Laryngoscope

Laryngoscope

Risk factors for auricular hematoma and recurrence after drainage

17-10-2019 – Prarthana J. Dalal, Matthew R. Purkey, Caroline P. E. Price, Douglas M. Sidle

Objectives/Hypothesis
To review an institutional experience with auricular hematoma across all clinical settings including the emergency department (ED) and outpatient clinics at an urban tertiary care academic hospital, characterize practice patterns across setting and specialty, and assess for factors predictive of treatment success.
Methods
Patients presenting to the ED, admitted to an inpatient ward, or seen in the outpatient setting between 2000 and 2017 with a diagnosis of auricular hematoma were reviewed. A number of relevant patient features including demographic factors, medications, and social risk factors were analyzed, as were several factors related to the presentation and management of the hematoma to identify variables of clinical significance.
Results
A total of 87 individual cases were identified. Auricular hematomas most commonly occurred in males after sports‐related trauma (e.g., martial arts, wrestling, boxing). Factors associated with lower rates of recurrence included initial treatment by or in consultation with an otolaryngologist and application of a bolster dressing.
Conclusions
In our cohort, initial management of auricular hematoma by an otolaryngologist or with an otolaryngology consultation and placement of a bolster dressing was associated with lower rates of hematoma recurrence.
Level of Evidence2b Laryngoscope, 2019

Associations between national financial trends and facial plastic surgery procedural volume

11-10-2019 – Shekhar K. Gadkaree, Justin C. McCarty, Rachel E. Weitzman, Adeeb Derakhshan, Suresh Mohan, Regan W. Bergmark, David A. Shaye

Journal Article

Objective(s)To characterize procedural trends in facial plastic and reconstructive surgery procedures in relation to the United States economy.
Methods
Retrospective cohort study examining annual procedure rates were determined from the American Society of Plastic Surgeons (ASPS) National Clearinghouse of Plastic Surgery Procedural Statistics from January 1 2007 to December 30, 2017. Procedures were compared to economic activity of the United States as measured by gross domestic product (GDP) were compared using Kolmogorov‐Smirnov goodness of fit testing and piecewise multivariate regression modeling.
Results
Annual trends in procedural rates showed an overall decrease in the rates of rhinoplasty (284,960 to 218,924), blepharoplasty (240,660 to 209,571), and otoplasty (28,571 to 23,433) from 2007 to 2017. Total cosmetic surgery remained fairly stable, while minimally invasive cosmetic surgery increased in frequency over the study period. On piecewise regression analysis, rhinoplasty (P = .02), rhytidectomy (P = .007), invasive cosmetic surgery (P < .001) were significantly associated with GDP, whereas otoplasty (P = .98) and reconstructive surgery (P = .11) were not associated with GDP.
Conclusion
Cosmetic plastic surgery procedures show a greater correlation to GDP than reconstructive procedures. Trends in plastic surgery cases over the last decade show a decreasing number of rhinoplasty, otoplasty, and blepharoplasty, with stabilization in the last few years. An increasing number of reconstructive cases are found.
Level of Evidence4 Laryngoscope, 2019

Pepsin and oropharyngeal pH monitoring to diagnose patients with laryngopharyngeal reflux

11-10-2019 – Michael Weitzendorfer, Stavros A. Antoniou, Philipp Schredl, Kai Witzel, Isabella C. Weitzendorfer, Alexandra Majerus, Klaus Emmanuel, Oliver O. Koch

Journal Article

Objectives
The aim of this study was to compare the diagnostic accuracy of salivary pepsin with oropharyngeal p
H monitoring using the Restech measurement system (Dx‐p
H) for the diagnosis of laryngopharyngeal reflux (LPR).
Study Design
Prospective cohort study.
Methods
Seventy patients with primary symptoms related to LPR underwent gastroscopy, high‐resolution manometry, p
H throughout 24‐hour monitoring (MII‐p
H), and barium esophagography between October 2015 and May 2018. In addition, an ear, nose, and throat examination was performed, including assessment of Belafsky Reflux Finding Score (RFS). Clinical symptoms were evaluated with the Belafsky Reflux Symptom Index (RSI) and the Gastrointestinal Quality of Life Index (GIQLI). Simultaneous to MII‐p
H, pepsin determination and Dx‐p
H were performed.
Results
Of 70 patients, 41 (58.6%) subjects with a pathological De
Meester score showed higher mean values of pepsin (mean value: 216 ng/m
L, 95% confidence interval CI: 172 to 260), compared to patients with a normal De
Meester score (mean value: 161 ng/m
L, 95% CI: 115 to 207). Salivary pepsin showed a specificity of 86.2% and sensitivity of 41.5% for diagnosing LPR using the optimal cutoff value of 216 ng/m
L. Furthermore, a significant correlation between the values of salivary pepsin and the RSI score was seen in patients with pathological results in MII‐p
H (r = 0.344; P = 0.046).
However, elevated Dx‐p
H measurements showed no significant correlation with either MII‐p
H, RSI score, RFS score, or GIQLI score, or with the results of pepsin measurement.
Conclusion
Pepsin measurement in saliva could be an alternative tool to assist office‐based diagnosis of LPR, whereas Dx‐p
H does not seem to be an adequate test.
Level of Evidence2B Laryngoscope, 2019

Trends in hearing rehabilitation use among vestibular schwannoma patients

11-10-2019 – Madeleine A. Drusin, Brienne Lubor, Tasher Losenegger, Samuel Selesnick

Journal Article

Objective
Most patients with vestibular schwannoma (VS) have significant hearing loss in the affected ear as a result of either their tumor or treatment. There is a paucity of data on which hearing rehabilitation options, if any, are preferred by patients with VS. Our study analyzed the use of hearing rehabilitation devices among VS patients.
Methods
Patients with unilateral VS treated at our institution from January 2008 to August 2018 were identified. Those with bilateral VS, profound hearing loss in the contralateral ear, neurofibromatosis type 2, or inadequate follow‐up were excluded. Patients who met inclusion criteria were given two online questionnaires: an 8‐item instrument that assesses use of hearing rehabilitation devices and the Abbreviated Profile of Hearing Aid Benefit.
Results
Of 212 eligible patients, 61 completed both surveys. The majority (88%) were able to hear “poorly” or “not at all” in the affected ear, but less than one‐third had ever used a hearing rehabilitation device. Most had used conventional hearing aids (30%) or contralateral routing of signal/bilateral contralateral routing of signal (30%), whereas only a handful had used bone‐anchored hearing devices or cochlear implant. Patients who did not pursue hearing rehabilitation were either not bothered by their deficit or were unaware of their options. Most had good functionality despite their deficit.
Conclusion
Whereas 88% of patients treated for VS had a significant hearing loss, the majority did not pursue hearing rehabilitation but maintained good functional performance. Many did not remember being counseled about hearing rehabilitation options, indicating that regular and repeated counseling may be needed to increase patient utilization of hearing rehabilitation after VS treatment.
Level of Evidence4 Laryngoscope, 2019

Outcomes in children with down syndrome and mild obstructive sleep apnea treated non‐surgically

11-10-2019 – Javier J.M. Howard, Kathleen M. Sarber, Wenwen Yu, David F. Smith, Raisa O. Tikhtman, Narong Simakajornboon, Stacey L. Ishman

Journal Article

Objectives
Nasal steroids, oral anti‐leukotrienes and supplemental oxygen are effective in the treatment of mild obstructive sleep apnea (OSA) in otherwise healthy children. However, their efficacy is unknown in children with Down syndrome (DS). Here we examine the effect of single medication therapy versus observation versus oxygen on polysomnographic outcomes in these children.
Methods
We reviewed children (<18 years) diagnosed with DS and mild OSA (obstructive apnea‐hypopnea index o
AHI ≥1 to <5 events/hour) treated non‐surgically (with supplemental oxygen, one medication, or observation) between 2012 and 2017. Demographic data, comorbid diagnoses, and pre‐ and posttreatment polysomnograms were analyzed. We assessed pre‐ and posttreatment o
AHI, oxyhemoglobin saturation nadir, percent total sleep time (%TST) in rapid eye movement (REM), and end‐tidal carbon dioxide (ETCO2) >50 mm
Hg.
Results
Twenty‐four children met inclusion criteria; 10 treated with medication, one with oxygen, and 13 with observation (baseline o
AHI was 3.5, 3.3, and 2.9 events/hour, respectively). There was no significant change in o
AHI, oxyhemoglobin saturation nadir, ETCO2, or percent TST in REM after treatment for any treatment group (P = .21–.94). There was no association between reported symptoms and AHI severity or change in AHI. OSA resolved in one patient treated with observation and two treated with medication, but worsened in two each in the medication and observation groups. Resolution of OSA occurred in 20% treated with medication, 7.7% with observation, and 0% with oxygen (P = .82).
Conclusion
In our cohort, resolution of mild OSA was low. This suggests that consideration should be given to multimodality treatments in children with DS and mild OSA. Prospective studies will help establish effectiveness in this cohort.
Level of Evidence4 Laryngoscope, 2019

microRNAs in sudden hearing loss

11-10-2019 – Desmond A. Nunez, Printha Wijesinghe, Shahin Nabi, David Yeh, Cathie Garnis

Journal Article

Objectives
To compare the circulating micro
RNA (mi
RNA) expression profiles between sudden sensory neural hearing loss (SSNHL) patients and age‐matched normal hearing controls.
Study Design
Prospective cohort multi‐center study.
Methods
Patients presenting within 28 days of onset of SSNHL were prospectively recruited along with contemporaneous age‐matched controls. Pooled sera of four patient (n = 09, mean age = 53.0 years; 07, 55.0; 10, 52.9; 10, 51.6) and two control (09, 51.2 and 03, 50.0) groups were assessed using a Taq
Man Low Density Array. The patients’ sera were also divided into two pools, untreated (04, 57.7) and treated (32, 52.6) for additional analysis. mi
RNA expression level was derived from cycle threshold (Ct) values normalized to a global mean. Inter‐group mean Ct differences with fold changes ≥2.0 and ≤0.5 at P < .05 were considered significant. Bioinformatic databases were used to identify putative target m
RNAs or validated genes and their functional annotations.
Results
Thirty‐six SSNHL patients (mean age 53.0 ± standard deviation (SD) 15.2 years) and 12 controls (50.9 ± 11.9) were studied. Eight mi
RNAs hsa‐mi
R‐590‐5p/ ‐186‐5p/ ‐195‐5p/ ‐140‐3p/ ‐128‐3p/ ‐132‐3p/ ‐375‐3p, and ‐30a‐3p were identified as significantly differentially expressed in SSNHL patients. Most of these mi
RNAs were abundantly identified in the nervous system and the putative target messenger RNAs (m
RNAs) were enriched in signaling pathways such as phosphatidyl inositol 3 kinase/protein Kinase B (PI3K/Akt), Ras and mitogen‐activated protein kinase (MAPK).
Conclusion
These findings suggest the possible cellular signaling pathways that underlie the disruption of auditory signal transmission in SSNHL.
Level of Evidence2 Laryngoscope, 2019

Endoscopic Removal of a Cervical Esophageal Duplication Cyst

11-10-2019 – Brittany A. Leader, Michael J. Rutter, Sally R. Shott, Matthew M. Smith

Case Reports

A 6‐month‐old female presented for 2 months of noisy breathing. Flexible laryngoscopy showed limited bilateral vocal fold abduction. Computed tomography revealed a non‐enhancing 3.6 × 2.3 × 3.5 cystic prevertebral mass spanning C2‐T. Using an endoscopic approach, the overlying mucosa was incised, and the cyst was freed and fully excised from the surrounding mucosa with blunt microlaryngeal instruments without complication. Three months postoperatively she had no respiratory issues and was eating well. Flexible laryngoscopy revealed bilateral vocal fold mobility. We propose that endoscopic removal of a cervical esophageal duplication cyst in selected cases is an alternative to open excision. Laryngoscope, 2019

Readability of patient‐reported outcome measures for chronic rhinosinusitis and skull base diseases

11-10-2019 – Saangyoung E. Lee, Zainab Farzal, Adam J. Kimple, Brent A. Senior, Brian D. Thorp, Adam M. Zanation, Charles S. Ebert

Journal Article

Objective
Outcome measures in healthcare that presume a higher level of patient health and overall literacy may inadequately estimate the disease experiences of less‐educated patients and further disadvantage them. Patient‐Reported Outcome Measures (PROMs) are widely used communication tools for clinical practice and are often used to evaluate and guide management for chronic rhinosinusitis (CRS) and skull base diseases. However, their readability and subsequent incomprehensibility for patients have not been assessed. The aim of this study is to evaluate the readability of commonly used PROMs for these conditions and whether they meet recommended readability levels.
Methods
Three readability measures, Gunning Fog, Simple Measure of Gobbledygook (SMOG), and FORCAST were used in the evaluation of commonly used PROMs for CRS and skull base disease. PROMs with sixth‐grade readability level or lower were considered to meet health literacy experts recommendations.
Results
A total of 11 PROMs were reviewed (8 CRS, 3 skull base). Gunning Fog consistently estimated the easiest readability, whereas FORCAST the most difficult. One hundred percent of CRS and 67% of skull base PROMs were above National Institutes of Health and health literacy experts recommended reading levels. PROMs developed more recently had easier readability.
Conclusion
PROMs are important clinical tools in otolaryngology that help guide management of disease for improved patient‐centered care. Like many other fields of medicine, those used in otolaryngology are beyond recommended reading levels. Development of PROMs in the future should meet recommended readability levels to fully assess the disease experience of our patients.
Level of Evidence4 Laryngoscope, 2019

Aerodynamically driven phonation of individual vocal folds under general anesthesia in canines

11-10-2019 – James T. Heaton, James B. Kobler, Mark P. Ottensmeyer, Robert H. Petrillo, Monica A. Tynan, Daryush D. Mehta, Robert E. Hillman, Steven M. Zeitels

Journal Article

Objectives/Hypothesis
We previously developed an instrument called the Aerodynamic Vocal Fold Driver (AVFD) for intraoperative magnified assessment of vocal fold (VF) vibration during microlaryngoscopy under general anesthesia. Excised larynx testing showed that the AVFD could provide useful information about the vibratory characteristics of each VF independently. The present investigation expands those findings by testing new iterations of the AVFD during microlaryngoscopy in the canine model.
Study Design
Animal model.
Methods
The AVFD is a handheld instrument that is positioned to contact the phonatory mucosa of either VF during microlaryngoscopy. Airflow delivered through the AVFD shaft to the subglottis drives the VF into phonation‐like vibration, which enables magnified observation of mucosal‐wave function with stroboscopy or high‐speed video. AVFD‐driven phonation was tested intraoperatively (n = 26 VFs) using either the original instrument design or smaller and larger versions three‐dimensionally printed from a medical grade polymer. A high‐fidelity pressure sensor embedded within the AVFD measured VF contact pressure. Characteristics of individual VF phonation were compared with typical two‐fold phonation and compared for VFs scarred by electrocautery (n = 4) versus controls (n = 22).
Results
Phonation was successful in all 26 VFs, even when scar prevented conventional bilateral phonation. The 15‐mm‐wide AVFD fits best within the anteroposterior dimension of the musculo‐membranous VF, and VF contact pressure correlated with acoustic output, driving pressures, and visible modes of vibration.
Conclusions
The AVFD can reveal magnified vibratory characteristics of individual VFs during microlaryngoscopy (e.g., without needing patient participation), potentially providing information that is not apparent or available during conventional awake phonation, which might facilitate phonosurgical decision making.
Level of Evidence
NALaryngoscope, 2019

Olfactory cleft and sinus opacification differentially impact olfaction in chronic rhinosinusitis

11-10-2019 – Catherine Loftus, Rodney J. Schlosser, Timothy L. Smith, Jeremiah A. Alt, Vijay R. Ramakrishnan, Jose L. Mattos, Elliott Mappus, Kristina Storck, Frederick Yoo, Zachary M. Soler

Journal Article

Objectives
Prior studies have indicated that olfactory cleft (OC) opacification correlates with olfaction in patients with chronic rhinosinusitis (CRS). However, the results have been unclear in patients without polyps. The purpose of this study was to further explore the relationship between OC opacification, sinus opacification, and olfactory function in patients with CRS.
Methods
One hundred and forty‐eight patients with CRS were prospectively enrolled across five institutions. Olfactory function was evaluated using the Sniffin’ Sticks tests (Burghardt, Wedel, Germany) and the 17‐item Questionnaire of Olfactory Disorders (QOD‐NS). Computed tomography (CT) scans for each patient were acquired and Lund‐Mackay scores recorded. Opacification of the OC was determined using Osiri
X MD (Pixmeo, Bernex, Switzerland) and correlated with olfaction scores.
Results
A total of 148 CRS patients, 73 CRS without nasal polyps (CRSs
NP) and 75 CRS with nasal polyps (CRSw
NP), as well as 30 control subjects were enrolled. Overall OC opacification averaged 63.7% in CRS patients and 47.1% in control subjects (P < 0.001). In the overall cohort, OC opacification significantly correlated with threshold, discrimination, and identification (TDI) (r = −0.520; P < 0.001) and QOD‐NS scores (r = 0.374; P < 0.001). CRSw
NP patients demonstrated a significant correlation between OC opacification and TDI scores (r = −0.464; P < 0.001) but not the CRSs
NP group (r = −0.143; P = 0.229). Lund‐Mackay score correlated with TDI in both the CRSs
NP (r = −0.300; P = 0.010) and CRSw
NP (r = −0.271; P = 0.019) groups.
Conclusion
CT opacification is associated with olfactory dysfunction differentially based on nasal polyp status. Smell loss in CRSw
NP correlated with both OC opacification and Lund‐Mackay score, whereas CRSs
NP correlated only with Lund‐Mackay score, indicating different relationships between olfactory function and local inflammatory processes in these disorders.
Level of Evidence2 Laryngoscope, 2019

The Role of Spirometry and Dyspnea Index in the Management of Subglottic Stenosis

11-10-2019 – Kevin Tie, Robert A. Buckmire, Rupali N. Shah

Journal Article

Objectives
We aimed to assess the role of spirometry measures and Dyspnea Index (DI) in response to treatment of subglottic stenosis (SGS) and ability to predict need for surgery. We also assessed correlations between spirometry measures, DI, and physical SGS parameters.
Methods
Thirty‐seven adult female SGS patients were prospectively enrolled. Spirometry data and DI were obtained at serial clinic visits; physical SGS parameters were obtained intraoperatively. PIFR, PEFR, EDI, FEV1/FVC, and DI were compared preoperatively to postoperatively for patients who underwent operative intervention. Spirometry data, DI, and physical SGS parameters were analyzed for correlations, and receiver operating characteristic (ROC) curves were created for spirometry measures and DI to determine optimal cutoffs for recommending surgery.
Results
Means of all measured spirometry measures changed significantly from preoperative to postoperative visits (P < .05). Mean DIs changed significantly between preoperative (27.5, n = 13, SD = 8.6) and postoperative visits (8.6, n = 13, SD = 5.5, P < 5 × 10‐5). All Pearson correlations were negligible to moderate. The area under the curve (AUC) for peak inspiratory flow rate (PIFR) was 0.903 (95% CI, 0.832–0.974) with cutoff at 2.10 L/s; the AUC for DI was 0.874 (95% CI, 0.791–0.956) with cutoff between 22‐25; the AUC for peak expiratory flow rate (PEFR) was 0.806 (95% CI, 0.702–0.910) with cutoff at 2.5 L/s; all other ROC curves were less than good.
Conclusion
PIFR, PEFR, EDI, FEV1/FVC, and DIs significantly improve after treatment for SGS. No strong correlations exist between spirometry measures, DI, and physical SGS parameters. PIFR was the most sensitive and specific for predicting timing of operative intervention in our cohort.
Level of Evidence1b Laryngoscope, 2019

Satisfaction in Academic Otolaryngology: Do Physician Demographics Impact Press Ganey Survey Scores?

