affected. The incidence was measured at 0.06 per 100 thousand people. The majority of tumors were considered high grade (grade III/IV; 92.2%). At presentation, patients were most commonly advanced stage (American Joint Committee on Cancer AJCC stage IV) at 29.3%, followed by AJCC stages II and III (20.7%, respectively). T2 tumors were most common at 28.8%. Cervical node involvement and distant metastasis were measured at 53.7% and 10.4%, respectively. One‐year, 5‐year, and 10‐year disease‐specific survival was 87.7%, 60.7%, and 29.8%, respectively. No prognostic factors were identified in this study.
Conclusion
Basaloid squamous cell carcinoma represents a histologic subtype of nasopharyngeal carcinoma with excellent short‐term outcomes but poor survival at 10 years when compared to conventional squamous cell carcinomas.
Level of Evidence
NA Laryngoscope, 129:2727–2732, 2019

Can anatomical assessment of hypopharyngolarynx in awake patients predict obstructive sleep apnea?

20-11-2019 – Adrien Bolzer, Bruno Toussaint, Cécile Rumeau, Patrice Gallet, Roger Jankowski, Duc Trung Nguyen

Journal Article

Objectives/Hypothesis
To assess the relationships between laryngeal and hypopharyngeal morphology and obstructive sleep apnea‐hypopnea syndrome (OSAHS) in awake patients.
Study Design
Prospective study.
Methods
Awake flexible fiberoptic laryngoscopy and sleep studies were performed in 80 patients for snoring or OSAHS suspicion. Endoscopic videos were reviewed by two examiners to assess morphological characteristics of hypopharynx and larynx using a standardized examination of appearance, shape and position of epiglottis, shape of retropharyngeal‐epiglottic aerospace (RPEA), modified Cormack‐Lehane score, and length ratios of the hypopharynx and epiglottis. The multivariate logistic regression model was used to assess independent predictors of moderate/severe OSAHS.
Results
The interrater agreements were moderate for epiglottis appearance (κ = 0.52), epiglottis form (κ = 0.66), and epiglottis position (κ = 0.49), but fair for the shape of RPEA (κ = 0.26) and modified Cormack‐Lehane scoring (κ = 0.38). The presence of a mega‐epiglottis was significantly correlated with the severity of OSAHS (P < .05). By multivariate logistic regression analysis, independent predictors of moderate/severe obstructive sleep apnea were mega‐epiglottis (adjusted odds ratio a
OR: = 4.78, 95% confidence interval CI: 1.23‐18.56, P = .024), modified Cormack‐Lehane score of 2 (a
OR: 15.3, 95% CI: 1.8‐130.3, P = .012), or modified Cormack‐Lehane score of 3 (a
OR: 10.03, 95% CI: 1.3‐78.2, P = .03) and aging (a
OR = 1.07, 95% CI: 1.01‐1.14, P = .025).
Conclusions
Routine flexible fiberoptic laryngoscopy performed by otorhinolaryngologists in awake patients may help to detect some predictors of OSAHS such as presence of mega‐epiglottis, and modified Cormack‐Lehane score of 2 or more. Investigation of sleep disorders should be proposed in these patients.
Level of Evidence2 Laryngoscope, 129:2782–2788, 2019

Spare roof technique in reduction rhinoplasty: Prospective study of the first one hundred patients

20-11-2019 – Mariline Santos, Ângela Reis Rego, Miguel Coutinho, Cecília Almeida e Sousa, Miguel Gonçalves Ferreira

Objective
Assess the aesthetic and functional outcomes of the first 100 patients who underwent reduction rhinoplasty with the spare roof technique (SRT).
Methods
Prospective, interventional, and longitudinal study performed on consecutive patients undergoing primary rhinoplasty by SRT. All the surgical procedures were performed by the surgeon who first described this technique. The validated Portuguese version of the Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty was used. Patients completed the questionnaire presurgery and again 3 and 12 months postsurgery. In addition, a visual analogue scale (VAS) was used to score nasal patency for both sides.
Results
The study population included 100 Caucasian Mediterranean patients (33 males; 67 females). Mean age at surgery was 32.8 years. Analysis of the preoperative and postoperative mean aesthetic VAS scores showed a significant improvement from 3.67 to 8.1 (P < 0.001) and 8.44 (P < 0.001), respectively, 3 and 12 months postsurgery. Analysis of the five aesthetic Likert scale questions all showed a highly significant improvement after rhinoplasty. The mean preoperative aesthetic sum score was 13.9, which improved to 8.26 and 7.08, respectively, 3 and 12 months postsurgery (P < 0.001), indicating a significant improvement of subjective body image in relation to nasal appearance. Analysis of the preoperative and postoperative mean functional VAS score showed a significant improvement on both sides.
Conclusion
This prospective statistical study confirms that SRT significantly improved patient quality of life regarding nose function and appearance. It is a reliable technique that can help deliver consistently good results in reduction rhinoplasty in Caucasian patients with dorsal hump seeking rhinoplasty.
Level of Evidence2 Laryngoscope, 129:2702–2706, 2019

“Esophageal pepsin and proton pump synthesis in barretts esophagus and esophageal adenocarcinoma”

20-11-2019 – Tina L. Samuels, Kenneth W. Altman, Jon C. Gould, Tammy Kindel, Matthew Bosler, Alexander MacKinnon, Catherine E. Hagen, Nikki Johnston

Journal Article

Objectives/Hypothesis
Gastroesophageal reflux disease and associated metaplasia of the esophagus (Barretts esophagus BE) are primary risk factors for esophageal adenocarcinoma (EAC). Widespread use of acid suppression medications has failed to stem the rise of EAC, suggesting that nonacid reflux may underlie its pathophysiology. Pepsin is a tumor promoter in the larynx and has been implicated in esophageal carcinogenesis. Herein, specimens from the esophageal cancer spectrum were tested for pepsin presence. Pepsin‐induced carcinogenic changes were assayed in an esophageal cell culture model.
Study Design
Laboratory analysis.
Methods
Pepsin was assayed in reflux and cancer free esophagi, BE, EAC, and esophageal cancer lacking association with reflux (squamous cell carcinoma SCC). Refluxed or locally synthesized pepsin was assayed by Western blot. Local synthesis of pepsin and proton pumps was assayed via reverse transcription–polymerase chain reaction. The effect of pepsin on BE and EAC markers was investigated via enzyme‐linked immunosorbent assay and quantitative polymerase chain reaction in human esophageal epithelial cells treated with pepsin or control diluent.
Results
Pepsinogen and proton pump m
RNA were observed in BE (3/5) and EAC (4/4) samples, but not in normal adjacent specimens, SCC (0/2), or reflux and cancer‐free esophagi. Chronic pepsin treatment (0.1–1 mg/m
L, 4 weeks) of human esophageal cells in vitro induced BE and EAC markers interleukin 8 and KRT8 and depleted normal esophageal marker KRT10 (P < .05) expression.
Conclusions
Local synthesis of pepsin and proton pumps in BE and EAC is not uncommon. Absence of these molecules in normal (noncancer) esophagi, SCC, and in vitro data support a role for pepsin in reflux‐attributed carcinogenic changes in the esophagus.
Level of Evidence
NA Laryngoscope, 129:2687–2695, 2019

Sex distribution and sex data handling in published otolaryngology research

20-11-2019 – Jennifer J. Liang, Alexandra Belcastro, Jessica Levi

Journal Article

Objectives/Hypothesis
To characterize the sex distribution and sex data handling in published otolaryngology research.
Study Design
Published research data analysis.
Methods
The total number of male and female participants, study characteristics, and sex data handling were abstracted from all original studies containing human participants published in five major otolaryngology journals from January 1, 2016 to December 31, 2016 and January 1, 2006 to December 31, 2006.
Results
Of the 1,128 studies from 2016 included in the analysis, 88.5% specified the sex of participants. There were 3,605,636 (42.1%) men and 4,515,508 (52.8%) women, with 429,006 (5.0%) participants unspecified. However, the average proportions of male and female participants (wherein studies are weighted the same, regardless of number of participants) were 0.579 and 0.421, respectively. Studies from the United States had a significantly higher proportion of women than studies from outside the United States. Subspecialties varied significantly in proportions. Average sex proportions in 2016 remained similar to those in 2006. For all studies, fewer than 40% of studies used any sex data for reporting of outcomes, for any sex‐related analysis, or for discussion of results.
Conclusions
There was a higher average proportion of male participants than female. Studies originating in the United States included a greater number of female participants than those originating elsewhere, a possible result of explicit sex‐inclusion policies governing research in the United States. Inclusion of women did not changed from 2006 to 2016, but analysis of sex data improved. Improvement of reporting, analysis, and discussion with regard to sex would benefit otolaryngology research and improve treatment for both sexes.
Level of Evidence
NA Laryngoscope, 129:E420–E427, 2019

