Faculty Bibliography

We report a case of cervical esophageal perforation caused by the Heimlich maneuver in a healthy 16-year-old boy. The patient reported a short coughing episode while eating rice, and his mother performed the Heimlich maneuver on him. Five days later, he presented to the emergency department with throat pain, odynophagia, secretion intolerance, muffled voice, and neck stiffness. He was admitted to the pediatric intensive care unit for conservative management. The next day he underwent transcervical incision and drainage of purulence, but the esophageal perforation could not be visualized at that time. The perforation was identified several days later and successfully repaired surgically. Esophageal perforation as a complication of the Heimlich maneuver is exceedingly rare, but the clinician should be aware of this entity in the differential diagnosis, as it is associated with a high mortality rate and warrants multidisciplinary care, including timely surgical intervention.

Following recurrent laryngeal nerve (RLN) injury, recovery results in poor functional restitution of the paralyzed vocal fold. Netrin-1 has been found to be upregulated in the rat posterior cricoarytenoid muscle (PCA) during nerve regeneration. We evaluated the effect of ectopic Netrin-1 in the PCA during RLN reinnervation. The right RLN was transected and Netrin-1 was injected into the PCA (2.5, 5, 10, 15, 20μg/ml). At 7 days post injury fluorescent retrograde tracer was injected into the PCA and Thyroarytenoid (TA) muscles. At 9 days tissues were harvested. Immunostaining showed reinnervation patterns in the laryngeal muscles and labelled motoneurons in the nucleus ambiguus. Lower concentrations of Netrin-1 (2.5 and 5μg/ml) showed no significant changes in laryngeal muscles reinnervation. Higher concentrations of Netrin-1 significantly reduced motor end plate innervation. The most effective dose was 10μg/ml showing reduced number of innervated motor endplates in the PCA. The somatotopic organization of the nucleus ambiguus was altered in all concentrations of Netrin-1 injection. These findings indicate that injection of Netrin-1 into the PCA changes the reinnervation pattern of the RLN.

OBJECTIVE:Although vocal fold (VF) leukoplakia is commonly treated with in-office laser, there is no data on its long-term effectiveness. This study hypothesizes that VF leukoplakia treated by serial in-office laser results in long-term disease control with maintenance of voice and minimal morbidity. STUDY DESIGN:Retrospective review (2008-2015). METHODS:Forty-six patients with VF leukoplakia treated by in-office KTP (potassium titanyl phosphate) or PDL (pulsed dye laser) were included. Median follow-up from final laser treatment was 19.6 months. Main outcomes included: 1) rate of disease control, 2) percentage of disease regression using ImageJ analysis. Secondary outcomes included vocal assessment using the Voice Handicap Index-10 (VHI-10). RESULTS:Patients underwent a median of 2 (range: 1-6) in-office laser treatments. Time between treatments was median 7.6 months. After final treatment, 19 patients (41.3%) had no disease; two patients (4.3%) progressed to invasive cancer; overall disease regression was median 77.1% (P < 0.001); and VHI-10 score decreased by median 5 (P = 0.037). Thirty-one patients (67.4%) were responders (controlled with in-office treatment only); failures were 13 patients (28.3%) who required operative intervention and two patients (4%) who underwent radiation. Compared to responders, failures demonstrated significantly shorter duration between treatments (median 2.3 vs. 8.9 months, P = 0.038) and significantly less regression (median 49.3% vs. 100%, P = 0.006). CONCLUSION:Serial outpatient KTP or PDL treatment of VF leukoplakia is effective for disease control with minimal morbidity and preservation of voice quality. We suggest that patients requiring repeated in-office treatment every 6 months may benefit from earlier operative intervention; other factors associated with in-office success remain unclear. LEVEL OF EVIDENCE:4. Laryngoscope, 127:1644-1651, 2017.

OBJECTIVE:Contralateral reactive lesions (RLs) represent a distinct entity among benign bilateral vocal fold (VF) lesions. Lack of uniform nomenclature and a myriad of surgical options have hampered attempts to develop treatment guidelines. The objective of this study is to better define RLs and their prognosis, through the development of a standard nomenclature, with an aim to guide treatment and delineate the role of phonosurgery. STUDY DESIGN:Case series with chart review. SETTING:Tertiary care center. SUBJECTS AND METHODS:Analysis was performed on patients with Current Procedural Terminology code 31545. Operative reports with a primary lesion and contralateral RL were included. Outcomes included the Voice Handicap Index-10 (VHI-10) and GRBAS (grade, roughness, breathiness, asthenia, and strain) scale, lesion persistence/recurrence, mucosal wave, and edge character based on blinded videostroboscopy review. RESULTS:A nomenclature was developed based on intraoperative RLs (n = 30), defined by lesion consistency (fibrous or polypoid) and relationship to normal VF edge (gradual or steep). Reactive lesion treatment included no intervention, excision, potassium titanyl phosphate laser, steroid injection, or a combination thereof. Observations included the following: inconsistent treatment modalities were employed, excision of RLs did not yield better outcomes, fibrous RLs were more likely to persist and polypoid lesions more likely to recur, gradual lesions were more likely to remain disease free, and most treatments showed improved mucosal wave, VHI-10, and GRBAS. CONCLUSIONS:Reactive lesions have not been well classified, and treatments are based on subjective intraoperative decision making with unpredictable outcomes. The nomenclature proposed will allow for a better definition of the RL and provide a framework for future research to identify optimal treatment.

