Laryngoscope

Review of Pediatric Otolaryngology Clinical Trials: Past Trends and Future Opportunities

29-01-2020 – Kunal R. Shetty, Sevan R. Komshian, Anand Devaiah, Jessica R. Levi

Objectives/Hypothesis
Pediatric otolaryngologic conditions are highly prevalent in the United States. Although data gathered from clinical trials drive therapeutic strategies, the trends of research in pediatric otolaryngology remain unclear. The objective of this study was to characterize recent trials in pediatric otolaryngology to better understand current directions of study and to identify opportunities for future research.
Study Design
Retrospective analysis.
Methods
A retrospective analysis of United States pediatric clinical trials in otolaryngology between 2001 and 2017 was conducted on Clinical
Trials.gov. Criteria for inclusion included otolaryngologic trials with at least one trial arm of participants <18 years of age, interventional design that was closed, and conducted in the United States. We assessed the information available to us on Clinical
Trials.gov to identify recent trends in pediatric otolaryngology interventional research. We used PubMed to examine publication rates and National Institutes of Health Re
PORTER to characterize funding patterns for these trials.
Results
Of the 122 trials analyzed, 25% investigated treatments for rhinitis, 25% for acute otitis media, and 50% for all other conditions. Drug studies comprised 72% of all trials. Overall, 65% had their results published in a peer‐reviewed journal. Industry funding accounted for 73% of financial support.
Conclusions
Continued focus on the development of pediatric otolaryngologic clinical trials allows an opportunity to better represent the wide spectrum of disease and therapy in the specialty. Increasing the rates of results publication and federal funding may spearhead a more balanced landscape of clinical trials and further advance the care of children with otolaryngologic disease.
Level of Evidence
NA Laryngoscope, 2020

Machine Learning for Predicting Complications in Head and Neck Microvascular Free Tissue Transfer

28-01-2020 – Eric J. Formeister, Rachel Baum, P. Daniel Knott, Rahul Seth, Patrick Ha, William Ryan, Ivan El‐Sayed, Jonathan George, Andrew Larson, Karolina Plonowska, Chase Heaton

Journal Article

Objectives/Hypothesis
Machine learning (ML) is a type of artificial intelligence wherein a computer learns patterns and associations between variables to correctly predict outcomes. The objectives of this study were to 1) use a ML platform to identify factors important in predicting surgical complications in patients undergoing head and neck free tissue transfer, and 2) compare ML outputs to traditionally employed logistic regression models.
Study Design
Retrospective cohort study.
Methods
Using a dataset of 364 consecutive patients who underwent head and neck microvascular free tissue transfer at a single institution, 14 clinicopathologic characteristics were analyzed using a supervised ML algorithm of ensemble decision trees to predict surgical complications. The relative importance values of each variable in the ML analysis were then compared to logistic regression models.
Results
There were 166 surgical complications, which included bleeding or hematoma in 30 patients (8.2%), fistulae in 25 patients (6.9%), and infection or dehiscence in 52 patients (14.4%). There were 59 take‐backs (16.2%), and six total (1.6%) and five partial (1.4%) flap failures. ML models were able to correctly classify outcomes with an accuracy of 65% to 75%. Factors that were identified in ML analyses as most important for predicting complications included institutional experience, flap ischemia time, age, and smoking pack‐years. In contrast, the significant factors most frequently identified in traditional logistic regression analyses were patient age (P = .03), flap type (P = .03), and primary site of reconstruction (P = .06).
Conclusions
In this single‐institution dataset, ML algorithms identified factors for predicting complications after free tissue transfer that were distinct from traditional regression models.
Level of Evidence2c Laryngoscope, 2020

Effect of Timing of Intravenous Fentanyl Administration on the Incidence of Posttonsillectomy Nausea and Vomiting

27-01-2020 – Hye Jin Kim, Min‐Soo Kim, Ha Yan Kim, Wyun Kon Park, Won Shik Kim, Sungmi Kim, Hyun Joo Kim

Journal Article

Objective/Hypothesis
Fentanyl is commonly administered toward the end of tonsillectomy to prevent emergence delirium and reduce postoperative pain. However, it can delay emergence from anesthesia and increase the risk of postoperative nausea and vomiting (PONV). The goal of our study was to compare the risk of PONV based on the timing of fentanyl administration at the end of tonsillectomy in children.
Study Design: Prospective, double‐blind, randomized controlled trial.
Methods
One hundred forty patients aged 3 to 7 years undergoing tonsillectomy were divided into two groups. Fentanyl (1 μg/kg) was administered at the end of surgery in group 1 (n = 70) and at 10 to 15 minutes before the end of surgery in group 2 (n = 70). Time to regular breathing and time to emergence from anesthesia were measured from the end of surgery. PONV and pediatric anesthesia emergence delirium scale scores were assessed every 10 minutes after admission to the postanesthesia care unit.
Results
Incidences of PONV (2.9% vs. 2.9%, P > .99) and emergence delirium (11.4% vs. 5.7%, P = .23) were not significantly different between the two groups. Time to regular breathing (mean difference = 2.3 minutes; 95% confidence interval CI: 0.9 to 3.7 minutes) and time to emergence (median difference = 6.5 minutes; 95% CI, 2.5 to 10.5 minutes) were significantly longer in group 1 than in group 2.
Conclusions
Although there was no beneficial effect on PONV, recovery of regular breathing and consciousness was quicker with earlier fentanyl administration. Emergence delirium was well‐controlled, similar to that with fentanyl administration at the end of surgery.
Level of Evidence1b Laryngoscope, 2020

Genetic Testing for Congenital Bilateral Hearing Loss in the Context of Targeted Cytomegalovirus Screening

27-01-2020 – Joseph Peterson, Carla Nishimura, Richard J. H. Smith

Journal Article

Objectives/Hypothesis
To determine the prevalence of children with genetic hearing loss who are cytomegalovirus (CMV) positive at birth and the relative proportion of genetic and CMV etiology among children with congenital bilateral hearing loss.
Study Design
Database review.
Methods
We performed a review of clinical test results for patients undergoing comprehensive genetic testing for all known hearing loss–associated genes from January 2012 to January 2019. This population was reviewed for reported CMV status and genetic causes of congenital bilateral hearing loss.
Results
In the Oto
SCOPE database, 61/4,282 patients were found to have a documented CMV status, and 661/4282 had documented bilateral congenital hearing loss. Two patients were identified who had both a positive CMV result and a genetic cause for their hearing loss. Forty‐eight percent of patients with bilateral congenital hearing loss (320/661) were found to have a genetic etiology. In 62% (198/320), the hearing loss was associated with pathogenic variants in GJB2, STRC, SLC26A4 or an Usher syndrome–associated gene.
Conclusions
We estimate that ~2% of CMV‐positive newborns with hearing loss have a known genetic variant as a cause. The subcohort of CMV‐positive newborns with symmetric mild‐to‐moderate bilateral hearing loss will have at least a 7% chance of having pathogenic gene variants associated with hearing loss. In a CMV‐positive neonate who failed their newborn hearing screen bilaterally, genetic screening needs to be considered for accurate diagnosis and possible deferment of antiviral treatment.
Level of Evidence4 Laryngoscope, 2020

Surgical Site Infection Affects Length of Stay After Complex Head and Neck Procedures

24-01-2020 – Nicole L. Lebo, Alexandra E. Quimby, Lisa Caulley, Kednapa Thavorn, Natasha Kekre, Sarah Brode, Stephanie Johnson‐Obaseki

Journal Article

Objectives/Hypothesis
Quality improvement (QI) initiatives emphasize a need for reduction in hospital length of stay (LOS). We sought to determine the impact of surgical site infections (SSIs) on LOS after complex head and neck surgery (HNS).
Study Design
Retrospective cohort analysis.
Methods
An analysis of the American College of Surgeons National Surgical Quality Improvement Program was undertaken. All adult patients undergoing complex HNS from 2005 to 2016 were included in the analysis. Our main outcomes were SSI incidence and increase in hospital LOS attributable to SSI.
Results
Of 4,014 patients identified, 16.5% developed SSI. History of smoking, diabetes, preoperative wound infection, contaminated or dirty wound classes, and prolonged operative time were found to significantly predict postoperative SSI. Adjusting for significant pre‐ and postoperative factors, SSI was associated with significantly increased LOS (hazard ratio = 0.486, 95% confidence interval: 0.419‐0.522).
Conclusions
SSI following complex HNS is associated with significantly increased hospital LOS. This result supports the need for institutional QI strategies that target SSIs after head and neck procedures in an effort to provide the highest quality care at the lowest possible cost. Our analysis identifies risk factors that can allow identification of patients at high risk of SSI and prolonged hospitalization.
Level of Evidence2b Laryngoscope, 2020

Prevalence of Tinnitus and Associated Factors Among Asian Americans: Results From a National Sample

24-01-2020 – Janet S. Choi, Alison J. Yu, Courtney C. J. Voelker, Joni K. Doherty, John S. Oghalai, Laurel M. Fisher

Journal Article

Objectives
A previous study demonstrated low rates of high‐frequency hearing loss and noise exposure among Asian Americans (AAs). This study examined the prevalence of tinnitus and associated factors among AAs using the first nationally representative sample of AAs.
Study Design
Cross‐sectional analysis of a national health survey.
Methods
We analyzed data from the 2011 to 2012 National Health and Nutritional Examination Survey, during which 3,669 participants aged 20 to 69 years completed questionnaires on tinnitus (AA participants, n = 530). Tinnitus was defined as bothersome ringing lasting 5 minutes or more in the past 12 months. Prevalence of any tinnitus in the past 12 months was calculated incorporating sampling weights. Logistic regression was used to examine the associations with relevant factors.
Results
The prevalence of any tinnitus was 6.6% (95% confidence interval CI: 4.5‐8.6) among AAs, significantly lower than the prevalence among the overall population at 16.5% (95% CI: 14.3‐18.8. After adjusting for audiometric hearing loss and demographics, AAs were less likely to report any tinnitus than whites (odds ratio OR = 0.43 95% CI: 0.24‐0.75), blacks (OR = 0.60 95% CI: 0.37‐0.95), and Hispanics (OR = 0.60 95% CI: 0.45‐0.78). Rates of tinnitus were not different from whites or blacks once comorbidities, noise exposure, and depression were taken into account. Among AAs, reporting exposure to work‐related noise (OR = 2.92 95% CI: 1.15‐7.41) and having a major depressive disorder (OR = 6.45 95% CI: 1.15‐36.12) were significant factors associated with tinnitus in a multivariate model.
Conclusions
The prevalence of tinnitus is significantly lower among AAs in comparison to other racial groups. Noise exposure and depression were significant factors associated with tinnitus among AAs.
Level of Evidence2b Laryngoscope, 2020

Clinical Experience of Vibroplasty With Direct Coupling to the Oval Window Without Use of a Coupler

24-01-2020 – Sang Hyun Kwak, Young Min Moon, Gi‐Sung Nam, Seong Hoon Bae, Sung Huhn Kim, Jinsei Jung, Jae Young Choi

Journal Article

Objectives/Hypothesis
To investigate the efficacy of direct implantation of a Vibrant Soundbridge (VSB) implant in the oval window (OW) without the use of an OW coupler in patients with severe mixed hearing loss.
Study Design
Retrospective chart review
Methods
A total of 62 patients underwent VSB implantation between July 2016 and December 2018 at Severance Hospital in Seoul, South Korea. Among them, eight patients (nine ears) with moderate‐to‐severe mixed hearing loss were implanted with a VSB directly in the OW. A floating mass transducer (FMT) was attached to the stapes footplate and covered with tragal cartilage. The outcomes were evaluated using pure‐tone audiogram and speech audiogram preoperatively and postoperatively. Word recognition score (WRS; % correct) were measured at the most comfortable loudness (MCL) level to evaluate speech perception.
Results
All cases posed difficulty with round window vibroplasty during surgery, and eventually, an FMT was appropriately placed in the OW without a coupler. Preoperative and postoperative bone conduction thresholds were not different. VSB‐aided threshold improved in terms of functional and effective gains. Interestingly, four cases showed improved air conduction thresholds without the use of a VSB. In addition, MCL level with a VSB was significantly lower than that with a hearing aid, and VSB‐aided WRS improved over time.
Conclusions
Direct implantation of a VSB in the OW without the use of a coupler showed favorable hearing outcomes, and the OW vibroplasty was safe. Direct OW vibroplasty without a coupler is a reliable procedure and can be a good option for hearing rehabilitation in patients with severe mixed hearing loss.
Level of Evidence4 Laryngoscope, 2020

The Therapeutic Effects of Straw Phonation on Vocal Fatigue

23-01-2020 – Jing Kang, Chao Xue, Zhewei Lou, Austin Scholp, Yi Zhang, Jack J. Jiang

Journal Article

Objectives
Straw phonation has been investigated for its vocal warm‐up effects on healthy populations and therapeutic effects on voice patients. The purpose of this article was to determine whether it is beneficial for vocal fatigue.
Study Design
Prospective cohort study
Methods
Twenty‐five healthy participants were recruited into 1‐hour vocal loading tasks followed by 10‐minute vocal rest or straw phonation on 2 different days. Various parameters including phonation threshold pressure (PTP), mean airflow, closed quotient (CQ), current speaking effort level (EFFT), and laryngeal discomfort (DISC) were acquired at baseline, after vocal load, and after the intervention.
Results
Increased PTP, EFFT, and DISC were observed after vocal load. Decreased PTP, EFFT, and DISC were then acquired after both vocal rest or straw phonation. More significant improvements were obtained in straw phonation when compared with vocal rest. Additionally, significantly increased mean flow and decreased CQ were obtained after straw phonation when compared to vocal rest.
Conclusions
Straw phonation has the potential to adjust aerodynamics within the vocal tract leading to improved vocal efficiency, optimized vibration mode, and attenuated vocal fatigue. This study provided a promising treatment for vocal fatigue that could have wide clinical relevance to voice users with high voice demands.
Level of Evidence4 Laryngoscope, 2020

Airway Surgery Communication Protocol: A Quality Initiative for Safe Performance of Jet Ventilation