Polysomnography outcomes in children with small tonsils undergoing drug‐induced sleep endoscopy–directed surgery

20-11-2019 – Craig Miller, Erin Kirkham, Cheng‐Cheng Ma, Natalia Filipek, David L. Horn, Kaalan Johnson, Maida L. Chen, Sanjay R. Parikh

Objectives/Hypothesis
The optimal surgical treatment to improve sleep apnea in children with small tonsils is not known. Drug‐induced sleep endoscopy (DISE) may be useful in selecting effective surgical procedures for this patient population. This study compared polysomnography (PSG) measures before and after DISE‐directed surgery in children with small tonsils. We hypothesize that DISE‐directed surgery improves PSG measures in children with small tonsils. We also aimed to identify the most common surgery performed in this population.
Study Design
Retrospective chart review.
Methods
A retrospective review was performed of subjects who underwent DISE at a single pediatric tertiary care center over a 6‐year period. Inclusion criteria were 1+ tonsils and PSG performed before and after DISE‐directed surgery. Exclusion criteria were previous tonsillectomy and tonsils score 2+ or greater. Pre‐ and postoperative PSG parameters were compared using paired t tests.
Results
Average age was 7 ± 4 years old at the time of surgery. The most common DISE‐directed intervention was supraglottoplasty (n = 23). DISE‐directed surgery significantly improved mean apnea‐hypopnea index (AHI) from 14.4 to 8.0 (P = .02). Although improvements were seen in mean obstructive AHI (12.5 to 5.5), O2 nadir (87.0 to 88.3), and ODI (10.6 to 5.8), these measures did not reach statistical significance.
Conclusions
DISE‐directed surgery significantly improves AHI in children with small tonsils. The most common intervention performed on these children was supraglottoplasty. Interestingly, adenotonsillectomy was rarely performed in this cohort. Additionally, supraglottic collapse, prompting supraglottoplasty, is difficult to accurately assess in an awake child, supporting use of a DISE‐directed approach in this patient population.
Level of Evidence4 Laryngoscope, 129:2771–2774, 2019

Septal floor rotational flap pedicled on ethmoidal arteries for endoscopic skull base reconstruction

20-11-2019 – Song Mao, Mingxian Li, Dawei Li, Hai Lin, Haibo Ye, Ru Tang, Kaiming Su, Weitian Zhang

Journal Article

Object
Expanded endonasal approaches have dramatically changed how skull base surgery is performed, and nasoseptal flap (NSF) has significantly improved skull base reconstruction. However, challenges remain when the pterygopalatine artery is invaded by tumors; when it must be sacrificed to approach the lateral sphenoidal recess; when late‐occurrence leak occurs in the sella after transsphenoidal surgery; and also when the leak is on the posterior wall of the frontal sinus, which is too distant for NSF to reach. This article describes a septal floor rotational flap pedicled on ethmoidal arteries for endoscopic skull base reconstruction in certain cases.
Study Design
Case series.
Method
In this article, we retrospectively review a series of 19 patients who underwent skull base reconstruction with a septal floor rotational flap pedicled on the ethmoidal arteries.
Result
All 19 flaps, including the anterior and posterior artery pedicled flaps, survived without significant complications, and no postoperative cerebrospinal fluid leak occurred during follow‐up.
Conclusion
Ethmoidal arteries pedicled septal floor rotational flap, with their strong blood supply and large coverage area, are ideal replacements for NSF. These flaps are qualified in locations ranging from the posterior wall of the frontal sinus to the lateral sphenoidal recess and in cases ranging from tumor invading the pterygopalatine fossa to sellar late‐occurred leak after transsphenoidal surgery.
Level of Evidence4 Laryngoscope, 129:2696–2701, 2019

Readmissions following ambulatory pediatric endoscopic sinus surgery

20-11-2019 – Mallory McKeon, Genevieve Medina, Kosuke Kawai, Michael Cunningham, Eelam Adil

Journal Article

Objectives/Hypothesis
Endoscopic sinus surgery (ESS) is indicated in select pediatric patients with medically refractory sinus disease. Our objectives were to examine indications and rates of readmission following ambulatory pediatric ESS and identify specific subgroups that may benefit from inpatient admission.
Study Design
Retrospective database review.
Methods
The Pediatric Health Information Systems (PHIS) 2004–2016 database was retrospectively reviewed for patients age <18 years who underwent ambulatory ESS between January 2011 and December 2016 and were readmitted within 30 days postoperatively. Data regarding demographics, extent of surgery, comorbidities, adjunctive procedures, and cost were collected. A multivariable mixed‐effects logistic regression model was employed for analysis.
Results
We identified 3,669 unique pediatric ESS cases with 128 readmissions within 30 days (3.5%; 95% confidence interval CI: 2.9%‐4.1%). Median cost of readmission was $980 (mean, $5,890; standard deviation, $13,421). The most common indication for readmission was epistaxis (17.2%), followed by nausea/abdominal pain (14.1%). Respiratory infection (13.3%) and sinusitis (10.2%) presented a combined readmission rate exceeding that of epistaxis alone. Multivariable analysis indicated age <3 years (odds ratio OR: 3.41, 95% CI: 1.96‐5.93) and a prior diagnosis of asthma (OR: 2.88, 95% CI: 1.99‐4.18) or cystic fibrosis (OR: 1.57, 95% CI: 1.00‐2.44) significantly increased the risk of readmission. Extent of ESS and simultaneous adenoidectomy, septoplasty, or turbinate reduction had no significant impact on readmission rates.
Conclusions
ESS is a relatively safe outpatient surgical procedure in pediatric patients, with an overall readmission rate of 3.5%. Clinicians should consider careful preoperative evaluation of very young patients and those with cystic fibrosis or asthma to optimize perioperative management and determine if postoperative admission is warranted, given their significantly higher readmission rates.
Level of Evidence
NALaryngoscope, 129:2681–2686, 2019

Tonsil size and outcome of uvulopalatopharyngoplasty with tonsillectomy in obstructive sleep apnea

20-11-2019 – Samuel Tschopp, Kurt Tschopp

Journal Article

Objectives/Hypothesis
To investigate the relationship of tonsil volume and grade on outcomes of uvulopalatopharyngoplasty (UPPP) with tonsillectomy in patients with obstructive sleep apnea (OSA).
Study Design
Retrospective cohort analysis.
Methods
Data of 70 consecutive patients undergoing UPPP with tonsillectomy between 2015 and 2018 were analyzed. Patients with an apnea‐hypopnea index (AHI) <10/hr or concomitant surgery other than nasal surgery were excluded. Tonsil volume was measured intraoperatively. Preoperatively and 3 months after surgery we assessed the AHI using respiratory polygraphy, daytime sleepiness using the Epworth Sleepiness Scale (ESS), and a visual analog scale for the snoring index (SI).
Results
Tonsil grade and volume both showed a significant correlation with preoperative AHI. Postoperative AHI was not significantly different between grades and volume. The AHI reduction after surgery increased significantly with larger volume and higher tonsil grade. For all grades, the postoperative ESS was significantly reduced compared to the preoperative value, but was not significantly correlated with tonsil volume. Preoperative and postoperative SI was not significantly correlated between tonsil grade or volume. In all grades, SI was significantly reduced after surgery.
Conclusions
In our study, we found that large tonsils are responsible for higher preoperative AHI values, and their removal leads to greater reduction of initial AHI. However, the postoperative effect on daytime sleepiness and snoring reduction is not significantly correlated with tonsil size and volume, indicating that these parameters are mainly influenced by other factors. The knowledge of the significance of tonsil size and volume is important for ear, nose, and throat physicians when counseling OSA patients.
Level of Evidence2c Laryngoscope, 129:E449–E454, 2019

Patient‐defined duration of benefit from juvederm (hyaluronic acid) used in injection laryngoplasty

20-11-2019 – J. Tyler Bertroche, Megan Radder, Dorina Kallogjeri, Randal C. Paniello, Joseph P. Bradley

