Faculty Bibliography

OBJECTIVES/HYPOTHESIS: Idiopathic ulcerative laryngitis (IUL) is a distinct, clinical entity that presents after a prolonged upper respiratory infection with cough. It is characterized by the development of bilateral ulcerations of the mid-membranous vocal folds followed by a protracted course of healing. The purpose of this review was to characterize the typical patient presentation, clinical findings, and prognosis. STUDY DESIGN: Multi-institutional retrospective review METHODS: Retrospective review of charts and videostroboscopic exams from patients with IUL at eight institutions. RESULTS: Fifteen cases met the criteria for IUL and were included in the study. The mean age of the patients was 49 years, and 93% were female. All patients were nonsmokers. Multiple medical interventions were employed by the treating otolaryngologist during the course of the disease, none of which resulted in acute resolution of the ulcerations. The average time from initial presentation to resolution of the disease was 3.3 months. All of the patients reported that their voice was improved after resolution of the disease process. However, in the majority of the patients (60%) there were persistent vibratory abnormalities after resolution of the ulcerations. CONCLUSIONS: This is the first multi-institutional study to define the complete disease course of IUL and to establish diagnostic criteria. IUL is a rare yet well-recognized clinical entity; however, there is no established etiology for this condition and no definitive treatments have emerged. Further study is needed to establish the etiology/risk factors of this condition and to determine optimal medical management

OBJECTIVES/HYPOTHESIS: Although the potassium titanyl phosphate (KTP) laser is versatile, the variability in laser parameters for laryngeal pathologies and the lack of clinical efficacy data remain problematic. We provide preliminary data regarding these parameters for benign lesion regression. In addition, we describe a novel method for the quantification of the effects of the KTP laser on vocal fold (VF) lesions. STUDY DESIGN: Retrospective chart review. METHODS: Images were captured from examinations before and after in-office KTP treatment in patients with a range of benign lesions. Laser settings were noted for each patient. Imaging software was then used to calculate a ratio of lesion area to VF length. Ten percent of images were requantified to determine inter-rater reliability. RESULTS: Thirty-two patients underwent 47 procedures for lesions including hemorrhagic polyp, nonhemorrhagic polyp, vocal process granuloma, Reinke's edema, cyst/pseudocyst, leukoplakia, and squamous cell carcinoma in situ. No statistically significant differences were observed with regard to the laser parameters used as a function of lesion type. Regardless, by 1 month following treatment, all lesions had significantly decreased in size, except nonhemorrhagic polyps. Similar data were obtained at 2-month follow-up. We then compared the pre-KTP lesion size with the smallest lesion size quantified during the 1-year follow-up period. All lesions were significantly smaller, with the exception of Reinke's edema. Inter-rater reliability was quite good. CONCLUSIONS: KTP laser effectively reduced VF lesion size, irrespective of the laser parameters used. In addition, our quantification method for lesion size appeared to be both viable and reliable. Laryngoscope, 2011

OBJECTIVE/HYPOTHESIS: The 532-nm KTP laser is clinically useful to induce benign vocal fold lesion regression without a fibrotic response. Previously, we described an in vivo model for KTP-induced injury in the rat larynx. This study uses this model to correlate the KTP-induced histologic and biochemical changes with the absence of long-term vocal fold fibrosis seen in clinical scenarios. STUDY DESIGN: In vivo. METHODS: Unilateral vocal fold injury was induced via KTP laser at 10W (20mS pulse width) as described by our laboratory previously. Animals were subjected to serial endoscopic imaging from postoperative days 1 through 3. Animals were euthanized at 1 day, 4 weeks, and 12 weeks posttreatment and subjected to histologic analyses via hematoxylin and eosin and trichrome staining, as well as RT-PCR analyses for MMP-3, 9, transforming growth factor-beta (TGF-beta), and COX-2 mRNA expression. Uninjured vocal folds were used as controls. RESULTS: Our study revealed gross healing of the vocal fold mucosa by 3 days posttreatment, and an immediate, moderate inflammatory infiltrate with no subsequent ultrastructural changes on histology. MMP-3 and COX-2 expression increased transiently, although no changes were seen in expression of MMP-9, an MMP involved in extracellular matrix remodeling, or TGF-beta, a profibrotic cytokine. CONCLUSIONS: These data suggest that the KTP laser induces a modest inflammatory response, selective MMP expression, and no long-term fibrotic processes in a clinically relevant simulation. Laryngoscope, 2011