20-01-2020 – Laura Matrka, Liuba Soldatova, Brad W. deSilva, Daniel Traetow

Journal Article

Objectives
To assess whether manual jet ventilation can safely be performed with variable anesthesia and operating room (OR) staff experience levels and communication skills.
Methods
Jet ventilation procedures for airway stenosis at a single institution over 35 months were retrospectively reviewed. OR and anesthesia staff were assigned scores based on experience level and communication skills. Data were analyzed for any association between the experience or communication skills of the staff and the successful use of jet ventilation, complication rate, or ultimate patient outcome, controlling for intraoperative variables and patient and airway complexity. A detailed preoperative surgeon‐led communication protocol was followed in all cases.
Results
Seventy procedures in 46 patients were performed. Jet ventilation was successful in 69 of 70 cases. No relationship was found between staff experience or communication scores and the successful use of jet ventilation, complication rate, or ultimate patient outcome. The percentage of cases performed with a fully experienced team was low, at 7.1%. The experience level of the certified registered nurse anesthetist was significantly associated with likelihood of using an adequate paralytic dose upfront (P = 0.017), which in turn correlated with shorter anesthesia time by 19.7 minutes (P = 0.0131); however, neither affected complication rate nor ultimate patient outcome. The statements above remained true in cases of medically complex patients, difficult airways with high degrees of stenosis, and multiple shift changes.
Conclusions
Manual jet ventilation can be performed safely even in settings of lower staff experience level or communication skills given a surgeon experienced in the technique and a strict communication protocol.
Level of Evidence4 Laryngoscope, 130:S1–S13, 2020

Table of contents

20-01-2020 –

Masthead

20-01-2020 –

Sistrunk centennial: Evolution of a classic operation

20-01-2020 – Glenn Isaacson

Objectives/Hypothesis
To trace the evolution of the Sistrunk procedure.
Study Design
Historical review.
Methods
We reviewed historical materials in the English, French, and German literature including journal articles, book chapters, genealogical sources, and obituaries to identify the emerging concepts leading to the Sistrunk operation. These included references to the embryology of the thyroid and of the branchial apparatus as well as incremental advances in the surgical management of midline congenital cervical cysts and fistulae. PubMed, the Google Internet search engine, Archive.org, and Google Translate were primary investigational tools.
Results
Understanding of human embryology evolved rapidly in the mid and late 1800s. Discovery of the thyroglossal duct and its role in thyroid development led to improvements in existing surgery for thyroglossal duct remnants. Sistrunk was aware of the anatomy and histopathology of these remnants and used this knowledge to refine existing surgical approaches.
Conclusions
The elements of thyroglossal duct remnant surgery existed for decades before Sistrunk popularized his modified approach to dissection of the suprahyoid portion of the tract. His innovation and his clear description of the operation made it accessible to surgeons around the world.
Level of Evidence
NA Laryngoscope, 130:E45–E47, 2020

Aspiration in the otherwise healthy Infant—Is there a natural course for improvement?

20-01-2020 – “Geoffrey C. Casazza, M. Elise Graham, Fadi Asfour, Molly OGorman, Jonathan Skirko, Jeremy D. Meier”

Objectives/Hypothesis
Timing and indication for surgical intervention is a major challenge in managing pediatric oropharyngeal dysphagia. No study has evaluated a natural course of swallowing dysfunction in otherwise healthy infants. Our objective was to review the outcomes and time to resolution of abnormal swallow in infants with aspiration.
Study Design
Retrospective case series at a tertiary childrens hospital.
Methods
Fifty patients under 1 year old with aspiration on a modified barium swallow study were included. Patients born <34 weeks, with medical or genetic comorbidities, or who underwent surgical intervention for aspiration were excluded. Patients were followed until aspiration resolved on a swallow study. Kaplan‐Meier survival analysis was performed.
Results
Forty patients (25 patients 50% by 6 months, 10 20% by 1 year, three 6% by 2 years, and two 4% at the end of the follow‐up interval) were recommended a normal diet, and 10 patients (20%) were still aspirating by the end of the follow‐up interval. Median time to resolution was 202 ± 7 days (range, 19–842 days), probability 48% (95% confidence interval CI: 0.34‐0.62). The probability of resolution at 6 months was 46% (95% CI: 0.4‐0.68), at 1 year was 64% (95% CI: 0.51‐0.77), at 2 years was 76% (95% CI: 0.64‐0.88), and at the end of the follow‐up interval 81.3% (95% CI: 0.7‐0.92).
Conclusions
The majority of infants with aspiration and without any other major comorbidities improved within 1 year. Future research should be directed toward better understanding swallowing dysfunction in neurologically normal infants.
Level of Evidence4 Laryngoscope, 130:514–520, 2020

The changing landscape of vestibular schwannoma diagnosis and management: A cross‐sectional study

20-01-2020 – Khodayar Goshtasbi, Mehdi Abouzari, Omid Moshtaghi, Ronald Sahyouni, Autefeh Sajjadi, Harrison W. Lin, Hamid R. Djalilian

Journal Article

Objectives
To assess the current state of the diagnosis and management of vestibular schwannoma (VS) as well as treatment trends, and to evaluate the role of treatment setting and various specialists in treatment plan.
Methods
Patients diagnosed with VS completed a voluntary and anonymous survey. The questionnaires were distributed through Acoustic Neuroma Association website, Facebook page, and e‐mail newsletters from January to March 2017.
Results
In total, 789 VS patients completed the survey. Of those, 414 (52%) underwent surgery; 224 (28%) underwent radiotherapy; and 121 (15%) were observed. General otolaryngologists diagnosed 62% of responders, followed by primary care (11%) and neurotologists (10%). Patients who underwent surgery were significantly younger and had larger tumors compared to those treated with radiation or observation. The ratio of patients having nonsurgical versus surgical resection changed from 1:2 to 1:1 for the periods of 1979 through 2006 versus 2007 through 2017, respectively. Neurosurgeons (40%) and neurotologists (38%) were the most influential in treatment discussion. Neurotologists (P < 0.001) and general otolaryngologists (P = 0.04) were more influential than neurosurgeons for the decision process in patients with smaller tumors. Patients treated at academic versus nonacademic private institutions reported similar tumor sizes (P = 0.27), treatment decisions (P = 0.09), and decision satisfaction (P = 0.78).
Conclusion
There is a continuing trend toward nonsurgical management, with approximately half of the patients opting for nonsurgical management. In this cohort, the patients commonly presented with otologic symptoms and otolaryngologists made the most diagnoses. Neurotologists and neurosurgeons were the most influential in treatment discussion.
Level of Evidence
NA Laryngoscope, 130:482–486, 2020

Long‐term results of sleep‐related quality‐of‐life and behavioral problems after adenotonsillectomy

20-01-2020 – In Sik Song, Seung‐No Hong, Jae Woo Joo, Mun Soo Han, Sun Jin Hwang, Min Young Seo, Seung Hoon Lee

Journal Article

Objectives
Improvements in sleep‐related quality of life (QOL) and behavioral problems have been observed in children with obstructive sleep apnea (OSA) during a short‐term follow‐up after adenotonsillectomy. Whether this trend continues beyond the short term remains unclear. Therefore, we aimed to evaluate the long‐term effects of surgery in children with OSA.
Methods
The study participants comprised 20 children with OSA who underwent adenotonsillectomy. We used the scores from the Attention Deficit and Hyperactivity Disorder Rating Scale (ADHD‐RS) and total scores from the Korean OSA‐18 Survey (KOSA‐18) before and after adenotonsillectomy to compare and analyze behavioral problems and OSA‐specific health‐related QOL, respectively, during a long‐term follow‐up. Respiratory disturbance parameters from standard polysomnography and subjective symptom scores for snoring and apnea were also investigated.
Results
The mean patient age was 6.6 ± 3.4 years (range, 3–13), and the male‐to‐female ratio was 15:5. The mean follow‐up period was 54.5 months (range, 27–98). The total scores for both ADHD‐RS (from 17.6 to 10.5; P = 0.006) and KOSA‐18 (from 74.3 to 40.7; P = 0.001) decreased significantly from before to after surgery. Significant decreases were also observed in the subjective symptom scores for snoring (from 5.4 to 2.4; P = 0.000) and apnea (from 3.3 to 0.8; P = 0.002).
Conclusion
Significant improvement was observed in sleep‐related QOL and behavioral problems in children with OSA during long‐term follow‐up after adenotonsillectomy.
Level of Evidence4 Laryngoscope, 130:546–550, 2020

Deep neuromuscular blockade for endolaryngeal procedures: A multicenter randomized study

20-01-2020 – Prok Laosuwan, Phuriphong Songarj, Worawut Lapisatepun, Settapong Boonsri, Oraluxna Rodanant, Wirat Wasinwong, Wimonrat Sriraj, Jittiya Watcharotayangul, Mingkwan Wongyingsinn

Journal Article

Objectives/Hypothesis
The aim of the present study was to compare the surgical condition between deep neuromuscular blockade (NMB) and moderate NMB.
Study Design
Multicenter, randomized, parallel intervention trial.
Methods
One hundred two patients underwent microscopic endolaryngeal surgery at four university hospitals. The patients were randomized into moderate NMB (train‐of‐four 1‐2) (M group) or deep NMB (post‐tetanic count 1‐2) (D group) with moderate or high doses of rocuronium, respectively. Surgical rating conditions (SRCs) were evaluated during the surgery. Sugammadex was given to the M group at 2 mg/kg and the D group at 4 mg/kg. Perioperative clinical signs and conditions were recorded until discharge from the postanesthesia care unit.
Results
Clinically acceptable SRC was observed in 49 patients (100%) in the D group and 43 patients (89.6%) in the M group (P = .027). The frequency of notable vocal fold movement in the M group was significantly higher than the D group (70.8% vs. 32.7%). The patients in the M group required more additional doses of rocuronium (47.9%) than the D group (20.4%) to maintain full relaxation (P = .005). The median time (interquartile range) from administration of sugammadex to train‐of‐four ratio 0.9 in the D group was shorter than the M group (120 109–180 minutes vs. 180 minutes 120–240 minutes, P = .034).
Conclusions
Deep NMB with high doses of rocuronium combined with 4 mg/kg of sugammadex for reversal during endolaryngeal surgery provided better SRC and anesthetic conditions than moderate NMB of rocuronium with 2 mg/kg of sugammadex.
Level of Evidence1b Laryngoscope, 130:437–441, 2020

Epidemiology and gender differences in pediatric recreational and firearms noise exposure in the USA

20-01-2020 – Jay M. Bhatt, Harrison W. Lin, Neil Bhattacharyya

Journal Article

Objective
We aim to identify contemporary noise exposures and hearing protection use among U.
S. children in a large, population‐based study.
Methods
Cross‐sectional analysis of the 2014 National Health Interview Series was performed. Results from in‐person interviews of families with children under 18 years of age in all 50 states were queried. Potentially harmful exposures to loud sounds and patterns of hearing protection use in the last 12 months were analyzed after representative sample weights were applied.
Results
Among 73.4 million children, 18.4% (9.1 ± 0.4 million) (boys: 23.2%, girls: 13.5%; P < 0.001) were exposed to firearms noise, and 28.2% (20.7 ± 0.6 million) (boys: 30.5%, girls: 25.8%; P < 0.001) to firecrackers and other explosive sounds. Exposure to recreational “very‐loud” noise exposure was more common (7.9%; 5.8 ± 0.3 million), consisting of music players (46.5%), fireworks (44.8%), lawnmowers (42.6%), and firearms (32.5%). However, only 17.1% of boys and 15.6% of girls, totaling 16.4% of all children, always used hearing protection during noise exposures.
Conclusion
Children in the United States are commonly exposed to firearms and recreational loud noises. Hearing protection is infrequently used, and gender disparities in patterns of exposure and use of hearing protection are prevalent. Those children and families at risk should be identified via public health initiatives and appropriately counseled by healthcare providers.
Level of Evidence
NA Laryngoscope, 130:541–545, 2020

Salvage open partial horizontal laryngectomy after failed radiotherapy: A multicentric study

20-01-2020 – Andy Bertolin, Marco Lionello, Marco Ghizzo, Isida Cena, Federico Leone, Sara Valerini, Francesco Mattioli, Erika Crosetti, Livio Presutti, Giovanni Succo, Giuseppe Rizzotto

Journal Article

Objectives
The primary aim of the present study was to report our multi‐institutional experience in surgical salvage with open partial horizontal laryngectomies (OPHL) after failed radiotherapy (RT) for laryngeal squamous cell carcinoma (LSCC). Secondary aims were to analyze the prognostic meaning of the main clinical and pathological parameters in relation to the oncologic outcome and to compare our results with the available literature.
Study Design
A retrospective multicenter analysis of surgical oncological outcomes.
Methods
We retrospectively review the clinical charts of 70 recurrent LSCC patients after primary RT failure undergone salvage OPHL.
Results
At last follow‐up, 46 patients (65%) were disease‐free; six (9%) were alive with disease; nine (12%) died because of the disease; and nine (12%) died without evidence of disease. The final local control, overall survival, disease‐specific survival, and laryngectomy‐free survival were 87%, 75%, 87%, and 91%, respectively. Twelve patients (17%) experienced postoperative complications, whereas 18 patients (25%) experienced late sequelae. In five patients (7%), decannulation was not possible because of postoperative laryngeal stenosis.
Conclusion
In selected patients, when proper selection criteria for conservation laryngeal surgery are adopted, OPHL can be considered for salvage after RT failure.
Level of Evidence4 Laryngoscope, 130:431–436, 2020

Arytenoid vertical height discrepancy in predicting outcomes after unilateral vocal cord medialization

20-01-2020 – Eugene Wong, Murray Smith, Danielle B. Stone, Carsten E. Palme, Mark C. Smith, Faruque Riffat

Objectives/Hypothesis
Unilateral vocal fold paralysis is a structural abnormality that often occurs secondary to dysfunction of the recurrent laryngeal nerve and typically presents as a breathy voice. Medialization laryngoplasty is a constellation of procedures that improves apposition of the vocal cords. Many patients, however, fail to experience sufficient improvement in vocal quality postoperatively despite apparent glottic closure on stroboscopy. This suggests that asymmetry in other cord characteristics may also have acoustic consequences. Our hypothesis is that arytenoid height symmetry may play a significant role in vocal quality. To our knowledge there are no human observational studies examining this topic. We therefore aimed to correlate asymmetry in arytenoid height and patient‐reported satisfaction in voice quality after thyroplasty.
Study Design
Retrospective cohort analysis.
Methods
A retrospective review of prospectively collected data on consecutive patients who underwent medialization thyroplasty at a tertiary Sydney, Australia hospital was performed. Data collected included age, sex, onset of symptoms, as well as well as preoperative and 3‐month postoperative maximum phonation time and Voice Handicap Index (VHI). Preoperative computed tomography scans were assessed for discrepancy of arytenoid vertical height discrepancy.
Results
Twenty‐three patients (56.5% female) with mean age of 52.4 ± 14.9 years were included. Most patients underwent injection thyroplasty (78.3%, n = 5), whereas the remaining underwent an open approach. A statistically significant inverse correlation was found between increasing height discrepancy and VHI improvement (r = −0.6, P = .003.) Revision surgery was associated with increased height discrepancy.
Conclusions
Findings of this study may affect future recommendations to address height discrepancy in surgery to treat unilateral vocal cord paralysis.
Level of Evidence3 Laryngoscope, 130:418–422, 2020