Objectives/Hypothesis
Injection laryngoplasty has become valuable in treating laryngologic disorders including vocal cord atrophy, paralysis, and paresis. Although materials such as carboxymethylcellulose and calcium hydroxylapatite are Food and Drug Administration (FDA) approved, they are not without limitations. Juvederm (hyaluronic acid) is an alternative treatment that is not FDA approved. Although studies have examined Juvederms longevity in cutaneous injections, there are limited data examining durability of Juvederm used in laryngoplasty. We aimed to determine the longevity and effectiveness of Juvederm used in injection laryngoplasty.
Study Design
Retrospective cohort study.
Methods
Subjects who underwent injection laryngoplasty using Juvederm were reviewed. Longevity was defined as the time between injection and the date that a patient first noted subjective deterioration of their voice. All subjects were subsequently followed using videostroboscopy to evaluate for Juvederm resorption. Longevity was analyzed using a Kaplan‐Meier survival model, and effectiveness of laryngoplasty was determined using the Voice‐Related Quality of Life index scores and analyzed using a Wilcoxon signed ranks test.
Results
Fifty‐nine subjects met inclusion criteria and underwent Juvederm injection laryngoplasty. Kaplan‐Meier survival analysis revealed a mean longevity of 10.6 months (95% confidence interval: 9.1‐12.0 months). Wilcoxon signed ranks analysis of the pre‐ and postinjection Voice Related Quality of Life (VRQOL) scores revealed improvement, with a mean preinjection VRQOL of 49.2 (standard deviation SD = 25.8) and mean postinjection VRQOL of 68.2 (SD = 27.5) (P < .001).
Conclusions
Injection laryngoplasty using Juvederm is an effective treatment for vocal cord atrophy, paralysis, and paresis. Knowledge of the patient‐defined duration of benefit following laryngoplasty using Juvederm plays an important role in counseling patients as well as in the planning of future interventions.
Level of Evidence4 Laryngoscope, 129:2744–2747, 2019

The benefit of trans‐attic endoscopic control of ossicular prosthesis after cholesteatoma surgery

20-11-2019 – Hassan Haidar, Zaid Abu Rajab Altamimi, Aisha Larem, Waqar Aslam, Ali Elsaadi, Hassanin Abdulkarim, Emad Al Duhirat, Ashraf Nabeel Mahmood, Abdulsalam Alqahtani

Objective
To show the efficiency of using transmastoid atticotomy (TMA) endoscopy on the outcome of ossiculoplasty in patients with cholesteatoma.
TMA is often performed as part of the surgical management of patients with middle ear cholesteatoma extending to the epitympanum. TMA can also be used as an access for endoscopic view to confirm the right alignment and stability of the ossicular prosthesis because the reconstruction of the tympanic membrane will obscure the visualization of the prosthesis.
Methods
A retrospective study was done at a tertiary referral institute, including 133 ears with cholesteatoma that underwent canal wall‐up tympanomastoidectomy (CWU) with ossicular reconstruction using titanium prosthesis between August 2013 and August 2015. Post packing of the ear canal and position, stability, and axis of the prosthesis were checked using endoscope positioned in the attic through TMA. A postoperative pure‐tone average air–bone gap (ABG) of 20 d
B or less was considered as a successful hearing result. Results are compared with historical control groups.
Results
Of the 133 ears, 88 patients underwent reconstruction with partial ossicular replacement prosthesis (PORP), whereas the rest (45 patients) had total ossicular replacement prosthesis (TORP). A postoperative ABG ≤ 20 d
B was obtained in 77.4% of all the patients (79.5% for PORP; 73.3% for TORP).
Conclusion
Endoscopic assessment of the ossicular prosthesis via the attic, after repositioning of the tympanomeatal flap and packing the ear canal, decreases the risk of immediate ossiculoplasty failure and improves the functional outcome after ossicular chain reconstruction in cholesteatoma surgery.
Level of Evidence4 Laryngoscope, 129:2754–2759, 2019

A rare invasion route for differentiated thyroid carcinoma: The tracheoesophageal common party wall

20-11-2019 – John R. Sims, Lauren E. Yue, Rebecca A. Ho, Azita S. Khorsandi, Margaret Brandwein‐Weber, Mark L. Urken

Case Reports

Thyroid carcinoma can infiltrate the aerodigestive tract. Invasion via the common party wall of the tracheoesophageal groove (TEG) is rare. A review of patients with thyroid cancer invading the aerodigestive tract was performed. We describe three cases of invasive thyroid cancer presenting 4 to 6 years after the initial thyroidectomy. Original pathology showed positive margins near the recurrent laryngeal nerve and TEG. A partial tracheal resection with a stair‐step reconstruction was performed in one case; the other cases required total laryngopharyngectomy. Surgeons should be prepared to perform oncologically complete resections at the primary surgery to avoid potentially significant clinical consequences requiring aggressive surgery. Laryngoscope, 129:E455–E459, 2019

Measuring Flap Oxygen Using Electron Paramagnetic Resonance Oximetry

20-11-2019 – Marc A. Polacco, Huagang Hou, Periannan Kuppusamy, Eunice Y. Chen

Journal Article

Objectives/Hypothesis
To determine if electron paramagnetic resonance (EPR) oximetry is a viable technology to aid in flap monitoring.
Study Design
Prospective cohort.
Methods
This was a cohort study assessing accuracy and speed of EPR oximetry in detecting ischemia of a saphenous artery–based flap in a rat model, using transcutaneous oximetry as a control. Measurements were obtained under both resting and ischemic conditions for nine Sprague Dawley rats (18 flaps), for 3 postoperative days following flap elevation.
Results
The mean partial pressure of oxygen prior to tourniquet application was 66.9 ± 8.9 mm Hg with EPR oximetry and 64.7 ± 5.2 mm Hg with transcutaneous oximetry (P = .45). Mean partial pressures of oxygen during tourniquet application were 8.9 ± 3.2 mm Hg and 8.5 ± 2.9 mm Hg for EPR oximetry and transcutaneous oximetry, respectively (P = .48), and 67.2 ± 6.9 mm Hg and 65.3 ± 6.1 mm Hg after tourniquet release for EPR oximetry and transcutaneous oximetry, respectively (P = .44). The mean ischemia detection time of EPR oximetry was 49 ± 21 seconds.
Conclusions
Offering timely, accurate, and noninvasive tissue oxygen measurements, EPR oximetry is a promising adjunct in flap monitoring.
Level of Evidence
NA Laryngoscope, 129:E415–E419, 2019

Sonolocation during submandibular sialolithotomy

20-11-2019 – Nahir J. Romero, Andrew Fuson, Christopher R. Kieliszak, Arjun S. Joshi

Journal Article

Objectives/Hypothesis
Ultrasound is a proven tool for diagnostic and therapeutic purposes for treatment of salivary gland pathology. It is also useful for localization of calculi during submandibular gland transoral sialolithotomy when calculi cannot easily be palpated. Our objective was to determine the efficacy of sialolith localization using ultrasound during submandibular gland sialolithotomy.
Study Design
Retrospective case series.
Methods
A study performed utilizing data compiled from 2009 through 2016 in a tertiary academic center. Treatment was completed in 164 patients with sialadenitis and sialolithiasis by submandibular gland transoral sialolithotomy in either the office (81%) or the operating room (19%). Ultrasound was used for localization of sialoliths during submandibular gland sialolithotomy. Main treatment outcomes studied were success of the procedure, complications, and follow‐up.
Results
Successful sialolithotomy was performed in (147 patients) 90% of cases. Complications were minimal and included stricture formation, which occurred in 3% (five patients) of cases, followed by ranula formation in 1.8% (three patients) of cases. There were no incidences of lingual nerve injury.
Conclusions
Ultrasound can be used effectively for precise sialolith localization intraoperatively.
Level of Evidence4Laryngoscope, 129:2716–2720, 2019

Objectively measuring social attention of thyroid neck scars and transoral surgery using eye tracking

20-11-2019 – Michelle C. Juarez, Lisa Ishii, Jason C. Nellis, Kristin Bater, Pauline P. Huynh, Nicholas Fung, Halley Darrach, Jonathon O. Russell, Masaru Ishii