11-10-2019 – Lauren F. Tracy, Nicolette Jabbour, Batsheva R. Rubin, Lindsay B. Sobin, Claire M. Lawlor, Krystyne C. Basa, Jessica R. Levi, Jeremiah C. Tracy

Journal Article

Objectives/Hypothesis
Patient satisfaction is increasingly emphasized and measured in healthcare delivery. However, patient satisfaction is multifactorial and difficult to comprehensively assess. The objective of this study was to assess for correlation between patient satisfaction measured by Press Ganey surveys (PGS) and physician demographics of gender, years in practice, academic rank, and specialty in academic otolaryngology.
Study Design
Review of publicly available PGS scores in academic otolaryngology practice.
Methods
Public websites of academic otolaryngology departments were assessed for inclusion of PGS scores. Individual physician profiles were queried for years in practice, academic rank, and specialty. Gender was determined by picture or profile pronouns. Univariate and multivariate analyses compared PGS scores with studied variables.
Results
Forty‐seven of 113 (42.8%) academic practices publicly reported physician PGS score. Of 1,360 affiliated otolaryngologists, 742 (54.6%,592 male:150 female) revealed PGS scores. Average PGS score for male and female providers was equivalent (PGS = 4.73, P = .84). There was no significant difference in PGS scores by academic rank (P = .28). A weak statistically significant decrease in mean PGS scores was associated with longer duration of practice (r = −0.11, P = .018). Head and neck oncologic surgeons had higher mean PGS score in comparison to other specialties (PGS = 4.81, P < .05). General/comprehensive otolaryngologists had lower average PGS score (PGS = 4.66) in comparison to specialists (P < .05).
Conclusions
Physician gender and academic rank do not correlate with patient satisfaction in academic otolaryngology as measured by publicly reported PGS scores. Head and neck oncology is rated more highly than other specialties, and physicians in practice for longer demonstrate decreased PGS scores. With PGS scores tied to physician evaluation and reimbursement, investigation into the generalizability of PGS in otolaryngology is warranted.
Level of Evidence
NALaryngoscope, 2019

Auricular acupuncture for adult tonsillectomy

11-10-2019 – Anil N. Shah, Chad B. Moore, Matthew T. Brigger

Journal Article

Objectives
Adult tonsillectomy causes significant postoperative pain that can last over 14 days, but narcotic regimens only provide a modest reduction in pain. Auricular acupuncture has been demonstrated to improve pain with minimal complications. This study compared acupuncture versus control for pain, opioid consumption, nausea, and return of diet and activity following tonsillectomy.
Methods
A prospective, single‐blinded randomized controlled trial was performed on 134 adults undergoing tonsillectomy at a tertiary care teaching hospital. Each patient was randomized to receive either auricular (Battlefield protocol) acupuncture with auricular bandages or bandages alone while under general anesthesia. Subjects journaled daily postoperative pain, diet, activity, and opioid consumption, then returned to the clinic on postoperative day 14 for a final questionnaire and evaluation.
Results
Ninety‐nine patients completed the study with 50 patients in the acupuncture group and 49 patients in the control group. Pain scores for the acupuncture group following tonsillectomy were significantly lower than the control group on the day of surgery (2.9, 4.3; P = .01), but there was no statistically significant difference in pain thereafter. There was an equivalent level of postoperative narcotic usage, nausea, emesis, functional activity and diet between the two groups. The main complication following tonsillectomy was secondary hemorrhage and there was no significant difference between the two groups (20%, 10%; P = .13).
Conclusion
Auricular acupuncture provides increased pain relief on the day of surgery, an effect that seems to diminish after 24 hours.
Level of Evidence1b Laryngoscope, 2019

Patterns of Dysphagia and Airway Protection in Infants with 22q11.2‐Deletion Syndrome

11-10-2019 – Nicole S. Wong, Zipei Feng, Christina Rappazzo, Catherine Turk, Chelsea Randall, Julina Ongkasuwan

Journal Article

Objective22q11.2‐deletion syndrome is a genetic condition that affects 1:3000 births. In addition to cardiac anomalies and immunosuppression, individuals with 22q11.2‐deletion syndrome can have feeding difficulties from birth resulting in failure to thrive and infections. This study aims to characterize the dysphagia seen in infants with 22q11.2‐deletion syndrome.
Methods
This is a retrospective chart review of infants with 22q11.2‐deletion syndrome who underwent videofluoroscopic swallow studies (VFSS) from June 1, 2008 to January 1, 2018 at a tertiary childrens hospital. Demographic data and VFSS findings were collected.
Results
Forty‐four patients were identified, 52% were females, and mean age at VFSS was 71 days. In their lifetime, 30% of the patients had at least 1 episode of pneumonia, 66% had NG‐tube placement and 41% required G‐tube placement. 93% had oral‐phase dysphagia, and 89% had pharyngeal‐phase dysphagia. Twenty‐two patients (50%) demonstrated evidence of penetration. Eighteen patients (41%) showed tracheal aspiration. Of the patients that showed tracheal aspiration, 83% of them aspirated “silently.” Three patients (7%) had upper esophageal sphincter (UES) opening dysfunction.
Conclusion
Vast majority of the infants with 22q11.2‐deletion syndrome referred for swallow studies demonstrated evidence of dysphagia in both oral and pharyngeal phases with deficits in swallow physiology not yet documented in other studies. Importantly, more than 80% of these infants showed evidence of “silent” tracheal aspiration, which can lead to recurrent pneumonia and significant morbidity if overlooked. Prompt recognition is paramount in these infants to intervene early and reduce long‐term complications and also develop targeted interventions.
Level of Evidence4 Laryngoscope, 2019

Elective neck dissection during salvage laryngectomy: A systematic review and meta‐analysis

08-10-2019 – Jennifer H. Gross, Peter M. Vila, Laura Simon, Zain H. Rizvi, Joseph Zenga, Ryan S. Jackson, Patrik Pipkorn

Journal Article, Review

Objectives
The primary objective was to determine the rate of occult cervical nodal metastasis in patients undergoing elective neck dissection (END) during salvage laryngectomy. The secondary objective was to compare survival and postoperative complication rates between patients undergoing END versus observation.
Methods
A medical librarian performed a comprehensive search for END outcomes in laryngeal cancer patients undergoing salvage laryngectomy after primary chemoradiation therapy. Seventeen retrospective studies and 1 prospective study met inclusion criteria, with a total of 1,141 patients (799 END, 350 observed).
Results
The rate of nodal positivity was 11% among patients who underwent END during their salvage laryngectomy. Three studies and 155 patients were included in a 5‐year overall survival (OS) analysis with no significant difference in OS (95% confidence interval CI: 0.82‐2.22). After inclusion of six studies and 494 patients (249 END, 245 observed), the risk of fistula formation was not statistically different (95% CI: 0.61‐2.56). Due to significant heterogeneity between studies and inadequate data, most patients could not be included in the meta‐analysis of outcomes.
Conclusion
Salvage laryngectomy patients undergoing END have an occult nodal positivity rate of 11%. Meta‐analysis showed no statistically significant differences in 5‐year OS between patients undergoing END versus observation. Laryngoscope, 2019

An assessment of transparency and reproducibility‐related research practices in otolaryngology

08-10-2019 – Austin L. Johnson, Trevor Torgerson, Mason Skinner, Tom Hamilton, Daniel Tritz, Matt Vassar

Journal Article

Objectives/Hypothesis
Clinical research serves as the foundation for evidence‐based patient care, and reproducibility of results is consequently critical. We sought to assess the transparency and reproducibility of research studies in otolaryngology by evaluating a random sample of publications in otolaryngology journals between 2014 and 2018.
Study Design
Review of published literature for reproducible and transparent research practices.
Methods
We used the National Library of Medicine catalog to identify otolaryngology journals that met the inclusion criteria (available in the English language and indexed in MEDLINE). From these journals, we extracted a random sample of 300 publications using a PubMed search for records published between January 1, 2014 and December 31, 2018. Specific indicators of reproducible and transparent research practices were evaluated in a blinded, independent, and duplicate manner using a pilot‐tested Google form.
Results
Our initial search returned 26,498 records, from which 300 were randomly selected for analysis. Of these 300 records, 286 met inclusion criteria and 14 did not. Among the empirical studies, 2% (95% confidence interval CI: 0.4%‐3.5%) of publications indicated that raw data were available, 0.6% (95% CI: 0.3%‐1.6%) reported an analysis script, 5.3% (95% CI: 2.7%‐7.8%) were linked to an accessible research protocol, and 3.9% (95% CI: 1.7%‐6.1%) were preregistered. None of the publications had a clear statement claiming to replicate, or to be a replication of, another study.
Conclusions
Inadequate reproducibility practices exist in otolaryngology. Nearly all studies in our analysis lacked a data or material availability statement, did not link to an accessible protocol, and were not preregistered. Taking steps to improve reproducibility would likely improve patient care.
Level of Evidence
NALaryngoscope, 2019

Expression of aquaporins in inner ear disease

08-10-2019 – Sung Hwa Dong, Sung Su Kim, Sang Hoon Kim, Seung Geun Yeo

Journal Article, Review

The inner ear is responsible for hearing and balance and consists of a membranous labyrinth within a bony labyrinth. The balance structure is divided into the otolith organ that recognizes linear acceleration and the semicircular canal that is responsible for rotational movement. The cochlea is the hearing organ. The external and middle ear are covered with skin and mucosa, respectively, and the space is filled with air, whereas the inner ear is composed of endolymph and perilymph. The inner ear is a fluid‐filled sensory organ composed of hair cells with cilia on the upper part of the cells that convert changes in sound energy and balance into electric energy through the hair cells to transmit signals to the auditory nerve through synapses. Aquaporins (AQPs) are a family of transmembrane proteins present in all species that can be roughly divided into three subfamilies according to structure and function: 1) classical AQP, 2) aquaglyceroporin, and 3) superaquaporin. Currently, the subfamily of mammalian species is known to include 13 AQP members (AQP0–AQP12). AQPs have a variety of functions depending on their structure and are related to inner ear diseases such as Menieres disease, sensorineural hearing loss, and presbycusis. Additional studies on the relationship between the inner ear and AQPs may be helpful in the diagnosis and treatment of inner ear disease. Laryngoscope, 2019

Accuracy of the minimal leak test for endotracheal cuff pressure monitoring

08-10-2019 – Yamil Selman, Rafael Arciniegas, Joseph M. Sabra, Tanira D. Ferreira, David J. Arnold

Journal Article

Objectives
To determine the accuracy of the minimum leak test as a surrogate for target endotracheal cuff pressure of 20–30 cm H2O in intubated patients.
Methods
Cuff pressures were measured at the University of Miami Hospital using the minimum leak test on every intubated patient once per shift, then cuff pressure was reevaluated using handheld numerical manometers and recorded pressures above or below the target range, readjusting the pressure as needed. This assessment was repeated throughout each patients intubation for up to 6 days. The readjustment rate of the test and the probability of a patient needing at least one adjustment were determined.
Results
One hundred twenty‐two patients were evaluated. Median age was 67 years (range 29–95), 52% were male, 48% were female. Patients were followed for an average of 4.7 days. Seven hundred twenty‐two minimum leak tests were performed. Of these, 170 required readjustment into the target range (24% readjustment rate). Of the tests outside target range, 66% of cuffs were overinflated and 34% were underinflated. Fifty‐five percent of patients required at least one adjustment.
Conclusion
Despite ubiquitous use of the minimum leak test for endotracheal cuff pressure adjustment, the test has an unacceptably high error rate resulting in cuff pressures above or below the target range. Most patients will require at least one adjustment throughout an intubation, putting them at risk for tracheal injury, stenosis, or leak and aspiration. The minimum leak test is not sufficiently accurate for endotracheal cuff pressure monitoring. Formal manometry is superior and should be used to optimize patient outcomes.
Level of Evidence4 Laryngoscope, 2019

The minimal clinically important difference of the dyspnea index in laryngotracheal stenosis

08-10-2019 – Alan J. Gray, Molly Huston, Devin Didericksen, Tanya K. Meyer, Albert Merati, Simon Brisebois

Journal Article

Objective
The Dyspnea Index (DI) is a validated patient‐reported outcome (PRO) instrument that has been used in the management of laryngotracheal stenosis (LTS). The minimal clinically important difference (MCID) is an established concept to help determine the change in a PRO instrument that reflects meaningful change for the patient. It is not known what change in the DI is of clinical significance in airway surgery. This study aims to determine the MCID for the DI in patients undergoing surgical treatment for LTS.
Methods
This is a prospective cohort study in which 26 patients with LTS completed the DI (score range 0 to 40) before and 6 to 8 weeks postoperatively, in addition to a Global Ratings Change Questionnaire (GRCQ), scored from −7 to +7, at the postoperative interval. A hypothesis test was carried out to test the association between GRCQ and change in DI. The MCID for change in DI was determined using anchor‐based analysis.
Results
Overall mean change in DI was −11, and mean change in GRCQ was +5. Change in DI scores were significantly different among the improvement and no improvement groups (P value <0.002). Area under the receiver operating curve was 0.92, demonstrating high discriminatory ability of the change in DI score. A change of −4 was determined to be the threshold that discriminated between significant improvement and no improvement.
Conclusion
A decrease of 4 in the DI can be considered as the MCID for patients with LTS after surgical treatment.
Level of Evidence2b Laryngoscope, 2019

Unexpected High‐Risk Pathologic Features Following Thyroidectomy in the Chinese Immigrant Population

08-10-2019 – Arvind K. Badhey, Erin Moshier, Ameya Jategaonkar, Anni Wong, Kristen Echanique, Raymond L. Chai

Journal Article

Objective
To compare rates of unexpected high‐risk pathologic features between Chinese and non‐Asian patients who underwent thyroidectomy for papillary thyroid cancer.
Methods
This was a retrospective cohort study at a tertiary academic urban medical center. Patients who underwent thyroidectomy for papillary carcinoma from 2015 to 2017 were included. Patient demographics, tumor characteristics, and tumor histopathology were analyzed. Primary outcome was the presence of adverse histopathologic features such as lymphovascular invasion (LVI) or microscopic/minimal extrathyroidal extension (m
ETE). Differences between the groups were analyzed using multivariate logistical regression analysis and propensity score‐weighted analysis.
Results
One hundred seventy‐nine patients were included: 58 Chinese‐born and 121 non‐Asian. The median age of the cohort was 47 years old (36–58). Twenty‐nine percent of patients were male, and 71% were female. There was no statistically significant difference between the two cohorts in rates of LVI, multifocality, extent of surgery, or presence of thyroiditis. Patients with m
ETE were more likely to have larger tumors (P = 0.00247). Both the multivariate and propensity‐weighted models demonstrated that Chinese ancestry was independently associated with an increased rate of unexpected m
ETE (adjusted prevalence ratio, 2.52; 95% confidence interval, 1.82–3.48).
Conclusionm
ETE is significantly higher in the immigrant Chinese compared to the non‐Asian population. Given the high prevalence of unexpected m
ETE in the Chinese population, the added risk of this finding should be brought into the discussion during initial surgical planning.
Level of Evidence3 Laryngoscope, 2019

Metformin effects on FOXP3+ and CD8+ T cell infiltrates of head and neck squamous cell carcinoma

08-10-2019 – Dev Amin, Tony Richa, Mehri Mollaee, Tingting Zhan, Patrick Tassone, Jennifer Johnson, Adam Luginbuhl, David Cognetti, Ubaldo Martinez‐Outschoorn, Robert Stapp, Charalambos Solomides, Ulrich Rodeck, Joseph Curry

Journal Article

Objectives
Alterations of cellular metabolism have been implicated in immune dysfunction in the tumor microenvironment (TME) of head and neck squamous cell carcinoma (HNSCC). Metformin has recently emerged as a candidate of interest for combination with immunotherapy in HNSCC. This study investigated the effect of metformin on immune cell infiltrates of HNSCC.
Methods
Retrospective analysis of T cell infiltrates in primary tumor specimens from patients enrolled in a clinical window of opportunity trial of presurgical metformin. Metformin was titrated to a standard diabetic dose (2000 mg/day) for a minimum of 9 days (mean 13.6 days) prior to surgical resection. Pre and posttreatment surgical specimens from 36 patients (16 HPV+, 20 HPV−) were comparatively analyzed. FOXP3+ and CD8+ immune cell infiltrates in the tumor and peritumoral stroma of pre and posttreatment HNSCC specimens were quantified by digital image analysis using Visiopharm software.
Results
Metformin treatment was associated with a 41.4% decrease in FOXP3+ T cells in intratumor regions of interest (P = .004) and a 66.5% increase in stromal CD8+ T cells at the leading edge of the tumor (P = .021) when compared to pretreatment biopsies. This was reflected in increased CD8+/FOXP3+ cell ratios within the tumor (P < .001) and stromal compartments (P < .001). The effects of metformin occurred independently of HPV status.
Conclusion
Metformin treatment may favorably alter the immune TME in HNSCC independent of HPV status.
Level of Evidence1b. This study is most accurately described as a non‐randomized controlled trial and therefore may reflect a level of evidence below 1b but above 2a from the provided “levels of evidence” chart. Laryngoscope, 2019

Progressive Dominant Hearing Loss (Autosomal Dominant Deafness‐41) and P2RX2 Gene Mutations: A Phenotype–Genotype Study

08-10-2019 – Xue Zhong Liu, Denise Yan, Rahul Mittal, Megan E. Ballard, Yong Feng

Journal Article

Objectives/Hypothesis
P2RX2 encoding P2X purinoreceptor 2 has been identified as the gene responsible for autosomal dominant deafness‐41 (DFNA41) as well as mediating vulnerability to noise‐induced hearing loss (NIHL). The objective of this study was to investigate the audiological and molecular characteristics of P2RX2‐related deafness, with emphasis on its role in NIHL by determining the audiological characteristics of a previously reported six‐generation DFNA41 family with a 10‐year follow‐up. We have also summarized phenotype–genotype correlations of P2RX2‐related deafness in human and mouse models.
Study Design
We describe clinical longitudinal follow‐up in the DFNA41 family with P2RX2 (p.
Val60Leu) mutation and perform a systematic literature search in PubMed and poster presentations on meeting/conference websites to identify current insights into P2RX2‐mediated NIHL.
Methods
Clinical and physical examinations of the family members were performed, and audiograms were obtained to assess the hearing thresholds. Clinical follow‐up features in this DFNA41 family are presented along with correlation analyses of phenotype–genotype in all reported families with P2RX2‐related deafness.
Results
Progressive hearing impairment was confirmed by history and by audiological follow‐up testing in all the patients. The onset of hearing loss was between age 25 and 35 years. All affected subjects had bilateral sensorineural hearing loss involving all frequencies with some significant gender differences.
Conclusions
Our study and the review of the literature suggest that P2RX2 plays a crucial role in predisposition to noise‐induced and age‐related hearing loss. A better knowledge about the P2RX2‐associated genetic variants can help in developing novel therapeutic strategies.
Level of Evidence2b Laryngoscope, 2019

Gastrostomy utilization by oropharyngeal cancer patients is partially driven by swallowing function

30-09-2019 – Karishma Chhabria, Sagar Kansara, Hoda Badr, Carol Stach, Madeline Vernese, Allison Lerner, Aaron Harms, David J. Hernandez, Andrew T. Huang, George Chen, Robert B. Parke, Scott Charnitsky, Vlad C. Sandulache

Journal Article

Objective
Oropharyngeal squamous cell carcinoma (OPSCC) incidence is rapidly increasing, as are survival rates, in large part due to the human papillomavirus (HPV). Treatment intensity, however, has remained unchanged, making treatment‐related toxicity (i.e., dysphagia) a critical problem for an increasing number of patients. The primary objective of this study was to determine whether pretreatment objective swallowing measures can predict percutaneous fluoroscopic guided gastrostomy tube (PFG) utilization during OPSCC treatment.
Methods
Forty‐one newly diagnosed OPSCC patients treated with radiation underwent evaluation of swallow function with modified barium swallow study (MBSS) prior to and at completion of radiation treatment using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST); a subset of patients were evaluated using the MD Anderson Dysphagia Inventory (MDADI).
Results
Patients were male (100%), primarily Caucasian (85.4%) and p16 positive (85.4%) with mean age of 65.7 years. PFG were placed in 70.7% patients (n = 29) and used by 63.4% (n = 26). Pre‐ and post‐treatment DIGEST scores were associated with T‐classification (t = −2.9, p = .001, t = −2.7, p = .01) and indicated deteriorating swallow function during treatment (mean change = 0.46 t = −2.7, p = .01). DIGEST and MDADI scores were generally not associated with patient PFG utilization. DIGEST and MDADI scores were significantly correlated prior to, but not following completion of treatment.
Conclusion
Pre‐treatment DIGEST and patient reported swallowing outcomes (MDADI) can be useful in identifying patients with unsafe and/or grossly inefficient swallowing function. However, objectively measured swallow function was not associated with PFG utilization. Development of PFG placement algorithms (reactive vs. prophylactic) therefore require additional inputs/metrics.
Level of Evidence4 Laryngoscope, 2019

Frequency of post‐tonsillectomy hemorrhage relative to time of day

30-09-2019 – Sun Joo Kim, Jonathan Walsh, David E. Tunkel, Emily F. Boss, Andrew H. Lee

Journal Article

Objectives
Postoperative hemorrhage is a serious complication of tonsillectomy, with secondary bleeding rates affecting up to 0.8% to 3% of patients. Although these bleeds are anecdotally perceived as occurring more frequently at night, the occurrence of hemorrhage relative to the time of day has not been investigated. We measured the frequency of post‐tonsillectomy hemorrhage onset relative to the time of day.
Methods
We reviewed electronic medical records of all patients who experienced postprocedural hemorrhage (International Classification of Disease, Ninth Edition ICD‐9 998.11, ICD‐10 J95.830 at two hospitals within a tertiary academic health system in a 10‐year period). Patient demographics, time of bleed onset, emergency room ED arrival time, and management (operating room vs. observation) were abstracted. Patients without a recorded bleeding time were excluded. Time of bleed onset was categorized as morning (6:01 am–12 pm), afternoon (12:01 pm–6 pm), evening (6:01 pm–12 am), or overnight (12:01 am–6 am). Chi‐square goodness of fit test was used to assess the distribution of hemorrhage timing (P ≤ 0.05).
Results
A total of 7,396 patients underwent tonsillectomy May 2008 through May 2018, among whom 121 (2%) post‐tonsillectomy hemorrhage patients were identified. Among the 104 patients with ED arrival times, 29 (28%) arrived in the morning; 15 (14%) arrived in the afternoon; 40 (38%) arrived in the evening; and 20 (19%) arrived overnight (P = 0.003). Sixty patients (mean age 17.1 years, standard deviation 16.6) had a recorded timing of bleed onset. Bleed onset occurred most commonly overnight (24, 40%), followed by evening (21, 35%), afternoon (11, 18%), and morning (4, 7%) (P = 0.0007).
Conclusion
In this cohort, post‐tonsillectomy hemorrhage occurred most frequently between midnight and 6 am. Our findings confirm anecdotal experience and provide data in setting caregiver expectations.
Level of Evidence4 Laryngoscope, 2019

Cryosurgical ablation for treatment of rhinitis: A prospective multicenter study

30-09-2019 – Michael T. Chang, Sunhee Song, Peter H. Hwang

Journal Article

Objective
To assess the efficacy and safety of cryoablation of the posterior nasal nerve (PNN) for treatment of chronic rhinitis.
Methods
This was a prospective single‐arm trial of 98 adult patients at six U.
S. centers with chronic allergic and nonallergic rhinitis. PNN cryoablation was performed in‐office under local anesthesia using a handheld device. Patients discontinued use of intranasal ipratropium 3 days prior to treatment and throughout the study period. Reflective Total Nasal Symptom Score (r
TNSS) was measured at pretreatment baseline and posttreatment at 1 month, 3 months, 6 months, and 9 months. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was completed at pretreatment and 3 months posttreatment. Adverse effects and postprocedure medication usage were recorded.
Results
Ninety‐eight procedures (100%) were successfully completed. r
TNSS significantly improved over pretreatment baseline (6.1 ± 1.9) at 1 month (2.9 ± 1.9, P < 0.001), 3 months (3.0 ± 2.3, P < 0.001), 6 months (3.0 ± 2.1, P < 0.001), and 9 months (3.0 ± 2.4, P < 0.001) postprocedure. Nasal congestion and rhinorrhea subscores improved significantly at all time points (P < 0.001). Both allergic and nonallergic rhinitis subcohorts showed improvement (P < 0.001), with a comparable degree of improvement between groups. RQLQ significantly improved over pretreatment baseline (3.0 ± 1.0) at 3 months (1.5 ± 1.0, P < 0.001), and all RQLQ subdomains demonstrated improvement. Of 54 patients using intranasal medication at baseline, 19 (35.2%) were able to discontinue use. Twenty‐nine adverse effects were reported, including headache, epistaxis, and sinusitis.
Conclusion
Cryoablation of the PNN for chronic rhinitis is safe and can result in relief of nasal symptoms and improvements in quality of life.
Level of Evidence4 Laryngoscope, 2019