“Relationship of vocal fold atrophy to swallowing safety and cough function in Parkinsons disease”

20-01-2020 – Yin Yiu, James A. Curtis, Sarah E. Perry, Michelle S. Troche

Journal Article

Objectives
When swallowing function is compromised in patients with Parkinsons disease (PD), cough plays a crucial role in clearing the airway and preventing pulmonary complications. The aim of this study was to determine the influence of vocal fold atrophy severity as measured by the bowing index (BI) on airway protection in PD.
Methods
Thirty participants with PD completed measures of voluntary and reflex cough. Flexible laryngoscopy with endoscopic evaluation of swallowing allowed for measurement of BI using ImageJ software. Swallowing safety was scored on the Penetration‐Aspiration Scale (PAS). Regression and receiver operating characteristic (ROC) analyses were performed to test our study aim.
Results
Twenty‐four of 30 participants had some degree of vocal fold atrophy (BI >0). When controlling for age, disease duration did not significantly influence BI. BI was not predictive of any sensorimotor parameters of cough including measures of cough airflow, reflex cough threshold, or urge to cough. BI discriminated participants with near‐normal (PAS 1–3) swallowing safety from participants with impaired (PAS 4–8) swallowing safety (P = .01, sensitivity: 87.0%, specificity: 71.4%, cutoff value BI >4.6).
Conclusion
Vocal fold atrophy is a potential factor contributing to poor swallowing safety in PD. BI was not associated with cough function in this PD cohort, contrary to prior studies that have shown improved cough measures after vocal fold augmentation. Vocal fold atrophy in PD remains an important area of study as a targetable intervention for patients with airway protective dysfunction. Future studies should include measures of glottic closure during vocal fold adduction.
Level of Evidence
Level 3 Laryngoscope, 130:303–308, 2020

Socioeconomic and demographic determinants of postoperative outcome after endoscopic sinus surgery

20-01-2020 – Sarek A. Shen, Aria Jafari, Jesse R. Qualliotine, Adam S. DeConde

Journal Article

Objectives/Hypothesis
Socioeconomic and demographic factors have a significant impact on healthcare utilization and surgical outcomes. The effect of these variables on baseline symptom severity and quality of life (QOL) after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) is not well established. Our goal was to investigate the association of sociodemographic factors on QOL before and after ESS, as reflected by the 22‐item Sino‐Nasal Outcome Test (SNOT‐22) score.
Study Design
Retrospective case series.
Methods
From October 2016 to August 2018, 244 patients with chronic rhinosinusitis who underwent ESS were included. Socioeconomic and demographic data, surgical characteristics, and baseline and postoperative SNOT‐22 scores were recorded. Univariate and multivariate regression were performed to identify determinants of baseline symptom severity and improvement following ESS.
Results
Nonwhite patients reported worse baseline symptoms severity (SNOT‐22, 52.06 vs. 43.76, P = .021) compared to white patients, yet lower CRS symptoms at follow‐up (SNOT‐22, 23.38 vs. 28.63, P = .035). Relative improvement was higher in nonwhite patients as well (41.2% vs. 36.5%, Mann‐Whitney U = 1,747, P = .015). In an adjusted multivariate logistic regression model, below‐median income ($71,805 California) was associated with worse baseline symptom severity (β = 7.72; 95% confidence interval CI: 1.10, 14.26). Nonmarried patients (β = 6.78; 95% CI: 2.22, 13.48) and white patients (β = 8.45; 95% CI: 0.40, 13.97) had worse QOL at follow‐up.
Conclusions
Nonwhite patients and those with below‐median income present with more severe CRS symptoms at baseline. However, a greater degree of absolute and relative QOL improvement was found in nonwhite and married patients following ESS. Improved understanding of the significance of socioeconomic and demographic factors and attention to cultural differences/marital status could have a substantial impact on ESS outcomes.
Level of Evidence4 Laryngoscope, 130:297–302, 2020

Long‐term outcomes of tonsillectomy for recurrent tonsillitis in adults

20-01-2020 – Sharon Tzelnick, Ohad Hilly, Shlomo Vinker, Gideon Bachar, Aviram Mizrachi

Background
There is uncertainty regarding the effectiveness of tonsillectomy for recurrent tonsillitis in the adult population. Several studies have described a reduced number and severity of tonsillitis episodes; however, the impact of tonsillectomy on healthcare burden has yet to be studied. The aim of the present study was to evaluate the long‐term outcomes of tonsillectomy in the adult population.
Methods
A retrospective review of the central database of Clalit Health Services, Tel Aviv, Israel, between 2003 and 2009 was performed. The study included all adult patients (>18 years) who underwent tonsillectomy due to recurrent tonsillitis. Clinical and epidemiological data from 3 years before and after surgery were collected and analyzed.
Results
A total of 3,701 patients were included in the study. Mean age was 37.4 years, and 42.9% were males. Following surgery, there was a significant decrease in the total number of tonsillitis episodes, otolaryngologist clinic visits, consumption of pertinent antibiotics, and respiratory complaints. Moreover, a reduced number of hospitalizations to the otolaryngology department and shorter hospitalization duration were also noted. Although the total number of hospitalizations was unaffected, there was an increase in the number of primary care office visits. Finally, a break‐even time analysis revealed an average of 2.7 years following tonsillectomy.
Conclusion
Tonsillectomy for recurrent tonsillitis is effective in decreasing the number and severity of tonsillitis episodes and might also have an economic benefit. The impact of tonsillectomy on general health needs to be further evaluated; however, it appears that there is no increase in overall morbidity.
Level of Evidence
NA Laryngoscope, 130:328–331, 2020

Shift in the timing of microvascular free tissue transfer failures in head and neck reconstruction

20-01-2020 – Larissa Sweeny, Michael Topf, Mark K. Wax, Eben L. Rosenthal, Benjamin J. Greene, Ryan Heffelfinger, Howard Krein, Adam Luginbuhl, Daniel Petrisor, Scott H. Troob, Brian Hughley, Steve Hong, Tingting Zhan, Joseph Curry

Journal Article

Objective
Analyze the cause and significance of a shift in the timing of free flap failures in head and neck reconstruction.
Study Design
Retrospective multi‐institutional review of prospectively collected databases at tertiary care centers.
Methods
Included consecutive patients undergoing free flap reconstructions of head and neck defects between 2007 and 2017. Selected variables: demographics, defect location, donor site, free flap failure cause, social and radiation therapy history.
Results
Overall free flap failure rate was 4.6% (n = 133). Distribution of donor tissue by flap failure: radial forearm (32%, n = 43), osteocutaneous radial forearm (6%, n = 8), anterior lateral thigh (23%, n = 31), fibula (23%, n = 30), rectus abdominis (4%, n = 5), latissimus (11%, n = 14), scapula (1.5%, n = 2). Forty percent of flap failures occurred in the initial 72 hours following reconstruction (n = 53). The mean postoperative day for flap failure attributed to venous congestion was 4.7 days (95% confidence interval CI, 2.6–6.7) versus 6.8 days (CI 5.3–8.3) for arterial insufficiency and 16.6 days (CI 11.7–21.5) for infection (P < .001). The majority of flap failures were attributed to compromise of the arterial or venous system (84%, n = 112). Factors found to affect the timing of free flap failure included surgical indication (P = .032), defect location (P = .006), cause of the flap failure (P < .001), and use of an osteocutaneous flap (P = .002).
Conclusion
This study is the largest to date on late free flap failures with findings suggesting a paradigm shift in the timing of flap failures. Surgical indication, defect site, cause of flap failure, and use of osteocutaneous free flap were found to impact timing of free flap failures.
Level of Evidence4 Laryngoscope, 130:347–353, 2020

Cortical‐Basal Ganglia‐Cerebellar Networks in Unilateral Vocal Fold Paralysis: A Pilot Study

20-01-2020 – Philip L. Perez, Kristine L. Cueva, Clark A. Rosen, VyVy N. Young, Molly L. Naunheim, Katherine C. Yung, Sarah L. Schneider, Danielle Mizuiri, David J. Klein, John F. Houde, Leighton B. Hinkley, Srikantan S. Nagarajan, Steven W. Cheung

Journal Article

Objectives/Hypothesis
To evaluate differences in cortical‐basal ganglia‐cerebellar functional connectivity between treated unilateral vocal fold paralysis (UVFP) and healthy control cohorts using resting‐state functional magnetic resonance imaging (RS‐f
MRI).
Study Design
Cross‐sectional.
Methods
Ten UVFP study patients treated by type I thyroplasty and 12 control subjects underwent RS‐f
MRI on a 3‐Tesla scanner to evaluate differences in functional connectivity of whole‐brain networks. Spontaneous RS‐f
MRI data were collected using a gradient echo planar pulse sequence, preprocessed, and analyzed to compare seed‐to‐voxel maps between the two cohorts. Seeds were placed in the caudate, putamen, and globus pallidus divisions of the basal ganglia in both hemispheres. Group contrasts were tested for statistical significance using two‐tailed unpaired t tests corrected for multiple comparisons with a cluster false discovery rate threshold of P < .05.
Results
UVFP patients demonstrated increased connectivity between both caudate nuclei and the precuneus, a node of the default mode network, compared to healthy controls. Both caudate nuclei also showed decreased connectivity with the left cerebellar hemisphere. The putamen and globus pallidus divisions of the basal ganglia were not abnormally connected to other brain structures.
Conclusions
UVFP patients treated by type I thyroplasty exhibited long‐term alterations of cortical‐basal ganglia‐cerebellar networks thought to be important for self‐referential voice quality awareness and learning processes that compensate for changes to the paralyzed hemilarynx. This pilot study on relatively small cohorts adds to growing evidence for persistent central nervous system changes in treated UVFP. Replication studies with larger numbers of subjects will be essential to validate and extend findings.
Level of Evidence3b Laryngoscope, 130:460–464, 2020

Optimal reassessment time for treatment response in posterior canal benign paroxysmal positional vertigo

20-01-2020 – Mee Hyun Song, Tae Hoon Kong, Dae Bo Shim

Journal Article

Objectives/Hypothesis
The present study aimed to evaluate the optimal reassessment time for treatment response in posterior canal benign paroxysmal positional vertigo (PC‐BPPV) following the initial Epley maneuver.
Study Design
Prospective, single‐blinded, randomized study.
Methods
One hundred eight patients with PC‐BPPV agreed to participate. These patients received a single modified Epley maneuver (recommended by the 2008 American Academy of Otolaryngology–Head and Neck Surgery guidelines) daily until positional nystagmus disappeared during the Dix‐Hallpike maneuver 24 hours after the treatment. Repeated Dix‐Hallpike testing to reassess the treatment response was performed at 1 hour (post‐1 hour), every 24 hours (post‐24 hours) until the positional nystagmus resolved, 1 week (post‐1 week), and 1 month (post‐1 month) following the therapeutic maneuver. The difference in the resolution rates at post‐1 hour and post‐24 hours reassessment was analyzed, and the recurrence rates at post‐1 week and post‐1 month were evaluated.
Results
The resolution rate was 67.6% at post‐1 hour, which increased to 79.6% at post‐24 hours reassessment. There was a statistically significant difference in the results of the Dix‐Hallpike test between post‐1 hour and post‐24 hours follow‐up. After complete resolution, nine out of 108 patients (8.3%) demonstrated recurrence within 1 month.
Conclusions
Reassessment after 24 hours following the initial Epley maneuver is more advantageous than a 1‐hour follow‐up in patients with PC‐BPPV. This information may be helpful for clinicians in deciding the appropriate follow‐up period after treatment for PC‐BPPV.
Level of Evidence1b Laryngoscope, 130:496–499, 2020

Multifactorial positive influence of cochlear implantation on patients with single‐sided deafness

20-01-2020 – Sophia M. Häußler, Vanessa Köpke, Steffen Knopke, Stefan Gräbel, Heidi Olze

Journal Article

Objectives
Single‐sided deafness (SSD) is an extreme case with profound unilateral hearing loss in the poorer ear and regular hearing in the other ear. The aim of this study is to investigate the impairment in the daily life of SSD patients and the influence of cochlear implants (CI) on their health‐related quality of life (HRQoL), the impact on existing tinnitus distress and psychological comorbidities, and audiometric parameters.
Methods
In total, 21 patients (8 male and 13 female) were included, and the Charité Test Battery was applied for all patients. Data on HRQoL were collected with the Nijmegen Cochlear Implant Questionnaire and the Medical Outcome Study Short Form 36 (SF‐36) Survey. Tinnitus distress was assessed with the Tinnitus Questionnaire (TQ). Data with regard to psychological comorbidities were collected using four validated questionnaires. Speech perception was assessed with the Freiburg Monosyllable Test (FMS), the Oldenburg Sentence Test (OLSA), and the Oldenburg Inventory (OI).
Results
HRQoL improved in the subdomain social interactions. Tinnitus distress dropped significantly 6 months postoperatively. SSD patients preoperatively showed elevated levels of stress, depressive symptoms, and anxiety. Postoperatively, these psychological symptoms improved with regard to stress, tension, and demands.
The audiometry tools revealed a significant improvement in directional hearing (OI), speech perception in silence, and in the speech intelligibility threshold (OLSA).
Conclusion
There was an improvement in HRQoL and a reduction of tinnitus and cognitive distress. The preoperatively elevated stress level decreased significantly, and psychological comorbidities such as depressive symptoms and anxiety all improved postimplantation.
Level of Evidence
II‐2 Laryngoscope, 130:500–506, 2020

Effect of anesthesia on evoked auditory responses in pediatric auditory brainstem implant surgery

20-01-2020 – Kevin Wong, Ruwan Kiringoda, Vivek V. Kanumuri, Samuel R. Barber, Kevin Franck, Nita Sahani, M. Christian Brown, Barbara S. Herrmann, Daniel J. Lee