Journal Article

Objective
Measure the social attention of thyroid neck scars and transoral surgery using eye tracking.
Methods
Observers viewed images of patients with thyroid neck scars, control patients with no scars, and patients who underwent transoral thyroidectomy as an eye‐tracking monitor recorded their eye movements. Hotellings multivariate analysis, followed by planned posthypothesis testing, were used to compare fixation times for the central triangle (CT), peripheral face, and neck between the three groups. To assess if these gaze patterns would normalize with transoral surgery, a two‐sample t test was done to assess for differences in neck fixations between control and transoral patients and between transoral and traditional thyroidectomy.
Results
One hundred and thirty participants completed the eye‐tracking experiment (mean age 24.3 years, 65 females). Observers directed the majority of their attention to the CT in both control and scar patients. Observers paid more attention to the neck (103.72 ms, P < .0001, 95% confidence interval CI 55, 152 ms) and less to the peripheral face (115.50 ms, P = .01, 95% CI 19, 211 ms) in patients with neck scars than in control patients. Furthermore, transoral surgery eliminated this attentional distraction wherein there was no difference in the fixation time to the neck (−39.198 ms P = .16, 95% CI −93.978, 15.5816 ms) between controls and those who underwent transoral surgery.
Conclusion
Observers directed their gaze away from the face and toward the neck in patients with thyroid neck scars. Furthermore, this distraction was eliminated with tranoral surgery. These findings shed light onto the altered observer perceptions of patients with thyroid neck scars.
Level of Evidence
NA Laryngoscope, 129:2789–2794, 2019

Otolaryngology boot camps: Current landscape and future directions

20-11-2019 – Kelly M. Dean, Christine E. DeMason, Sukgi S. Choi, Kelly M. Malloy, Sonya Malekzadeh

Objectives
Simulation‐based boot camps have gained popularity over the past few years, with some surgical specialties implementing mandatory national boot camps. However, there is no consensus in otolaryngology on boot camp timing, learner level, or curriculum. The purpose of this study is to examine the current landscape and gather opinions regarding future curriculum and standardization of boot camps in otolaryngology.
Methods
A survey was developed to examine current resident participation and boot camp content while also seeking opinions regarding improving boot camp enrollment and standardizing curriculum. A cross‐sectional survey of all otolaryngology residency program directors in the United States and Puerto Rico was performed via Survey
Monkey. Responses were collected anonymously, and results were analyzed by descriptive statistical analysis.
Results
Of the 45% (48 of 106) who responded, 76.6% reported their residents participate in boot camps. The most common skills taught were basic suturing and airway management skills. The majority (95%) was likely to send residents to a local boot camp, with 56% favoring early postgraduate year (PGY)‐1 participation and 42% favoring a 1‐day boot camp. Subsidized expenses, improved regional access, and supplementary boot camp information would help the program director in their decision to send residents to boot camp. Only 32% felt boot camps should be standardized, and 27% felt they should be mandatory.
Conclusion
Many otolaryngology residency programs participate in boot camps. Additional data on the benefits of boot camps, improved access, and reduced financial burden may improve participation. Further discussion of ideal timing, PGY level, and standardized curriculum should occur in conjunction with the otolaryngology academic societies and oversight from accreditation and certifying bodies.
Level of Evidence
NA Laryngoscope, 129:2707–2712, 2019

Improving decision making in larynx cancer by developing a decision aid: A mixed methods approach

20-11-2019 – Japke F. Petersen, Adriana Berlanga, Martijn M. Stuiver, Olga Hamming‐Vrieze, Frank Hoebers, Philippe Lambin, Michiel W.M. Brekel

Objective
Patients diagnosed with advanced larynx cancer face a decisional process in which they can choose between radiotherapy, chemoradiotherapy, or a total laryngectomy with adjuvant radiotherapy. Clinicians do not always agree on the best clinical treatment, making the decisional process for patients a complex problem.
Methods
Guided by the International Patient Decision Aid (PDA) Standards, we followed three developmental phases for which we held semi‐structured in‐depth interviews with patients and physicians, thinking‐out‐loud sessions, and a study‐specific questionnaire. Audio‐recorded interviews were verbatim transcribed, thematically coded, and analyzed. Phase 1 consisted of an evaluation of the decisional needs and the regular counseling process; phase 2 tested the comprehensibility and usability of the PDA; and phase 3 beta tested the feasibility of the PDA.
Results
Patients and doctors agreed on the need for development of a PDA. Major revisions were conducted after phase 1 to improve the readability and replace the majority of text with video animations. Patients and physicians considered the PDA to be a major improvement to the current counseling process.
Conclusion
This study describes the development of a comprehensible and easy‐to‐use online patient decision aid for advanced larynx cancer, which was found satisfactory by patients and physicians (available on www.treatmentchoice.info). The outcome of the interviews underscores the need for better patient counseling. The feasibility and satisfaction among newly diagnosed patients as well as doctors will need to be proven. To this end, we started a multicenter trial evaluating the PDA in clinical practice (Clinical
Trials.gov Identifier: NCT03292341).
Level of Evidence
NA Laryngoscope, 129:2733–2739, 2019

Burden of treatment: Reported outcomes in a head and neck cancer survivorship clinic

20-11-2019 – Marci Lee Nilsen, Leila J. Mady, Jacob Hodges, Tamara Wasserman‐Wincko, Jonas T. Johnson

Objective
With the intensification and utilization of multimodal treatment, acute toxicities have increased; however, the frequency of treatment sequelae in long‐term head and neck cancer (HNC) survivors are poorly described. The purpose of this analysis was to determine the prevalence and predictors of patient‐reported late and long‐term treatment‐related sequelae in HNC survivors.
Methods
We performed a cross‐sectional analysis of patient‐reported outcomes from 228 survivors attending a multidisciplinary HNC survivorship clinic. The primary outcomes comprised quality of life (QOL), symptoms of anxiety and depression, and swallowing dysfunction.
Results
Male gender, tumor sites in the oropharynx and larynx, longer time since treatment, and treatment with surgery alone were associated with higher physical QOL (P < .05). Male gender, longer time since treatment, and treatment with surgery alone were associated with higher social‐emotional QOL (P < .05). A reduction in anxiety symptoms and a higher QOL were related to longer time since treatment; however, a reduction in swallowing dysfunction symptoms was only related to longer time since treatment until approximately 6 years. After 6 years, survivors reported worse swallowing dysfunction (P < .05). One hundred thirty‐two survivors (56%) reported at least three treatment‐related effects that impacted their daily life. Finally, advanced stage disease at diagnosis (stage III–IV) was also associated with severe swallowing dysfunction (P = .004).
Conclusion
These data indicate the remarkable prevalence of treatment‐related effects in HNC survivors. These results highlight the need for de‐intensification of therapies, where appropriate, and for a better understanding of pathophysiology and new approaches to mitigating treatment effects.
Level of Evidence4 Laryngoscope, 129:E437–E444, 2019

Feasibility and tolerability of measuring translaryngeal pressure during exercise

20-11-2019 – Zoe Fretheim‐Kelly, Thomas Halvorsen, John‐Helge Heimdal, Eric Strand, Maria Vollsæter, Hege Clemm, Ola Roksund

Objectives/Hypothesis
To determine if simultaneous tracheal and supraglottic pressure measurement performed during a continuous laryngoscopy exercise (CLE) test is possible, tolerable, and feasible, and if so, whether measurements can be used to determined airflow resistance over the larynx, thus providing an objective outcome measure for the CLE test, the gold standard for diagnosing exercise‐induced laryngeal obstruction.
Study Design
Explorative descriptive clinical study.
Methods
A CLE test was performed with the addition of two pressure sensors (Mikro‐Cath 825‐0101; Millar, Houston, TX) placed at the epiglottic tip and at the fifth tracheal ring. To place sensors, laryngeal anesthesia and a channel scope were required. Tolerability and feasibility was determined by a Likert score and subjective indication from subjects and operators. Adjustments to the technique were made to increase tolerability. The pressure data were continuously collected and analyzed for artifacts, drifts, frequency response, and used with flow data to calculate translaryngeal resistance.
Results
All subjects (n = 7) completed all procedures. Two main areas of concern were identified regarding tolerability: application of topical anesthesia to the larynx and nasal discomfort due to the added diameter of the laryngoscope. Protocol adjustments improved both. Pressure data were obtained from all procedures in all subjects, were consistent, and followed physiological trends.
Conclusions
Continuous measurement of the translaryngeal pressure gradient during a CLE test is possible, feasible, and tolerable. A CLE test with direct measurement of the translaryngeal pressure gradient might become a valuable tool in the objective assessment of respiratory function, and normal values should be established in health and disease.
Level of Evidence
NA Laryngoscope, 129:2748–2753, 2019