Live porcine model for surgical training in tracheostomy and open‐airway surgery

30-09-2019 – Ashley R. Deonarain, Robert V. Harrison, Karen A. Gordon, Nikolaus E. Wolter, Thomas Looi, Marvin Estrada, Evan J. Propst

Journal Article

Objectives/Hypothesis
To evaluate the validity of a live porcine model for surgical training in tracheostomy and open‐airway surgery.
Study Design
Prospective observational study.
Methods
Eleven expert otolaryngologists–head and neck surgeons rated a live porcine models realism/anatomical accuracy (face validity) and perceived effectiveness as a training tool (content validity) for tracheostomy and laryngotracheoplasty using anterior costal cartilage and thyroid ala cartilage grafts using a 53‐item post‐trial questionnaire with a five‐point Likert scale.
Results
Experts rated the face validity of the live porcine model a median (interquartile range IQR) of 4/5 (4–5) and the content validity a median (IQR) of 5/5 (4–5) for each surgical procedure. Overall, 91% strongly agreed or agreed that the simulator would increase trainee competency for tracheostomy and laryngotracheoplasty using costal cartilage graft, and 82% strongly agreed or agreed that it would increase trainee competency for laryngotracheoplasty using thyroid ala cartilage graft.
Conclusions
The live porcine model has high face and content validity as a training tool for tracheostomy and laryngotracheoplasty using costal cartilage and thyroid ala cartilage grafts. This training model can help surgical trainees practice these complex, low‐frequency procedures.
Level of Evidence
NALaryngoscope, 2019

Elevated troponin: A marker for noncardiac complications after resection of head and neck cancers

30-09-2019 – Tobial McHugh, Han Zhang, Michael Xie, Michael K. Gupta

Journal Article

Objective
To examine if troponin positivity (TP) in patients who undergo head and neck cancer mucosal resections (HNS) predicts noncardiac complications (NCC).
Background
Major HNSs are arduous operations that place stress on the patients hemodynamic system. TP after noncardiac surgery previously has been shown in up to 25% of patients, which may signal cardiac complications (CC) or NCC. Although CC after HNS has been observed, no study has investigated the relationship of TP to NCC.
Methods
All patients who underwent HNS at a tertiary‐care cancer center from July 2014 to July 2016 were included and underwent postoperative troponin measurements as part of an institutional cardiac protocol. Comparative and multivariate regression analysis were used to compare TP and troponin‐negative (TN) patients for NCC.
Results
One hundred seventy‐two patients underwent HNS. Of those, 15% developed TP during the postoperative period. There was no significant difference between TP and TN for gender, tumor‐node‐metastasis staging, Charlson comorbidity index, and smoking status. Risk of NCC in TP was 73.1% versus 28.1% in TN (P < 0.001). A significant difference (P < 0.05) in wound complications, length of hospital stay (LOHS), and incidence of pneumonia was found between both groups. Nonparametric testing confirmed significant difference in pneumonia (Z = −3.469, P = 0.001) and LOHS (−3.110, P = 0.002). Multivariate regression analysis confirmed a significant difference in LOHS independent of CC (R2 = 0.122, P < 0.0001).
Conclusion
TP is not an uncommon occurrence after HNS and is associated with statistically significant increases in wound complications, LOHS, and pneumonia. However, the overall significance of these findings remains unclear, and further research is warranted to determine if outcomes may be improved by closely monitoring these patients for TP.
Level of Evidence4 Laryngoscope, 2019

Total endoscopic stapes surgery: Systematic review and pooled analysis of audiological outcomes

30-09-2019 – Andrew C. Hall, Rishi Mandavia, David Selvadurai

Journal Article

Objective
This study evaluates the current evidence base for total endoscopic stapes surgery, specifically to establish current efficacy and safety of the technique within clinical practice.
Data Sources
A systematic review of the literature on endoscopic stapes surgery was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis checklist. A comprehensive search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials database for relevant publications for all available dates with appropriate Medical Subject Headings search criteria in January 2018.
Study Selection
Out of the 160 articles identified in the search, 14 met the inclusion criteria for further analysis. Four of these were level III and 10 level IV evidence.
Data Extraction
A pooled patient population of 314 individuals was analyzed.
Data Synthesis
Documented postoperative air bone gap closure to within 20 d
B was found in 95.3% of individuals (285 patients). Facial nerve palsy (temporary) occurred in three patients (0.6%), with all recovering. No total sensorineural hearing losses were recorded, but two moderate sensorineural hearing losses occurred (0.6%). Perilymph fistula was noted on four occasions (1.3%). Chorda tympani trauma was documented in 3.5% of cases, with taste disturbance documented in 13 patients (5%).
Conclusions
Our pooled analysis uses the current published evidence to establish the complication rate and audiological outcome for the endoscopic approach to stapes surgery. These outcomes are comparable to those documented in traditional use of the microscope for stapedectomy. Laryngoscope, 2019

Laryngeal adductor function following potassium titanyl phosphate laser welding of the recurrent laryngeal nerve

30-09-2019 – Neel K. Bhatt, Brian T. Faddis, Randal C. Paniello

Journal Article

Objectives/Hypothesis
Recurrent laryngeal nerve (RLN) transection injuries may occur during thyroidectomy and other surgical procedures. Laser nerve welding has been shown to cause less technique‐related axonal damage than the traditional suture method. We compared functional adductor results using these two methods of RLN repair.
Study Design
Animal model.
Methods
Canine hemilarynges underwent pretreatment testing of laryngeal adductor function, followed by RLN transection and repair using potassium titanyl phosphate (KTP) laser welding (n = 8) or microneural suture (n = 16) techniques. Six months later, adductor function was measured again and expressed as a proportion of the pretreatment value.
Results
The mean laryngeal adductor pressure ratios were 82.4% (95% confidence interval CI: 72.8%‐92.0%) for the laser repair group and 55.5% (95% CI: 49.4%‐61.6%) for the suture control group, with a difference of 26.9% (95% CI: 15.3%‐38.5%). Both spontaneous and stimulated glottic closure was observed in the laser welding and microsuture repair groups.
Conclusions
Laser nerve welding resulted in greater strength of adduction than suture repair of an acutely transected RLN. Suture anastomosis may traumatize more axons than the laser. Stronger vocal fold adduction is associated clinically with better protection from aspiration and improved voice outcomes. KTP laser welding should be considered for anastomosis of the RLN and other nerves.
Level of Evidence
NALaryngoscope, 2019

Are diuretics useful in the treatment of meniere disease?

30-09-2019 – Sagit Stern Shavit, Anil K. Lalwani

Journal Article

Endoscopically assisted transstomal primary repair of an acquired tracheoesophageal fistula

30-09-2019 – David S. Leonard, Allison Slijepcevic, Joseph T. Bertroche

Journal Article

Does Cochlear Implantation Improve Cognitive Function?

30-09-2019 – Aaron C. Moberly, Karl Doerfer, Michael S. Harris

Journal Article

CT Navigation and sialendoscopy‐assisted transfacial removal of a parotid stone: A technical note

30-09-2019 – Pasquale Capaccio, Lorenzo Bresciani, Daniele Di Pasquale, Michele Gaffuri, Sara Torretta, Lorenzo Pignataro

Journal Article

Solving periprosthetic leakage with a novel prosthetic device

30-09-2019 – Japke F. Petersen, Liset Lansaat, Frans Hilgers, Michiel Brekel

Audiologic and surgical outcomes in endoscopic revision stapes surgery

30-09-2019 – Ashley M. Nassiri, Robert J. Yawn, Matthew M. Dedmon, Anthony M. Tolisano, Jacob B. Hunter, Brandon Isaacson, Alejandro Rivas

Journal Article

Validation of training levels in endoscopic endonasal surgery of the skull base

30-09-2019 – Philippe Lavigne, Daniel Faden, Paul A. Gardner, Juan C. Fernandez‐Miranda, Eric W. Wang, Carl H. Snyderman

Journal Article

Objective
A five‐level training program was first proposed 10 years ago for surgeons learning endoscopic endonasal surgery (EES) of the skull base. Levels were based on the complexity of anatomy, risk of neurovascular injury, intradural dissection, technical difficulty and vascularity of tumors.
Method
A three‐phase validation concept is proposed: 1) face validity (the classification is related to clinically significant elements), 2) construct validity (the classification predicts the outcome), and 3) inter‐team validation (the classification applies to other surgical teams). Consecutive cases over a 1‐year time span were retrospectively classified. Primary outcome measures included: complication rates (cranial nerve injury, stroke and vascular injury, cerebrospinal fluid CSF leak and infection), estimated blood loss and duration of surgery.
Results
Two hundred and nine consecutive cases were analyzed. The distribution of cases for each category was: 63 cases in level II, 70 cases in level III, 66 cases in level IV, and 10 cases in level V. Construct validity demonstrated statistical difference with increasing rate of complications from level II to level III and from level III to level IV; also, specific rates of cranial nerve injury and CSF leak increased between levels III and IV. Face validity identified 162 citations since publication of the original article. Inter‐team validation demonstrated no difference between two teams of surgeons.
Conclusion
This study provides a three‐phase validation of training levels for endoscopic skull base surgery. Adoption of a progressive systematic approach to learning EES from least complex to advanced procedures is expected to minimize the risks while surgical teams gain experience.
Level of Evidence3Laryngoscope, 129:2253–2257, 2019

Eye movement desensitization and reprocessing as a treatment for tinnitus

30-09-2019 – John S. Phillips, Sally Erskine, Tal Moore, Ian Nunney, Catherine Wright

Journal Article

Objectives/Hypothesis
To determine the effectiveness of eye movement desensitization and reprocessing (EMDR) as a treatment for tinnitus.
Study Design
Single‐site prospective interventional clinical trial at a university hospital in the United Kingdom.
Methods
Participants were provided with t
EMDR. This is a bespoke EMDR protocol that was developed specifically to treat individuals with tinnitus. Participants received a maximum of 10 sessions of t
EMDR. Outcome measures including tinnitus questionnaires and mood questionnaires were recorded at baseline, discharge, and at 6 months postdischarge.
Results
Tinnitus Handicap Inventory and Beck Depression Inventory scores demonstrated a statistically significant improvement at discharge after EMDR intervention (P = .0005 and P = .0098, respectively); this improvement was maintained at 6 months postdischarge. There was also a moderate but not significant (P = .0625) improvement in Beck Anxiety Inventory scores.
Conclusions
This study has demonstrated that the provision of t
EMDR has resulted in a clinically and statistically significant improvement in tinnitus symptoms in the majority of those participants who took part. Furthermore, the treatment effect was maintained at 6 months after treatment ceased. This study is of particular interest, as the study protocol was designed to be purposefully inclusive of a diverse range of tinnitus patients. However, as a small uncontrolled study, these results do not consider the significant effects of placebo and therapist interaction. Larger high‐quality studies are essential for the verification of these preliminary results.
Level of Evidence4Laryngoscope, 129:2384–2390, 2019

Impact of treating facilities’ type and volume in patients with major salivary gland cancer

30-09-2019 – Craig A. Bollig, Robert P. Zitsch

Journal Article

Objectives/Hypothesis
Investigate the relationship between facility volume and type on overall survival (OS) in patients with major salivary gland cancer undergoing surgical treatment.
Study Design
Retrospective review of the National Cancer Database (NCDB) 2004–2015.
Methods
The NCDB was queried for patients with surgically treated major salivary gland cancer. The mean number of cases treated at each institution was calculated. High‐volume facilities (HVFs) were defined as the top 10% of centers. Univariate and multivariate propensity score‐matched analyses were performed to evaluate the impact of facility volume and type on OS.
Results
A total of 8,658 patients were analyzed. Distribution among facilities was highly skewed, with a median value of 1.38 cases/year (range, 0.11–23.25). On univariate analysis, treatment at HVFs was not associated with improved OS. However, there were significantly more patients with adverse clinical features treated at HVFs. Treatment at HVFs was associated with increased rates of concomitant neck dissections and lower rates of positive margins. In propensity‐score matched cohorts, OS was not significantly improved in patients treated at HVFs (hazard ratio HR: 0.979; 95% confidence interval CI: 0.879‐1.091) or academic/research institutions (HR: 0.914; 95% CI: 0.821‐1.018).
Conclusions
Regionalization of care is occurring in patients with major salivary gland malignancies. Patients treated at HVFs had greater rates of adverse clinical features and more commonly underwent neck dissections, although adjuvant radiotherapy rates were similar between facility types. There was no apparent survival benefit to patients treated at HVFs or academic/research institutions, although there were lower rates of positive margins at HVF.
Level of Evidence
NALaryngoscope, 129:2321–2327, 2019

What makes us tick: Implications of personality differences among otolaryngology residents and faculty

30-09-2019 – Jennifer A. Villwock, Sarah N. Bowe, Duncan C. Rotich, Alvin Beltramo, Alan Friedman, Shannon M. Kraft

Journal Article

Objective
The rapid personal and professional growth experienced during medical training and practice is impacted by personality. The surgeons personality is renowned in both medical lore and literature. However, it is now known that the personality characteristics of todays millennial trainees differ from older faculty. This study investigates the variability of different personality attributes among otolaryngology residents and faculty, as well as the practical implications of these findings.
Methods
The opportunity to complete a series of web‐based, commercially available, self‐administered five factor‐based personality assessments was given to otolaryngology residents and faculty at nine academic training programs. The psychometrically validated assessments evaluate innate personality 1) strengths, 2) challenges, and 3) motivators/values. Differences between groups in the assessed metrics were evaluated using two‐tailed t tests.
Results
Seventy‐eight otolaryngology faculty and 104 residents completed all three assessments. Of the assessed metrics, there were several significant differences between residents and faculty (all P < 0.05). Residents scored higher than faculty in the domains of interpersonal sensitivity, sociability, and inquisitiveness. With respect to potential challenges, faculty displayed higher levels of skepticism and reservation. In contrast, residents scored higher in the categories of mischievous and dutiful. As for motivators/values, although both groups were highly motivated by altruism, faculty valued tradition more than residents, whereas residents valued hedonism and affiliation more than faculty.
Conclusion
There are notable differences between residents and faculty in multiple domains, with implications for communication, education, and professional development.
Level of Evidence3Laryngoscope, 129:2286–2290, 2019

Utilization and reimbursements for sinus procedures: A five‐year analysis

30-09-2019 – Lindsey K. Koester, Parul Goyal

Journal Article

Objectives/Hypothesis
Balloon sinuplasty has become an increasingly popular option for patients undergoing surgical treatment of sinusitis. This study analyzes utilization and growth of these procedures across a large cohort of patients over a 5‐year period.
Study Design
Retrospective data review.
Methods
This was a retrospective review of Medicare utilization and billing data. Utilization and payment values were obtained from Medicare claims data using Centers for Medicare and Medicaid Services datasets. All Medicare claims were analyzed from 2012 to 2016. Data were extracted for balloon sinuplasty and endoscopic sinus surgery claims. Procedure location, total submitted claims, charges, and payments were compared.
Results
From 2012 to 2016, the number of balloon procedures increased from 5,603 to 25,640. Traditional endoscopic sinus surgery procedures increased from 15,509 to 18,164. Aggregate Medicare payments to otolaryngologists for endoscopic sinus surgery have remained relatively stable, whereas there has been a 450% increase in total payments to providers of balloon sinuplasty. In 2016, total payments to providers of balloon procedures ($40.5 million) were substantially higher than payments to providers of non–balloon‐based endoscopic sinus surgery ($4.7 million). The number of providers performing balloon procedures has increased 277% versus 17% for traditional sinus surgery.
Conclusions
There has been a rapid expansion in the number of sinus procedures in the Medicare population from 2012 to 2016. Office‐based balloon procedures account for the overwhelming majority of the increases in procedures and payments. Per procedure and aggregate payments are now higher for sinuplasty procedures than for traditional sinus surgery.
Level of Evidence
NALaryngoscope, 129:2224–2229, 2019

Safety of office‐based percutaneous injection laryngoplasty with calcium hydroxylapatite

30-09-2019 – Minhyung Lee, Doh Young Lee, Tack‐Kyun Kwon

Journal Article

Objective
To evaluate the safety of office‐based calcium hydroxylapatite (Ca
HA) injection laryngoplasty via the cricothyroid approach through an analysis of all procedures performed over a period of 10 years at a single institution.
Methods
In total, 962 office‐based Ca
HA injection laryngoplasty via the cricothyroid approach procedures were performed by a single physician at our institution between 2007 and 2016. From these, 955 procedures performed in 617 patients were included in our analysis. The medical records of all 617 patients were retrospectively reviewed. We classified all procedure‐related complications according to the time of onset. Complications that occurred during the procedure were considered intraprocedural complications, whereas complications that developed within 1 week after injection and those that developed after 1 week and were recorded more than twice in the medical records were considered acute and delayed complications, respectively. Failed cases were categorized separately as failure.
Results
Five cases were failed (0.5%). Intraprocedural complications included superficial injection in eight cases (0.8%). Acute and delayed onset of dyspnea was observed in three (0.3%) and two (0.2%) cases, respectively. The incidence of failures and major complications requiring active intervention was 1.6%.
Conclusion
Our findings suggest that office‐based Ca
HA injection laryngoplasty via the cricothyroid approach is as safe as conventional transoral injection laryngoplasty.
Level of Evidence4Laryngoscope, 129:2361–2365, 2019

Hairy polyps: A new case presentation and a pathogenetic hypothesis

30-09-2019 – Jonathan C. Simmonds, Jad Jabbour, Jennifer A. Vaughn, Vera A. Paulson, Dennis S. Poe, Reza Rahbar

Hairy polyps are benign lesions found in the oropharynx or nasopharynx that are thought to be present at birth and can lead to upper airway obstruction in infants. Also known as naso‐oropharyngeal choristoma, they are increasingly viewed as aggregates of bigeminal tissue, likely from the first or second branchial arches, found in aberrant locations. They are benign lesions that are usually successfully treated by surgical excision. Here we present a rare case of a hairy polyp originating in the eustachian tube of a 7‐week‐old male, discuss our management of the patient, and put forth a new hypothesis as to the origin of these lesions.
Laryngoscope, 129:2398–2402, 2019

Children with unilateral cochlear nerve canal stenosis have bilateral cochleovestibular anomalies

30-09-2019 – Luis D. Vilchez‐Madrigal, Susan I. Blaser, Nikolaus E. Wolter, Adrian L. James, Blake C. Papsin, Karen A. Gordon, Sharon L. Cushing, Evan J. Propst

Objectives/Hypothesis
To investigate the cochleovestibular apparatus bilaterally in children with isolated unilateral bony cochlear nerve canal (b
CNC) stenosis.
Study Design
Retrospective review.
Methods
Imaging studies of children with unilateral b
CNC stenosis (<1.0 mm) on computed tomography imaging (N = 36) were compared with controls imaged due to trauma without temporal bone injury (N = 32). Twenty‐six measurements were obtained in each ear, assessing the bony internal auditory canal (IAC), cochlea, and vestibular end‐organs, and were analyzed using one‐way analysis of variance for intersubject comparisons and paired t tests for intrasubject comparisons with a Bonferroni adjustment for multiple comparisons (P = .0006).
Results
Patients with b
CNC stenosis had a smaller IAC (P < .000) and cochlea (P < .000) on the stenotic side as compared with controls. Although the vestibular end‐organ was also smaller in b
CNC ears, this difference was not significant. The contralateral ear also had a smaller b
CNC (P < .000) and cochlea (P < .000) as compared with controls, although to a lesser degree than the stenotic side.
Conclusions
Children with unilateral b
CNC stenosis have abnormal biometry of both the cochlea and the vestibular end‐organ in the affected and the normal contralateral ear as compared with controls.
Level of Evidence3b
Laryngoscope, 129:2403–2408, 2019

Wideband tympanometry and absorbance measurements in otosclerotic ears

30-09-2019 – Elżbieta Niemczyk, Magdalena Lachowska, Emanuel Tataj, Katarzyna Kurczak, Kazimierz Niemczyk

Journal Article

Objectives
This study aimed to assess absorbance using a thorough analysis of individual points of its plot in ears with intraoperatively confirmed otosclerosis. To the best of our knowledge, until recently no analyses have been performed that concerned the shape of an absorbance plot and a detailed analysis of its individual points. This study is the first to undertake such an issue.
Methods
A total of 77 otosclerotic ears were included in the study. Pure tone audiometry, low frequency tympanometry, and wide band tympanometry including absorbance were performed preoperatively. The average patients’ age in the group was 43.49 years (standard deviation = 10.44). Individual points of absorbance plot were thoroughly analyzed. Parameters were analyzed, such as resonance frequency; number of peaks; maximum absorbance (Height); and plot Width at the following Heights: 1/3, 1/2, and 2/3 (Width1/3, Width1/2, Width2/3, respectively), as well as associated absorbance parameters and frequencies.
Results
Data analysis revealed five different types of absorbance plots. Numerous statistically significant differences regarding the parameters of individual points of the plots were found among the distinguished types.
Conclusions
There are five types of absorbance plots in otosclerotic ears: type I, characterized by two distinct peaks, closely resembling normal ear absorbance plot; type II with a single distinct peak reaching high values of absorbance; type III with reduced absorbance for frequencies <2000 Hz; type IV with reduced absorbance for all frequencies; and type V with reduced absorbance for frequencies >2000 Hz. Absorbance measurements may play an important role in the diagnostics of otosclerosis; however, further research is necessary in this area.
Levels of Evidence4Laryngoscope, 129:E365–E376, 2019

Otolaryngology Residency Interviewing Dates and Practices: What Should an Applicant Expect?