Journal Article

Objective
Electrically evoked auditory brainstem responses (EABR) guide placement of the multichannel auditory brainstem implant (ABI) array during surgery. EABRs are also recorded under anesthesia in nontumor pediatric ABI recipients prior to device activation to confirm placement and guide device programming. We examine the influence of anesthesia on evoked response morphology in pediatric ABI users by comparing intraoperative with postoperative EABR recordings.
Study Design
Retrospective review.
Methods
Seven children underwent ABI surgery by way of retrosigmoid craniotomy. General anesthesia included inhaled sevoflurane induction and propofol maintenance during which EABRs were recorded to confirm accurate positioning of the ABI. A mean of 7.7 ± 2.8 weeks following surgery, the ABI was activated under general anesthesia or sedation (dexmedetomidine) and EABR recordings were made. A qualitative analysis of intraoperative and postoperative waveform morphology was performed.
Results
Seven subjects (mean age 20.6 months) underwent nine ABI surgeries (seven primary, two revisions) and nine activations. EABRs were observed in eight of nine postoperative recordings. In three cases, intraoperative EABRs during general anesthesia were similar to postoperative EABRs with sedation. In one case, sevoflurane and propofol were used for intra‐ and postoperative recordings, and waveforms were also similar. In four cases, amplitude and latency changes were observed for intraoperative versus postoperative EABRs.
Conclusion
Similarity of EABR morphology in the anesthetized versus sedated condition suggests that anesthesia does not have a large effect on far‐field evoked potentials. Changes in EABR waveform morphology observed postoperatively may be influenced by other factors such as movements of the surface array.
Level of Evidence4 Laryngoscope, 130:507–513, 2020

Increasing preoperative apnea severity improves upper airway stimulation response in OSA treatment

20-01-2020 – Sean S. Evans, Joshua Richman, Do‐Yeon Cho, Kirk Withrow

Journal Article

Objective
Examine the patient characteristics of those undergoing upper airway stimulation (UAS) for the treatment of continuous positive airway pressure (CPAP)‐refractive obstructive sleep apnea (OSA) at a tertiary care medical center to determine objective clinical predictors of success.
Methods
Retrospective chart review of the first 25 consecutive patients between August 2015 and December 2016 treated with UAS at a tertiary care academic center. Demographic data, medical and sleep history, pre‐ and postoperative polysomnography data, and sleep endoscopy findings were collected. Statistical analysis was performed using two‐sided t test with bivariate and linear regression analysis.
Results
In our cohort of 25 patients, mean age was 67.5 ± 7.6 years, and mean body mass index (BMI) was 28.2 ± 3.8 kg/m2 with 42% female. One patient was excluded from analysis for unmasking of complete central apnea with therapy. AHI decreased by a mean of 33.8 events/hour following treatment (95% confidence interval: 25.8 to 41.7, P < 0.001). Preintervention AHI was associated with therapy response, with each point of preintervention AHI leading to an average decrease of 1.03 points (P < 0.001). Eighty‐three percent of patients achieved a treatment AHI < 5, whereas 92% achieved an AHI < 10. Mean device use was 49.5 ± 10.4 hours per week. Ninety‐two percent of patients were discharged the day of surgery. No major adverse events occurred.
Conclusion
UAS continues to gain popularity for the treatment of CPAP‐refractive OSA; therefore, identification of predictors of success is crucial. Our study, although small, suggests that more severe preintervention AHI does not preclude significant therapy response and may expand the inclusion criteria for UAS, meriting further investigation.
Level of Evidence4 Laryngoscope, 130:556–560, 2020

Impact of international classification of diseases, 10th revision, on head and neck surgery

20-01-2020 – Zaid Al‐Qurayshi, Russell Robins, Nitin Pagedar, Gregory W. Randolph, Emad Kandil

Journal Article

Objectives
Review changes in the number of International Classification of Diseases, 10th Revision, Clinical Modification (ICD‐10‐CM) codes utilized in head and neck surgery service and associated changes in cost and charges of health services.
Methods
A retrospective cross‐sectional analysis was performed utilizing the Nationwide Readmissions Database, 2015. The study population included patients who were admitted for a primary head and neck procedure. Patients discharged in the third quarter (Q3), coding system ICD‐9‐CM, compared to patients discharged in the fourth quarter (Q4), coding system ICD‐10‐CM.
Results
A total of 11,456 and 10,431 patients discharged in Q3 and Q4, respectively. Comparing the top 90% billed disease codes demonstrated that the number of ICD‐10‐CM codes was more by a factor of 1.20. However, classifying codes by type of surgery, fewer codes were used in patients who had laryngeal surgeries or tonsillectomy/adenoidectomy by a factor of 0.8. Codes used to document the primary diagnoses for patients who underwent tracheostomy increased the most by a factor of 1.42. Controlling for multiple factors that would affect the cost of health services, there were no significant changes in the cost of management per case (Q3: $70,189.00 ± 1,546.39 vs. Q4: $70,502.00 ± 1,560.17, P = 0.68) or hospital charges (Q3: $273,411.00 ± 7,852.78 vs. Q4: 265,996 ± 7922.77, P = 0.05).
Conclusion
The ICD‐10‐CM provides an expansion of codes. Initial indication is that utilization of ICD‐10‐CM codes for head and neck surgery is within expected parameters and appears not to affect the cost of management and hospital charges despite the overall increase in ICD codes in the newer version.
Level of Evidence
NA Laryngoscope, 130:398–404, 2020

Smoking cessation improves olfactory functions

20-01-2020 – Ayse Secil Dinc, Tijen Sengezer, Melih Cayonu, M. Melih Sahin

Journal Article

Objectives
The aim of this study was to investigate changes in olfactory function after smoking cessation.
Methods
We conducted a cross‐sectional study involving 28 volunteers who were admitted to the smoking cessation section of our hospital. Olfactory tests were performed immediately before smoking cessation and 45 days after smoking cessation. The duration of smoking and the number of cigarettes smoked per day were noted.
Results
The mean duration of smoking was 25.5 ± 12 years, and the participants smoked 21.6 ± 6.6 cigarettes per day. There was a significant improvement in odor discrimination, odor identification, and TDI scores (i.e., the total score of odor threshold, odor discrimination, and odor identification tests) 45 days after smoking cessation (P = .003, P = .002, and P < .001, respectively). Furthermore, a statistically significant negative correlation was found between the duration of cigarette smoking and the Sniffin’ Sticks olfactory tests performed after smoking cessation, namely odor discrimination, odor identification, and TDI (P = .008, P = .002, P = .001, respectively).
Conclusion
A significant improvement was observed in odor discrimination, odor identification, and TDI scores after smoking cessation. However, this improvement was inversely associated with the duration of smoking, indicating that a longer duration of smoking may result in an insufficient improvement after smoking cessation.
Level of Evidence4 Laryngoscope, 130:E35–E38, 2020

Epidemiology and treatment trends for primary tracheal squamous cell carcinoma

20-01-2020 – Mohammad K. Hararah, William A. Stokes, Ayman Oweida, Tejas Patil, Arya Amini, Julie Goddard, Daniel W. Bowles, Sana D. Karam

Journal Article

Objective
Management of tracheal squamous cell carcinoma (TSCC) has been complicated by the lack of prognostic data and staging. We describe the epidemiology of TSCC and current treatment approaches.
Methods
Five hundred thirty‐two adult patients with primary TSCC from 2004 to 2012 in the National Cancer Database were identified. Demographic, clinical factors, and 5‐year overall survival were analyzed. Staging was classified as localized, regional extension, and distant spread. Treatment modality was defined as “no treatment (NT),” “limited surgery (LS),” “curative surgery (CS),” “LS with any adjuvant therapy (AT) (LS+AT),” “CS with AT (CS+AT),” “radiation therapy (RT),” or “chemoradiation (CRT).”Results
Overall survival was 25%. Majority of cases were males, white, and occurred in sixth/seventh decades. Twenty‐six percent of cases received CRT, 20% underwent LS+AT or CS+AT, 20% underwent LS or CS only, and 17% underwent RT alone. On multivariate analysis, CS (HR 0.42, 95% CI: 0.26–0.69), CS+AT (HR 0.44, 95% CI: 0.36–0.77), CRT (HR 0.48, 95% CI: 0.35–0.67), and RT (HR, 0.66 95% CI: 0.46–0.94) were associated with decreased likelihood of death compared to NT. Elderly patients and those with poor performance status had worse outcomes even on multivariate analysis.
Conclusions
TSCC is increasingly treated with surgery and systemic therapy in addition to RT, with improved survival outcomes. CS, CS+AT, CRT, or RT provided improved survival advantage in patients with variable levels of improvement based on the extent of the disease. Prospective trials would help differentiate survival advantages between treatment modalities. Patients’ goals of care, comorbidities, and age should be considered when deciding appropriate treatment recommendations.
Level of Evidence
NA Laryngoscope, 130:405–412, 2020

Treatment modalities in sinonasal mucosal melanoma: A national cancer database analysis

20-01-2020 – Ashwin Ganti, Anish Raman, Aryan Shay, Hannah N. Kuhar, Samuel R. Auger, Tirth Patel, Edward C. Kuan, Aidnag Z. Diaz, Pete S. Batra, Bobby A. Tajudeen

Journal Article

Objectives/Hypothesis
The purpose of this study was to investigate the association of demographic factors, tumor stage, and treatment modalities for overall survival in patients with sinonasal mucosal melanoma (SNMM).
Study Design
Retrospective database review.
Methods
The National Cancer Database was queried for patients of all ages with SNMM between 2004 and 2015. Univariate Kaplan‐Meier and multivariate Cox regression analyses were performed to evaluate the association of suspected prognostic factors with overall survival.
Results
A total of 1,874 patients with SNMM were included in the analysis. The 5‐year overall survival was 24%. Prognostic factors associated with decreased survival include advanced age (hazard ratio HR: 1.02, 95% confidence interval CI: 1.01‐1.03), T4 disease (HR: 1.44, 95% CI: 1.09‐1.89), and presence of distant metastases (HR: 3.22. 95% CI: 2.06‐5.04). Improved survival was associated with surgical resection only when margins were negative (HR: 0.44; 95% CI: 0.30‐0.65). In patients with metastatic disease, administration of immunotherapy (HR: 0.14; 95% CI: 0.04‐0.49) was associated with improved survival. Surgical approach, radiotherapy, and chemotherapy were nonsignificant predictors of survival.
Conclusions
This investigation is the largest to date to analyze the association of treatment modalities with overall survival in SNMM. Surgery remains the mainstay of treatment in patients with SNMM. However, administration of immunotherapy may confer survival benefit to patients with metastatic disease.
Level of Evidence
NA Laryngoscope, 130:275–282, 2020

Rapid in‐field failures following adjuvant radiation for buccal squamous cell carcinoma

20-01-2020 – Oren Factor, William Su, Stanislav Lazarev, Brett Miles, Eric Genden, Sonam Sharma, Vishal Gupta, Krzysztof Misiukiewicz, Richard L. Bakst

Journal Article

Objectives/Hypothesis
Squamous cell carcinoma originating in the buccal mucosa and retromolar trigone (RMT) have historically poor outcomes. Difficulties in discriminating tumor origin often result in these subsites being combined in surgical and pathological reports. We aimed to determine if making this anatomical distinction has implications for treatment design and clinical outcomes.
Study Design
Retrospective case series.
Methods
We identified 27 tumors from either the buccal mucosa patients or RMT patients who underwent surgery followed by radiation. For patients who developed a local failure, we fused the pretreatment imaging, simulation computed tomography, and follow‐up imaging to determine the location of failures relative to the radiation field. We calculated the 2‐year locoregional control and 2‐year disease‐free survival.
Results
The median time from surgery to radiation was 50 days (range, 32–133 days). The 2‐year locoregional control for buccal mucosa versus RMT, respectively, were 35.9% versus 68.4% (P = .252). The 2‐year disease‐free survival rates were 32.7% versus 68.4%, respectively (P = .196). The median times to failure were 12.00 months (range, 4.9–115.0 months) versus 18.5 months (range, 4.5–61.0 months), respectively. All buccal mucosa failures occurred within the high‐dose planning target volume, with a median dose of 60 Gy within the failure region. Following locoregional failure, 10 of the 12 patients have died, with a median time from local failure to death of 3.6 months (range, 1–17.6 months).
Conclusions
Squamous cell carcinomas of the buccal mucosa appear to have a poor prognosis characterized by rapid in‐field failure. Therefore, differentiating tumor origin may be important for prognostication and treatment.
Level of Evidence3 Laryngoscope, 130:413–417, 2020

Congenital laryngomalacia: Is it an inflammatory disease? The role of vitamin D

20-01-2020 – Megahed M. Hassan, Ahmed M. Emam, Ahmed M. Mahmoud, Al Husseiny Awad, Ibrahim Rezk, Ashraf Abou‐Taleb, Montasser M. Mohamed, Essam A. A. El‐Magd

Journal Article

Objectives/Hypothesis
Laryngomalacia is the most common cause of stridor in infants. The exact pathophysiology is still not well understood. Our objective was to investigate whether laryngomalacia is an inflammatory disease, focusing on the possible role of vitamin D.
Study Design
Case‐control study.
Methods
Sixty Egyptian infants and 60 mothers were included in this study. They were divided into four equal groups (n = 30 for each): infants with laryngomalacia (LM‐infants), control infants (C‐infants), mothers of the infants with laryngomalacia (LM‐mothers), and mothers of the control infants (C‐mothers). Laryngoscopy was performed and serum 25‐hydroxyvitamin D (25OH‐vitamin‐D) and interleukin 6 (IL‐6) were estimated.
Results
Significant increase of serum IL‐6 associated with a significant decrease in serum 25(OH)‐vitamin D was observed in the LM‐infants compared to the C‐infants (P < .001 for both). LM‐mothers had significantly lower 25(OH)‐vitamin D status compared to C‐mothers (P < .001).
Conclusions
Deficiency of 25(OH)‐vitamin D in LM‐infants may result in dysregulation of the immune responses with elevation of a proinflammatory cytokine (IL‐6). Laryngomalacia could be an inflammatory disease due to 25(OH)‐vitamin D deficiency as evidenced by the high level of IL‐6. This finding may open the door to the appropriate prevention, diagnosis, and treatment, especially for moderate to severe laryngomalacia.
Level of Evidence3b Laryngoscope, 130:448–453, 2020