The most common primary malignancy of the larynx is the squamous cell carcinoma (SCC). The primary malignant melanoma is quite rare in this location. Less than 60 cases of laryngeal melanomas have been reported to date. To our knowledge, collision primary malignant melanoma and invasive squamous cell carcinoma in the vocal cords has not been reported. We report a 53-year-old male patient who was diagnosed with a collision tumor of laryngeal melanoma and invasive SCC. Multiple Th17 pathway related genes including CTLA-4, IL-17A-F, PLZF, FoxP3, RorgammaT, CD27, and CD70 were analyzed by reverse transcriptase-polymerase chain reaction (Rt-PCR) in this case. Both IL-17A and CD70 genes were detected in this case of collision tumor. The results may define useful biomarkers for early diagnosis of mucosal melanoma and open an immunotherapeutic field for clinical management with the potential benefit from the immunomodulators that enhance both genes

The symptom of cough may result from a multitude of etiologies involving different parts of the aerodigestive tract. This article focuses on the association of cough and swallowing dysfunction in the sense that cough may be an indicator of swallow dysfunction and in the importance of cough in preventing aspiration and aspiration-related disorders. Whereas these associations have been known for a long time, research is starting to connect the dots, allowing targeting of strategies aimed at diagnosing and preventing illness in certain dysphagic patients

OBJECTIVES/HYPOTHESIS: To identify contemporary indications, treatment principles, technique, injection materials, complications, and success rates of vocal fold injection augmentation. STUDY DESIGN: Multi-institutional retrospective review. METHODS: Records of patients undergoing injection augmentation at seven university medical centers from July 2007 through June 2008 were reviewed for information regarding diagnosis, unilateral or bilateral injection, route of injection, anesthesia, treatment site (office or operating room), material used, reason for technique selected, and technical success. RESULTS: In 12 months, 460 injections were performed, 236 (51%) in awake, unsedated patients, and 224 (49%) under general anesthesia. Indications included vocal fold paralysis (248; 54%), paresis (97; 21%), atrophy (68; 15%) and scar (47; 10%). Scar was more likely to be treated in the operating room (P = .000052). In awake patients, 112 (47%) injections were performed by transcricothyroid approach, 55 (23%) by peroral approach, 49 (21%) by transthyrohyoid membrane approach, and 20 (8%) by transthyroid cartilage approach. Neither technical success rate (99% vs. 97%) nor complication rate (3% vs. 2%) differed between awake and asleep techniques. The most common materials in the clinic setting were methylcellulose (35%), bovine collagen (28%), and calcium hydroxylapatite (26%); in the operating room these were calcium hydroxylapatite (36%) and methylcellulose (35%). Calcium hydroxylapatite was more likely to be used under general anesthesia (P = .019). Five-year data show that the use of injection in the awake patient rose from 11% to 43% from 2003 to 2008. CONCLUSIONS: Injection augmentation remains a safe, effective, and clinically practical treatment with a high rate of success, whether performed in the awake or asleep patient. The rapid adoption of awake injection over the past 5 years speaks to its clinical utility. Complication rates are low and equivalent to those under general anesthesia. Otolaryngologists continue to use a variety of techniques and materials to treat a range of conditions of glottic insufficiency.

Patients or Programs: A 15-year-old boy with multiple injuries after a bicycle accident. Program Description: The patient was admitted to an acute care hospital after a bicycle accident resulting in diffuse axonal injury with callosal tear and T10 vertebral fracture. He self extubated and required reintubation and later for right lower lobe pneumonia (PNA). He presented to rehabilitation (rehab) with waxing and waning alertness and decreased short-term memory. He required maximum assistance (A) for activities of daily living (ADL). He ambulated with minimal A with a widened base of support. Soon after admission, he became tachypneic and hypoxemic, was transferred to acute care and treated for PNA. During his second rehab stay, he had 2 days of worsening stridor, thought to be related to upgrading his diet with possible aspiration. A 3-cm subglottic narrowing was seen on neck CT and was considered secondary to trauma from intubation. He had a balloon dilation of the trachea but had continued stridor. He required tracheal reconstruction with subsequent prolonged bedrest with his chin sewn to his chest. He was later readmitted to rehab. His rehab course was greatly prolonged by medical problems and extended bedrest. Setting: Acute pediatric rehabilitation unit. Results: Upon discharge, he was modified independent (I) to I in his ADLs and ambulated with modified I. His higher executive functioning appeared to be normal but he continued to have difficulties with problem solving and math skills. Discussion: As with all rehab patients, close physiatric care is required to monitor for medical issues that arise during therapy. If a patient presents with dyspnea or stridor during therapy, a broad differential diagnosis should be suspected, including aspiration PNA, asthma exacerbation and tracheal stenosis. Tracheal stenosis is a potential postintubation complication and may be fatal if not recognized. This typically does not manifest until 4-6 weeks post injury; thus it may not be seen in an acute care setting. It is likely to be seen in acute rehabilitation and needs to be acted upon in that setting. Conclusions: Many rehab patients are admitted post intubation. Postintubation tracheal stenosis should be suspected in those who present with dyspnea, stridor or wheezing