Surgery versus radiation for T1 glottic carcinoma: Second primary considerations

20-11-2019 – Sidharth V. Puram, Neil Bhattacharyya

Journal Article

Although early glottic carcinoma is managed with radiation therapy (RT) or surgery, there is limited data on differences in second primary cancers of the larynx. We utilized the Surveillance, Epidemiology, and End Results (SEER) database to query T1 glottic carcinomas and assess the incidence of second primary laryngeal malignancies. Cumulative hazard for second primary laryngeal malignancies was compared with the log‐rank method. Among 844 surgical and 2,272 RT cases, observed‐to‐expected incidence ratios of laryngeal second primaries were 10.19 (5.89–16.55) and 6.87 (4.64–9.81) per 10 thousand person‐years, respectively. Mean person‐years at risk were comparable at 8.16 years (surgery) and 8.01 years (RT), and relative increased risk of laryngeal second primary was 20.95 (surgery) versus 14.09 (RT) per 10 thousand person‐years. Mean times to development of a second primary were also comparable (304 vs. 305 months, P = 0.898). Thus, second laryngeal primary development is analogous between cases treated with surgery alone versus RT. Continued discussion and investigation of surgery versus RT for early glottic squamous cell carcinoma will need to leverage these findings, along with ongoing investigation of voice and survival outcomes, to develop more well‐informed treatment algorithms. Laryngoscope, 129:2713–2715, 2019

Self‐reported mini olfactory questionnaire (Self‐MOQ): A simple and useful measurement for the screening of olfactory dysfunction

20-11-2019 – Lai‐quan Zou, Lena Linden, Mandy Cuevas, Marie‐Luise Metasch, Antje Welge‐Lüssen, Antje Hähner, Thomas Hummel

Journal Article

Objectives
Olfactory dysfunction is a common problem. However, too little attention has been paid to questionnaires used to evaluate quantitative olfactory dysfunction. Therefore, the current study aimed to develop a simple self‐reported Mini Olfactory Questionnaire (Self‐MOQ) for the screening of quantitative olfactory dysfunction in clinical practice.
Methods
Two hundred and eighty‐five patients who had subjective complaints of olfactory disorder participated. The Sniffin’ Sticks test score was used to define functional anosmia, hyposmia, or normosmia. We assessed the factor structure as well as internal consistency, convergent validity, and discrimination performance.
Results
The results showed that the final version of the Self‐MOQ included only one factor with five items. The Self‐MOQ has a good internal reliability (Cronbachs α = 0.84) and validity (r = −0.60, P < 0.001). The receiver operating characteristic analyses indicated that the Self‐MOQ as compared to a visual analogue scale (VAS) is an effective measure for discriminating normosmic from hyposmic/anosmic patients, anosmic patients, and hyposmic patients.
Conclusion
The Self‐MOQ is a simple, reliable and valid questionnaire to screen olfactory dysfunction in clinical practice that appears to be superior to the use of VASs but does not replace olfactory testing.
Level of Evidence4Laryngoscope, 2019

Reporting of Clinical Trial Interventions Published in Leading Otolaryngology–Head and Neck Surgery Journals

20-11-2019 – Trevor Torgerson, Austin L. Johnson, Sam Jellison, Margo Tanghetti, Jean‐Maria Langley, Lily H. P. Nguyen, Matt Vassar

Journal Article

Objectives/Hypothesis
Randomized controlled trials (RCTs) play a crucial role in advancing patient care within otolaryngology–head and neck surgery (OTL‐HNS), yet studies have shown the reporting of these trials needs improvement. Here, we evaluate the completeness of intervention reporting of RCTs in OTL‐HNS and evaluate whether the publication of the Template for Intervention Description and Replication (TIDie
R) checklist has influenced intervention reporting.
Study Design
Retrospective Cross‐Sectional Analysis.
Methods
We searched PubMed for RCTs published in top OTL‐HNS journals in two cohorts, one before the release of the TIDie
R and one afterward. A sample of 300 RCTs was randomly selected and screened for inclusion. Once the dataset was finalized, we extracted trial characteristics and assessed each trials adherence to the TIDie
R checklist. We then used descriptive characteristics, a generalized estimated equation, time‐series analysis, and a two‐sample t test to analyze our data.
Results
After screening was completed, 173 RCTs were included in our analysis. Of these RCTs, 103 (59.5%) showed <60% adherence to the TIDie
R checklist. We found a slight increase in adherence to TIDie
R items after the checklist was released, although this was not statistically significant (P = .91). In addition, we found that trials with a crossover study design or multiple interventions and those that provided a Consolidated Standards for Reporting Trials statement were associated with greater adherence to the TIDie
R checklist.
Conclusions
The majority of OTL‐HNS RCTs included in our analysis showed suboptimal reporting factors related to the TIDie
R checklist. Requiring a TIDie
R statement and automating the journal requirements process for all OTL‐HNS clinical trials would be a worthwhile, efficient approach to improving research quality and ultimately patient care within OTL‐HNS.
Level of Evidence
NALaryngoscope, 2019

Positional Awake Endoscopy Versus DISE in Assessment of OSA: A Comparative Study

20-11-2019 – Sherif M. Askar, Amal S. Quriba, Elham M. Hassan, Ali M. Awad

Journal Article

Objective
To compare awake endoscopy with Müllers maneuver (MM) during both sitting and supine positions, with drug‐induced sleep endoscopy (DISE) as regard determination of different levels, patterns, and degrees of collapse of the upper airway in adult patients with obstructive sleep apnea (OSA).
Methods
The study included adult patients with OSA symptoms, who had apnea hypopnea index (AHI) > 15. Patients were examined by MM in a sitting position, then during supine position; DISE then followed. Site, pattern, and degree of obstruction were assessed by experienced examiners according to the nose oropharynx hypopharynx and larynx classification.
Results
Eighty‐one adult subjects were included. The most common pattern of collapse at the retro‐palatal level was the concentric pattern, while the predominant pattern at the hypopharyngeal level was the lateral wall collapse. The analysis of the pattern of collapse of the study group revealed that the individual pattern did not change (for the same patient at the same level) in the majority of patients whatever the maneuver or the position.
Conclusion
This study demonstrates the feasibility of positional awake endoscopy for providing valuable surgical information as regard level, pattern, and degree of severity in OSA. The data of positional awake endoscopy were comparable to those gained from DISE with less morbidity and costs. The idea and results of this work provide a useful foundation for future research in this area. Multicenter studies are encouraged to obtain more reliable conclusions and more clear standards aiming at a better surgical planning.
Level of Evidence4 Laryngoscope, 2019

Efficacy of pentoxifylline–tocopherol–clodronate in mandibular osteoradionecrosis

20-11-2019 – Alexis Dissard, Nathalie P. Dang, Isabelle Barthelemy, Candice Delbet, Mathilde Puechmaille, Arnaud Depeyre, Bruno Pereira, Fanny Martin, Florent Guillemin, Julian Biau, Sonia Mirafzal, Thierry Mom, Laurent Gilain, Nicolas Saroul

Journal Article

Objectives/Hypothesis
PENTOCLO treatment, associating pentoxifylline, tocopherol, and clodronate, resolves radiation‐induced fibrosis. The main aim of the present study was to prospectively assess efficacy in mandibular osteoradionecrosis (ORN).
Study Design
Prospective cohort study.
Methods
Twenty‐seven patients with mandibular ORN were included in the Pentoclauvergne Study between January 2014 and February 2016. After an initial 28‐day phase of antibiotic, antifungal, and corticosteroid therapy, they received the PENTOCLO association daily until cure or a maximum of 24 months. The main assessment criterion was exposed bone area (EBA); secondary criteria comprised the Subjective, objective, management, and analytic (SOMA) score.
Results
Under PENTOCLO, EBA decreased by 28% at 2 months, 55% at 6 months, and 92% at 24 months; the SOMA score decreased by 23%, 38%, and 50%, respectively. A complete treatment course cured 76.5% of patients at a mean 9.6 months.
Conclusions
PENTOCLO is a simple, well‐tolerated, and effective treatment for mandibular ORN.
Level of Evidence4 Laryngoscope, 2019