Quantifying vocal fold wound‐healing biomechanical property changes

20-01-2020 – Gregory R. Dion, Teja Guda, Shigeyuki Mukudai, Renjie Bing, Jean‐Francois Lavoie, Ryan C. Branski

Journal Article

Objectives
Development of novel vocal fold (VF) therapeutics is limited by a lack of standardized, meaningful outcomes. We hypothesize that automated microindentation‐based VF biomechanical property mapping matched to histology permits quantitative assessment.
Study Design
Ex vivo.
Methods
Twelve anesthetized New Zealand white rabbits underwent endoscopic right VF injury. Larynges were harvested/bisected day 7, 30, or 60 (n = 4/group), with four uninjured controls. Biomechanical measurements (normal force, structural stiffness, and displacement at 1.96 m
N) were calculated using automated microindentation mapping (0.3 mm depth, 1.2 mm/s, 2 mm spherical indenter) with a grid overlay (>50 locations weighted toward VF edge, separated into 14 zones). Specimens were marked/fixed/sectioned, and slides matched to measurement points.
Results
In the injury zone, normal force/structural stiffness (mean, standard deviation SD/mean, SD) increased from uninjured (2.2 m
N, 0.64/7.4 m
N/mm, 2.14) and day 7 (2.7 m
N, 0.75/9.0 m
N/mm, 2.49) to day 30 (4.3 m
N, 2.11/14.2 m
N/mm, 7.05) and decreased at 60 days (2.7 m
N, 0.77/9.1 m
N/mm, 2.58). VF displacement decreased from control (0.28 mm, 0.05) and day 7 (0.26 mm, 0.05) to day 30 (0.20 mm, 0.05), increasing at day 60 (0.25 mm, 0.06). A one‐way ANOVA was significant; Tukeys post hoc test confirmed day‐30 samples differed from other groups (P < 0.05), consistent across adjacent zones. Zones far from injury remained similar across groups (P = 0.143 to 0.551). These measurements matched qualitative histologic variations.
Conclusion
Quantifiable VF biomechanical properties can be linked to histology. This technological approach is the first to simultaneously correlate functional biomechanics with histology and is ideal for future preclinical studies.
Level of Evidence
NA Laryngoscope, 130:454–459, 2020

Identification of a Novel CNV at 8q13 in a Family With Branchio‐Oto‐Renal Syndrome and Epilepsy

20-01-2020 – Meichao Men, Wu Li, Hongsheng Chen, Jiayu Wu, Yong Feng, Hui Guo, Jia‐Da Li

Objectives
Branchio‐oto‐renal (BOR) syndrome is characterized by branchial defects, hearing loss, preauricular pits, and renal anomalies, whereas patients with all symptoms except renal defects are diagnosed as branchio‐oto (BO) syndrome. BOR/BO is one of the most common forms of autosomal dominant syndromic hearing loss, and EYA1 is the major causative gene. In this study, clinical and genetic analyses as well as auditory rehabilitation were performed in a Chinese family with BOR/BO syndrome.
Methods
Three affected individuals from a Chinese family were analyzed by whole exome sequencing (WES) to analyze the single nucleotide variants and copy number variations (CNVs). Whole genome sequencing was used to identify the breakpoints of CNVs; and quantitative polymerase chain reaction was utilized to verify the CNVs. Furthermore, cochlea implantation was performed in one patient to reconstruct hearing.
Results
A heterozygous 2.69 Mb deletion at chromosome 8q13 (chr8: 69582185‐72275725) cosegregates with the BOR/BO symptoms in this family, resulting in heterozygous loss of the EYA1 gene. In addition to typical BOR/BO symptoms, epilepsy or gastroesophageal reflux was observed in some patients. Cochlear implantation resulted in significant hearing improvement in one patient.
Conclusions
A novel deletion involving the whole EYA1 gene was identified by WES. To the best of our knowledge, epilepsy or gastroesophageal reflux was reported in BOR/BO patients for the first time, which expanded the BOR/BO phenotypes spectrum. Successful auditory rehabilitation can be achieved with cochlear implantations in some BOR/BO patients.
Level of Evidence4 Laryngoscope, 130:526–532, 2020

Pattern of cochlear obliteration after vestibular Schwannoma resection according to surgical approach

20-01-2020 – Yening Feng, John I. Lane, Christine M. Lohse, Matthew L. Carlson

Objectives/Hypothesis
To investigate the prevalence and course of cochlear obliteration according to microsurgical approach to inform clinical decision making regarding optimal timing of cochlear implantation.
Study Design
Retrospective radiologic review and chart review.
Methods
Patients who underwent microsurgical resection of vestibular schwannoma (VS) with a minimum of two available postoperative magnetic resonance imaging (MRI) scans were analyzed. The prevalence and timing of cochlear and labyrinthine obliteration was classified using relevant MRI sequences.
Results
MRI studies in 60 patients were analyzed: 20 translabyrinthine (TL), 20 retrosigmoid, and 20 middle fossa (MF) cases. The first and last postoperative MRI was obtained a median of 3.4 months (interquartile range (IQR), 3.0–3.7 months) and 35 months (IQR, 27–83 months) after surgery, respectively. At the time of the first postoperative MRI, 21 (35%) patients had partial basal turn obliteration, and none of the patients had complete basal turn obliteration. At the time of the last postoperative MRI, six (10%) patients had partial basal turn obliteration and 17 (28%) patients had complete basal turn obliteration. The pattern of partial or complete basal turn obliteration differed significantly among all three surgical approaches (P < .001). Specifically, the risk of partial or complete obliteration of the basal turn was highest in the TL cohort and lowest in the MF cohort.
Conclusions
The prevalence and timing of cochlear obliteration after VS microsurgery varies significantly according to surgical approach. The risk of early and complete obliteration is highest in the TL group and lowest in the MF cohort. These data may inform clinical decision making regarding optimal timing of cochlear implantation in patients with advanced hearing loss after microsurgical resection.
Level of Evidence4 Laryngoscope, 130:474–481, 2020

From presumed benign neck masses to delayed recognition of human papillomavirus–positive oropharyngeal cancer

20-01-2020 – “Ruth J. Davis, Eleni Rettig, Nafi Aygun, Lisa Rooper, Gypsyamber DSouza, David W. Eisele, Carole Fakhry”

Journal Article

Objectives/Hypothesis
To describe patients with delayed diagnosis of human papillomavirus–positive oropharyngeal squamous cell carcinoma (HPV‐OPC) after initial incorrect diagnosis of branchial cleft cyst or nondiagnostic workup of unilateral neck mass.
Study Design
Retrospective case series.
Methods
Patients with delayed diagnosis of HPV‐OPC after initial nondiagnostic workup for unilateral neck mass were eligible. Medical record abstraction was performed to describe clinical characteristics at initial presentation and later diagnosis of HPV‐OPC. To estimate nodal growth rates, the short axis diameter of the lymph nodes was determined from imaging reports.
Results
Six patients met eligibility criteria. After a median interval of 42 months (range, 3 months–7 years) from initial presentation with unilateral neck mass, patients were diagnosed with HPV‐OPC. At the time of HPV‐OPC diagnosis, five were AJCC eighth edition overall stage I, and one was stage II. Primary tumors were T0 or T1 in the majority (83.3%, n = 5). Among five patients with available serial imaging, despite diagnostic delay, three of five still had a single lymph node without involvement of additional nodes, whereas the remaining two developed additional suspicious nodes (ipsilateral and contralateral). Two of five developed evidence of extranodal extension. Median lymph node growth was 9.5% per year (range, −6% to 32%).
Conclusions
Although the natural history of HPV‐OPC is not well understood, this case series suggests that it can be slow growing and mimic benign processes, leading to diagnostic delays. Adults presenting with neck masses should undergo complete diagnostic evaluation.
Level of Evidence4 Laryngoscope, 130:392–397, 2020

Safety and reliability of a handheld stimulator for neural monitoring during thyroid surgery

20-01-2020 – Bradley R. Lawson, Dipti Kamani, Mohamed Shama, Natalia Kyriazidis, Gregory W. Randolph

Journal Article

Objective
The Checkpoint nerve stimulator (Checkpoint Surgical, Cleveland, OH) is a U.
S. Food and Drug Administration‐approved device for neural localization and monitoring during surgery. Its safety, efficacy, and reliability for neural monitoring during thyroid and parathyroid surgery have not been compared to more standard formats of neural monitoring.
Study Design
Retrospective review.
Methods
Vagal, recurrent, and superior laryngeal nerve monitoring were performed using both the Checkpoint stimulator and Medtronic NIM 3.0 laryngeal electromyography endotracheal tube (Medtronic, Jacksonville, FL) during thyroid and parathyroid surgery. A total of 21 operated sides in 15 patients were included for analysis. Latency and amplitude data for the Checkpoint stimulator were recorded using the NIM monitor and compared to normative endotracheal tube surface electrode data.
Results
Mean amplitude using the Checkpoint stimulator was 574.6 microvolts (μV), 1060.6 μV, and 182.8 μV for the vagus, recurrent laryngeal, and superior laryngeal nerves, respectively. Mean amplitude using standard laryngeal electromyography was 709 μV, 1077.0 μV, and 183.7 μV for the same nerves. Mean latency was significantly shorter with stimulation of the recurrent laryngeal nerve compared to the vagus nerve with both stimulators (P < 0.001). No neural injuries occurred during the study.
Conclusion
The Checkpoint stimulator is a safe and reliable alternative to traditional laryngeal electromyography providing equivalent induced electromyography of the vocalis for neural monitoring during thyroid and parathyroid surgery.
Level of Evidence4 Laryngoscope, 130:561–565, 2020

Industry Payments for Otolaryngology Research: A Four‐Year Analysis of the Open Payments Database

20-01-2020 – Philip R. Brauer, Elliot Morse, Saral Mehra

Journal Article

Objective
To characterize industry research payments to otolaryngologists.
Study Design
Cross‐sectional retrospective analysis.
Methods
We examined research payments made to otolaryngologists 2014 through 2017 included in the Open Payments Database. Trends in payment values over time were characterized and compared to other surgical specialties. Geographical and temporal trends in payments to specific principal investigators, along with the ties to specific companies, were analyzed.
Results
Among surgical specialties, otolaryngology was the second lowest paid in terms of total compensation from industry for research per active U.
S. physician. The median (mean) payment to otolaryngologists was $819 ($5,514), $548 ($3,083), $771 ($3,484), and $1,000 ($5,768) in 2014, 2015, 2016, and 2017, respectively. There was typically a higher mean and median payment per otolaryngologists in the Northeast, although significant differences between each region varied by year. The 40 most highly funded recipients had total compensation that was on average spread over 3.35 years of the database, 2.975 different companies, and 7.35 distinct scientific studies—all significantly higher compared to otolaryngologists with less funding.
Conclusion
Research payments to otolaryngologists are concentrated in a small number of otolaryngologists; however, many of the most highly funded principal investigators worked on numerous studies with a variety of different companies over many years. Our characterization of the Open Payments Database over 4 years illustrates the depth of relationship between otolaryngology research and industry as well as raises awareness regarding the ease of connecting otolaryngologists to research payments.
Level of Evidence
NA Laryngoscope, 130:314–320, 2020

Physiologic Model for Seasonal Patterns in Flu Transmission

20-01-2020 – Ryan S. Ference, James A. Leonard, Howard D. Stupak

Seasonal patterns in flu transmission have observational validity in temperate climates. However, there is no consensus mechanism explaining the increased incidence of flu during the winter. The physiologic effects of cold weather and dry air on the upper respiratory system may contribute to immune dysfunction and increased susceptibly to flu‐causing pathogens. Low temperature limits the absolute humidity of air. Persistent exposure to dry air leads to airway desiccation and failure of the mucociliary system. The resultant physiologic and histopathologic changes that occur in the airway increase susceptibility to flu‐causing pathogens. Laryngoscope, 130:309–313, 2020

Clinical Value of Fused PET/MRI for Surgical Planning in Patients With Oral/Oropharyngeal Carcinoma

20-01-2020 – Kazuki Hayashi, Masahiro Kikuchi, Yukihiro Imai, Daisuke Yamashita, Megumu Hino, Kyo Ito, Keiji Shimizu, Hiroyuki Harada, Shogo Shinohara

Objectives/Hypothesis
To evaluate the usefulness of fused positron emission tomography (PET)/magnetic resonance (MR) images for surgical planning in patients with oral/oropharyngeal cancer and suspected mandibular invasion.
Study Design
Individual cohort study.
Methods
Eleven of 17 patients with suspected mandibular invasion of squamous cell carcinoma of the lower gingiva, oropharynx, and buccal mucosa who underwent 18F‐fluorodeoxyglucose (FDG) PET/computed tomography (CT) and contrast‐enhanced MR imaging (MRI) and had fused PET/MR images were enrolled in this study. The area for surgical resection was determined based on the fused images. The usefulness of these images was confirmed by comparing them with the histopathologic findings in the resected tumors.
Results
Histopathologic evaluation of the surgical specimens revealed that nine of the 11 patients had invasion into the mandible and/or medial pterygoid muscle. All patients had a negative surgical margin. The sensitivity and specificity for detection of mandibular/medial pterygoid muscle invasion was 100%/40% and 83%/100% by fused PET/MRI, respectively, and 100%/20% and 100%/60% by PET/CT, respectively. Interobserver reproducibility between two radiologists/nuclear medicine physicians and two head and neck surgeons showed that the only statistically significant κ values were for PET/MRI.
Conclusions
PET/MRI can be easily understood by head and neck surgeons, who are not diagnostic imaging professionals, and can be used when planning the area to be surgically resected in patients with oral/oropharyngeal cancer and clinically suspected mandibular invasion. Considering the expense of a hybrid PET/MRI system, creation of a fused PET/MR image would provide a reasonable and reliable tool for clinical use in these patients.
Level of Evidence2b Laryngoscope, 130:367–374, 2020

Practice patterns of reflux medication prescriptions in otolaryngology compared to other specialties