30-09-2019 – Andrew H. Lee, Ross Liao, Patrick Young, Paul H. Yi, Douglas Reh, David W. Eisele, Alexander T. Hillel

Journal Article

Objectives/Hypothesis
Scheduling otolaryngology interviews may be a challenge for residency applicants due to overlapping interview dates. Our objective was to identify otolaryngology interview date patterns and scheduling conflicts over the past six application cycles.
Study Design
Retrospective review of otolaryngology online forums (Otomatch.com and Student Doctor Network).
Methods
Online threads related to residency interview dates posted during the 2012 to 2013 through 2017 to 2018 interview seasons on Otomatch.com were reviewed. Program directors were contacted to complete any missing data. The χ‐ goodness‐of‐fit test and the χ2 test of independence was used to compare proportions. Analysis of variance was used to compare values across years.
Results
Data from an average of 98 programs (99%) per year were obtained. The majority of invitations arrived late October (49%), followed by early November (37.1%). Interviews occurred primarily in December (48.4%) and January (37.5%). Programs on average scheduled 2.47 (range, 0–4) interview dates. Most interviews fell on Fridays (28.7%) and Saturdays (22.7%) (P < .0001), with an increasing trend toward interviewing on consecutive days. There was substantial overlap in interview dates, with six dates alone accounting for an average of 31.3% of all interviews in a given interview cycle.
Conclusions
The majority of otolaryngology interviews occur in December or January and fall on a Friday or Saturday. There is considerable overlap with the potential for scheduling conflicts. Our findings can help set expectations for applicants regarding interview invitations, as well as a strategy for scheduling interviews.
Level of Evidence
NALaryngoscope, 129:2280–2285, 2019

Impact of Balloon Diameter on Dilation Outcomes in a Model of Rabbit Subglottic Stenosis

30-09-2019 – Cláudia Schweiger, Catherine K. Hart, Meredith E. Tabangin, Aliza P. Cohen, Nicholas J. Roetting, Alessandro Alarcón

Objective
To determine the appropriate balloon size for dilation using a previously described reproducible survival animal model of subglottic stenosis.
Study Design
Prospective animal study.
Methods
We conducted a prospective study including 16 New Zealand White rabbits. The airway of each animal was sized with an endotracheal tube (ETT), and subglottic stenosis (SGS) was endoscopically induced using Bugbee electrocautery to 75% of the circumference of the subglottis, followed by 4‐hour intubation. Two weeks postoperatively, the rabbits airways were sized and then dilated using a 6‐, 7‐, 8‐, or 9‐mm balloon, with four animals in each experimental group. Following dilation, animals were again sized and subsequently euthanized. The cricoid lumen was measured microscopically in each animal.
Results
Prior to inducing stenosis, all animals were sized with a 3.5 ETT. After inducing injury but prior to dilation, airways showed grade 2 SGS that sized with a 2.5 ETT with no leak. Postdilation, animals dilated with 6‐ or 7‐mm balloons (n = 8) sized with a 3.0 ETT, and animals dilated with an 8‐ or 9‐mm balloon (n = 8) sized with a 3.5 ETT. Postdilation median cricoid lumen measurements were 12.5 mm2 (6‐mm balloon), 13.92 mm2 (7 mm), 16.83 mm2 (8 mm), and 17.15 mm2 (9 mm); two cricoid fractures occurred in the 9‐mm group.
Conclusion
The postdilation cricoid lumen diameter increased with increased balloon size, and the use of an 8‐mm balloon achieved the largest cricoid lumen diameter without causing fracture. Further research is necessary to determine the ideal duration of dilation and optimal intervals between dilations.
Level of Evidence
NALaryngoscope, 129:2409–2413, 2019

Injection of bevacizumab and cyanoacrylate glue for hereditary hemorrhagic telangiectasia

30-09-2019 – Nadim Khoueir, Michel Borsik, Domitille Camous, Philippe Herman, Benjamin Verillaud

Journal Article

Objectives/Hypothesis
The objective of this study was to report for the first time on the results of submucosal injections of bevacizumab used in conjunction with cyanoacrylate glue sclerotherapy in hereditary hemorrhagic telangiectasia (HHT).
Study Design
Retrospective analytic chart review.
Methods
We performed a chart review that included all patients with HHT treated with intranasal bevacizumab and cyanoacrylate glue for refractory epistaxis at Lariboisiere University Hospital from 2013 with a minimum follow‐up of 6 months. We injected 100 mg (25 mg/m
L) of bevacizumab diluted in 2 m
L of serum at the base of the telangiectasias, and sclerotherapy with an injection of cyanoacrylate glue was used adjunctively. Treatment efficacy was based on changes in Epistaxis Severity Scores (ESS) and the Bergler‐Sadick Scale. Quality of life and patient satisfaction were evaluated using the Cantril Self‐Anchoring Ladder (CL) and Likert scale, respectively.
Results
Thirty‐one patients were included, with a mean follow‐up of 26.6 months. The average ESS score significantly decreased from 7.82 to 3.89 (P < .05). The Bergler‐Sadick score significantly improved (P < .05) following the treatment, including the frequency (from 2.74 to 1.64) and the quantity (from 2.54 to 1.51) scales. Quality of life was significantly improved (P < .05) using the CL score (from 4.16 to 7.22). The Likert satisfaction scale related to the treatment efficacy was high, with an average of 7.03 out of 10. No complications were noted.
Conclusions
Submucosal injections of bevacizumab in conjunction with cyanoacrylate glue sclerotherapy significantly reduced epistaxis and improved the quality of life in HHT. Prospective comparative studies are needed to further evaluate the significance of this treatment modality.
Level of Evidence3b
Laryngoscope, 129:2210–2215, 2019

Determining effectiveness of EBM education in otolaryngology residents using modified fresno test

30-09-2019 – Shahin Bastaninejad, Akbar Soltani, Soheila Dabiran, Amin Amali, Suzan Adil, Pedram Borghei, Alireza Mazarei

Journal Article

Objective
To determine the effectiveness of education in evidence‐based medicine (EBM) on the knowledge, competency, and skills of otolaryngology residents of Tehran University of Medical Sciences (TUMS) at Amir‐Alam and Imam Khomeini Hospitals.
Methods
In a quasi‐experimental (before‐and‐after) study, all ear, nose, and throat residents of TUMS (n = 41) entered the study. The residents underwent the modified Fresno test. Then, two EBM workshops with a similar content were held on 2 separate days in each hospital, with each session lasting 6 hours. The learned material was practiced in weekly journal clubs. Six months after the workshop, the modified Fresno test was applied again, and the results were analyzed.
Results
A significant improvement in the modified Fresno test score was observed. The mean score of the modified Fresno test was 57.43 ± 22.07 before the workshop and 79.26 ± 22.48 after the workshop (P < 0.001).
Conclusion
The results of the study show that EBM education and practice of the learned materials in journal clubs can improve the knowledge and skills of residents.
Further research with larger samples is needed to improve the precision of our findings and to increase confidence in the results.
Level of Evidence2Laryngoscope, 129:2291–2294, 2019

Novel, anatomically appropriate balloon dilation technique of the glottis to treat posterior glottic stenosis in a 3D‐printed model

30-09-2019 – Daniel J. Cates, Michael J. Magnetta, Libby J. Smith, Clark A. Rosen

Journal Article

Objective
Posterior glottic stenosis (PGS) often requires a destructive surgical treatment. Early PGS treatment involves glottic dilation to reduce airway constriction associated with chronic PGS. Round laryngeal dilation may not optimize posterior glottic dilation due to the teardrop shape of the glottis and may injure vocal fold tissue. We compared pressure applied to the glottis during traditional single balloon dilation and a novel, anatomically appropriate dilation technique (teardrop‐shaped glottic dilation TSGD).
Methods
Pressure sensors were affixed at various points on a three‐dimensional printed glottic model. The anterior glottis was stented with a triangular stent (18‐32F) in combination with balloon dilator (10–20 mm) placed in the posterior glottis (TSGD) in 30 unique combinations. Force applied to the vocal folds (VF) and posterior commissure (PC) during round balloon dilation and TSGD was measured.
Results
Dilatory force in the PC ranged from 0.0–3.8 newtons (N) using balloon dilators and 0.0–17.5 N using TSGD. The TSGD technique yielded a superior ratio of force applied to the PC versus VF (P = 0.0296) compared to round balloon dilation alone. Optimal targeting of the PC occurred when the sum of the anteroposterior (AP) dimensions of the stent and balloon dilator approached the AP length of the glottis.
Conclusion
Use of an anatomically appropriate glottic dilation maximizes expansive force applied to the posterior commissure and decreased force to the vocal folds. This study demonstrates that TSGD minimizes force to the anterior glottis and maximizes dilation of the posterior glottis. This technique may play a role in preventing laryngeal stenosis associated with chronic PGS.
Level of Evidence
NALaryngoscope, 129:2239–2243, 2019

Multicenter randomized crossover trial evaluating the provox luna in laryngectomized subjects

30-09-2019 – Chathura B.B. Ratnayake, Renske Fles, I. Bing Tan, Laura W.J. Baijens, Walmari Pilz, Cees A. Meeuwis, Pauline H.E. Janssen‐van Det, Rob Son, Michiel W.M. Van den Brekel

Journal Article

Objectives
The aim of this study was to compare the relative compliance and the dermatological and pulmonary outcomes when the Provox Luna system (Atos Medical, Malmö, Sweden) is added during the night to the usual tracheastoma care of laryngectomized subjects.
Methods
This was a multicenter randomized crossover trial conducted in the Netherlands Cancer Institute, Erasmus Medical Center, and Maastricht University Medical Center in The Netherlands. The study included 46 laryngectomized subjects with prior heat and moisture exchanger (HME) and adhesive experience.
Results
A significant improvement in the number of compliant individuals was found: Luna: n = 43 of 45 (96%); usual care: n = 35 of 46 (76%), P = 0.02. The Luna period was associated with longer intervals of daily HME use (Luna 23.2 hours range: 15.6–24.0 hours, usual care UC: 21.5 hours range: 6.0–24.0 hours, P = 0.003) and an increased frequency of skin improvement overnight (Luna 3.9 days standard deviation (SD): 7.0 days), Usual Care: 8.1 days (SD: 10.8 days, P = 0.008). Fifty‐six percent (n = 26) of participants wanted to continue using the Provox Luna system at the conclusion of the study.
Conclusion
An improvement in compliance and skin recovery overnight was observed when the Provox Luna was added to the usual adhesive and HME use. Therefore, there is utility in supplementing the usual post‐total laryngectomy care with the Provox Luna system at night, particularly in the setting of compliance concerns and in subjects who desire dermatological relief overnight.
Level of Evidence1b
Laryngoscope, 129:2354–2360, 2019

Isolated Recovery of Adductor Muscle Function Following Bilateral Recurrent Laryngeal Nerve Injuries

30-09-2019 – Ádám Bach, Balázs Sztanó, Vera Matievics, Zsófia Bere, Fabian Volk, Andreas Müller, Gerhard Förster, Paul F. Castellanos, László Rovó

Objectives/Hypothesis
The aim of this study was to analyze the phoniatric and respiratory outcomes of a subset of bilateral vocal cord paralysis (BVCP) patients who were all treated with unilateral endoscopic arytenoid abduction lateropexy (EAAL). EAAL is a nondestructive, minimally invasive glottis widening operation, which does not damage either the surgically treated or the contralateral vocal cord. Therefore, it does not impair the regeneration potential of the recurrent laryngeal nerve.
Study Design
Case series.
Methods
Ten out of 21 BVCP patients who were treated with EAAL showed signs of isolated adduction recovery at 1 year and were chosen for this study. Functional results (objective and subjective voice analysis, spirometric measurement) and vocal cord movements were assessed preoperatively, 1 week and 1 year after EAAL. Laryngeal electromyography was performed on the 12th postoperative month.
Results
The volitional adductor movement seen on laryngoscopy was corroborated by laryngeal electromyography evaluation. Peak inspiratory flow increased significantly after EAAL. Quality‐of‐life scores also showed high patient satisfaction. Shimmer showed consistent improvement along with harmonic‐to‐noise ratio and average maximal phonation time in parallel with the improving vocal cord movement. Complex voice analysis and subjective self‐evaluation tests also demonstrated significant improvement.
Conclusions
EAAL, as a minimally invasive, nondestructive airway widening technique, does not interfere with the potential regeneration process that can still occur after BVCP, allowing for laryngeal functional recovery. It is a safe and effective treatment for BVCP that allows a simple solution with good phonatory, swallowing, and respiratory benefits by unilateral passive and reversible vocal cord lateralization.
Level of Evidence4Laryngoscope, 129:2334–2340, 2019

Methodology for the establishment of primary porcine vocal fold epithelial cell cultures

30-09-2019 – Elizabeth Erickson‐DiRenzo, Ciara Leydon, Susan L. Thibeault

Journal Article

Objective
A current lack of methods for epithelial cell culture significantly hinders our understanding of the role of the epithelial and mucus barriers in vocal fold health and disease. Our first objective was to establish reproducible techniques for the isolation and culture of primary porcine vocal fold epithelial cells. Our second objective was to evaluate the functional significance of cell cultures using an in vitro exposure to an inflammatory cytokine.
Methods
Epithelial cells were isolated from porcine vocal folds and expanded in culture. Characterization of cultures was completed by immunostaining with markers for pan‐cytokeratin (epithelial cells), vimentin (stromal cells), von Willebrand factor (endothelial cell), and MUC1 and MUC4 (mucin) glycoproteins. Established epithelial cell cultures were then exposed to the inflammatory cytokine tumor necrosis factor alpha (TNF‐α) for 24‐hours, and transcript expression of MUC1 and MUC4 was evaluated.
Results
Reproducible, porcine vocal fold epithelial cell cultures, demonstrating cobblestone appearance characteristic of the typical morphology of epithelial cell cultures were created. Cells showed positive staining for pan‐cytokeratin with limited expression of vimentin and von Willebrand factor. Epithelial cells also expressed MUC1 and MUC4. TNF‐α significantly increased transcript expression of MUC4.
Conclusion
Here, we present the first report of successful culture of primary porcine vocal fold epithelial cells. Cultures will provide researchers with a valuable new in vitro tool to investigate vocal fold epithelium and mucus as well as the effects of common challenges, including inflammatory cytokines, on these barriers.
Level of Evidence
NALaryngoscope, 129:E355–E364, 2019

High‐density surface electromyography: A visualization method of laryngeal muscle activity

30-09-2019 – David J. Bracken, Gladys Ornelas, Todd P. Coleman, Philip A. Weissbrod

Journal Article

Objectives/Hypothesis
Laryngeal muscle activation is a complex and dynamic process. Current evaluation methods include needle and surface electromyography (s
EMG). Limitations of needle electromyography include patient discomfort, interpretive complexity, and limited duration of recording. s
EMG demonstrates interpretive challenges given loss of spatial selectivity. Application of high‐density s
EMG (HD s
EMG) arrays were evaluated for potential to compensate for spatial selectivity loss while retaining benefits of noninvasive monitoring.
Study Design
Basic science.
Methods
Ten adults performed phonatory tasks while a 20‐channel array recorded spatiotemporal data of the anterior neck. Data were processed to provide average spectral power of each electrode. Comparison was made between rest, low‐, and high‐pitch phonation. Two‐dimensional (2D) spectral energy maps were created to evaluate use in gross identification of muscle location.
Results
Three phonatory tasks yielded spectral power measures across the HD s
EMG array. Each electrode within the array demonstrated unique power values across all subjects (P < .001). Comparison of each electrode to itself across phonatory tasks yielded differences in all subjects during rest versus low versus high, rest versus low, and rest versus high and in 9/10 subjects (P < .001) for low versus high phonation. Symmetry of HD s
EMG signal was noted. Review of 2D coronal energy maps allowed for gross identification of cricothyroid muscle amidst anterior strap musculature.
Conclusions
HD s
EMG can be used to identify differences in anterior neck muscle activity between rest, low‐, and high‐pitch phonation. HD s
EMG of the anterior neck holds potential to enhance diagnostic and therapeutic monitoring for pathologies of laryngeal function.
Level of Evidence
NALaryngoscope, 129:2347–2353, 2019

Mandibular muscle attachments in genial advancement surgery for obstructive sleep apnea

30-09-2019 – Cherine H. Kim, Nichole Loree, Peter S. Han, Erin T. Ostby, Daniel I. Kwon, Jared C. Inman

Journal Article

Objectives/Hypothesis
Genioglossus advancement is performed in select patients with obstructive sleep apnea. Surgical techniques attempt to capture the genial tubercle of the mandible; however, measurements of the genioglossus, geniohyoid, and digastric muscles are poorly delineated. This investigation is the largest anatomic study exploring the muscles of genial advancement surgery and the first to quantitatively characterize muscular attachments relative to the tubercle, providing new insights from an anatomic perspective on optimizing muscular advancement.
Study Design
Cadaveric study.
Methods
Fifty‐three fresh cadaveric mandibles underwent dissection of the genial tubercle and genioglossus, geniohyoid, and digastric muscles.
Results
Genial tubercle, geniohyoid, and genioglossus mean height was 7.78 mm, 5.15 mm, and 6.11 mm, respectively. On average, the geniohyoid began 4.88 mm and ended 10.03 mm from the inferior border of the mandible; the genioglossus 11.91 mm and 18.01 mm, similarly. Intermuscular distance, if present, was 2.67 mm; the muscles overlapped in 28% of cadavers. The combined vertical height of the muscles at their mandibular attachment was 13.94 mm, significantly differing from the height of the genial tubercle. The left and right lateral insertion of the digastric muscles was 19.34 mm and 19.31 mm, respectively, from midline.
Conclusions
The variable range of muscle attachments suggests that genioglossal and geniohyoid attachments extend beyond the genial tubercle and may not originate concentrically from the tubercle, but overlap and lie in very close proximity. Mandibular anterior muscle attachments require anatomic accuracy and an effective operative evaluation of advancement before reproducible, clinically effective osteotomies can be recommended.
Level of Evidence
NALaryngoscope, 129:2424–2429, 2019

Bell Palsy and the Risk of Cardio‐Cerebrovascular Disease: A Population‐Based Follow‐Up Study

30-09-2019 – Jong‐Yeup Kim, Myoung Suk Kim, Myeong Hee Kim, Dong‐Kyu Kim, Myeong Sang Yu

Journal Article

Objective
To evaluate the risk of cardio‐cerebrovascular disease (CCVD), such as ischemic stroke and acute myocardial infarction (AMI), in patients diagnosed with Bell palsy
Study Design
Population‐based follow‐up study.
Methods
We used the National Sample Cohort 2002 to 2013 data from the Korea National Health Insurance Service. The Bell palsy group comprised all patients diagnosed with Bell palsy (n = 730). The comparison group comprised patients selected randomly using propensity score matching (n = 1,460). The Kaplan‐Meier survival analysis, log‐rank test, and Cox proportional‐hazards regression models were used to calculate the disease‐free survival rate and hazard ratio (HR) of CCVD for each group.
Results
Of the total study population, ischemic stroke developed in 15.7% of patients with Bell palsy and 9% of patients in the comparison group during the 12‐year follow‐up period. After adjusting for other factors, the HR of ischemic stroke during the 12‐year follow‐up period was 1.84 times greater in the Bell palsy group than in the comparison group (95% confidence interval CI, 1.43–2.36). However, the adjusted HR of developing ischemic stroke for patients with Bell palsy treated concurrently with antiviral agents and steroids was 1.12 (95% CI, 0.62.–2.04). There was no significant relationship between Bell palsy and risk of AMI development (HR, 1.13; 95% CI, 0.71–1.82).
Conclusion
Bell palsy is linked with an increased incidence of ischemic stroke. Our data suggest that Bell palsy may be used as an indicator of increased stroke risk, and concurrent treatment with antiviral agents and steroids may be effective in preventing ischemic stroke.
Level of Evidence
NALaryngoscope, 129:2371–2377, 2019

Tumor growth rate: A new prognostic indicator of hearing preservation in vestibular schwannoma surgery

30-09-2019 – Andrea Lovato, Emilio García ibañez, Luis García ibañez, Cosimo Filippis

Journal Article

Background
The management of small‐ to medium‐size (< 20 mm) sporadic vestibular schwannomas (VSs) continues to inspire debate. Preoperative pure tone thresholds and tumor size are recognized prognostic features of hearing preservation after surgery.
Objective
To investigate what preoperative characteristics were associated with nonserviceable hearing after surgery for VSs.
Methods
We retrospectively reviewed the audiological results of 92 patients treated with the middle cranial fossa (MCF) approach for resection of VSs (< 20 mm). Sex, age, symptoms, tumor site, tumor size, growth rate, and hearing class according to American Academy of Otolaryngology–Head and Neck Surgery guidelines were evaluated. Negative outcome was progression after surgery to nonserviceable hearing according to Gardner‐Robertson classification. We included only patients with preoperative serviceable hearing.
Results
After surgery, 48 patients (52.2%) had nonserviceable hearing. At univariate analysis, sex age, symptoms, tumor site, and size were not associated to hearing outcome. Tumor growth rate ≥ 2.16 mm/year (P = 0.02, odds ratio 8.5) and preoperative hearing class B (P = 0.03, OR 5.89) were statistically associated to nonserviceable hearing after VSs resection. Tumor growth rate ≥ 2.16 mm/year was also significantly associated to preoperative hearing class B (P = 0.01). At multivariate analysis, the only independent prognostic factor of progression to nonserviceable hearing in operated VSs was tumor growth rate ≥ 2.16 mm/year (P = 0.01, OR = 4.15).
Conclusion
We found a new prognostic indicator of hearing preservation after VS surgery with the MCF approach: the tumor growth rate. This feature should be further investigated before being considered in the decision‐making process of VS treatment.
Level of Evidence4Laryngoscope, 129:2378–2383, 2019

Preventing Restenosis of Marsupialized Rathke Cleft Cysts Using a Nasoseptal Flap Lining