Patient values regarding overlapping surgery: Identification of distinct patient subgroups

20-11-2019 – Alexander Langerman, Alexandra Arambula, Kemberlee Bonnet, David G. Schlundt, Kathleen M. Brelsford

Journal Article

Objectives/Hypothesis
To explore patient values associated with their comfort level with surgical trainees and attending surgeon absence from the operating room.
Study Design
Qualitative interviews with general medical patients.
Methods
We analyzed data from qualitative interviews with patients that included a quantitative rating on a visual analog scale (VAS) of comfort consenting to three surgical scenarios, including overlapping surgery, to identify subgroups of patients based on comfort level. After identifying subgroups, we compared qualitative responses from participants who were generally comfortable with overlapping surgery to those who were uncomfortable to identify themes associated with these perceptions.
Results
We identified three subgroups of patients based on the patterns of VAS responses. Participants who were comfortable with overlapping surgery expressed trust in the surgeon and delegation process. Those who were most uncomfortable expressed a strong desire to know who was operating on them, and a desire for control over their surgical process. Subjects uncomfortable with overlapping surgery were also generally not sensitive to tradeoffs (cost, timing).
Conclusions
We identified distinct subgroups of patients based on their comfort level with trainee independence and primary attending availability. By examining the predominant values in these subgroups, we identified potential explanations for patient discomfort with attending absence. Strategies to enhance patients’ knowledge about the process of surgery and a sense of control over their own care may improve comfort with trainee participation and overlapping surgery.
Level of Evidence6 Laryngoscope, 2019

“Relationship between video head impulse test, ocular and cervical vestibular evoked myogenic potentials, and compartmental magnetic resonance imaging classification in menières disease”

19-11-2019 – Laureline Kahn, Charlotte Hautefort, Jean‐Pierre Guichard, Michel Toupet, Clément Jourdaine, Hélène Vitaux, Philippe Herman, Romain Kania, Emmanuel Houdart, Arnaud Attyé, Michael Eliezer

Journal Article

Objectives/Hypothesis
Currently, it is possible to assess in vivo the morphology of each compartment of the endolymphatic spaces 4 hours after an intravenous administration of gadolinium on magnetic resonance imaging (MRI). The aim of this study was to assess the correlation between otolithic and ampullar functions (cervical vestibular evoked myogenic potential cVEMP, ocular vestibular evoked myogenic potential oVEMP, video head impulse test VHIT) and delayed inner ear MRI based on a compartmental, anatomically based classification that included the cochlea, the saccule, the utricle, and the ampullas.
Study Design
Retrospective case–control study.
Methods
In this retrospective study, we performed three‐dimensional fluid‐attenuated inversion recovery sequences with delayed acquisition in 26 healthy subjects and 31 definite Menières disease (MD) patients. Each subject was then graded on MRI on the basis on cochlear, saccular, utricular, and ampullar hydrops in MD patients. All patients underwent pure‐tone audiometry, VHIT, cVEMP, and oVEMP testing.
Results
Cochlear, saccular, utricular, and ampullar hydrops were found on MRI in 88%, 91%, 50%, and 8.5% respectively. We found no significant correlation between the presence of saccular hydrops versus cVEMP, utricular hydrops versus oVEMP, and ampullar hydrops versus VHIT. However, the severity of endolymphatic hydrops on MRI was correlated to the degree of hearing loss.
Conclusions
We proposed a compartmental, anatomically based classification for endolymphatic hydrops on MRI, which included the whole vestibular compartment. Using this classification, we observed increasing morphological changes as the disease evolved, affecting first the saccule, then the utricle, and finally the ampullas. The severity of vestibular endolymphatic hydrops is only correlated to hearing loss severity.
Level of Evidence3 Laryngoscope, 2019

Neurophysiological monitoring of tongue muscle activation during hypoglossal nerve stimulation

19-11-2019 – Joshua J. Sturm, Oleg Modik, Maria V. Suurna

Journal Article

Objectives/Hypothesis
Upper airway stimulation for obstructive sleep apnea (OSA) via implantable hypoglossal nerve stimulation (HGNS) reduces airway obstruction by selectively stimulating nerve fibers that innervate muscles that produce tongue protrusion, while avoiding fibers that produce tongue retraction. This selective stimulation likely depends upon the location, intensity, and type of electrical stimulation delivered. This study investigates the impact of changing stimulation parameters on tongue muscle activation during HGNS using intraoperative nerve integrity monitoring in conjunction with electromyography (EMG).
Study Design
Prospective case series.
Methods
Ten patients undergoing unilateral HGNS implantation for OSA in a university hospital setting were studied. Data included EMG responses in tongue muscles that produce protrusion (genioglossus), retraction (styloglossus/hyoglossus), and stiffening (transverse/vertical) in response to intraoperative bipolar probe electrical stimulation of lateral and medial branches of the hypoglossal nerve (HGN) and to implantable pulse generator (IPG) unipolar and bipolar settings after placement of the stimulation cuff.
Results
Stimulation of medial division HGN branches resulted in EMG responses in genioglossus muscles, but not in styloglossus/hyoglossus muscles, whereas stimulation of the lateral division HGN branches drove responses in styloglossus/hyoglossus muscles. Variable responses in transverse/vertical muscles were observed with stimulation of lateral and medial division branches. After electrode cuff placement, unipolar and bipolar HGN stimulation configurations of IPG resulted in unique patterns of muscle activation.
Conclusions
The relative activation of extrinsic and intrinsic tongue musculature by HGNS is determined by stimulus location, intensity, and type. Intraoperative neurophysiological monitoring of tongue muscle activation enables proper electrode cuff placement and may provide essential data for stimulus optimization.
Level of Evidence4 Laryngoscope, 2019

Clinician adherence to the clinical practice guideline: Acute otitis externa

15-11-2019 – Nicholas Mildenhall, Adam Honeybrook, Thomas Risoli, Sarah B. Peskoe, Amie Kim, David Kaylie

Journal Article

Objectives/Hypothesis
Over 10 years have passed since the Clinical Practice Guideline: Acute Otitis Externa (CPG‐AOE) was first published, and it has been several years since its update. We sought to assess clinicians’ adherence as well as referral patterns.
Study Design
Survey.
Methods
A 23‐question survey was distributed to regional primary care clinicians evaluating demographic data, perception of the clinical practice guideline (CPG), adherence, and details of specialist referral. Statistical analysis was performed to compare adherence and referral patterns using the Fisher exact test or the χ2 test.
Results
One hundred seventeen clinicians completed the survey. Fifteen respondents (12.8%) had reviewed the CPG. The recommendations with the least reported adherence were pain management (39.1%) and accounting for prior radiotherapy as a modifying factor (43.0%). The recommendations of prescribing ototopical therapy and avoiding systemic antimicrobials in uncomplicated acute otitis externa had adherence of 94.0% and 83.8%, respectively. When analyzed by provider type (e.g., resident, nurse practitioner/physician assistant), there were no significant differences in adherence. No significant differences in adherence were observed based on previous review of the CPG. When reporting frequency of specialist referral, the majority of respondents selected rarely (53.9%). The most favored reason for referral was symptoms >4 weeks (86.3%).
Conclusions
Of the providers who responded, very few had reviewed the CPG‐AOE. Despite the added emphasis on pain management in the CPG update, this recommendation had the lowest adherence. Rates of adherence were similar across provider types and did not differ significantly if the CPG was reviewed. Efforts at improved provider education should be considered to increase adherence to the CPG.
Level of Evidence
NA Laryngoscope, 2019

Tumor Volume Useful Beyond Classic Criteria in Selecting Larynx Cancers For Preservation Therapy

13-11-2019 – Jonathan M. Sharrett, Matthew C. Ward, Eric Murray, Joseph Scharpf, Eric D. Lamarre, Brandon L. Prendes, Robert R. Lorenz, Brian B. Burkey, Shlomo A. Koyfman, Neil M. Woody, John F. Greskovich, David J. Adelstein, Jessica L. Geiger, Nikhil P. Joshi