20-01-2020 – Friederike S. Luetzenberg, Nancy Jiang

Objectives/Hypothesis
To describe the trends in proton pump inhibitor (PPI) prescription rates and durations and compare them to those of H2‐receptor antagonists (H2RAs) between 2013 and 2016 in otolaryngology, gastroenterology, and family practice, following the increasing publications on PPI adverse effects and inappropriate prescribing.
Study Design
Retrospective review of publicly available Medicare Part D prescribing data.
Methods
PPI and H2RA prescription and beneficiary data were obtained through the Centers for Medicare and Medicaid Services website. For prescription rates, 30‐day fill counts were analyzed nationally and regionally per 10,000 Medicare members. Days supply per beneficiary was examined to show average prescription durations. Results were compared between otolaryngology, gastroenterology, and family practice. Medication‐related economic burden per year was calculated based on reported drug cost.
Results
From 2013 to 2016, PPI 30‐day fill counts remained stable, whereas H2RA prescription rates increased by up to 62% per 10,000 Medicare beneficiaries. The South consistently prescribed two to three times as much antireflux medication as the lowest prescribing region over time and across all three specialties. The days supply per beneficiary remained stable and ranged from an average of 128 to 203 days depending on the specialty. Antireflux medication‐related healthcare cost decreased steadily.
Conclusions
Despite numerous publications describing a multitude of adverse events and inappropriate prescribing patterns of PPIs in the past decade, prescription rates and durations per beneficiary have remained stable in the fields of otolaryngology, gastroenterology, and family practice. Additionally, H2RA prescriptions have increased from 2013 to 2016.
Level of Evidence
NA Laryngoscope, 130:321–327, 2020

Risks and complications of thyroglossal duct cyst removal

20-01-2020 – Jennifer L. Anderson, Kimberly Vu, Yarah M. Haidar, Edward C. Kuan, Tjoson Tjoa

Objectives/Hypothesis
Thyroglossal duct cysts (TGDCs) are the most common congenital neck cyst and typically present in childhood or adolescence, although a subset remains asymptomatic until adulthood. Although treatment involves surgical excision, few large‐scale studies exist regarding the risks of surgical treatment of TGDCs in adults. This study aims to describe the characteristics of adult patients undergoing TGDC excision and to analyze risk factors associated with reoperation or other postoperative complications.
Study Design
Retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.
Methods
Patients age ≥ 18 years in the NSQIP database who underwent TGDC removal from 2005 to 2014 were included. Covariates included patient demographics, comorbidities, preoperative variables, and intraoperative variables. Outcomes included reoperation, complications, and length of hospital stay.
Results
A total of 793 cases met inclusion criteria. Patients were predominantly female (57.0%) and white (64.3%), with a mean age of 44.3 years. Thirty‐day mortality did not occur in this cohort, but 3.0% of patients experienced at least one complication. Forty‐eight patients (6.1%) underwent reoperation. Wound infection rates were higher in revision operations compared with primary operations (8.3% and 0.9%, respectively; P = .003). Low preoperative sodium was associated with reoperation (P = .047). Additionally, length of hospital stay was associated with increased total operative time (P = .02).
Conclusions
TGDC excision is a safe and well‐tolerated procedure in the adult population, with low complication rates. However, the risk of reoperation, surgical‐site infections, and medical complications should be taken into consideration during preoperative planning.
Level of Evidence
NA Laryngoscope, 130:381–384, 2020

Chemical receptors of the arytenoid: A comparison of human and mouse

20-01-2020 – Marie E. Jetté, Matthew S. Clary, Jeremy D. Prager, Thomas E. Finger

Objectives/Hypothesis
The larynx is a highly responsive organ exposed to mechanical, thermal, and chemical stimuli. Chemicals elicit responses both in intraepithelial nerve fibers and in specialized chemosensory cells, including scattered solitary cells as well as taste cells organized into taste buds. Activation of both chemosensory cells and taste buds in the larynx elicit cough, swallow, or apnea with exposure to sour or bitter substances, and even by water or sweet‐tasting chemicals. In an effort to begin understanding their function, we sought to compare the distribution, density, and types of chemosensory cells and chemoresponsive nerve fibers in laryngeal epithelium of humans and mice.
Study Design
Animal and human laboratory analysis.
Methods
Using immunohistochemistry, we identified taste cells and polymodal nociceptive nerve fibers in the arytenoid area of the laryngeal epithelium of the following: 1) infants undergoing supraglottoplasty for laryngomalacia, and 2) a cadaveric specimen procured from a 34‐year‐old donor. We then compared these findings to both preweanling and mature mouse tissue.
Results
Arytenoid tissue from both human and mouse contained many taste buds containing type II taste cells—bitter, sweet, or umami sensing—which were innervated by nerve fibers expressing P2X3 type adenosine triphosphate receptors. Type III cells (acid responsive) were also present, but they were fewer in human tissue than in equivalent tissue from mice. In both species, the epithelium was densely innervated by free nerve endings.
Conclusions
Our findings suggest that from a standpoint of chemosensation, human and mouse larynges are biologically similar. This suggests that a murine model can be used effectively in laryngeal chemosensory research.
Level of Evidence
NA Laryngoscope, 130:423–430, 2020

Measuring the health utility of chronic eustachian tube dysfunction

20-01-2020 – Meron Teklu, Marta Kulich, Alan G. Micco, Kristin Brindisi, Andrew Ferski, Katherine Niekamp, Caroline P.E. Price, Bruce K. Tan

Objective
To assess the health utility of chronic Eustachian tube dysfunction (ETD).
Methods
This is a prospective study of 53 patients with chronic ETD recruited from a tertiary clinic from April 2017 to July 2018. The 7‐Item Eustachian Tube Dysfunction Questionnaire (ETDQ‐7) was administered, and health utility was evaluated using the Euro
Qol‐5 Dimensions‐3 Level Instrument (EQ‐5D‐3L), the visual analogue scale (VAS), time tradeoff (TTO), and standard gamble (SG). Participants were grouped into medical or procedural management groups. One‐week follow‐up included repeated health utility measures and ETDQ‐7.
Results
Fifty‐three patients were included in the final analysis. Of those, 34 were managed medically, and 19 received myringotomies ± PE tubes. The mean baseline ETDQ‐7 was 4.26 ± 1.31; whereas health utility measures were different depending on the method utilized: EQ‐5D‐3L 0.90 ± 0.11; VAS 0.76 ± 0.21; TTO 0.85 ± 0.23; and SG 0.94 ± 0.11 (P < .001). There was a significant change in ETDQ‐7 (P = .001) and TTO (P = .011) scores posttreatment. On the ETDQ‐7, question 2 (pain in the ears) was significantly associated with VAS (P = .032), and question 4 (ear symptoms during a cold or sinusitis) was significantly associated with TTO (P = .006).
Conclusion
Chronic ETD has a significant burden on quality of life, with a health utility similar to gastroesophageal reflux disease and moderate asthma. Although treatment‐related changes are measurable using disease‐specific quality‐of‐life measures, only TTO was significantly changed after treatment. Health utility seemed to depend on the method of measurement but provided a benchmark for evaluating cost‐effectiveness of innovations to manage ETD.
Level of Evidence2 Laryngoscope, 130:E39–E44, 2020

Treatment modality impact on quality of life for human papillomavirus–associated oropharynx cancer

20-01-2020 – Mary Jue Xu, Karolina A. Plonowska, Zev R. Gurman, Amanda K. Humphrey, Patrick K. Ha, Steven J. Wang, Ivan H. El‐Sayed, Chase M. Heaton, Jonathan R. George, Sue S. Yom, Alain P. Algazi, William R. Ryan

Objectives/Hypothesis
Compare treatment‐related quality of life (QOL) impact for early‐stage human papillomavirus–associated oropharynx squamous cell carcinoma (HPV+ OPSCC) patients.
Study Design
Retrospective cohort at a tertiary center.
Methods
Stage I (T0‐2/N0‐1) HPV+ OPSCC patients (n = 76) with pretreatment Karnofsky scores ≥80 reported QOL after surgery alone (n = 17, 22%), surgery with adjuvant radiation ± chemotherapy (S‐a
CXRT) (n = 23, 30%), or definitive radiation ± chemotherapy (d
CXRT) (n = 36, 47%) with the University of Washington QOL version 4 (UW‐QOL); European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, Core Module (EORTC QLQ‐C30) and Head and Neck Module (EORTC QLQ‐HN35); University of Michigan Xerostomia, and Neck Dissection Impairment Index questionnaires (median follow‐up = 2.2 years, interquartile range = 1.0–4.2 years). Treatment adverse events and gastrostomy tube rates were assessed.
Results
Over 87% of each treatment group reported good or better overall QOL. Each group had low gastrostomy tube and treatment‐specific complication rates. S‐a(C)XRT and d(C)XRT patients had similar mean scores with wide ranges for most individual and all composite categories. S‐a(C)XRT compared to d(C)XRT patients reported significantly fewer dental problems (EORTC QLQ‐C30/HN35 means = 10.1 vs. 34.3, P = .007), worse appearance (UW‐QOL means = 72.8 vs. 82.6, P = .02), and worse coughing (EORTC QLQ‐C30/HN35 means = 31.9 vs. 15.7, P = .007). Surgery alone compared to d(C)XRT and S‐a(C)XRT patients reported significantly better salivary/taste/oral functions and less pain, financial, oral/dental, and sexual problems.
Conclusions
For early‐stage HPV+ OPSCC, patients usually achieve acceptable QOL regardless of treatment. S‐a(C)XRT and d(C)XRT patients report generally similar QOL including neck/shoulder pain/function, but with a wide range in a limited patient sample. Surgery alone should be considered, when oncologically and functionally safe, given the better associated QOL.
Level of Evidence4 Laryngoscope, 130:E48–E56, 2020

The impact of expanded endonasal skull base surgery on midfacial growth in pediatric patients

20-01-2020 – Arjun K. Parasher, David K. Lerner, Jordan T. Glicksman, Phillip B. Storm, John Y.K. Lee, Arastoo Vossough, Steven Brooks, James N. Palmer, Nithin D. Adappa

Journal Article

Objective
Surgical resection of skull base tumors in children is increasingly accomplished through an expanded endonasal approach (EEA). We aim to evaluate the potential effect of the EEA on midfacial growth as a result of iatrogenic damage to nasal growth zones.
Methods
We performed a retrospective review of children undergoing craniopharyngioma resection via an open transcranial or EEA. Pre‐ and postoperative magnetic resonance imaging was evaluated for growth in four midfacial measurements based on established cephalometric landmarks: anterior midface height, posterior midface height, palatal length, and sella–nasion distance. Statistical analysis was conducted using a mixed‐effects linear regression model.
Results
Twenty‐two patients underwent an EEA (n = 12) or open transcranial approach (n = 10) for tumor resection with 3 years of imaging follow‐up. There was no difference in midfacial growth between groups for each measurement. Compared to the open group, patients undergoing EEA demonstrated relative anterior midface height growth of −0.42 mm (P = 0.880), posterior midface height growth of −0.44 mm (P = 0.839), palatal length growth of 0.35 mm (P = 0.894), and sella–nasion distance growth of −2.16 (P = 0.365).
Conclusion
We found no difference in midfacial growth measurements between patients undergoing craniopharyngioma resection via an EEA and the open transcranial route after 3 years of imaging follow‐up. Preliminary results on midfacial growth demonstrate that the EEA is a safe alternative to traditional transcranial approaches for the pediatric population. Further investigation with larger sample size and longer duration of follow‐up is warranted to more thoroughly investigate the long‐term implications of the EEA to the skull base.
Level of Evidence3 Laryngoscope, 130:338–342, 2020

A 3D‐printed polycaprolactone/β‐tricalcium phosphate mandibular prosthesis: A pilot animal study

20-01-2020 – Jae Hong Park, Soo Yeon Jung, Chi‐Kyou Lee, Myung Jin Ban, Sang Jin Lee, Ha Yeong Kim, Hyun Ju Oh, Byeong Kook Kim, Hae Sang Park, Si‐Hyong Jang, Han Su Kim

Objective
In this study, we assessed the effectiveness of a tonsil‐derived mesenchymal stem cell (TMSC)‐transplanted polycaprolactone/beta‐tricalcium phosphate prosthesis (specifically designed for easier fixing and grafting with a single scaffold) on rabbit mandible osteogenesis.
Methods
The mandibles of 18 rabbits were exposed, and 10 × 8‐mm bone defects were made. Two rabbits did not receive implants; four were reconstructed with the scaffold control (SC) (SC group); four were reconstructed with scaffolds soaked in peripheral blood (PB) (PB group); four were reconstructed with TMSC‐transplanted scaffolds (TMSC group); and four were reconstructed with differentiated osteocyte‐transplanted scaffolds (DOC) (DOC group). Each rabbit was sacrificed 12 weeks after surgery, and the area of new bone formation was investigated by mechanical testing, histology, and micro‐computed tomography.
Results
More extended and denser new bone masses were observed in the TMSC and DOC groups, although fibrosis and vascular formation levels were similar in all groups, suggesting that the dual‐structured scaffold alone provides a good environment for bone attachment and regeneration. The bone volumes of representative scaffolds from the SC, PB, TMSC, and DOC groups were 43.12, 48.35, 53.10, and 57.44% of the total volumes, respectively.
Conclusion
The design of the scaffold resulted in effective osteogenesis, and TMSCs showed osteogenic potency, indicating that their combination could enable effective bone regeneration.
Level of Evidence
NA Laryngoscope, 130:358–366, 2020

Multi‐Year Effect of Human Papillomavirus Vaccination on Recurrent Respiratory Papillomatosis

20-01-2020 – Hiroumi Matsuzaki, Kiyoshi Makiyama, Ryoji Hirai, Hirotaka Suzuki, Ryohei Asai, Takeshi Oshima

Journal Article

Objective
To examine whether human papilloma virus (HPV) vaccination in combination with surgical resection could suppress recurrence for an extended period of time in patients with recurrent respiratory papillomatosis (RRP).
Methods
In a prospective case series, data of patients who received combination therapy comprising surgery and quadrivalent HPV vaccination (Gardasil; Merck & Co., West Point, PA) were collected. Patients were followed up for RRP from March 2012 to July 2018 in an academic tertiary care center. The patients comprised 16 adults with RRP who were observed for >12 months after HPV vaccination, and whose HPV‐DNA status was tested before and for >12 months after completion of combination therapy. The outcomes of this study were the severity score of larynx disease, tumor incidence rate, and relationship between this rate and HPV‐DNA negative conversion after therapy.
Results
The severity score of laryngeal disease significantly decreased from before combination therapy to the time of final examination (P = 0.00045). The tumor incidence rate decreased to approximately 20% during the period from 12 to 47 months after HPV vaccination. Regarding HPV‐DNA status in the final test results of each patient, 12 of 16 (75%) patients showed negative conversion; these 12 were significantly less likely to experience recurrence than patients who persistently tested positive for HPV‐DNA during the period between 12 and 47 months after vaccination.
Conclusion
HPV vaccination prevented recurrence associated with RRP surgery for 4 years in 80% of patients. This may be an effective adjuvant therapy, and HPV‐DNA negative conversion after HPV vaccination might predict prevention of recurrence.
Level of Evidence2 Laryngoscope, 130:442–447, 2020