30-09-2019 – “Edward C. Kuan, Monica S. Trent, Neil N. Luu, Michael A. Kohanski, Charles C. Tong, Bert W. OMalley, Nithin D. Adappa, James N. Palmer”

Journal Article

Objectives
Rathke cleft cysts (RCCs) are rare, benign lesions formed from remnants of Rathke pouch during embryologic development. However, following marsupialization, maintaining tract patency remains a challenge. Several techniques for decreasing stenosis have been described, including free mucosal grafting, silastic spacing, and using steroid‐eluting stents. Nasoseptal flaps (NSFs) have a reliable vascular supply and are widely utilized in skull base reconstruction. We present a novel technique to maintain patency of the marsupialized RCC cavity by lining it with an NSF to promote long‐term drainage and re‐epithelialization of the RCC cavity.
Methods
Retrospective chart review of all patients who underwent surgery for symptomatic RCCs. These patients underwent endoscopic endonasal surgery between February 3, 2016, and June 12, 2018, with marsupialization followed by circumferential NSF lining. Primary outcomes include symptomatic control, surgical complications, and RCC cavity patency.
Results
Seven patients underwent RCC marsupialization with no intraoperative cerebrospinal fluid leak, followed by circumferential lining of the marsupialized cavity with an NSF. In each case, no cyst re‐accumulation or recurrent symptoms were noted, and the NSF lining provided long‐term patency of the tract in all cases to a mean of 6.7 ± 10.1 months of follow‐up, including one patient with sustained patency at 29 months follow‐up.
Conclusion
Utilization of the NSF to “stent open” the RCC cavity following marsupialization is a safe and effective means to prevent restenosis. Advantages include sustained patency of RCC cavity for complete drainage and a dependable vascular supply.
Level of Evidence4Laryngoscope, 129:2258–2261, 2019

The effect of curcumin on healing in an animal nasal septal perforation model

30-09-2019 – Doğan Çakan, Sedat Aydın, Gökhan Demir, Kayhan Başak

Journal Article

Objectives/Hypothesis
We investigated the effect of intranasal topical curcumin on nasal septum mucosa wound healing in a nasal septal perforation model produced in rabbits.
Study Design
Experimental study.
Methods
Fourteen male New Zealand rabbits were included in the study. For each rabbit, 5‐mm‐diameter circular perforations were created at 5 mm away from the columella to the nasal septum. Curcumin (study group) and saline (control group) were administered intranasally once daily for 10 days. At the end of the 10th day, the animals were sacrificed and the nasal septum specimens were sent for histological examination. Epithelial regeneration and degeneration, cartilage degeneration and regeneration, presences of fibroblast, eosinophil, acute/chronic inflammatory and giant cells, capillary density, amounts of granulation tissue and collagen, and macroscopic closure rate of perforation parameters were compared in each group.
Results
Epithelial and cartilage regeneration, and the amounts of collagen and granulation tissue were significantly higher in the curcumin group compared to the control group (P < .05). No statistically significant difference was found in comparison of other parameters (P > .05).
Conclusions
Topical application of curcumin improves the wound‐healing process of nasal septum perforation in the animal model. Therefore, curcumin can be used as a safe and effective medical agent to prevent the development of septal perforation.
Level of Evidence
NALaryngoscope, 129:E349–E354, 2019

Barriers to thyroid cancer screening with ultrasound in patients with familial adenomatous polyposis

30-09-2019 – Celeste Nagy, Zachary Kelly, Steven Keilin, Field Willingham, Amy Chen

Journal Article

Objectives/Hypothesis
To identify barriers to care in patients with familial adenomatous polyposis (FAP) that have not undergone ultrasound for thyroid cancer (TC) screening.
Study Design
Case series and survey.
Methods
A study was conducted examining referral patterns for thyroid ultrasound (TUS) in FAP patients for TC screening. Patients with FAP seen at our institution were identified using International Classification of Diseases, Ninth Revision and Tenth Revision codes. Chart review was performed for TUS and the results were recorded. Patients and healthcare providers were surveyed to determine barriers to TUS and opportunities for improvement.
Results
Thirteen out of 35 patients surveyed (37%) were told by a healthcare provider that TUS was recommended for TC screening. The incidence for TC in FAP patients ranges from 15 to 12%, whereas the general population risk is 0.02% to 1%. In our series, one patient of 12 (8%) had TC. Barriers to care included poor patient education about the risk of TC in FAP and miscommunication among specialties for referral for TUS. Also, patients enrolled in a FAP registry have improved care, as they are more likely to undergo TUS than those not enrolled.
Conclusions
FAP patients are at a higher risk of developing TC. Therefore, it is important for these patients to be informed and follow the recommended guideline to get a baseline TUS for screening as well as receive better patient education about the risk of TC and improved communication among specialties. Additionally, patients enrolled in a FAP registry are more likely to undergo ultrasound for TC screening, so there needs to be more centralized coordination for the multidisciplinary care of this disease.
Level of Evidence
NALaryngoscope, 129:2436–2441, 2019

Modiolar rotational cheiloplasty: Addressing the central oval in facial paralysis

30-09-2019 – Aurora G. Vincent, Marc H. Hohman, Kris S. Moe

Journal Article

Objectives/Hypothesis
Current static reanimation of the midface fails to provide adequate functional and aesthetic improvement; there is a need for more effective static correction of the ptotic midface. Our objective herein was to describe a novel method of static midface suspension that produces improved functional and aesthetic outcomes compared to previous techniques. Specifically, our goal was to describe the technique of alar and oral commissure repositioning via modiolar rotational cheiloplasty with alar base transposition, and gingivobuccal sulcoplasty.
Study Design
Retrospective case series.
Methods
We retrospectively reviewed the results of a series of adult patients desiring surgical intervention for paralysis of the central oval of the face at a tertiary care referral center. We present our technique of modiolar rotational cheiloplasty first with an example case, including subjective outcomes reported by the patient and objective improvements in facial appearance using Massachusetts Eye and Ear Infirmary Facial Assessment by Computer Evaluation Program (MEEI FACE‐Gram) software, then demonstrate long‐term outcomes from the series.
Results
Clinically, patients noted subjective improvement in drooling, buccal stasis of food, dysarthria, nasal obstruction, and overall appearance. Patients with significant atrophy and lateral displacement of the lower lip underwent concomitant wedge resection, which further improved the symmetry and position of the lips. The MEEI FACE‐Gram software demonstrated objective improvement in symmetry of smile and position of the philtrum and nasal base in an example case.
Conclusions
Modiolar rotational cheiloplasty with alar base transposition is an effective and efficient static procedure for midface palsy that improves both function and appearance.
Level of Evidence4Laryngoscope, 129:2262–2268, 2019

Significance of intraparotid node metastasis in predicting local control in primary parotid cancer

30-09-2019 – Yanping Feng, Fei Liu, Guangyan Cheng, Qigen Fang, Xinyu Niu, Wei He

Objective
To analyze the metastasis rate in intraglandular lymph nodes (IGLNs) with a focus on discussing the significance of IGLN metastasis in local control (LC) of parotid gland cancer (PGC).
Methods
A total of 337 patients were enrolled. Information including age; sex; and pathologic variables such as tumor (T) stage, IGLN metastasis, and follow‐up findings was extracted and analyzed.
Results
IGLN metastasis was noted in 111 (32.9%) patients. Tumor stage, pathologic nodal stage, perineural invasion, resection status, and lymphovascular invasion were significantly related to IGLN metastasis. Local recurrence was noted in 67 (19.9%) patients. IGLN metastasis was an independent predictor of LC. The 10‐year LC rate was 94% for patients without IGLN metastasis, 56% for patients with metastasis in no more than two IGLNs, and 22% for patients with metastasis in more than two IGLNs. This difference was significant (P < 0.001).
Conclusion
The IGLN metastasis rate is relatively high in PGC patients and is significantly associated with disease grade and T stage. IGLN metastasis is associated with poorer local LC, and patients with more than two metastatic nodes have the worst prognosis.
Level of Evidence4Laryngoscope, 129:2309–2312, 2019

Prognostic impact of initial treatment in surgically salvaged recurrences of early glottic cancer

30-09-2019 – Luca Giovanni Locatello, Angelo Cannavicci, Oreste Gallo

Objective
The purpose of this study was to analyze the outcomes of surgically salvaged early glottic cancer (EGC) recurrences after initial radiotherapy (RT) or transoral laser microsurgery (TLM).
Methods
A matched pair analysis by recurrent tumor‐node‐metastasis stage (r
TNM) considering 27 patients who had TLM as initial treatment and 54 patients who failed after primary RT was performed. Post‐recurrence overall and disease‐specific survival (DSS) were evaluated.
Results
The RT‐failed group showed worse post‐recurrence overall survival (P < .001) and DSS (P = .005) compared to TLM‐first group despite the same r
TNM stage. The RT failed patients also showed more postoperative complications (longer mean decannulation time, P = .005; nasogastric feeding tube dependence, P = .012) and a higher rate of second locoregional recurrences (P = .004).
Conclusion
The RT‐failed EGC showed worse outcomes in terms of survival, complications, and locoregional recurrences compared to same recurrent TNM stage TLM‐failed cases.
Level of Evidence3Laryngoscope, 129:2328–2333, 2019

Low‐risk assessment of swallowing impairment using flexible endoscopy without food or liquid

30-09-2019 – Mitsuyoshi Imaizumi, Toshihiko Suzuki, Takashi Matsuzuka, Shigeyuki Murono, Koichi Omori

Journal Article

Objectives/Hypothesis
Flexible endoscopic evaluation of swallowing (FEES) is a relatively safe procedure to determine the safety of oral feeding, and consists of the introduction of food and liquid as well as a sensitivity test. However, the introduction of food and liquid can cause pneumonia or suffocation secondary to aspiration. To solve this problem, we investigated the possibility of performing FEES without introduction of food or liquid (referred to hereafter as FEES screen) to assess swallowing impairment severity.
Study Design
Retrospective study.
Methods
A total of 106 subjects with swallowing impairment underwent conventional FEES, and both their salivary pooling degree and larynx sensitivity were analyzed to detect swallowing impairment without the introduction of food or liquid. The subjects were divided into two groups: an undetectable swallowing impairment (USI) group and a detectable swallowing impairment (DSI) group. The general characteristics, functional impairment status, and clinical assistance requirements of the two groups were investigated and compared.
Results
The numbers of subjects in the USI and DSI groups were 64 and 42, respectively. The DSI group showed a significantly higher prevalence of aspiration during FEES, and their required levels of care were also significantly higher. Additionally, their levels of consciousness, oral intake ability, and activities of daily living were significantly low compared to the USI group.
Conclusions
This study demonstrated the feasibility of FEES screen for assessment of swallowing impairment severity. Using our low‐risk assessment, we were able to identify subjects with low oral intake ability as well as those who required intervention.
Level of Evidence4Laryngoscope, 129:2249–2252, 2019

Laryngeal fracture presentation and management in United States emergency rooms

30-09-2019 – Rosh K. V. Sethi, Dara Khatib, Maxwell Kligerman, Elliott D. Kozin, Stacey T. Gray, Matthew R. Naunheim

Journal Article

Objectives/Hypothesis
There are limited data on laryngeal fracture presentation and management in US emergency departments (EDs). We aimed to characterize patients who are diagnosed with laryngeal fractures in the ED and identify management patterns.
Study Design
Retrospective review of the Nationwide Emergency Department Sample (NEDS) from 2009 to 2011.
Methods
The NEDS was queried for patient visits with a primary diagnosis of open or closed laryngeal fracture (International Classification of Diseases, Ninth Revision codes 807.5 and 807.6). Patient demographics, comorbidities, ED management, and hospital characteristics were extracted.
Results
There were 3,102 ED visits with a diagnosis of laryngeal fracture during the study period. Mean patient age was 40.9 years (range, 3–93 years). The majority of patients were male (85.5%) and sustained a closed (vs. open) fracture (91.4%), with an overall mortality rate of 3.8%. The majority of patients were treated for more than one injury during the same visit (76.2%). Most patients were evaluated at a trauma hospital (53.9%), and most patients were admitted to the hospital (71.9%). Emergent intubation or tracheostomy was rarely reported (2.6% and 0.1% of all cases), and a minority of patients underwent fiberoptic flexible laryngoscopy in the ED (1.9%). Laryngeal fractures occurred more frequently during summer months (28.2%). Mean charge for the entirety of the ED stay was $4,957.34.
Conclusions
Laryngeal fracture is rare and frequently associated with other injuries. The frequency of emergent airway procedure, imaging, and flexible fiberoptic laryngoscopy is lower than expected, raising concerns about appropriate workup and management or recognition of injury in the ED setting.
Level of Evidence
NALaryngoscope, 129:2341–2346, 2019

Sclerotherapy and Topical Nasal Propranolol: An Effective and Safe Therapy for HHT‐Epistaxis

30-09-2019 – Santos Esteban‐Casado, Ana M. Martín de Rosales Cabrera, Angela Usarralde Pérez, Jose Javier Martínez Simón, Estefanía Zhan Zhou, M. Sol Marcos Salazar, Montserrat Pérez Encinas, Luisa Botella Cubells

Journal Article

Objectives
Epistaxis is the most frequent clinical manifestation of hereditary hemorrhagic telangiectasia (HHT). Several topical, systemic, and surgical treatments have been tried, but none have been completely effective. The aim of the present study is to evaluate whether a combined treatment sclerotherapy and topical therapy with propranolol 0.5% nasal formulation would reduce the epistaxis due to HHT and improve patients quality of life.
Methods
An observational cross‐sectional study was carried out. The primary outcome measure was frequency and severity of epistaxis as measured by the epistaxis severity score (ESS) at baseline (4 weeks before therapy) and at least 4 weeks after the treatment was implemented. Quality of life was analyzed using Euro
Qol‐5D (EQ‐5D) scale and visual analogue (VAS) scale before and after treatment.
Results
A total of 38 consecutive patients subjected to the combined treatment were evaluated (mean age: 57.2 years, standard deviation SD = 13.9; 60.5% women). The mean time of treatment was 37.1 weeks (SD = 14.9). Combined therapy significantly reduces frequency and severity of epistaxis, with an ESS improvement of 5 points from 6.9 ± 2.6 to 1.9 ± 1.3 (P < 0.05); however, the EQ‐5D scale increased from 0.66 ± 0.27 to 0.93 ± 0.12 (P < 0.05). The difference in VAS means showed an increase from 44.6 ± 28.3 to 82.5 ± 12.5 (P < 0.05). The increases in quality of life are in line with the drop in ESS.
Conclusion
The study demonstrated that combined therapy (sclerotherapy and topical nasal propranolol) significantly reduced the epistaxis due to HHT and increased patients’ quality of life.
Level of Evidence2c
Laryngoscope, 129:2216–2223, 2019

Drug‐induced sleep endoscopy: new insights in lateral head rotation compared to lateral head and trunk rotation in (non)positional obstructive sleep apnea patients

30-09-2019 – Patty E. Vonk, Megan J. Beek, Madeline J.L. Ravesloot, Nico Vries

Journal Article

Objective
To compare the effect of lateral head rotation to lateral head and trunk rotation on upper airway patency during drug‐induced sleep endoscopy (DISE) in nonpositional obstructive sleep apnea (OSA) patients (NPP) and positional OSA patients (PP).
Methods
Prospective cohort study.
Results
In total 92 patients were included. Seventy‐five patients were male (82%) with a mean age of 47.2 ± 11.3 years, a body mass index of 27.0 ± 3.3 kg/m2, and a median apnea–hypopnea index of 16.7 per hour (8.7, 26,5). Of all patients, 75% were PP. Lateral head rotation and lateral head and trunk rotation findings are similar in NPP at each possible level of obstruction, with exception of the oropharynx but not in PP. In PP, lateral head rotation and both lateral head and trunk observations were different at every possible obstruction site.
Conclusion
The effect of lateral head rotation and lateral head and trunk rotation on upper airway patency during DISE is significantly different in PP. In NPP, similar results regarding the degree of upper airway obstruction were found at the level of the velum, tongue base, and epiglottis.
Level of Evidence2b
Laryngoscope, 129:2430–2435, 2019

Optimal sequencing of chemoradiotherapy for locally advanced laryngeal cancer

30-09-2019 – Nishant K. Shah, Muhammad M. Qureshi, Michael A. Dyer, Sagar A. Patel, Kristine Kim, Peter C. Everett, Gregory A. Grillone, Scharukh M. Jalisi, Minh Tam Truong

Journal Article

Objective
To determine the optimal sequencing of chemoradiotherapy for locally advanced laryngeal cancer. The hypothesis was that concurrent chemoradiotherapy (CCRT) would be associated with improved overall survival (OS) compared to induction chemotherapy followed by radiotherapy (RT)/surgery (IC).
Methods
The National Cancer Database identified 8,154 patients with American Joint Commission on Cancer stage III/IV (excluding T1) laryngeal cancer between 2004 and 2013 treated with one of the established organ preservation techniques: CCRT or IC. The association between OS and total radiation dose (< 66 gray Gy or ≥ 66 Gy) was analyzed using the Kaplan‐Meier method, as was the association between OS and timing of IC (21–42, 43–100, or 101–120 days before RT). Hazard ratios (HR) adjusted for patient and clinical characteristics were computed using Cox regression modeling.
Results
The median follow‐up was 32.7 months. The estimated 5‐year OS for CCRT and IC was 49.9% and 50.6%, respectively (P = 0.653). On multivariate analysis, no difference was observed between the two regimens (IC, adjusted HR 0.96, 95% confidence interval CI 0.88–1.04, P = 0.268). Radiation dose ≥66 Gy had improved OS overall in CCRT group but not in IC patients. When comparing CCRT and IC in patients receiving ≥66 Gy, there was no difference in OS (adjusted HR 0.97, 95% CI 0.89–1.06, P = 0.552). Patients starting chemotherapy 21 to 42 or 101 to 120 days prior to RT had inferior OS compared to patients starting between 43 to 100 days.
Conclusion
For locally advanced laryngeal cancer, there is no difference in OS between CCRT and IC. Factors associated with survival included radiation dose and timing of induction chemotherapy before RT.
Level of Evidence3b
Laryngoscope, 129:2313–2320, 2019

Disparities in adherence to head and neck cancer follow‐up guidelines

30-09-2019 – Haley K. Perlow, Stephen J. Ramey, Vincent Cassidy, Deukwoo Kwon, Benjamin Farnia, Elizabeth Nicolli, Michael A. Samuels, Laura Freedman, Nagy Elsayyad, Raphael Yechieli, Stuart E. Samuels

Journal Article

Objectives
In this study, we aim to determine the frequency of adherence to National Comprehensive Cancer Network follow‐up guidelines in a population of head and neck cancer patients who received curative treatment. We will also assess the impact of race, ethnicity, socioeconomic status, and treatment setting on utilization of follow‐up care.
Methods
This study included patients with biopsy‐proven, nonmetastatic oropharyngeal or laryngeal cancer treated with radiotherapy between January 1, 2014, and June 30, 2016, at a safety‐net hospital or adjacent private academic hospital. Components of follow‐up care analyzed included an appointment with a surgeon or radiation oncologist within 3 months and posttreatment imaging of the primary site within 6 months. Univariable and multivariable analyses were conducted using a logistic regression model to estimate odds ratios and corresponding 95% confidence intervals.
Results
Two hundred and thirty‐four patients were included in this study. Of those, 88.8% received posttreatment imaging of the primary site within 6 months; 88.5% attended a follow‐up appointment with a radiation oncologist within 3 months; and 71.1% of patients attended a follow‐up appointment with a surgeon within 3 months. On multivariable analysis, private academic hospital treatment versus safety‐net hospital treatment was associated with increased utilization of both surgical and radiation oncology follow‐up. Non‐Hispanic black (NHB) patients, Hispanic patients, and those with a low socioeconomic status were also less likely to receive follow‐up.
Conclusion
Safety‐net hospital treatment, socioeconomic status, Hispanic ethnicity, and NHB race were associated with decreased follow‐up service utilization. Quality improvement initiatives are needed to reduce these disparities.
Level of Evidence2b
Laryngoscope, 129:2303–2308, 2019

Reliability of grading of facial palsy using a video tutorial with synchronous video recording

30-09-2019 – Gerd Fabian Volk, Rebecca Anna Schaede, Jovanna Thielker, Luise Modersohn, Oliver Mothes, Charles C. Nduka, Jodi Maron Barth, Joachim Denzler, Orlando Guntinas‐Lichius

Journal Article

Objective
To determine the intrarater, interrater, and retest reliability of facial nerve grading of patients with facial palsy (FP) using standardized videos recorded synchronously during a self‐explanatory patient video tutorial.
Study Design
Prospective, observational study.
Methods
The automated videos from 10 patients with varying degrees of FP (5 acute, 5 chronic FP) and videos without tutorial from eight patients (all chronic FP) were rated by five novices and five experts according to the House‐Brackmann grading system (HB), the Sunnybrook Grading System (SB), and the Facial Nerve Grading System 2.0 (FNGS 2.0).
Results
Intrarater reliability for the three grading systems was very high using the automated videos (intraclass correlation coefficient ICC; SB: ICC = 0.967; FNGS 2.0: ICC = 0.931; HB: ICC = 0.931). Interrater reliability was also high (SB: ICC = 0.921; FNGS 2.0: ICC = 0.837; HB: ICC = 0.736), but for HB Fleiss kappa (0.214) and Kendell W (0.231) was low. The interrater reliability was not different between novices and experts. Retest reliability was very high (SB: novices ICC = 0.979; experts ICC = 0.964; FNGS 2.0: novices ICC = 0.979; experts ICC = 0.969). The reliability of grading of chronic FP with SB was higher using automated videos with tutorial (ICC = 0.845) than without tutorial (ICC = 0.538).
Conclusion
The reliability of the grading using the automated videos is excellent, especially for the SB grading. We recommend using this automated video tool regularly in clinical routine and for clinical studies.
Level of Evidence4xs
Laryngoscope, 129:2274–2279, 2019

nAspergillus fumigatus induction of IL‐33 expression in chronic rhinosinusitis is PAR2‐dependent

30-09-2019 – Caroline J. Dietz, Hua Sun, William C. Yao, Martin J. Citardi, David B. Corry, Amber U. Luong