Journal Article

Objective
To investigate the association between tumor volume and locoregional failure (LRF) after concurrent chemoradiation (CCRT) for locally advanced larynx cancer (LC).
Methods
This is a retrospective cohort study from 2009 to 2014 identified from an institutional review board–approved registry. Fifty‐nine of 68 patients with locally advanced larynx cancer treated with definitive CCRT who had available imaging for review were identified. The main endpoint to be assessed was the association between gross tumor volumes (GTV; T = total, P = primary, N = nodal) and LRF. Receiver operative characteristic (ROC) curves were used to investigate diagnostic accuracy.
Results
Twenty LRFs were observed, resulting in a 2‐year LRF rate of 39% (95% CI, 23–52%). On UVA, the GTV‐T (P = .01), GTV‐P (P = .05), and GTV‐N (P = .04) were statistically significant predictors of LRF. Furthermore, age, smoking status, N‐stage, larynx subsite, and tracheostomy/feeding tube dependence were potentially associated with LRF (P < .3), whereas T‐stage (T3–4 vs. T2) was not (HR 1.05, 95% CI, 0.38–2.91, P = .92). In the multivariable model, GTV‐P (HR 1.022, 95% CI, 0.999–1.046, P = .07) and GTV‐N (HR 1.053, 95% CI, 1.0004–1.108, P = .05) were the two most impactful covariates on the models R2. ROC analysis suggested an optimal cut point of 12 cc in the GTV‐T. The 2‐year LRF for GTV‐T > 12 cc was 64.2% and ≤ 12 cc was 16.4%, P = .006.
Conclusion
GTV is associated with LRF after definitive CCRT for LC. Patients with bulky primary and/or nodal tumors may be better served with upfront surgical resection regardless of T‐stage. Further investigation into the safety of larynx preservation for low‐volume T4 tumors can be considered.
Level of Evidence4Laryngoscope, 2019

Obstructive sleep apnea: Do positional patients become nonpositional patients with time?

13-11-2019 – Arie Oksenberg, Vlada Goizman, Edith Eitan, Kitham Nasser, Natan Gadoth, Timo Leppänen

Journal Article

Objectives
Obstructive sleep apnea (OSA) patients with breathing abnormalities only or mainly in the supine posture are designated positional patients (PPs), whereas nonpositional patients (NPPs) have many breathing abnormalities in both lateral and supine postures. Positional therapy (PT), the avoidance of the supine posture during sleep, is the obvious treatment for PPs. The stability over time of being PP and leading factors that are involved in converting a PP to an NPP are addressed.
Methods
We analyzed polysomnographic (PSG) recordings of 81 consecutive adult patients with OSA who were judged to be PPs at the first PSG evaluation, and their follow‐up PSGs were obtained after an average period of 6.6 years.
Results
The follow‐up PSGs indicated that 57 PPs (70.4%) remained PPs, whereas 24 (29.6 %) converted to NPPs. Among PPs and NPPs, body mass index (P ≤ 0.05), overall Apnea–Hypopnea Index (AHI, P ≤ 0.087), and lateral AHI (P ≤ 0.046) increased and minimum Sp
O2 during rapid eye movement (REM) sleep (P ≤ 0.028) decreased significantly during the follow‐up. However, among patients who became NPPs, the changes in these parameters were significantly (P ≤ 0.05) more pronounced compared to the patients who remained PPs.
Conclusion
After an average of 6.6 years, 70.4% of PPs remained PPs. Therefore, if adherence for PT is good, they could continue to benefit from this therapy. For those who turned to NPPs, PT will not be the optimal treatment anymore; thus, these patients should be frequently monitored. Furthermore, an early treatment of PPs with PT would be highly beneficial to prevent worsening of their OSA.
Level of Evidence2b
Laryngoscope, 2019

The prognostic value of anterior commissure involvement in T1 glottic cancer: A systematic review and meta‐analysis

13-11-2019 – Michele Tulli, Massimo Re, Stefano Bondi, Luigi Ferrante, Marianxhela Dajko, Leone Giordano, Federico M. Gioacchini, Andrea Galli, Mario Bussi

Journal Article, Review

Objective
The anterior commissure is considered a laryngeal subsite, but it is not taken into account in the current T‐staging system. The impact of anterior commissure involvement (ACI) on the oncologic outcomes of T1 glottic tumors has not been well defined and remains controversial. The aim of this study was to assess the influence of ACI in the prognosis of T1 glottic tumors.
Methods
A systematic review and meta‐analysis of observational studies was performed by including studies published up to July 2019. Studies were selected if they had investigated the local control rate (LCR) at 5 years of clinical stage I (T1 and N0) glottic squamous cell carcinoma with and without ACI. The difference in LCR at 5 years between T1 glottic tumors without and with ACI was evaluated.
Results
The meta‐analysis showed that the difference in LCR at 5 years between T1 glottic tumors without and with ACI is 12% (95% confidence interval: 8%‐16%, p < 0,0001, I2 = 34.81%).
Conclusions
Our study pointed out that the anterior commissure involvement is a negative prognostic factor in LCR at 5 years for T1 glottic tumors. Our results suggest the need to consider ACI in the T staging of glottic tumors. Laryngoscope, 2019

The natural history of vocal fold cysts

12-11-2019 – Diana N. Kirke, Lucian Sulica

Journal Article

Objective
To determine the natural history of vocal fold cysts, by undertaking a retrospective analysis of data from a single clinical institute.
Methods
All patients diagnosed with vocal fold cysts were identified from January 2006 to June 2018. A total of 87 patients that elected not to have surgery or who had an interval of observation greater than 90 days prior to surgical intervention were further analyzed. The primary outcome was whether the cyst enlarged, reduced in size, resolved or ruptured. The secondary outcome measures were whether cyst characteristics (translucent or opaque by gross appearance and/or the presence of inflammation), voice therapy or duration of follow up (≤/> 300 days) had an impact upon natural history.
Results
There were 65 females and 22 males (47 years ±17). The mean duration of follow up was 589 days (Range 21 – 4523 days). The majority of cysts did not change (70.11%). The rest enlarged (12.64%), reduced in size (13.79%), resolved (1.15%) or ruptured (1.15%). There was no statistically significant relationship between the presence or absence of clinical signs of inflammation (P = .633) or voice therapy (P = .785) on natural history. There was an equivocal relationship between gross cyst appearance and natural history (P = .054), however there was a statistically significant relationship between the duration of follow up (P = .006) and natural history.
Conclusion
Most vocal fold cysts appear to remain static in size over time. About 30% change, with half of these enlarging and half shrinking. In addition to some possibility of change in size, there is a small chance of resolution or spontaneous rupture with potentially serious consequences to the voice.
Level of Evidence4. Laryngoscope, 2019

Peak sinus pressures during sneezing in healthy controls and post–skull base surgery patients

12-11-2019 – Zhenxing Wu, John R. Craig, Guillermo Maza, Chengyu Li, Bradley A. Otto, Alexander A. Farag, Ricardo L. Carrau, Kai Zhao

Journal Article

Objectives/Hypothesis
Patients are frequently advised to sneeze with an open mouth and avoid nose‐blowing following an endoscopic endonasal approache (EEA) to the skull base, despite a lack of quantitative evidence. This study applies computational fluid dynamics (CFD) to quantify sinus pressures along the skull base during sneezing.
Study Design
Case–control series.
Methods
Computed tomography or magnetic resonance imaging scans of four post‐EEA patients and four healthy controls were collected and analyzed utilizing CFD techniques. A pressure drop of 6,000 Pa was applied to the nasopharynx based on values in the literature to simulate expiratory nasal airflow during sneezing. Peak pressures along the skull base in frontal, ethmoid, and sphenoid sinuses were collected.
Results
Significant increases in skull base peak pressure was observed during sneezing, with significant individual variations from 2,185 to 5,685 Pa. Interestingly, healthy controls had significantly higher pressures compared to post‐EEA patients (5179.37 ± 198.42 Pa vs. patients 3,347.82 ± 1,472.20 Pa, P < .05), which could be related to higher anterior nasal resistance in unoperated healthy controls (0.44 ± 0.22 vs. 0.31 ± 0.16 Pa/m
L/sec for patients, P = .38). The sinus pressure buildup may be due to airway resistance functioning as a valve preventing air from being released quickly. Supporting this theory, there was a strong correlation (r = 0.82) between peak skull base pressure and the ratio of anterior resistance to total resistance. Within‐subject variation in pressures between different skull base regions was much lower (average = ~5%).
Conclusions
This study provided the first quantitative analysis of air pressure along the skull base during sneezing in post‐EEA patients through CFD, suggesting that pressure buildup may depend on individual anatomy.
Level of Evidence3b Laryngoscope, 2019

What is the optimal timing for tracheostomy in intubated patients?