Adenomatous tumors are an uncommon cause of a middle ear mass. Clinical findings may be nonspecific, leading to difficulties in differentiation from other middle ear tumors. Controversy also exists whether to classify middle ear adenoma and carcinoid as separate neoplasms, or alternatively within a spectrum of the same pathologic entity. Most adenomatous middle ear tumors are indolent in behavior, with a benign histologic appearance and slowly progressive growth. The mainstay of treatment is complete surgical resection, which affords the greatest likelihood of cure.

Vascular tumors pose a challenging problem in treatment, as surgical planning can be extensive. Often times, pre-operative embolization is required to minimize blood loss during surgery. With the advent of new biochemical compounds, embolization modalities have evolved over the past decade. Although rare, side effects and complications of embolic materials have been cited sporadically in the literature. We present an interesting case of a patient afflicted with facial paralysis and other cranial neuropathies following embolization of a paraganglioma, along with the appropriate imaging that confirms the etiology of her paralysis.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:The primary objective was to determine the incidence of pathologically positive lymph nodes in clinically N0 larynx cancer patients undergoing salvage surgery following nonsurgical primary therapy. Secondary aims included assessment of the impact of laryngeal subsite and neck dissection on disease status and survival. STUDY DESIGN/METHODS:Retrospective chart review. METHODS:Sixty-eight patients with recurrent laryngeal cancer and no evidence of neck disease who underwent salvage laryngectomy and neck dissection after undergoing failed primary radiotherapy or chemoradiation were examined. Main outcome measures included: standard demographics, primary, clinical, radiologic, and pathologic recurrent TNM stage, laryngeal subsite, nodal neck level, surgical intervention, margin status, disease status, survival, and imaging results. RESULTS:Fifty-three men and 15 women, aged 33 to 88 years (mean=62.7 years) with recurrent laryngeal cancer were included. Overall, 28.3% of patients had pathologic nodal disease, with supraglottic cancer showing the highest rate (60%, P=.02). Survival was not associated with laryngectomy type (P=.35). However, on multivariate analysis, laryngeal subsite was significantly predictive of survival with transglottic recurrences demonstrating decreased mean survival (20.7 months, P=.02), and supraglottic recurrences demonstrating prolonged mean survival (37.1 months, P=.03). Metabolic imaging (negative predictive value=0.86) proved more reliable than anatomic imaging (negative predictive value=0.71). CONCLUSIONS:The incidence of pathologically positive lymph nodes in clinically negative patients with recurrent laryngeal carcinoma following nonsurgical therapy warrants standard selective neck dissection. Subsite of recurrence, specifically supraglottis and transglottis, correlates with pathologic neck node positivity and survival. Metabolic imaging proved more reliable than anatomic imaging in negative predictability for nodal disease. LEVEL OF EVIDENCE/METHODS:4.

OBJECTIVE:We assessed the representation of numerosity in corticobasal syndrome (CBS), a neurodegenerative condition affecting the parietal lobe. METHOD/METHODS:Patients judged whether a target numerosity (e.g., "3") falls between two bounding numerosities (e.g., "1" and "5"). We manipulated the format for representing numerosity (Arabic numerals or dot arrays), the size of the gap between the two bounding numerosities, the absolute magnitude of the numerosities, and the order for presenting the bounding numerosities. In a subset of patients with available imaging, we related performance to cortical atrophy using voxel-based morphometry. RESULTS:CBS patients were significantly impaired overall (65.7% +/- 16.2 correct) compared to healthy seniors (96.6% +/- 2.4 correct), and required three times longer than controls to judge correct stimuli. This deficit was equally evident for Arabic numeral and dot array formats. Controls were significantly slower with smaller gaps than larger gaps, consistent with the greater challenge distinguishing between numerosities that are more similar to each other than very different numerosities. However, CBS patients were equally slow and inaccurate for all gap sizes. Controls also were significantly slower with larger numerosities than smaller numerosities, but CBS patients were equally slow and inaccurate with all numerosity magnitudes. Voxel-based morphometry revealed significant cortical atrophy in parietal and frontal regions in CBS compared to controls, including the intraparietal sulcus. CONCLUSIONS:These observations are consistent with the claim that the representation of numerosity is degraded in CBS.

Proteinuria is utilized to screen for underlying kidney disease and serves as a marker of disease progression. The aim of this study was to test the hypothesis that patients with proteinuria will have a higher frequency of urine dipstick positive for leukocytes as an index of noninfectious renal inflammation. In this retrospective analysis, 1,099 urine specimens were evaluated from 676 patients. Proteinuria was present in 39% of the samples and leukocyturia in 5.1%. The percentage of urines that were dipstick positive for leukocytes was similar in those specimens with or without proteinuria. However, in patients with proteinuria and concomitant leukocyturia, the mean serum creatinine concentration was higher (P=0.003) and the calculated GFR was lower (P=0.01) compared to those without this additional abnormality. These differences were noted despite similar age, gender distribution, and array of underlying diseases in these two groups. Based on these findings, urine dipstick testing for leukocytes as a primary means of screening otherwise healthy children for serious renal disease is of little value. However, in patients with established proteinuria, a positive dipstick result for leukocytes is a simple means of identifying those with more prominent noninfectious renal inflammation, a process which may promote kidney disease progression. This finding may serve as an early marker of the severity of renal injury, regardless of whether the primary process is glomerular or tubular