Journal Article

Objective
In the pathophysiology of chronic rhinosinusitis with nasal polyps (CRSw
NP), Aspergillus fumigatus (A. fumigatus) can upregulate IL‐33 from human sinonasal epithelial cells (SNECs), which then activates innate lymphoid cells causing release of IL‐13, an important driver of allergic inflammation. However, the mechanism by which A. fumigatus mediates the induction of IL‐33 expression remains to be elucidated. The objectives of this study were to determine the specific fungal component(s) and the receptor responsible for mediating the A. fumigatus induced increase in IL‐33 expression in SNECs from patients with CRSw
NP.
Methods
SNECs from CRSw
NP patients were cultured and stimulated with various fungal components in the absence or presence of 4‐(2‐Aminoethyl)benzenesulfonyl fluoride hydrochloride, an irreversible serine protease inhibitor, or GB83, a reversible protease activated receptor 2 (PAR2) inhibitor. IL‐33 expression was evaluated using quantitative real‐time polymerase chain reaction (q
RT‐PCR). PAR2 expression was examined in inflamed mucosa from nonatopic control and CRSw
NP patients.
Results
Elevation of IL‐33 expression in primary SNECs was found in response to fungal protease but not fungal cell wall components. PAR2 expression was elevated in inflamed mucosa from CRSw
NP patients in comparison to controls. The A. fumigatus fungal protease‐mediated elevation in IL‐33 expression by human SNECs was serine protease‐ and PAR2‐dependent.
Conclusion
These data suggest that serine protease activity of A. fumigatus is capable of inducing IL‐33 expression in CRSw
NP SNECs via PAR2, a potential therapeutic target in the treatment of CRSw
NP.
Level of Evidence
NALaryngoscope, 129:2230–2235, 2019

Carbon debris and fiber cleaving: Effects on potassium‐titanyl‐phosphate laser energy and chorioallantoic membrane model vessel coagulation

30-09-2019 – Lauren F. Tracy, James B. Kobler, Jarrad H. Van Stan, James A. Burns

Journal Article

Objectives/Hypothesis
Photoangiolytic precision afforded by the 532‐nm potassium‐titanyl‐phosphate (KTP) laser relies on predictable energy delivery. Inadequate energy output can cause vessel rupture, and excessive energy can cause thermal damage. The quality of the cleaved surface and carbon deposits from ablated tissue are two factors that could negatively impact fiber performance. The effects of these on energy output and blood vessel coagulation were assessed using a chorioallantoic membrane (CAM) model.
Study Design
Comparative analysis.
Methods
Laser fibers with carbon debris, optimal fiber cleaving, and suboptimal cleaving were inspected at three times magnification, and the light dispersion pattern of each fiber was rated. The average energy output from consecutive pulses through each fiber configuration was recorded. The effect of these fiber conditions on clinical efficacy was estimated by measuring vessel coagulation versus rupture in the CAM model. Repeated measures analysis of variance compared results.
Results
Carbon debris and suboptimal cleaving resulted in decreased energy output in comparison to optimal cleaving (−Δ244 m
J, d = 4.31, P < .001 and −Δ195 m
J, d = 6.04, P < .001). Optimal cleaving resulted in immediate coagulation of vessels. Fibers with suboptimal cleaving and carbon debris had unpredictable outcomes, requiring multiple pulses for coagulation or causing vessel rupture.
Conclusions
KTP laser fiber function is significantly affected by fiber tip condition. Carbon debris and suboptimal cleaving create significant attenuation of energy, which results in an unpredictable angiolytic effect, as demonstrated by increased vessel rupture in the CAM model. Optimal recleaving of KTP laser fibers restores prior energy output and predictable coagulation. Care should be taken to avoid carbon debris on laser‐fiber tips and to cleave fibers properly.
Level of Evidence
NALaryngoscope, 129:2244–2248, 2019

Audiologic profile of the jackson heart study cohort and comparison to other cohorts

30-09-2019 – Charles E. Bishop, Christopher Spankovich, Frank R. Lin, Samantha R. Seals, Dan Su, Karen Valle, John M. Schweinfurth

Journal Article

Objectives/Hypothesis
The objective of this study was to determine the audiological profile of an African American cohort, identify related factors, and compare them to other datasets.
Study Design
Cross‐sectional, longitudinal cohort study.
Methods
The Jackson Heart Study (JHS) is a longitudinal cohort study of 5,306 African Americans living in the metropolitan Jackson, Mississippi area, with a focus on cardiometabolic health. The JHS Hearing Study (n = 1,314) was implemented to measure the prevalence of hearing, tinnitus, and balance outcomes and relationship to predictor variables. Here we present prevalence and covariate relationships in comparison to the Epidemiology of Hearing Loss Study and the National Health and Nutrition Examination Survey.
Results
The prevalence of self‐reported hearing difficulty was 38.1% (n = 500). The prevalence of hearing loss based on audiometric pure tone threshold average (0.5, 1.0, 2.0, 4.0 k
Hz) of the better ear was 19.8% (n = 260) and for the worse ear 29.8% (n = 392). The prevalence of tinnitus was 29.5% (n = 388) and balance dysfunction 24.1% (n = 317). Relationships of hearing loss to demographic, cardiometabolic, and audiologic variables are presented.
Conclusions
These results demonstrate that hearing loss, tinnitus, and balance dysfunction are common issues affecting adult African Americans, and that hearing loss is related to numerous modifiable and nonmodifiable risk factors. Furthermore, our findings are consistent with lower prevalence of hearing loss in African Americans compared to the non–African American populations. However, despite the lower audiometric evidence of hearing loss, nearly 40% of participants reported hearing difficulty.
Level of Evidence2b
Laryngoscope, 129:2391–2397, 2019

Subpectoral implantation of the hypoglossal nerve stimulator: An effective technical modification

30-09-2019 – Nicholas L. Deep, John Peyton Hines, James M. Parish, Michael L. Hinni, Stephen F. Bansberg

Case Reports

Upper airway stimulation is now a well‐established treatment option for selected patients with obstructive sleep apnea. The implanted pulse generator of this system activates the hypoglossal nerve and is routinely placed in a subcutaneous pocket overlying the pectoralis muscle. This case report describes a patient with a history of bilateral mastectomy and radiation for breast cancer who required explantation due to device exposure and infection. The patient was successfully reimplanted by placing the implantable pulse generator deep to the pectoralis major muscle. Clinical circumstances involving the chest wall may warrant subpectoral placement of the implanted pulse generator.
Laryngoscope, 129:2420–2423, 2019

In Response to A Nomogram to Predict Osteoradionecrosis in Oral Cancer After Marginal Mandibulectomy and Radiotherapy

30-09-2019 – Tsung‐You Tsai, Ze Yun Tay, Kai‐Ping Chang, Yu‐Tung Huang

Letter

Regarding A Nomogram to Predict Osteoradionecrosis in Oral Cancer After Marginal Mandibulectomy and Radiotherapy

30-09-2019 – Gary S. Collins, Ben Van Calster

Letter

Regarding “what makes a great surgeon?”

30-09-2019 – Eric R. Carlson

Letter

In Response to Value of Lingual Lymph Node Metastasis in Patients With Squamous Cell Carcinoma of the Tongue

30-09-2019 – Qigen Fang

Letter

In reference to Value of lingual lymph node metastasis in patients with squamous cell carcinoma of the tongue

30-09-2019 – Wen‐Jiun Lin, Chen‐Chi Wang, Sheng‐Hwa Chen

Letter

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

30-09-2019 – Gregory J. Latham

Letter

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

30-09-2019 – Richard S. Cartabuke, Brian J. Anderson, Charles Elmaraghy, Dmitry Tumin, Joseph D. Tobias

Letter

Ninth editor‐in‐chief of the laryngoscope

30-09-2019 – Samuel H. Selesnick

Editorial

Masthead

30-09-2019 –

Table of contents

30-09-2019 –

The shifting relationship between weight and pediatric obstructive sleep apnea: A historical review

30-09-2019 – Katherine R. Keefe, Prachi N. Patel, Jessica R. Levi

Objectives
For more than a century, pediatric obstructive sleep apnea (OSA) was associated with failure to thrive. However, that association has faded over the last few decades. A 21st century child with OSA is much more likely to be overweight than underweight. This raises the question: Has pediatric OSA changed over time, or has the rise of childhood obesity in the United States created a new, separate disease? This literature review explores the historical shift in the relationship between weight and OSA, and the associated changes in treatment.
Results
We demonstrate a clear transition in the prevalence of failure to thrive and obesity in the OSA literature in the mid‐2000s. What is less clear is whether these two clinical phenotypes should be considered two distinct diseases, or whether subtle differences in one set of pathophysiologic pathways—adenotonsillar hypertrophy, altered inflammation, and increased energy expenditure—can lead to divergent metabolic outcomes. More research is needed to fully elucidate the pathophysiology of OSA in children with obesity.
Conclusions
We may need new and different treatments for obesity‐associated OSA as adenotonsillectomy—which is effective at reversing failure to thrive in OSA—is not as effective at treating OSA in children with obesity. One option is drug‐induced sleep endoscopy, which could personalize and improve surgical treatment of OSA. There is some evidence that therapies used for OSA in adults (e.g., weight loss and positive airway pressure) are also helpful for overweight/obese children with OSA.
Laryngoscope, 129:2414–2419, 2019

Contemporary Review and Case Report of Botulinum Resistance in Facial Synkinesis

30-09-2019 – Justin R. Shinn, Nkechi N. Nwabueze, Priyesh Patel, Cathey Norton, W. Russell Ries, Scott J. Stephan

Journal Article, Review

Background
Botulinum resistance poses significant treatment challenges for both patients and healthcare practitioners. We first present a case highlighting botulinum resistance in a patient who failed to respond to alternative formulations but who responded remarkably to incobotulinum toxin
A, an identical toxin free of complexing proteins. Secondly, we provide a treatment algorithm and a review of the literature detailing clinical and immunochemical botulinum resistance.
Results
Patients with botulinum resistance show a predisposition to failure on subsequent injections and possess a propensity toward neutralizing and nonneutralizing antibody development. The mechanisms of resistance are not entirely understood but thought to be secondary to an immunologic response. Risk factors for resistance include higher botulinum doses, more frequent injections, and high total lifetime dosage. Patients may still respond to other botulinum formulations or subtypes; however, this effect may be temporary.
Conclusion
This case report describes a patient who responded to incobotulinum toxin
A after failing treatment with the identical toxin compounded with buffer proteins, ultimately supporting the possibility of immune‐mediated resistance to the surrounding proteins and not the toxin itself. Often, impending treatment resistance is preceded by a poor or limited clinical response. Antibody testing is not indicated because it is neither sensitive nor specific and does not change clinical practice. Initially, higher doses of botulinum may overcome resistance without increasing treatment frequency, and side effects are far less common in those with clinical resistance. If higher dosages fail to produce a response, alternative botulinum formulations or subtypes can be considered.
Laryngoscope, 129:2269–2273, 2019

Weight gain velocity as a predictor of severe obstructive sleep apnea among obese adolescents

30-09-2019 – Romaine F. Johnson, Alexander Hansen, Ajay Narayanan, Ahana Yogesh, Gopi B. Shah, Ron B. Mitchell

Journal Article

Objectives/Hypothesis
To evaluate a cohort of obese adolescents with obstructive sleep apnea (OSA) to determine if increased yearly weight gain was a predictor of severe OSA.
Study Design
Retrospective cohort study.
Methods
Obese adolescents (body mass index percentile >95% for that age and sex based upon the Centers for Disease Control and Prevention weight classifications), ages 12 to 17 years, referred for full night polysomnography (PSG) were analyzed. We examined demographics, weight classifications, yearly weight gain from age 9 years onward, PSG data (apnea‐hypopnea index), and tonsil size. We performed a mixed‐effect linear regression model to test whether the velocity of weight gain was increased in obese patients with severe OSA when compared to those without severe OSA.
Results
This study included 166 obese adolescents, 105 with and 61 without severe OSA. The average age was 14 years and was predominately male (57%) and Hispanic (44%). The regression analysis found that the yearly change in weight among obese adolescents with severe OSA was significantly higher than those without (B = 1.4, standard error = 0.50, P = .005, 95% confidence interval: 0.42–2.4). For the group with severe OSA, weight increased 6.5 kg every year before their PSG, whereas for those without, weight increased 5.1 kg per year.
Conclusions
The rate of weight gain over time is an important predictor of severe OSA in obese adolescents.
Level of Evidence3b Laryngoscope, 2019

Development of augmented‐reality applications in otolaryngology–head and neck surgery

30-09-2019 – Austin S. Rose, Hyounghun Kim, Henry Fuchs, Jan‐Michael Frahm

Journal Article

Objectives/Hypothesis
Augmented reality (AR) allows for the addition of transparent virtual images and video to ones view of a physical environment. Our objective was to develop a head‐worn, AR system for accurate, intraoperative localization of pathology and normal anatomic landmarks during open head and neck surgery.
Study Design
Face validity and case study.
Methods
A protocol was developed for the creation of three‐dimensional (3D) virtual models based on computed tomography scans. Using the Holo
Lens AR platform, a novel system of registration and tracking was developed. Accuracy was determined in relation to actual physical landmarks. A face validity study was then performed in which otolaryngologists were asked to evaluate the technology and perform a simulated surgical task using AR image guidance. A case study highlighting the potential usefulness of the technology is also presented.
Results
An AR system was developed for intraoperative 3D visualization and localization. The average error in measurement of accuracy was 2.47 ± 0.46 millimeters (1.99, 3.30). The face validity study supports the potential of this system to improve safety and efficiency in open head and neck surgical procedures.
Conclusions
An AR system for accurate localization of pathology and normal anatomic landmarks of the head and neck is feasible with current technology. A face validity study reveals the potential value of the system in intraoperative image guidance. This application of AR, among others in the field of otolaryngology–head and neck surgery, promises to improve surgical efficiency and patient safety in the operating room.
Level of Evidence2b Laryngoscope, 129:S1–S11, 2019

Masthead

30-09-2019 –

Table of contents

30-09-2019 –

Otoscopic diagnosis using computer vision: An automated machine learning approach

18-09-2019 – Devon Livingstone, Justin Chau

Journal Article

Objective
Access to otolaryngology is limited by lengthy wait lists and lack of specialists, especially in rural and remote areas. The objective of this study was to use an automated machine learning approach to build a computer vision algorithm for otoscopic diagnosis capable of greater accuracy than trained physicians. This algorithm could be used by primary care providers to facilitate timely referral, triage, and effective treatment.
Methods
Otoscopic images were obtained from Google Images (Google Inc., Mountain View, CA), from open access repositories, and within otolaryngology clinics associated with our institution. After preprocessing, 1,366 unique images were uploaded to the Google Cloud Vision Auto
ML platform (Google Inc.) and annotated with one or more of 14 otologic diagnoses. A consensus set of labels for each otoscopic image was attained, and a multilabel classifier architecture algorithm was trained. The performance of the algorithm on an 89‐image test set was compared to the performance of physicians from pediatrics, emergency medicine, otolaryngology, and family medicine.
Results
For all diagnoses combined, the average precision (positive predictive value) of the algorithm was 90.9%, and the average recall (sensitivity) was 86.1%. The algorithm made 79 correct diagnoses with an accuracy of 88.7%. The average physician accuracy was 58.9%.
Conclusion
We have created a computer vision algorithm using automated machine learning that on average rivals the accuracy of the physicians we tested. Fourteen different otologic diagnoses were analyzed. The field of medicine will be changed dramatically by artificial intelligence within the next few decades, and physicians of all specialties must be prepared to guide that process.
Level of Evidence
NALaryngoscope, 2019

Tracheostomy in Extremely Preterm Neonates in the United States: A Cross‐Sectional Analysis

18-09-2019 – Cynthia S. Wang, Yann‐Fuu Kou, Gopi B. Shah, Ron B. Mitchell, Romaine F. Johnson

Journal Article

Objectives/Hypothesis
Bronchopulmonary dysplasia (BPD) and invasive respiratory support is increasing among extremely preterm neonates. Yet, it is unclear if there is a corresponding increase in tracheostomies. We hypothesize that in extremely preterm neonates with BPD, the incidence of tracheostomy has increased.
Study Design
Retrospective cross‐sectional analysis.
Methods
We analyzed the 2006 to 2012 Kids’ Inpatient Databases (KID) for hospital discharges of nonextremely preterm neonates (gestational age >28 weeks and <37 weeks or birth weight >1,500 g) and extremely preterm neonates (gestational age ≤28 weeks or birth weight ≤1,500 g). We studied tracheostomy placement trends in these two populations to see if they are increasing among extremely preterm neonates, especially those with BPD.
Results
The study included 1,418,681 preterm neonates (52% male, 50% white, 19% black, 20% Hispanic, 4.2% Asian), of whom 118,676 (8.4%) were extremely preterm. A total of 2,029 tracheostomies were performed, of which 803 (0.68%) were in extremely preterm neonates. The estimated percent change of occurrence of extremely preterm neonates with BPD increased 17% between 2006 and 2012, and tracheostomy placement increased 31%. Amongst all who received tracheostomies, mortality rate was higher in extremely preterm neonates compared to nonextremely preterm neonates (18% vs. 14%, P = .05). However, in extremely preterm neonates, those with tracheostomies had a lower mortality rate compared to those without (18% vs. 24%, P = .002).
Conclusions
Extremely preterm neonates, compared to nonextremely preterm neonates, experienced a marked increase in tracheostomies placed from 2006 to 2012 as well as an increased incidence of BPD, confirming our primary study hypothesis.
Level of Evidence4 Laryngoscope, 2019

Evaluating gender parity in operative experience for otolaryngology residencies in the United States

18-09-2019 – Richard K. Gurgel, Brandon R. Cardon, Chelsea McCarty Allen, Angela P. Presson, Brenna C. Kelly, Harriet W. Hopf, Sukgi S. Choi, Robert H. Miller

Journal Article

Objectives
Gender disparity exists in medicine, such as differences in pay and promotion opportunities. We hypothesize that there is also a gender difference in graduate medical education as manifested by operative case volume. This study compares surgical case volume by gender for graduating US otolaryngology residents.
Study Design
Cohort study.
Methods
With data use approval from the Accreditation Council for Graduate Medical Education, we evaluated the key indicator case log summaries of graduating otolaryngology residents from 2009–2017. Mean and standard deviation were used for all cases, and t‐tests were used to compare cases by resident gender. The Bonferroni method was used to adjust for multiple comparisons across years.
Results
Data from 1740 male and 804 female residents were evaluated. Across all years, the average number of key indicator cases reported was 778.8 and 813.6 by female and male residents, respectively, with an average difference of 34.8 cases per graduating year (95% confidence interval CI 19.4, 50.2; P < .001). When a resident self‐reported the role of resident surgeon/supervisor, the average number of key indicator cases reported was 602.6 and 643.9 by female and male residents, respectively, with an average difference of 41.3 cases per graduating year (95% CI, 28.0, 54.6; P < .001).
Conclusion
Gender‐based discrepancies in surgical case volume exist among graduating otolaryngology residents. This disparity is partially attributed to the self‐reported role in the surgery. This study has identified those discrepancies so that training programs can implement strategies to ensure improved gender parity.
Level of Evidence2b Laryngoscope, 2019

Obstructive sleep apnea, sleep symptoms, and their association with cardiovascular disease

18-09-2019 – Melissa S. Oh, Donald L. Bliwise, Andrew L. Smith, Nancy A. Collop, Arshed A. Quyyumi, Raj C. Dedhia

Journal Article

Objectives
To determine the frequency of obstructive sleep apnea (OSA), insomnia, restless legs, and other sleep symptoms in patients with cardiovascular disease and the association of these sleep disorders with quantitative cardiovascular measures.
Methods
Study design was a cross‐sectional survey and retrospective chart review. A questionnaire containing validated sleep symptoms was distributed to 202 patients with cardiovascular disease at a tertiary referral cardiology clinic. Following a focused review of these patients medical charts, their questionnaire responses were examined for associations with clinical cardiovascular parameters.
Results
Twenty‐one percent of patients reported a prior diagnosis of OSA. A total of 115 patients (60%) had at least one additional sleep symptom. Clinically significant insomnia was significantly associated with heart disease (relative risk RR = 1.5, confidence interval CI = 1.1 to 2.1), prior myocardial infarction or cerebrovascular accident (RR = 2.1, CI = 1.2 to 3.6), and heart failure (RR = 2.2, CI = 1.3 to 3.8). Left ventricular ejection fraction was significantly associated with insomnia by Insomnia Severity Index (β = −0.52, CI = −0.89 to −0.13).
Conclusion
The frequency of OSA in patients in this tertiary cardiology clinic was higher than the general population in the United States, with the majority of patients experiencing at least one sleep symptom. Insomnia symptoms were shown to be associated with multiple cardiovascular measures, including left ventricular ejection fraction. These findings imply an interwoven relationship between cardiovascular and sleep symptoms as captured by validated sleep questionnaires.
Level of Evidence
IV Laryngoscope, 2019

Female Representation in Otolaryngology Leadership Roles

18-09-2019 – Madison Epperson, Christopher J. Gouveia, Meredith E. Tabangin, Vinita Takiar, Rebecca Howell, Mekibib Altaye, Stacey L. Ishman, Alice L. Tang

Journal Article

Objectives/Hypothesis
Characterization of leadership within otolaryngology is key to evaluating trends and promoting program advancement. This study evaluates representation of women in otolaryngology holding residency and fellowship directorships, or chair positions, comparing sex differences in academic rank, years in practice, and scholarly activity.
Study Design
Cross sectional analysis.
Methods
A comprehensive list of otolaryngology residency and fellowship directors from Accreditation Council for Graduate Medical Education–accredited programs in 2017 to 2018 was compiled. Academic rank and years in practice were determined from departmental websites, with online search tools used as secondary resources. The h‐index was utilized as a measure of research productivity. Regression analysis was performed to analyze these variables.
Results
Among the 306 directorships, women held 57 (18.6%) of these positions, 27 (26.5%) residency and 30 (14.7%) fellowship directorships. Of the 99 chair positions, five (5.1%) were held by women. The majority (53.6%) of male directors were full professors, whereas only 26.3% of females were full professors (P = .04). Mean years in practice for female directors (13.9 ± 6.8) was less than that of male directors (20.3 ± 9.4, P < .0001). Similarly, mean h‐index for female directors (11 ± 7.2) was lower than for males (17.5 ± 12.5, P = .0001). After controlling for academic rank and years of practice in a multivariable regression, the h‐index remained lower for women than for men (P = .03).
Conclusions
Women are disproportionately underrepresented in positions of residency and fellowship directorships, and chair positions, consistent with other specialties. Women in leadership had lower academic ranks, fewer years of practice, and lower h‐indices than their male counterparts. This may represent a shift in academic otolaryngology as female otolaryngologists seek early involvement in leadership.
Level of Evidence4 Laryngoscope, 2019