Does drug‐induced sleep endoscopy affect surgical outcome? A multicenter study of 326 obstructive sleep apnea patients

20-01-2020 – Kenny P. Pang, Peter M. Baptista, Ewa Olszewska, Itzhak Braverman, Marina Carrasco‐Llatas, Srivinas Kishore, Sudipta Chandra, Hyung Chae Yang, Cybil Mei Zhi Wang, Yiong Huak Chan, Kathleen A. Pang, Edward B. Pang, Brian Rotenberg

Journal Article

Objectives/Hypothesis
Our objective was to determine whether drug‐induced sleep apnea (DISE) affects the successfulness of the surgical outcome.
Study Design
Prospective, seven‐country, nonrandomized trial.
Methods
There were 326 consecutive obstructive sleep apnea (OSA) patients who had nose, palate, and/or tongue surgery included in the study. DISE was performed in only one group.
Results
There were 170 patients in the DISE group and 156 patients in no‐DISE group. The mean preoperative body mass index (BMI) for the DISE group was 27.6 ± 4.6, whereas in the no‐DISE group it was 28.1 ± 3.9 (P = .23). The mean preoperative systolic blood pressure (SBP) for the DISE group was 130.4 ± 16.7, whereas in the no‐DISE group it was 142.9 ± 15.5 (P < .001). The mean preoperative diastolic blood pressure (DBP) for the DISE group was 81.4 ± 9.7, whereas in the no‐DISE group it was 89.1 ± 9.7 (P < .001). The mean preoperative apnea‐hypopnea index (AHI) for the DISE group was 32.6 ± 18.8, whereas in the no‐DISE group it was 33.7 ± 19.6 (P = .61). The mean postoperative AHI for the DISE group was 15.9 ± 12.6, whereas in the no‐DISE group it was 13.2 ± 8.8 (P = .023). The age‐, gender‐, BMI‐adjusted percentage change in AHI for the DISE group was −48.4 ± 31.9, whereas in the no‐DISE group it was −59.8 ± 18.6 (P < .001). The age‐, gender‐, and BMI‐adjusted success rate for the DISE group was 66.5%, whereas in the no‐DISE group it was 80.8% (P = .004). The age‐, gender‐, and BMI‐adjusted change in SBP for the DISE group was −6.1 ± 8.6, whereas in the no‐DISE group it was −13.3 ± 11.1 (P < .001). The age‐, gender‐, and BMI‐adjusted change in DBP in the DISE group was −5.2 ± 12.1, whereas in the no‐DISE group it was −12.4 ± 11.7 (P < .001). The mean age‐ and gender‐adjusted change in BMI for the DISE group was −4.6 ± 12.9, whereas in the no‐DISE group it was −6.3 ± 18.5 (P = .34). The Cohen effect of BMI on the overall AHI, lowest oxygen saturation, and blood pressure changes was 0.08.
Conclusions
DISE may not significantly affect surgical success in OSA.
Level of Evidence2c Laryngoscope, 130:551–555, 2020

Phantom odor perception and vascular conditions among adults in the United States: National Health and Nutrition Examination Survey 2011–2014

20-01-2020 – Kathleen E. Bainbridge, Danita Byrd‐Clark

Objectives/Hypothesis
Phantom odor perception has been correlated with burden of vascular risk among older adults. We evaluated associations between vascular conditions and phantom odor perception among adults in the United States.
Study Design
Cross‐sectional analysis.
Methods
Cross‐sectional data were collected as part of the 2011 to 2014 National Health and Nutrition Examination Survey, yielding a nationally representative sample of 7,417 adults aged 40 years and older. Phantom odor perception was defined as report of an unpleasant, bad, or burning odor when nothing is there. Participants reported on vascular conditions including history of stroke. Total cholesterol and glycated hemoglobinwere measured. High blood pressure was ascertained during an examination.
Results
Stroke was associated with a 76% greater likelihood of phantom odor perception. Congestive heart failure and angina were associated with three times and 2.8 times the odds of phantom odor perception among adults 40 to 59 years and 60 years and older, respectively. Adults with diagnosed, but controlled, high cholesterol reported phantom odors more frequently than those without high cholesterol. Adults with diagnosed, but controlled, high blood pressure reported phantom odors more frequently than those without high blood pressure. We observed a threefold greater odds of phantom odor perception among adults aged 60 years and older with diabetes, but only among those who use both insulin and oral medications.
Conclusions
Stroke, angina, congestive heart failure, well‐managed high blood pressure, and well‐managed high cholesterol are associated with phantom odor perception. Vascular or metabolic conditions or their treatments may contribute to reporting of phantom odor perception.
Level of Evidence
NA Laryngoscope, 130:332–337, 2020

Innovative management of severe tracheobronchomalacia using anterior and posterior tracheobronchopexy

20-01-2020 – Claire Lawlor, Charles Jason Smithers, Thomas Hamilton, Christopher Baird, Reza Rahbar, Sukgi Choi, Russell Jennings

Objectives/Hypothesis
Combined anterior and posterior tracheobronchopexy is a novel surgical approach for the management of severe tracheobronchomalacia (TBM). We present our institutional experience with this procedure. Our objective was to determine the utility and safety of anterior and posterior tracheopexy in the treatment of severe TBM.
Study Design
Retrospective chart review.
Methods
All patients who underwent anterior and posterior tracheopexy from January 2013 to July 2017 were retrospectively reviewed. Charts were reviewed for indications, preoperative work‐up, tracheobronchomalacia classification and severity, procedure, associated syndromes, synchronous upper aerodigestive tract lesions, and aberrant thoracic vessels. Main outcomes measured included improvement in respiratory symptoms, successful extubation and/or decannulation, vocal fold immobility, and new tracheotomy placement.
Results
Twenty‐five patients underwent anterior and posterior tracheopexy at a mean age of 15.8 months (range, 2–209 months; mean, 31 months if 2 outliers of 206 and 209 months included). Mean length of follow‐up was 26.8 months (range, 13–52 months). Indications for surgery included apneic events, ventilator dependence, need for positive pressure ventilation, tracheotomy dependence secondary to TBM, recurrent pneumonia, and exercise intolerance. Many patients had other underlying syndromes and synchronous upper aerodigestive tract lesions (8 VACTERL, 2 CHARGE, 1 trisomy 21, 1 Feingold syndrome, 17 esophageal atresia/tracheoesophageal fistula, 20 cardiac/great vessel anomalies, 1 subglottic stenosis, 1 laryngomalacia, 7 laryngeal cleft). At preoperative bronchoscopy, 21 of 25 patients had >90% collapse of at least one segment of their trachea, and the remaining four had 70% to 90% collapse. Following anterior and posterior tracheopexy, one patient developed new bilateral vocal‐fold immobility; one patient with a preoperative left cord paralysis had a new right vocal‐fold immobility. Postoperatively, most patients had significant improvement in their respiratory symptoms (21 of 25, 84%) at most recent follow‐up. Three patients with preexisting tracheotomy were decannulated; two patients still had a tracheotomy at last follow‐up. Two patients required new tracheotomy for bilateral vocal‐fold immobility.
Conclusions
Combined anterior and posterior tracheopexy is a promising new technique for the surgical management of severe TBM. Further experience and longer follow‐up are needed to validate this contemporary approach and to minimize the risk of recurrent laryngeal nerve injury.
Level of Evidence4 Laryngoscope, 130:E65–E74, 2020

Three‐dimensional assessment of the pharyngeal airway in Japanese preschoolers with orofacial clefts

20-01-2020 – Masahiro Takahashi, Tetsutaro Yamaguchi, Myoung K. Lee, Yoko Suzuki, Mohamed Adel, Daisuke Tomita, Takatoshi Nakawaki, Hiroshi Yoshida, Yu Hikita, Mayu Furuhata, Misato Tsuneoka, Ryo Nagahama, Mary L. Marazita, Seth M. Weinberg, Koutaro Maki

Journal Article

Objectives/Hypothesis
Individuals with orofacial clefts often experience respiratory problems because of nasopharyngeal abnormalities. Pharyngeal airway morphology is thought to differ among the various cleft types. We measured three‐dimensional (3D) airway volume using cone‐beam computed tomography (CBCT) analysis to evaluate and compare pharyngeal airways in Japanese preschoolers with and without orofacial clefts.
Study Design
Retrospective case‐control study.
Methods
We enrolled 83 subjects (37 boys, 46 girls; mean age = 4.66 ± 0.56 years) with nonsyndromic orofacial clefts and 16 noncleft healthy subjects (seven boys, nine girls; mean age = 5.30 ± 0.52 years) as controls. The subjects were divided into five groups. Four groups were based on the cleft type: isolated cleft palate, unilateral cleft lip and alveolus), unilateral cleft lip and palate, and bilateral cleft lip and palate. The fifth group included the noncleft controls. All subjects were examined with CBCT, and the 3D airway volume was measured. We analyzed group differences statistically using analysis of covariance with the Bonferroni post hoc pairwise comparison tests for the corrected means.
Results
Compared with the noncleft group, each cleft group exhibited significantly decreased total and nasal airway volumes and increased superior and inferior pharyngeal airway volumes. The differences were all statistically significant.
Conclusions
Our findings suggest that anatomical differences exist in pharyngeal airway volumes among various cleft groups and in those without a cleft.
Level of Evidence3b Laryngoscope, 130:533–540, 2020

Computational Fluid Dynamics Analysis of Surgical Approaches to Bilateral Vocal Fold Immobility

20-01-2020 – Gabriel Rios, Robert J. Morrison, Yi Song, Shanik J. Fernando, Christopher Wootten, Alexander Gelbard, Haoxiang Luo

Objectives
Bilateral vocal fold immobility (BVFI) is a rare and life‐threatening condition in which both vocal folds are fixed, resulting in airway obstruction associated with life‐threatening respiratory compromise. Treatment of BVFI is largely surgical and remains an unsatisfactory compromise between voice, breathing, and swallowing. No comparisons between currently employed techniques currently exist. We sought to employ computational fluid dynamics (CFD) modeling to delineate the optimal surgical approach for BVFI.
Methods
Utilizing clinical computed tomography of BVFI subjects, coupled with image analytics employing CFD models and subject pulmonary function data, we compared the airflow features in the baseline pathologic states and changes seen between endoscopic cordotomy, endoscopic suture lateralization, and posterior cricoid expansion.
Results
CFD modeling demonstrated that the greatest airflow velocity occurs through the posterior glottis on inspiration and anterior glottis on expiration in both the normal condition and in BVFI. Glottic airflow velocity and resistance were significantly higher in the BVFI condition compared to normal. Geometric indices (cross‐sectional area of airway) were lower in posterior cricoid expansion surgery when compared to alternate surgical approaches. CFD measures (airflow velocity and resistance) improved with all surgical approaches but were superior with posterior cricoid expansion.
Conclusion
CFD modeling can provide discrete, quantitative assessment of the airflow through the laryngeal inlet, and offers insights into the pathophysiology and changes that occur after surgery for BVFI.
Level of Evidence
NA. Laryngoscope, 130:E57–E64, 2020

Insurance status, stage of presentation, and survival among female patients with head and neck cancer

20-01-2020 – Neelima Panth, Matthew C. Simpson, Rosh K.V. Sethi, Mark A. Varvares, Nosayaba Osazuwa‐Peters

Objectives
Incidence trends and outcomes of head and neck cancer (HNC) among female patients are not well understood. The objective of this study was to estimate incidence trends and quantify the association between health insurance status, stage at presentation, and survival among females with HNC.
Study Design
Retrospective cohort study.
Methods
The Surveillance, Epidemiology, and End Results database (2007–2014) was queried for females aged ≥18 years diagnosed with a malignant primary head and neck cancer (HNC) (n = 18,923). Incidence trends for stage at presentation were estimated using Joinpoint regression analysis. The association between health insurance status and stage at presentation on overall and disease‐specific survival was estimated using Fine and Gray proportional hazards models.
Results
Incidence of stage IV HNC rose by 1.24% from 2007 to 2014 (annual percent change = 1.24, 95% CI 0.30, 2.20). Patients with Medicaid (adjusted odds ratio a
OR = 1.59, 95% confidence interval CI 1.45, 1.74) and who were uninsured (a
OR = 1.73, 95% CI 1.47, 2.04) were more likely to be diagnosed with advanced stage (stages III/IV) HNC. Similarly, patients with Medicaid (adjusted hazard ratio a
HR = 1.47, 95% CI 1.38, 1.56) and who were uninsured (a
HR =1.45, 95% CI 1.29, 1.63) were more likely to die from any cause compared to privately insured patients. Medicaid (a
HR = 1.34, 95% CI 1.24, 1.44) and uninsured (a
HR = 1.41, 95% CI 1.24, 1.60) patients also had a greater hazard of HNC‐specific deaths compared to privately insured patients.
Conclusions
Incidence of advanced‐stage presentation for female HNC patients in the United States has increased significantly since 2007, and patients who are uninsured or enrolled in Medicaid are more likely to present with late stage disease and die earlier.
Level of Evidence
NA Laryngoscope, 130:385–391, 2020

Incidence of inadequate perforators and salvage options for the anterior lateral thigh free flap

20-01-2020 – William W. Thomas, Haley E. Calcagno, James Azzi, Daniel Petrisor, Taylor Cave, Brittany Barber, Brett Miles, Ernest D. Gomez, Steven Cannady, Mohin Bhadkamkar, Matthew M. Hanasono, Mark K. Wax