12-11-2019 – Bharat A. Panuganti, Philip Weissbrod, Edward Damrose

Journal Article

Endoscopic versus microscopic stapes surgery outcomes: A meta‐analysis and systematic review

12-11-2019 – Alexandros Koukkoullis, István Tóth, Noémi Gede, Zsolt Szakács, Péter Hegyi, Gábor Varga, István Pap, Kinga Harmat, Adrienn Németh, István Szanyi, László Lujber, Imre Gerlinger, Péter Révész

Journal Article, Review

Objective
Compare intraoperative and postoperative outcomes of endoscopic and microscopic stapes surgery to provide objective evidence on whether the former is a better alternative than the latter.
Methods
We performed a systematic review and meta‐analysis for studies that compared endoscopic stapes surgery with microscopic stapes surgery. Only studies that met predetermined criteria were selected and assessed for bias and quality. Primary outcomes were postoperative air–bone gap (ABG) and chorda tympani nerve injury. Secondary outcomes were average operating time, tympanic membrane (TM) perforation, and postoperative taste disturbance, pain, and dizziness. We calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs) for dichotomous outcomes and weighted mean difference (WMD) with 95% CI for continuous outcomes. A confidence interval starting above 1.0 was considered as statistically significant. I2 and χ2 tests were used to quantify statistical heterogeneity. We used funnel plots to look for publication bias and performed a sensitivity analysis.
Results
Six nonrandomized cohort studies were eligible. The primary outcomes were ABG < 10 d
B: OR = 1.80 (95% CI: 0.96 to 3.38), ABG = 11 d
B to 20 d
B: OR = 1.49 (95% CI: 0.76 to 2.93), ABG > 20 d
B: OR = 2.51 (95% CI: 0.77 to 8.22), and chorda tympani injury: OR = 3.51 (95% CI: 1.55 to 7.93). Secondary outcomes were taste: OR = 2.36 (95% CI: 1.01 to 5.51), average operation time: WMD = 0.14 (95% CI: −11.69 to 11.98), TM perforation: OR = 1.70 (95% CI: 0.44 to 6.58); pain: OR = 0.84 (95% CI: 0.36 to 1.96), and dizziness: OR = 2.15 (95% CI: 0.94 to 4.89).
Conclusions
Endoscopic stapes surgery is a valid alternative to the microscope.
Level of Evidence2a
Laryngoscope, 2019

How I Do It: Midline posterior pharyngotomy for resection of postcricoid cancer

12-11-2019 – Jungirl Seok, Chang Hwan Ryu, Yuh‐Seog Jung, Junsun Ryu

Journal Article

Validity testing of a three‐dimensionally printed endoscopic sinonasal surgery simulator

12-11-2019 – Mohamedkazim M. Alwani, Thomas J. Svenstrup, Elhaam H. Bandali, Dhruv Sharma, Thomas S. Higgins, Arthur W. Wu, Taha Z. Shipchandler, Elisa A. Illing, Jonathan Y. Ting

Journal Article

Objectives/Hypothesis
To assess the face, content, construct, and concurrent validity of the PHACON Sinonasal Surgery Simulator (SNSS).
Study Design
Prospective cohort study.
Methods
A total of 12 otolaryngology residents were recruited to perform sinonasal surgery on the simulator followed by cadaveric heads. Resident performances were recorded and de‐identified. Face and content validities were evaluated based on 5‐point Likert scale questionnaires. The recordings were evaluated by extramural expert rhinologists based on a validated Global Rating Scale (GRS). These results were analyzed and compared to assess construct and concurrent validity.
Results
The appearance of anatomic structures was rated as realistic by 75% of all participants, while only 30% and 41.7% rated the mucosal and bony tissues as realistic, respectively. A total of 91.7% of participants found the model useful for teaching anatomy, while 66.7% said it was useful for teaching operative technique. Construct validity was confirmed by showing significant differences in performance between the novice and experienced groups. Concurrent validity was confirmed by showing significant correlation between performance on the model and gold standard (i.e. cadaver head).
Conclusions
This study demonstrates the face, content, concurrent, and construct validity of a 3D‐printed SNSS. Although this model has the potential to be a valuable tool in endoscopic sinus surgery training for otolaryngology residents, improvements are required with respect to the quality of simulated mucosal tissue as well as the simulated anatomy of the fronto‐ethmoid compartment
Level of Evidence: NALaryngoscope, 2019

Impact of primary tumor‐specific growth rate on treatment failure for nonoropharyngeal head and neck cancers

12-11-2019 – Claudia S. Roldan, Jie Jane Chen, M. Mohsin Fareed, M. Yahya Hameed, Thomas M. Churilla, Miriam N. Lango, Thomas J. Galloway

Journal Article

Objectives
To investigate the prognostic impact of primary tumor‐specific growth rate (TSGR) on treatment outcomes after definitive radiation therapy (RT) for nonoropharyngeal squamous cell carcinoma (non‐OPSCC).
Methods
The diagnostic tumor and nodal volumes of 39 non‐OPSCC patients were contoured and compared to corresponding RT planning scan volumes to determine TSGR. Overall survival (OS), disease‐free survival (DFS), and local recurrence‐free survival were evaluated according to the Kaplan‐Meier method; and hazard ratios (HR) were estimated using Cox regression. Based on the 75th percentile TSGR of 2.18%, we stratified patients into a high TSGR group (≥ 2.18% per day) and low TSGR group (< 2.18% per day).
Results
The median follow‐up was 22 months (range: 1–86 months) and median time between diagnostic and simulation computed tomography scans was 22 days (range: 7–170 days). Median RT dose was 70 Gy (range: 60–79.2 Gy). Based on the 75th percentile TSGR, OS at median follow‐up was 50.0% for the high TSGR group compared to 92.5% for the low TSGR group (HR 95% confidence interval (CI) = 2.121.16–11.42, P = 0.018). There was a trend toward worse DFS at median follow‐up for the high versus low TSGR groups, at 55.6% and 82.3%, respectively (HR 95% CI = 2.290.82–6.38, P = 0.103).
Conclusion
Our study contributes to growing literature on TSGR as a temporal biomarker in patients with non‐OPSCC. Patients with high TSGR ≥2.18% per day have significantly worse OS compared to those with TSGR below this threshold. Efforts to address treatment initiation delays may benefit patients with particularly aggressive and rapidly growing tumors.
Level of Evidence4 Laryngoscope, 2019

Narrow Band Imaging in Head and Neck Unknown Primary Carcinoma: a Systematic Review and Meta‐Analysis

12-11-2019 – “Pasquale Di Maio, Oreste Iocca, Armando De Vergilo, Marco Giudice, Raul Pellini, Luca DAscanio, Paweł Golusiński, Giampietro Ricci, Giuseppe Spriano”

Journal Article, Review

Objective
To estimate the diagnostic performance of Narrow Band Imaging (NBI) in patients with cervical metastasis from head and neck squamous cell carcinoma of unknown primary (SCCUP) origin.
Methods
PubMed, Embase, and Scopus databases were systematically scrutinized up to July 1, 2019, looking for studies that encompassed the NBI in the SCCUP diagnostic work up. The main inclusion criteria for eligible articles for the meta‐analysis were non‐evidence of primary tumor after physical examination and conventional cross‐section imaging before NBI assessment and the availability of complete data on the diagnostic accuracy of NBI. A set of random‐effects model meta‐analyses was then performed following the Meta‐analysis of Observational Studies in Epidemiology (MOOSE) guidelines.
Results
Five studies, conducted between January 2003 and September 2016, comprising 169 patients imaged with NBI, were included in the meta‐analysis. The pooled sensitivity and specificity of NBI in patients with head and neck SCCUP was 0.83 (99% CI, 0.54–0.95) and 0.88 (99% CI, 0.55–0.97), respectively. The positive and negative likelihood ratios were 6.38 (99% CI, 1.6–25.44) and 0.06 (99% CI, 0.005–0.86). The pooled diagnostic odds ratio (DOR) was 82.15 (99% CI, 7.06–955). The overall detection rate of NBI was 0.35 (99% CI, 0.18–0.53), which allowed localization the primary tumor in 61 out of 169 patients, otherwise not detected by the usual diagnostic work‐up.
Conclusions
Current available evidence suggests that NBI has a considerable diagnostic accuracy in patients affected by head and neck SCCUP. Laryngoscope, 2019