Results of the ADHERE upper airway stimulation registry and predictors of therapy efficacy

14-09-2019 – Erica Thaler, Richard Schwab, Joachim Maurer, Ryan Soose, Christopher Larsen, Suzanne Stevens, Damien Stevens, Maurits Boon, Colin Huntley, Karl Doghramji, Tina Waters, Alan Kominsky, Armin Steffen, Eric Kezirian, Benedikt Hofauer, Ulrich Sommer, Kirk Withrow, Kingman Strohl, Clemens Heiser

Journal Article

Objective/Hypothesis
The ADHERE Registry is a multicenter prospective observational study following outcomes of upper airway stimulation (UAS) therapy in patients who have failed continuous positive airway pressure therapy for obstructive sleep apnea (OSA). The aim of this registry and purpose of this article were to examine the outcomes of patients receiving UAS for treatment of OSA.
Study Design
Cohort Study.
Methods
Demographic and sleep study data collection occurred at baseline, implantation visit, post‐titration (6 months), and final visit (12 months). Patient and physician reported outcomes were also collected. Post hoc univariate and multivariate analysis was used to identify predictors of therapy response, defined as ≥50% decrease in Apnea‐Hypopnea Index (AHI) and AHI ≤20 at the 12‐month visit.
Results
The registry has enrolled 1,017 patients from October 2016 through February 2019. Thus far, 640 patients have completed their 6‐month follow‐up and 382 have completed the 12‐month follow‐up. After 12 months, median AHI was reduced from 32.8 (interquartile range IQR, 23.6–45.0) to 9.5 (IQR, 4.0–18.5); mean, 35.8 ± 15.4 to 14.2 ± 15.0, P < .0001. Epworth Sleepiness Scale was similarly improved from 11.0 (IQR, 7–16) to 7.0 (IQR, 4–11); mean, 11.4 ± 5.6 to 7.2 ± 4.8, P < .0001. Therapy usage was 5.6 ± 2.1 hours per night after 12 months. In a multivariate model, only female sex and lower baseline body mass index remained as significant predictors of therapy response.
Conclusions
Across a multi‐institutional study, UAS therapy continues to show significant improvement in subjective and objective OSA outcomes. This analysis shows that the therapy effect is durable and adherence is high.
Level of Evidence2Laryngoscope, 2019

Surgical treatment of paranasal sinus osteomas: A single center experience of 58 cases

14-09-2019 – Axel Wolf, Bettina Safran, Jakob Pock, Peter Valentin Tomazic, Heinz Stammberger

Journal Article

Objectives
Osteomas are osseous tumors that primarily occur at the skull, in particular the paranasal sinus system. Surgical tumor resection is the “gold standard” treatment in symptomatic osteomas. The aim of this study was to investigate the use of surgical approaches (endoscopic, open, combined) and to provide a step‐by‐step approach for patients’ management.
Methods
Fifty‐eight patients (31 m, 27 f, 42.1 ± 15.3 years) that were treated between 2001 and 2015 at our department were included in this retrospective, single center study.
Results
In almost half of cases (n = 28, 48.3%) endoscopic, endonasal approaches were used for tumor resection while open (n = 11, 19%) or combined (n = 19, 32.8%) approaches were used in the rest of the cohort. Open or combined approaches were applied in patients suffering from osteomas localized in the maxillary or frontal sinuses only.
Conclusion
Beside interviews, clinical examination, nasal endoscopy, and computed tomography are crucial for diagnosis of paranasal sinus osteomas. Magnet resonance imaging can be useful in extensive pathologies. The preoperative selection of the optimal approach for osteoma resection might be most challenging in patients’ management. Although useful recommendations regarding the use of surgical approaches have been published, technical requirements and surgical experience of surgeons have to be considered in the limitations of endoscopic approaches. If there are doubts about the resectability of an osteoma by an endoscopic approach, the surgical procedure may be started endoscopically, and, if necessary, it can be combined with an external approach.
Level of Evidence
IV Laryngoscope, 2019

Safety and Efficacy of MRI Scans in Patients With Implanted Microvascular Coupling Devices

13-09-2019 – Neelam Phalke, W. Walsh Thomas, James Azzi, Ryan J. Li, Daniel Petrisor, Mark K. Wax

Journal Article

Objective
To demonstrate the safety and compatibility of microvascular couplers in patients undergoing postoperative magnetic resonance imaging (MRI) scans.
Study Design
Retrospective case series.
Methods
A consecutive review of 1,252 patients undergoing free tissue transfer for head and neck reconstruction at Oregon Health and Sciences University (OHSU) between 2010 and 2017 who had microvascular coupler Synovis, Baxter Deerfield, IL (Synovis Life Technologies, Saint Paul, MN) implantation were reviewed. One hundred fifteen patients had a subsequent MRI scan, which consisted of a variety of Phillips (Amsterdam, Netherlands) MRI machines ranging from 1.0 to 3.0 Tesla (T) in magnetic strength.
Results
These 115 patients underwent 121 free flaps with 131 couplers (including 32 flow couplers) utilized for venous anastomoses. Couplers ranged in size from 1.5 to 4.0 mm (3.0 mm 42% followed by 3.5 mm 21%, 2.5 mm 19%, 2.0 mm 10%, 4.0 mm 6%, and 1.5 mm 2%. Three hundred fifty‐nine MRI scans (2 days to 91 months postoperatively) were obtained with 233 MRIs for cancer surveillance, and the remaining were obtained for neurologic disease, injury, or evaluation for metastases. No complications occurred related to the MRI and the metallic components of the coupler or other metal implants, such as reconstruction bars, vascular clips, or metallic surgical mesh. Additionally, no radiology report commented on MRI distortion due to the coupler placement, which contrasts the distortion seen with the other metallic implants.
Conclusion
Microvascular couplers and their constitutive stainless‐steel pins have not been found to cause any complications in a large series of consecutive patients undergoing multiple MRIs with magnetic strength up to 3 T. The U.
S. Food and Drug Administration advocates medical alert notification for patients with couplers; however, hesitation regarding potential MRI scanning for surveillance or otherwise is unwarranted.
Level of Evidence4 Laryngoscope, 2019

Endoscopic Versus Open Resection of Non‐Squamous Cell Carcinoma Sinonasal Malignancies

12-09-2019 – Roman Povolotskiy, Nicole I. Farber, Richard D. Bavier, Samantha Y. Cerasiello, Jean Anderson Eloy, Wayne D. Hsueh

Journal Article

Objective
Non‐squamous cell carcinoma (non‐SCC) variants of sinonasal cancer are rare cancers which are optimally managed with complete surgical resection. This study aims to assess the impact of surgical approach on outcomes by comparison of cases managed with open versus endoscopic resection.
Methods
The National Cancer Database 2004–2015 datasets were queried for all cases of non‐SCC initially managed with definitive surgery. Patients were grouped according to surgical approach (endoscopic vs. open) and compared for patient, tumor, and treatment variables using chi‐squared analyses. Logistic regression was used to determine predictors of receiving endoscopic surgery. Subgroups were compared for survival using Cox regression and perioperative outcomes.
Results
Of the 1595 cases of non‐SCC sinonasal cancers managed with definitive surgery, 42.2% were treated endoscopically. Open and endoscopic groups differed significantly by stage, primary site, histology, facility type, margin status, and clinical stage. Logistic regression showed that increased income was a significant predictor of receiving endoscopic surgery whereas stage IV (odds ratio: 0.58, P = .017) reduced the odds of receiving endoscopic surgery. Open resection patients had longer mean length of stay (LOS) than those who underwent endoscopic resection (5.09 vs. 3.16 days, P < .001). On Cox regression, no difference in survival was observed between open and endoscopic patients (P = .534).
Conclusions
Patients with non‐SCC sinonasal cancer managed with endoscopic surgery had a decreased LOS and no significant difference in survival compared to patients undergoing open resection. Therefore, an endoscopic approach may be considered a viable alternative to open resection.
Level of Evidence
NALaryngoscope, 2019

Association of voice and mental health diagnoses with differences in voice‐related care utilization

11-09-2019 – Victoria A. Jordan, Scott Lunos, Gretchen Sieger, Keith J. Horvath, Seth Cohen, Stephanie Misono

Journal Article

Objective
To compare healthcare utilization in voice patients with versus without mental health (MH) diagnoses
Study Design
Retrospective study using electronic medical records from large regional healthcare system.
Methods
We examined data on sociodemographic characteristics, comorbidities, voice‐related diagnoses, and patterns of healthcare utilization (including medication use, tests and procedures, and outpatient visits). The study period spanned January 2005 through June 2017.
Results
A total of 24,672 patients had at least one voice‐related diagnosis. Of these, 11,483 (47%) also had at least one MH diagnosis compared to 14% in the overall repository (P < 0.0001). The most common voice‐related diagnoses were nonspecific dysphonia (80%), acute laryngitis (30%), and vocal fold paresis/paralysis (7%). The 11,483 patients with both voice‐related and MH diagnoses were more likely to have acute laryngitis and/or nonspecific dysphonia; less likely to have laryngeal cancer and/or paresis/paralysis; and more likely to have seen a primary care provider, to have received medications, and to have undergone radiology studies. In contrast, the 13,189 patients with only voice‐related diagnoses had more overall voice‐related visits, were more likely to have seen an otolaryngologist, and were more likely to have undergone a voice evaluation with a speech language pathologist.
Conclusion
Voice patients with MH diagnoses were less likely to see otolaryngology and more likely to have radiology studies than voice patients without MH diagnoses. Further study is warranted to characterize temporal sequences of care in this group of patients and determine whether these differences are attributable to referral patterns from primary care.
Level of Evidence4 Laryngoscope, 2019

Impact of an Upper Respiratory Tract Infection on Botulinum Toxin Efficacy in Spasmodic Dysphonia Patients

11-09-2019 – Diana N. Kirke, Rachel Kaye, Andrew Blitzer

Journal Article

Objective
To determine whether the presence of a concomitant upper respiratory tract infection (URI) impacts upon Botulinum toxin (Bo
NT) efficacy in spasmodic dysphonia (SD) patients.
Study Design
Case series and literature review.
Methods
All SD patients with a concurrent URI, presenting for Bo
NT therapy at a clinical research center from November 2016 to December 2017 were included. A total of 12 patients were identified. Patients were followed for at least two Bo
NT treatment cycles (approximately 6 months). The primary outcome measure was efficacy of the initial Bo
NT injection and the secondary outcome measure was the efficacy of the subsequent Bo
NT injection.
Results
All subjects had adductor type SD (ADSD). There were 10 females and two males with a median age of 55 years (±19.5). All patients were well established on a consistent Bo
NT treatment regime, with an average administered dose of 1.0 unit (range 0.2–1.80 units). Bilateral injections were administered to 10 patients. Regarding the primary outcome measure, five failed to have any response to Bo
NT (41.7%), four had a partial response (33.3%), and three had a positive response to treatment (25.0%). When patients had their follow‐up injection in the absence of URI symptoms, 11 patients had a positive response to treatment (91.7%).
Conclusion
While the interplay between illness and Bo
NT efficacy is yet to be elucidated, we report that some patients are affected. We recommend that SD patients presenting for Bo
NT administration with a concomitant URI, should be counseled that their treatment might have decreased effect.
Level of Evidence4 Laryngoscope, 2019

Drain placement in thyroidectomy is associated with longer hospital stay without preventing hematoma

11-09-2019 – Christopher A. Maroun, Margueritta El Asmar, So‐Jin Park, Marie Line El Asmar, Gangcai Zhu, Christine G. Gourin, Carole Fakhry, Vaninder Dhillon, Ralph P. Tufano, Jonathon O. Russell, Rajarsi Mandal

Journal Article

Objective
To analyze the effect of drain placement on postoperative hematoma formation and other associated outcomes post–thyroid surgery in a large national cohort.
Methods
This was a retrospective study that analyzed data from the 2016–2017 National Surgical Quality Improvement Program (NSQIP) public use files. Baseline characteristics and perioperative outcomes were compared between drain and no drain cohorts.
Results
A total of 11,626 patients were included; 3281 had a drain placed intraoperatively and 8345 did not. Otolaryngologists were 6.98 times more likely to place a drain after thyroidectomy than general surgeons (P < .001), and patients undergoing subtotal or total thyroidectomy were 2.17 times more likely to have a drain placed than if undergoing partial thyroidectomy (P < .001). Drain placement did not reduce hematoma formation on both univariate and multivariate analyses (adjusted OR = 0.93, P = .696). A slightly larger proportion of patients underwent unplanned intubation postoperatively among those who had a drain placed (0.76% vs. 0.29%, P < .001). Patients who received a drain were on average 4.63 times as likely to remain in the hospital for 2 or more days compared to those who did not receive a drain.
Conclusion
Drain placement did not significantly affect postoperative hematoma formation following thyroidectomy. Drain placement should not be routinely employed in these patients. However, surgeon judgement and intraoperative considerations should be taken into account, as to when to place a drain.
Level of Evidence
N/ALaryngoscope, 2019

Trauma‐informed care improves management of paradoxical vocal fold movement patients

11-09-2019 – Robert T. Cristel, Parker T. Russell, H. Steven Sims

Journal Article

Objectives
Vocal cord dysfunction (VCD) has been used by clinicians, primarily pulmonologists, to describe a variety of conditions in which the regulation and coordination of vocal fold movements are part of the explanation of cough or difficulty breathing, mainly paradoxical vocal fold motion disorder (PVFM). Prior studies show an intersection of mental health issues, primarily anxiety, and PVFM. We began incorporating mental health screening tools using the Life Events Checklist‐5 (LEC‐5) and the Posttraumatic Stress Disorder (PTSD) Checklist for Civilians (PCL‐C) to assess symptomatology that may be related to traumatic life events. We seek to review the utility of these questionnaires for identifying patients who have experienced emotional trauma and use the principles of trauma‐informed care currently lacking for PVFM.
Methods
We incorporated mental health screening tools using the PCL‐C and LEC‐5 for anyone referred to the Chicago Institute for Voice Care for VCD from the pulmonology clinic at our institution. Each patient underwent a comprehensive strobovideolaryngoscopy including provocative maneuvers to provoke paradoxical movements.
Results
A total of 16 subjects were analyzed; of those, seven (43.8%) screened positive for PTSD with the PCL‐C. Overall, 58 traumatic events occurred among the 16 patients, with 31 (61.7%) of the traumatic events occurring in the seven positively screened for PTSD.
Conclusions
Using the PCL‐C and LEC‐5, the principles of trauma‐informed care principles were applied to patients initially referred for VCD who were found to have prior traumatic events. We recommend early mental health screening to establish a multidisciplinary team in PVFM.
Level of Evidence3Laryngoscope, 2019

Multicentric study applying the european laryngological society classification of benign laryngotracheal stenosis in adults treated by tracheal or cricotracheal resection and anastomosis

11-09-2019 – Ivana Fiz, Philippe Monnier, Jan C. Koelmel, Diana Di Dio, Francesco Fiz, Francesco Missale, Cesare Piazza, Giorgio Peretti, Christian Sittel

Journal Article

Objectives/Hypothesis
Introduction and widespread use of cricotracheal resection and anastomosis (CTRA) as routine treatment for high‐grade benign laryngotracheal stenosis (LTS) led to the need for a new classification system that could accurately predict surgical outcomes by integrating crucial stenosis and patient‐related information. In 2015, the European Laryngological Society (ELS) proposed a new classification for benign LTS. We retrospectively tested it in adults treated at three referral centers to assess its reliability in predicting surgical outcomes.
Study Design
Retrospective cohort study.
Methods
We included 166 adults treated by open tracheal resection and anastomosis (TRA) and CTRA procedures, restaged according to the ELS classification evaluating grade of stenosis (I–IV, Myer‐Cotton), number of subsites involved, and presence of systemic comorbidities. We correlated these parameters with decannulation, number of retreatments, and complications.
Results
Final decannulation was predicted by a proposed ELS score ≥ IIIb, history of previous treatment, and length of resection (P < .05). Decannulation was achieved in 99% of patients without and in 88% of patients with surgical complications (P < .01). The incidence of surgical complications was related to the proposed ELS score (P < .01); an ELS score < IIIb showed a lower complication rate compared to patients with a ≥ IIIb score (32.8% vs. 57.7%, P < .01). Additional treatment was required in 73 (44%) patients (mean = 2.7 ± 2.2, range = 1–11). ELS score ≥ IIIb, length of resection, and occurrence of surgical complications predicted the number of such treatments (P < .05, P < .05, and P < .001, respectively).
Conclusions
ELS classification of benign LTS is able to accurately predict success in adult TRA/CTRA procedures and may be helpful in choice of therapy and patient counseling.
Level of Evidence2b
Laryngoscope, 2019

Survival analysis and decannulation outcomes of infants with tracheotomies

11-09-2019 – Jordan Salley, Yann‐Fuu Kou, Gopi B. Shah, Ron B. Mitchell, Romaine F. Johnson

Journal Article

Objective
To evaluate for differences in time to decannulation and survival rates for pediatric tracheotomy patients based on ventilator status upon discharge.
Study Design
Retrospective longitudinal cohort study.
Methods
A single‐institution longitudinal study of pediatric tracheostomy patients was conducted. Patients were categorized based on mechanical ventilation status on discharge and principal reason for tracheostomy. Survival rates were determined using the Kaplan‐Meier method. The Wilcoxons Rank Sum test and Cox regression analysis evaluated differences in survival times and time to decannulation based on primary indication for tracheotomy and ventilation status.
Results
Chart review identified 305 patients who required a tracheostomy under the age of 3. The median age at the time of tracheotomy was 5.2 months. The indications for tracheotomy in these patients were airway obstruction in 145 (48%), respiratory failure in 214 (70%), and pulmonary toilet in 10 (3.3%). Seventy‐nine percent of patients were ventilator dependent at discharge. At the conclusion of the study period, 55% of patients were alive with tracheostomy in place, 30% patients were decannulated, and 15% patients were deceased. Patients with ventilator dependence at initial discharge, bronchopulmonary dysplasia, or airway obstruction were more likely to be decannulated. Hispanic patients were less likely to be decannulated. Patients had an equal probability of death regardless of ventilator status at discharge.
Conclusions
This study demonstrated that the time to decannulation and likelihood of decannulation varies based on the indication for the tracheostomy. The majority of patients with a tracheostomy were not decannulated at the conclusion of this study. Median time to decannulation was 2.5 years for patients with a median death time of 6 months.
Level of Evidence2b
Laryngoscope, 2019

Role of voice rest following laser resection of vocal fold lesions: A randomized controlled trial

09-09-2019 – Sandeep S. Dhaliwal, Philip C. Doyle, Sebastiano Failla, Sarah Hawkins, Kevin Fung

Journal Article

Objectives/Hypothesis
Voice rest is often prescribed following phonosurgery by most surgeons despite limited empiric evidence to support its practice. This study assessed the effect of postphonosurgery voice rest on vocal outcomes.
Study Design
Prospective, randomized controlled trial.
Methods
Patients with unilateral vocal fold lesions undergoing CO2 laser excision were recruited in a prospective manner and randomized into one of two groups: 1) an experimental arm consisting of 7 days of absolute voice rest, or 2) a control arm consisting of no voice rest. The primary outcome measure was the Voice Handicap Index‐10 (VHI‐10) questionnaire. Secondary outcomes included aerodynamic measurements (maximum phonation time), acoustic measures (fundamental frequency, jitter, shimmer, and harmonic‐to‐noise ratio), and auditory‐perceptual measures. Primary and secondary outcomes were assessed preoperatively and reassessed postoperatively at the 1‐ and 3‐month follow‐up. Patient compliance to voice rest instructions were controlled for using subjective and objective parameters.
Results
Thirty patients were enrolled with 15 randomized to each arm of the study. Statistical analysis for the entire cohort showed a significant improvement in the mean preoperative VHI‐10 compared to postoperative assessments at 1‐month (19.0 vs. 7.3, P < .05) and 3‐month (19.0 vs. 6.2, P < .05) follow‐up. However, between‐group comparisons showed no significant difference in postoperative VHI‐10 at either time point. Similarly, secondary outcome measures yielded no significant difference in between‐group comparisons.
Conclusions
Our study shows no significant benefit to voice rest on postoperative voice outcomes as determined by patient self‐perception, acoustic variables, and auditory‐perceptual analysis.
Level of Evidence1b
Clinical Trial Number
NCT02788435 (clinicaltrials.gov) Laryngoscope, 2019

Cricotracheal resection for adult subglottic stenosis: Factors predicting treatment failure

09-09-2019 – Ashok R. Jethwa, Wael Hasan, Carsten E. Palme, Antti A. Mäkitie, Osvaldo Espin‐Garcia, David P. Goldstein, Ralph W. Gilbert, Shaf Keshavjee, Andrew Pierre, Patrick J. Gullane