Journal Article

Objective
The anterolateral thigh (ALT) free flap is a soft tissue flap used in head and neck reconstruction. Occasionally, its perforators to the skin paddle are absent or too small to support the flap. Salvage options in this scenario have not been well described for head and neck reconstruction.
Methods
Multicenter review of 1,079 cases of planned ALT flaps where 28 initial flaps (2.6%) were discarded for nonviable skin paddle or lack of cutaneous perforators. Iatrogenic perforator injury was calculated separately. The total flap loss rate was 3.2%.
Results
In 12 cases, no perforators were noted after performing the anterior incision (early). Sixteen ALT flaps were discarded immediately before pedicle ligation (late).
Reconstruction was salvaged by seven anteromedial thigh (AMT), six radial forearm, five contralateral ALT, four rectus abdominus myocutaneous, three vastus lateralis, three profunda artery perforator, two tensor fascia lata, one rectus femoris, two pectoralis major, one cervicofacial rotational, and one fibula flap. Of the 28 cases, 12 salvage cases did not involve an additional wound for the patient. Five of the seven AMT flaps were harvested after the ALT was identified as nonviable in the early time point. Two patients had no viable ALT flaps on bilateral lower extremities.
Conclusion
The ALT flap is a reliable soft tissue flap, and rarely cutaneous perforators are not adequate to support the skin paddle. Multiple options exist to salvage the reconstruction without significant additional morbidity to the patient if said inadequacy is identified early.
Level of Evidence4 Laryngoscope, 130:343–346, 2020

Contemporary analysis of otolaryngic allergy

20-01-2020 – Willard C. Harrill, Gavin Setzen, Douglas Farquhar, Harold C. Pillsbury

Journal Article

Objectives
Investigate the current trends in otolaryngic allergy (OA).
Study Design
Cross‐sectional survey.
Methods
Survey of active AAOA membership.
Results
Response rate was 27.3%. Regional response distribution rates were proportional to the AAOA membership distribution within the United States (R2 = 0.95; P < 0.001), with no significant regional response bias demonstrated (P = 0.428).
Self‐reported duration to OA competency was 5.8 years. Physicians reporting OA competency were more likely to be board‐certified (P < 0.001) and have AAOA fellowship status (P < 0.001). The AAOA was reported to be the most valuable educational resource toward achieving OA competency, with residency training being least valuable (P < 0.001).91.5% of respondents’ practices offered OA services. Subcutaneous injections predominated at twice the utilization of sublingual immunotherapy. Allergy immunotherapy tablets were rarely utilized. Home allergy shots were offered by 45.2% of respondents. In‐office immunotherapy vial compounding was preferred (95.8%) to third‐party vendors. 94% of AAOA respondents identified patient compliance to be an issue within OA.
Non‐inhalant allergy service integration included food allergy (63.5%), asthma (44.9%), allergic fungal sinusitis (43.8%), penicillin allergy (18%), stinging insect allergy (12.6%), and aspirin desensitization (3.9%).
Conclusion
Reported duration to OA competency after residency was surprisingly long. Further investigation of current and future educational/clinical training is warranted given clinical integration reported for OA. Otolaryngology is in the unique position to develop a comprehensive sino‐allergy evidence‐based strategy integrating the extensive diagnostic and medical treatment arms alongside the surgical expertise of the specialty within a clinical sino‐allergy home concept.
Level of Evidence5 Laryngoscope, 130:283–289, 2020

Assessing fractional hair cell survival in archival human temporal bones

20-01-2020 – “Pei‐zhe Wu, Wei‐ping Wen, Jennifer T. OMalley, M. Charles Liberman”

Journal Article

Objectives/Hypothesis
Histopathological analysis of hair cell survival in human temporal bone sections has historically been binarized such that each hair cell row is rated as either present or absent, thereby greatly underestimating the amount of hair cell loss. Here, we describe and validate a technique to reliably assess fractional hair cell survival in archival sections stained with hematoxylin and eosin (H&E) using high‐resolution light microscopy and optical sectioning.
Study Design
Technique validation.
Methods
Hair cell counts in archival temporal bone slide sets were performed by several observers using either differential interference contrast (DIC) or confocal microscopy of the endogenous eosin fluorescence in hair cells. As a further cross‐check, additional decelloidinized sections were immunostained with hair cell markers myosin VI and VIIa.
Results
Cuticular plates and stereocilia bundles are routinely resolvable in DIC imaging of archival H&E‐stained human material using standard research‐grade microscopes, allowing highly accurate counts of fractional hair cell survival that are reproducible across observer and can be verified by confocal microscopy.
Conclusions
Reanalysis of cases from the classic temporal bone literature on presbycusis suggests that, contrary to prior reports, differences in audiometric patterns may be well explained by the patterns of hair cell loss.
Level of Evidence
NA Laryngoscope, 130:487–495, 2020

The impact of frailty on perioperative outcomes and resource utilization in sinonasal cancer surgery

20-01-2020 – Alexander N. Goel, Jivianne T. Lee, Jose G. Gurrola, Marilene B. Wang, Jeffrey D. Suh

Journal Article

Objectives/Hypothesis
Frailty is a measure of decreased physiologic reserve that has been associated with adverse outcomes in older surgical patients. We aimed to measure the association of preoperative frailty with outcomes in patients undergoing sinonasal cancer surgery.
Study Design
Retrospective cohort study.
Methods
We identified 5,346 patients in the Nationwide Readmissions Database undergoing sinonasal cancer surgery from 2010 to 2014. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty‐defining diagnoses indicator. Multivariate regression was used to analyze the association of frailty with postoperative outcomes.
Results
Frailty was present in 7.4% of patients. Frailty was a significant independent predictor of intensive care unit–level complications (odds ratio OR: 4.83; 95% confidence interval CI: 2.95‐7.93; P < .001) and nonhome discharge (OR: 3.07; 95% CI: 1.68‐5.60; P < .001). Compared to nonfrail patients, frail patients had threefold longer median length of stay (12 days vs. 4 days; P < .001) and more than twofold higher median hospital costs ($44,408 vs. $18,660; P < .001). Frailty outperformed advanced comorbidity (defined as Charlson‐Deyo score ≥3), age ≥80 years, and markers of surgical complexity (e.g., skull base/orbit involvement, flap reconstruction, neck dissection) in predicting serious complications, nonhome discharge, length of stay, and hospital costs.
Conclusions
Frailty appears to have a stronger and more consistent association with adverse outcomes and increased resource utilization after sinonasal cancer surgery than age or comorbidity index. This information may be used in surgical risk stratification and can guide strategies to prevent or mitigate adverse events in this high‐risk group.
Level of Evidence
NA Laryngoscope, 130:290–296, 2020

The association between the Nutrition‐Related index and morbidity following head and neck microsurgery

20-01-2020 – Harman S. Parhar, J. Scott Durham, Donald W. Anderson, Barret Rush, Eitan Prisman

Objectives/Hypothesis
Despite consensus that preoperative nutritional assessment is of importance in the head and neck surgical oncology population, it remains unclear how exactly malnutrition is associated with perioperative morbidity especially among those undergoing microvascular surgery. We aimed to study this association to help inform preoperative risk stratification, guide the use of nutritional interventions, and ultimately help prevent malnutrition related morbidity.
Study Design
Database analysis.
Methods
Retrospective, linked analysis of the 2011 to 2016 National Surgical Quality Improvement Program. After identifying eligible patients and stratifying according to the Nutrition‐Related Index, a univariate screen of preoperative demographic and clinical covariates was performed. Subsequently, propensity score matching was utilized to control for differences in baseline covariates. Perioperative complications and mortality were then analyzed using the propensity score–matched cohorts.
Results
Among 977 identified patients, 276 (28.2%) were malnourished. Malnourished patients had higher rates of comorbidity, were more likely to actively smoke, and were more likely to have primaries in the oropharynx or hypopharynx/larynx. After propensity score matching to control for confounders, malnourished patients had higher rates of pulmonary complications (21.5% vs. 11.6%, P < .01), higher rates of bleeding or need for transfusion (56.6% vs. 43.0%, P < .01), higher rates of venous thromboembolism (3.7% vs. 0.8%, P = .03), and a higher 30‐day mortality rates (3.7% vs. 0.0%, P < .01).
Conclusions
This nationwide analysis finds that 28.2% of patients undergoing surgery for head and neck cancers with free flap reconstruction are malnourished. Malnourishment was found to be independently associated with postoperative pulmonary complications, bleeding or need for transfusion, and 30‐day mortality.
Level of Evidence
NA Laryngoscope, 130:375–380, 2020

Demonstrating the benefits of a multidisciplinary aerodigestive program

20-01-2020 – Amanda G. Ruiz, Jay M. Bhatt, Emily M. DeBoer, Joel Friedlander, Norah Janosy, Melissa Brooks Peterson, Todd Wine, Robin Deterding, Jeremy D. Prager

Objectives/Hypothesis
The Aerodigestive Program (the Aero Program) at Childrens Hospital Colorado is a multidisciplinary program focused on airway, digestive, and lung disorders in complex children, involving collaboration between gastroenterology, pulmonology, anesthesiology, and otolaryngology in clinic and operating room. These programs have proliferated as institutions focus on providing greater care coordination and family satisfaction. However, few cost, charge, and satisfaction data exist to support these resource‐intensive programs. The goal of this study was to investigate the value of combined triple endoscopy delivered by the Aero Program through analysis of institutional charges, direct costs, operating room efficiency metrics, and parent satisfaction.
Study Design
Program evaluation.
Methods
Finance, satisfaction, efficiency, and quality‐of‐care metrics were evaluated within and outside of the Aero Program through retrospective queries of electronic health records, administrative databases, and parent surveys at our institution.
Results
Mean anesthesia time in the Aero Program was 54 minutes (49–60; 95% confidence interval), which was significantly less (P < .0001) than the estimated 89 minutes of having the three procedures done separately. Average charges and average direct costs for triple endoscopy were 38.8% and 41.9% less than the sum of the averages for separate procedures, respectively. Parent satisfaction was high for the Aero Program care.
Conclusions
As organizations move toward greater coordination of care for complex patients, multidisciplinary programs must demonstrate their value by delivering cost‐effective care. Aerodigestive programs have the potential to provide satisfying care that is less costly to the organization, insurer, and family. These programs represent a step in the evolution toward higher value care and value‐based payment methodology.
Level of Evidence4 Laryngoscope, 130:521–525, 2020

Anastomosing Hemangioma of the Nasal Cavity

20-01-2020 – Zheng‐Yi Huang, Chien‐Chin Chen, Bipin Thingujam

Case Reports

Anastomosing hemangioma (AH) is an uncommon benign vascular neoplasm first described in the genitourinary tract. Symptomatically and histologically mimicking malignant angiosarcoma, a few rare cases have been described in the nonrenal genitourinary tract. Here, we report a 37‐year‐old man with a nasal AH and epistaxis. To the best of our knowledge, this is the first case of AH reported in the nasal cavity. Awareness of this entity in the nasal cavity can be helpful in diagnosis and distinction from angiosarcoma. Laryngoscope, 130:354–357, 2020

Masthead

20-01-2020 –

Table of contents

20-01-2020 –

A systematic review and meta‐analysis of predictors of airway intervention in adult epiglottitis

20-01-2020 – Anders Sideris, Timothy R. Holmes, Benjamin Cumming, Thomas Havas

Journal Article, Review

Objective
Epiglottitis is typically considered a pediatric disease; however, there is growing evidence that the incidence of adult epiglottitis has changed since the introduction of the Haemophilus influenzae vaccine. The literature is composed of multiple small series with differing findings. To date, there has been no attempt to collaborate evidence on predictors of airway intervention in this disease.
Methods
The population of interest was adults with a diagnosis of epiglottitis. The primary outcome in this review was incidence of airway intervention. A comprehensive literature search was conducted of the MEDLINE and Embase databases, and a separate random‐effects model meta‐analysis was undertaken for all outcome data. Moderator tests for comparison between prevaccine and postvaccine estimates were made, and absolute risk difference (RD) and relative risk (RR) calculations were made for all predictors of airway intervention.
Results
Thirty studies and a total of 10,148 patients were finally included for meta‐analysis. A significant decrease in airway intervention was seen post vaccine introduction introduction from 18.8% to 10.9% (P = 0.01). The presence of an abscess (RD 0.27, P = 0.04; RR 2.45, P < 0.001), stridor (RD 0.64, P < 0.001; RR 7.15, P < 0.001), or a history of diabetes mellitus (RD 0.11, P = 0.02; RR 2.15, P = 0.01) were associated with need for airway intervention.
Conclusion
In the postvaccine era, clinicians should expect to have to secure airways in 10.9% of cases. The presence of an epiglottic abscess, stridor, or a history of diabetes mellitus are the most reliable clinical features associated with need for airway intervention.
Level of Evidence
NA Laryngoscope, 130:465–473, 2020

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

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

Journal Article, Review

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

Facial Nerve Branching Patterns Vary With Vascular Anomalies

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

Thyroid Cartilage Cysts, A Rare Entity Causing Dysphonia

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

Case Reports

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

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

08-01-2020 – Clemens Heiser, Benedikt Hofauer

Letter

Do Laryngologists and General Otolaryngologists Manage Laryngopharyngeal Reflux Differently?

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

Functional Electrical Stimulation for Presbyphonia: A Prospective Randomized Trial

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

Inhibition of glutaminase to reverse fibrosis in iatrogenic laryngotracheal stenosis

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

Journal Article

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

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

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

Journal Article

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

Tegmen attenuation in patients with idiopathic intracranial hypertension is progressive

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

Journal Article

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

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

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

Journal Article

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

Reconstructive and prosthodontic outcomes after multiple palatomaxillary reconstructions

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

Journal Article

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

Predicting the Number of Fibular Segments to Reconstruct Mandibular Defects

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

Journal Article

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

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

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

Journal Article

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

Development of a Modern Pediatric Airway Reference Tool

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

Journal Article

Progressive Scalp Thinning Over Mesh Cranioplasty and the Role of Lipotransfer

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

Laryngeal adductor reflex hyperexcitability may predict permanent vocal fold paralysis

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

Case Reports

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

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

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

Journal Article

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

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

Journal Article

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

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

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

Journal Article

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

Endoscopic Nasopharyngectomy Combined with a Nerve‐sparing Transpterygoid Approach

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

Hypoglossal Nerve Stimulation in Veterans with Obstructive Sleep Apnea

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

Journal Article

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

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

14-12-2019 – Urjeet A. Patel

Journal Article

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

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

14-12-2019 – Ishaan Dharia, Steven Bielamowicz

Journal Article

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

Three‐dimensional analysis of the human pharyngoesophageal sphincter

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

Journal Article

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

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

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

Journal Article

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

Erratum

12-12-2019 –

The Developmental Origin of the Auricula Revisited

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

Journal Article

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

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

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

Journal Article

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

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

Journal Article

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

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

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

Journal Article

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

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

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

Case Reports

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