Journal Article

Objectives/Hypothesis
Identify predictors of decannulation failure after cricotracheal resection (CTR) and thyrotracheal anastomosis (TTA) in patients with subglottic stenosis (SGS).
Study Design
Retrospective cohort study.
Methods
Charts of patients undergoing CTR and TTA for SGS at the University Health Network, Toronto, Ontario, Canada between 1988 and 2017 were reviewed. Patient, pathology, treatment, and outcome data were collected. The end points for statistical analysis were development of restenosis and permanent tracheostomy.
Results
One hundred fourteen patients (n = 114) were eligible for inclusion in this review. The mean age at primary resection was 46.9 years, 95 (83%) were females, and 19 (17%) were males. The rate of restenosis and permanent tracheostomy was 13% and 5%, respectively. Sixty‐two patients (54%) underwent a CTR and TTA, and 52 patients (46%) underwent a CTR, laryngofissure, and TTA. Traumatic stenosis (odds ratio OR = 10.3, P = .017), longer T‐tube duration (OR = 1.2, P = .011), combined glottic/subglottic stenosis (OR = 10.47, P = .010), start of the stenosis at the vocal cords (OR = 6.6, P = .029), postoperative minor complications (OR = 13.6, P = .028), and need for repeat surgery (OR = 44.1, P < .001) were associated with an increased risk of requiring permanent tracheostomy.
Conclusions
CTR and TTA are excellent surgical approaches for adult patients with subglottic stenosis. In this study, 5% of patients required permanent tracheostomy. Factors predicting treatment failure include traumatic stenosis, longer T‐tube duration, combined glottic/subglottic stenosis, start of stenosis at the level of vocal cords, postoperative minor complications, and need for repeat surgery.
Level of Evidence4 Laryngoscope, 2019

Esophageal manometry, pH testing, endoscopy, and videofluoroscopy in patients with globus sensation

09-09-2019 – Douglas J. Van Daele

Journal Article

Objectives/Hypothesis
Combine techniques commonly employed in the clinical workup of patients with isolated globus sensation to identify the most common pharyngoesophageal abnormality. The primary aim was to retrospectively review high‐resolution manometry, p
H probe testing, contrast videofluoroscopy, and endoscopy studies in patients with a primary complaint of globus sensation. The specific hypothesis was esophageal high‐resolution manometry identifies the most significant proportion of abnormalities compared to all other modalities.
Study Design
Retrospective cohort study.
Methods
An inclusive retrospective chart review was performed for patients evaluated between 2009 and 2016 with the primary complaint of globus sensation. Age at testing, self‐identified gender, associated diagnoses, and results from each modality were collected. Descriptive statistics and pairwise comparisons were performed as well as sensitivity and specificity calculations.
Results
One hundred seventy‐two patients met inclusion criteria. The cohort had an age range of 22.7 to 88.5 years and was predominantly female. Esophageal manometry identified abnormalities in 62.8% of patients, and p
H testing identified abnormal acidification in approximately 20%. The esophagram identified abnormalities in 24% of patients, and esophagogastroduodenoscopy identified abnormalities in 22%. Modified barium swallows were normal in 93% of patients. Measures of sensitivity and specificity of other modalities were poor compared to esophageal manometry and p
H testing.
Conclusions
Patients with isolated globus sensation have evidence of esophageal dysmotility and laryngopharyngeal and gastroesophageal reflux disease in high proportions. Esophageal high‐resolution manometry testing identifies the greatest proportion of abnormalities of the investigated modalities.
Level of Evidence4 Laryngoscope, 2019

Real‐world evidence for increased deep neck infection risk in patients with rheumatoid arthritis

09-09-2019 – Geng‐He Chang, Meng‐Chang Ding, Yu‐Cheng Chen, Yao‐Hsu Yang, Chia‐Yen Liu, Pey‐Jium Chang, Chuan‐Pin Lee, Meng‐Hung Lin, Cheng‐Ming Hsu, Ching‐Yuan Wu, Ko‐Ming Lin, Ming‐Shao Tsai

Journal Article

Objective
To investigate the association between rheumatoid arthritis (RA) and deep neck infection (DNI).
Study Design
Retrospective cohort study.
Methods
Patients newly diagnosed with RA between 2000 and 2011 were identified from the National Health Insurance Research Database in Taiwan. Moreover, patients without RA were randomly selected and matched at a 1:4 ratio by age, sex, urbanization level, income, and diabetes mellitus. The patients were followed up until death or the end of the study period (December 31, 2013). The primary outcome was the occurrence of DNI.
Results
In total, 30,207 patients with RA and 120,828 matched patients without RA were enrolled. Patients with RA had a significantly higher cumulative incidence of DNI than those without RA (P < 0.001). The adjusted Cox proportional hazard model demonstrated that RA was significantly associated with a higher incidence of DNI (hazard ratio: 2.80, 95% confidence interval: 2.26–3.46, P < 0.001). Therapeutic methods (surgical or nonsurgical) did not differ significantly between the patients with RA‐DNI and with non–RA‐DNI. Patients with RA‐DNI had higher rates of tracheostomy, mediastinitis, mediastinitis‐related mortality, and mortality than patients with non–RA‐DNI, although these differences were without statistical significance. RA patients receiving no therapy experienced higher rates of DNI compared with those receiving methotrexate alone, disease‐modifying antirheumatic drugs, or biologic therapies.
Conclusion
This study is the first to investigate the association between RA and DNI. We conclude RA is an independent predisposing factor for DNI.
Level of Evidence4 Laryngoscope, 2019

Safety‐relevant environmental sound identification in cochlear implant candidates and users

09-09-2019 – Benjamin L. Hamel, Kara Vasil, Valeriy Shafiro, Aaron C. Moberly, Michael S. Harris

Journal Article

Objectives/Hypothesis
To compare the identification of safety‐relevant environmental sounds between experienced cochlear implant (CI) users and CI candidates.
Study Design
Cross‐sectional.
Methods
A sample of 19 adult, postlingually deaf CI candidates (CI‐Cs), 47 experienced CI users (CI‐Es), and a control group of 37 age‐matched normal‐hearing adults were assessed using the Familiar Environmental Sounds Test–Identification (FEST‐I). A subset of 11 sounds relevant for safety were selected for analysis in the current study.
Results
Analysis of safety‐relevant sound identification accuracy revealed no significant difference in safety‐relevant environmental sound identification skills between CI‐E and CI‐C participants, with average scores of 68.1% and 67.9%, respectively. Both performed substantially lower than age‐matched normal hearing adults (95.1%). A significant moderate negative correlation (–0.4) was found between safety‐relevant sound accuracy and chronological age only in one group, the CI‐E group (r = –0.4, P < .005).
Conclusions
These findings fail to demonstrate superior performance in safety‐relevant environmental sound identification among CI‐Es compared with CI‐Cs. Although preliminary, these findings suggest that identification of safety‐relevant sounds is a significant area of weakness for both CI‐Es and CI‐Cs, both of whom may benefit from rehabilitation.
Level of Evidence4 Laryngoscope, 2019

A new editor‐in‐chief for The Laryngoscope

09-09-2019 – Michael G. Stewart

Editorial

Perioperative outcomes after tracheoplasty: A NSQIP analysis 2014–2016

09-09-2019 – Romaine F. Johnson, Nathan Eaviz, John M. Truelson, Andrew T. Day

Journal Article

Objectives
Tracheoplasty or tracheal resection and are essential components of the care of patients with severe tracheal stenosis. We aimed to study the perioperative outcomes of patients after tracheoplasty or resection using a national surgical registry.
Methods
We analyzed the 2014 to 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use file for patients who underwent tracheal resection or tracheoplasty (CPT codes 31750, 31760, 31780, and 31781). We analyzed the perioperative outcomes including length of stay (LOS), dehiscence, unplanned reintubations, unplanned surgeries, and 30‐day readmission rates. A random 4:1 sample of non‐tracheoplasty patients served as the control group.
Results
From 2014 to 2016, 126 patients underwent tracheoplasty. The median age was 56 years (IQR = 45–63). There were 93 (74%) females, 88 (70%) white, and 3.2% (4/126) Hispanic. The median LOS was 7 days (IQR = 5–10 days). Of these, 4.8% (6/126) developed wound infections and 3/126 (2.4%) developed wound dehiscence. Five out of 126 required unplanned reintubation (4.0%) and 16/126 (13%) had an unplanned reoperation. The 30‐day unplanned readmission rate was 16% (20/126). The wound infection, unplanned intubations, and readmission rates were significantly higher (P < .005) than the control group.
Conclusions
The 30‐day perioperative outcomes of adult patients undergoing tracheoplasty showed that adverse events are common, but severe adverse events such as death are rare. Continued research into risk mitigation among these patients is warranted.
Level of Evidence
NALaryngoscope, 2019

Pathophysiology of iatrogenic and idiopathic vocal fold paralysis may be distinct

09-09-2019 – Ted Mau, Solomon Husain, Lucian Sulica

Journal Article

Objective
Spontaneous vocal recovery from idiopathic vocal fold paralysis (VFP) appears to differ in time course from recovery in iatrogenic VFP. This study aimed to determine if this difference could be explained by differing mechanisms causing recurrent laryngeal nerve (RLN) dysfunction, specifically whether idiopathic VFP is consistent with a focal RLN axonal lesion.
Study Design
Case series with mathematical modeling.
Methods
A review of 1267 cases of unilateral VFP over a 10‐year period yielded 114 subjects (35 idiopathic, 79 iatrogenic) with a discrete onset of spontaneous vocal recovery. The time‐to‐recovery data were fit to a previously described two‐phase model that incorporates the Seddon classification of neuropraxia and higher grades of axonal injury. Alternatively, the data were fit to a single phase model that does not assume a focal axonal lesion.
Results
Time to vocal recovery in iatrogenic VFP can be reliably modeled by the assumption of a focal axonal lesion, with an early recovery group corresponding to neuropraxia and a late recovery group with more severe nerve damage. Time to recovery in idiopathic VFP can be more simply modeled in a single phase, with a time course that mirrors those in diverse biological processes such as transcription and microtubule growth.
Conclusion
Idiopathic VFP may not be caused by a focal axonal lesion. Neuritis may be a compatible mechanism. The iatrogenic VFP data lend further support to the concept that the severity of RLN injury, not the length of axon to regenerate, is the chief determinant of recovery time after iatrogenic injury.
Level of Evidence4 Laryngoscope, 2019

Predictors of voice outcome in pediatric non‐selective laryngeal reinnervation

09-09-2019 – Julina Ongkasuwan, Maria Catalina L. Espinosa, Sarah Hollas, Danielle Devore, Teresa Procter, Ethan Bassett, Aloysia Schwabe

Journal Article

Objectives
Non‐selective laryngeal reinnervation (NSLR) using the ansa cervicalis to the recurrent laryngeal nerve (RLN) is a promising treatment option for pediatric unilateral neuronal vocal fold movement impairment (VFMI). The aim is to describe our clinical outcomes with this technique and to identify preoperative characteristics that may predict postoperative voice outcomes.
Methods
This is a cohort study of pediatric patients with unilateral neuronal VFMI, who underwent NSLR from March 2012 to July 2018. Pre‐ and postoperative Pediatric Voice Related Quality of Life (PVRQOL) questionnaires, Consensus Auditory Perceptual Evaluation of Voice (CAPE‐V) ratings, and objective voice measures were obtained. In addition, patients underwent preoperative laryngeal electromyography (LEMG).
Results
Thirty‐two patients were identified. Twenty‐one had complete data sets for analysis. The mean duration of VFMI was 9.02 years (range 1.1–26.1 years). There were significant improvements in PVRQOL (P = .0005), in all CAPE‐V subsets (P ≤ .0001 to .0195), mean and maximum intensities (P = .0342 and 0.0110, respectively), cepstral peak prominence (P = .0001), and cepstral spectral index of dysphonia (P ≤ .0001). A worse preoperative LEMG correlated with a greater change in maximum phonation time (P = .0162) and maximum intensity (P = .0346). Age at injury and duration of injury had no significant impact on voice outcomes; however, patients with concurrent posterior glottic insufficiency did have smaller changes in PVRQOL (P = .012).
Conclusion
NSLR is an effective treatment for pediatric unilateral neuronal VFMI even many years after initial RLN injury. LEMG may help predict voice outcomes of reinnervation in pediatric patients, but further data is still needed.
Level of Evidence4 Laryngoscope, 2019

Exercise‐induced laryngeal obstruction (EILO) in children and young adults: From referral to diagnosis

09-09-2019 – Elizabeth O. Shay, Edouard Sayad, Claudio F. Milstein

Journal Article

Objective
To identify different presentations, referral patterns, comorbidities, and laryngoscopy findings in children and young adults with exercise‐induced laryngeal obstruction (EILO).
Methods
We performed a retrospective chart review of 112 patients, age <26 years, with EILO between 2013 and 2016.
Results
Of the 112 patients who met criteria, 91 were female and 21 were male. Patients were most frequently referred by pulmonologists (60.7%). The majority of patients (93%) participated in organized sports, most of them at a competitive level. The mean age at symptom onset was 13.8 ± 3.3 years, and the mean age of diagnosis was 15.4 ± 3.0 years. Sixty‐seven (59.8%) patients presented with a prior diagnosis of asthma, the majority of whom had failed asthma treatment. The most common symptoms reported were dyspnea (93.8%), wheezing/stridor (78.6%), and throat tightness (48.2%). Ninety‐one (81.3%) patients had spirometry performed, with 46 (51.1%) showing inspiratory loop flattening. On flexible laryngoscopy, 87 (78.4%) of 111 patients had paradoxical vocal fold motion. Supraglottic involvement was observed to obstruct the airway in 26 (23.9%) patients, with patterns of obstruction similar to those observed in children with laryngomalacia.
Conclusion
Most patients participated in competitive sports, were female, and presented with exertional dyspnea. Most patients were diagnosed with exercise‐induced asthma but treated unsuccessfully. Almost one‐quarter of our patients showed supraglottic collapse obstructing the airway. Exercise‐induced laryngeal obstruction is a more descriptive term than paradoxical vocal fold motion or vocal cord dysfunction, which only describe vocal fold involvement. The time to diagnosis of EILO was shorter than previously reported, suggesting that awareness of this condition is increasing.
Level of Evidence4 Laryngoscope, 2019

Office‐based CO2 laser surgery for benign and premalignant laryngeal lesions

09-09-2019 – David J. Wellenstein, Jimmie Honings, Anouk S. Schimberg, Henrieke W. Schutte, Jasmijn M. Herruer, Frank J.A. Hoogen, Robert P. Takes, Guido B. Broek

Journal Article

Objective
Patients with laryngeal pathology are often treated with CO2 laser surgery, usually in the operating room under general anesthesia. Although office‐based laser surgery using several other laser types has been investigated, prospective studies on office‐based CO2 laser surgery are scarce. Our goal was to investigate the feasibility of office‐based CO2 laser surgery for benign and premalignant laryngeal pathology by analyzing completion rate, safety, effect on voice quality, and success rate (i.e., no residual or recurrent disease).
Methods
A prospective cohort study was performed of 30 consecutive procedures. Inclusion started in June 2016 and was completed in August 2018. Adult patients with clinically benign or premalignant laryngeal lesions who could not undergo transoral laser microsurgery in the operating room under general anesthesia were included. Reasons were either contraindications for general anesthesia, previously failed therapeutic laryngoscopy under general anesthesia, and preference of a procedure under topical anesthesia by the patient. The mean follow‐up was 9 months.
Results
Thirty procedures were performed in 27 patients (24 males) with an average age of 62 years. Twenty‐nine (97%) procedures were fully completed without complications. The mean preoperative Voice Handicap Index (VHI) score (VHI 44) significantly decreased 2 months (VHI 28, P = 0.032) and 6 months (VHI 14, P < 0.001) after the procedure. Almost two‐thirds of patients showed no residual or recurrent disease at their follow‐up visits.
Conclusion
Office‐based CO2 laser surgery is a feasible and safe procedure that results in significant voice‐quality improvement. Almost two‐thirds of patients did not require further treatment.
Level of Evidence2 Laryngoscope, 2019

Laryngeal afferent modulation of swallowing interneurons in the dorsal medulla in perfused rats

09-09-2019 – Shinya Fuse, Yoichiro Sugiyama, Keiko Hashimoto, Toshiro Umezaki, Yoshitaka Oku, Mathias Dutschmann, Shigeru Hirano

Journal Article

Objectives
The purpose of this study was to investigate the influence of laryngeal afferent inputs on brainstem circuits that mediate and transmit swallowing activity to the orofacial musculature.
Methods
Experiments were performed on 19 arterially perfused juvenile rats. The activities of swallowing interneurons in relation to their respective motor outputs in the hypoglossal and vagus nerves were assessed during fictive swallowing with or without concurrent laryngeal sensory stimulation at intensities of 20, 40, and 60 μA.
Results
The hypoglossal nerve activity was gradually enhanced with increasing intensity of the sensory stimulation, while the vagus nerve activity was not altered. The activities of various interneurons were modulated by the laryngeal stimulation, but more than 50% of the recorded neurons were inhibited by the stimulation. Some interneurons demonstrated no obvious change in their discharge rates with laryngeal sensory stimulation during fictive swallowing.
Conclusion
Laryngeal afferent inputs partially modulated the swallowing motor activity via enhanced or suppressed activities of the swallowing interneurons, while the essential motor pattern underlying the pharyngeal stage of swallowing remained basically unchanged. Thus, the output patterns of the complex sequential movements of swallowing could be basically predetermined and further adjusted according to sensory information related to the properties of the ingested food by a swallowing central pattern generator.
Level of Evidence
NA Laryngoscope, 2019

Preoperative augmentative and alternative communication enhancement in pediatric tracheostomy

05-09-2019 – Rachel Santiago, Michelle Howard, Natasha D. Dombrowski, Karen Watters, Mark S. Volk, Roger Nuss, John M. Costello, Reza Rahbar

Journal Article

Objectives/Hypothesis
Describe augmentative communication tools and strategies used by pediatric patients referred to inpatient speech‐language pathologists prior to tracheostomy placement.
Study Design
Retrospective review.
Methods
A review of patients who underwent initial tracheostomy placement from 2013‐2016 was conducted at a tertiary pediatric center. Eligible patients were those who were referred to a specialized speech‐language pathologist prior to the date of the tracheostomy placement to support communication abilities. Patients were identified by surgical procedural and billing codes. Data collected included patient demographics, speech and language disorders, and interventions performed. Chart review and cross analysis of billing data for types of assessment and intervention procedures were conducted by two speech‐language pathologists for consensus agreement.
Results
Forty‐six patients (aged 1 month–27 years, mean = 12.9 years) were included in the study. Average time between the bedside communication assessment and tracheostomy procedure date was 17 days. Baseline speech‐language disorders were identified in 11 patients (24%). Thirty‐eight (83%) patients were nonspeaking at the time of consultation. Thirty‐two (70%) patients utilized an electronic communication tool, and 36 (78%) utilized low‐technology communication strategies during the preoperative period. A total of 32 (70%) patients were documented as using no‐technology or speech‐enhancement strategies during the acute hospitalization.
Conclusions
Multidisciplinary tracheostomy teams should consider consultation to speech‐language pathologists for patients prior to tracheostomy placement to assess for utility of high‐technology, low‐technology, and no‐technology augmentative and alternative communication strategies.
Level of Evidence4 Laryngoscope, 2019

Respiratory Epithelial Adenomatoid Hamartoma is Frequent in Olfactory Cleft After Nasalization

05-09-2019 – Duc Trung Nguyen, Roger Jankowski, Ayoub Bey, Guillaume Gauchotte, Jean Matthieu Casse, Pedro Augusto Gondim Teixeira, Patrice Gallet, Cécile Rumeau

Journal Article

Objectives
To assess the site and histopathology of polyps at the first revision surgery for recurrent nasal polyposis (NP) after radical ethmoidectomy (nasalization).
Study Design
Retrospective study.
Methods
Between January 2008 and December 2015, a total of 62 patients having undergone revision surgery for recurrent NP after nasalization were included. The site and histology of the recurrence of polyps were analyzed according to operative and pathological reports.
Results
Histology showed classical inflammatory nasal polyps (CINP) in 91% of nasal cavities at primary surgery versus respiratory epithelial adenomatoid hamartoma (REAH) or REAH associated to CINP in 54.8% at revision surgery (P < .0001). Polyps were principally observed in the ethmoidal complex in 70% of nasal cavities during primary surgery and in the olfactory clefts in 88.7% during revision surgery (P < .0001). The mean interval between nasalization and first revision surgery was 8.8 ± 4.4 years (0.4–21.7 years). This interval was significantly shorter for grade 3 polyps, polyps removed from both ethmoidal complex and olfactory cleft at primary surgery, association of CINP and REAH at primary surgery, and when primary surgery had preserved the middle turbinates.
Conclusion
Polyp recurrences after nasalization were mainly observed in the olfactory clefts and can be different histological features: inflammatory polyps, respiratory epithelial adenomatoid hamartoma, or a combination of both.
Level of Evidence4 Laryngoscope, 2019

Adjunctive techniques to improve access of the endoscopic prelacrimal recess approach

05-09-2019 – Grace C. Khong, Gaurav Medikeri, Claire Tierney, Samuel C. Leong

Journal Article

Objectives
To determine whether adjunctive surgical techniques could improve access of instruments provided by the endoscopic prelacrimal recess approach to the anatomical boundaries of the maxillary sinus, and pterygopalatine and infratemporal fossa.
Methods
Ten fresh‐frozen adult cadaver heads were utilized. The anatomical areas of interest were fixed, bony boundaries of the maxillary sinus, infratemporal fossa, and pterygopalatine fossa: alveolar recess (AR), zygomatic recess (ZR), perpendicular plate of the palatine bone (PB), ascending ramus of mandible (RM), floor of the orbit medial and lateral to infraorbital nerve (M‐ION and L‐ION, respectively). Access to the areas were compared using standard sinus surgery instruments (straight and 45° forceps) introduced via the prelacrimal recess approach, trans‐septal window and canine fossa puncture.
Results
The prelacrimal recess approach successfully provided access to the PB and M‐ION in >90% of dissections when using both the straight and 45° forceps. With the straight forceps, the ability to successfully access to the AR and ZR was the lowest at 50% and 35% respectively, although improving to 75% and 60% respectively with the 45° forceps. Access to the AR, ZR, and L‐ION improved significantly when the 45° forceps was introduced through the trans‐septal window. Frequency of access to the RM when either instruments when introduced through the canine fossa puncture was no greater than 60% of the dissections.
Conclusions
The addition of a small trans‐septal window for instruments significantly improved access of the prelacrimal recess approach especially to the orbital floor, lateral margins of the maxillary sinus, and retromaxillary space.
Level of Evidence4 Laryngoscope, 2019