Faculty Bibliography

Objective: Glucocorticoids are commonly used treatments in otolaryngology, but guidelines about their use are vague and irregular. We sought to assess clinical practices with regard to glucocorticoid use for patients with laryngeal disease and to ascertain factors driving clinician drug choice. Method: A web-based survey was distributed to otolaryngologists via email using the Ear, Nose, and Throat (ENT) Journal database. This survey was composed of 20 questions and collected the following data from respondents: 1) indications for the use of glucocorticoids in their practice, 2) decision-making process influencing the choice of glucocorticoid, 3) background and demographics. Results: Two hundred eight otolaryngologists completed the survey, with 99% (n = 196) reporting that glucocorticoids were valuable to their practice. "Previous experience/results," "familiarity," and "use in practice" (n = 144, 114, and 79, respectively) were commonly cited reasons for choosing a particular glucocorticoid, whereas pharmacokinetic profile and "academic literature" were infrequently cited concerns. Only 54.4% (n = 106) of respondents said that they were more likely to prescribe glucocorticoids for vocal performers as compared to other patients. Additionally, most respondents said side effects only "occasionally" prevented them from prescribing glucocorticoids to patients. Conclusion: These results suggest that glucocorticoid prescription practices vary greatly between otolaryngologists, and drug choice is driven primarily by clinician preference rather than more objective factors. These findings indicate a need for further research about this powerful class of drugs, and the importance of establishing clear, appropriate guidelines regarding their use.

OBJECTIVES: The recently published Clinical Practice Guideline: Hoarseness (Dysphonia) revealed major deficits in the literature regarding relatively routine clinical decision-making. One of the more controversial points in the Guideline regarded the utility and timing of laryngeal visualization via flexible laryngoscopy, potentially because of sparse literature regarding the risks and potential morbidity. We sought to prospectively address this issue in order to optimize evaluation protocols. METHODS: Two-hundred fifty consecutive patients with a variety of complaints completed a survey after undergoing flexible laryngoscopy. The survey queried 1) demographics; 2) discomfort of pretreatment anesthesia and scope placement in the nose and pharynx; 3) fear of future examinations; and 4) patient perception and past experience. Concurrently, the laryngoscopist reported the complications and anatomic variations encountered. RESULTS: The discomfort and pain ratings from both the anesthetic spray and the scope placement were low. No statistically significant differences were observed with regard to sex; however, women reported greater fear associated with examinations (p = 0.0001). Anatomic abnormalities were observed in 14.4% of patients, and these patients reported greater discomfort, pain, and fear regarding the examination. No adverse events were observed. CONCLUSIONS: Flexible laryngoscopy was well tolerated, with little to no risk. The presence of nasal anatomic abnormalities predicted increased discomfort.

OBJECTIVE/HYPOTHESIS: To determine the efficacy of the potassium titanyl phosphate (KTP) laser in lesion reduction, as well as preservation of mucosal wave and glottic closure in a cohort of patients with benign laryngeal pathology across multiple institutions. STUDY DESIGN: Multi-institutional and retrospective. METHODS: One hundred two patients who underwent in-office KTP procedures at multiple academic laryngology practices with at least a single follow-up visit were included. Image analysis was used to quantify vocal fold lesion size before and after treatment. A subset of images was analyzed by expert reviewers to determine the impact of this treatment on glottic closure and mucosal wave. RESULTS: Statistically, when considering all lesions, KTP induced a significant reduction in lesion size. Post hoc analyses revealed some lesion specificity; all lesions decreased in size, with the exception of vocal fold scar. Mucosal wave and glottic closure were improved or unchanged in more than 90% of the patients examined. The inter- and intrarater reliabilities of the lesion quantification method were excellent. CONCLUSIONS: With great care and insight, the KTP laser appears to be a valuable tool for the treatment of various benign laryngeal lesions. Furthermore, KTP laser therapy appears to preserve or improve mucosal wave and glottic closure. The lesion measurement protocol previously described by our group appears to be reliable.

OBJECTIVES: The recently published Clinical Practice Guideline raised issues related to the value and timing of laryngoscopy in patients with hoarseness. We sought to determine the extent to which these guidelines concur with clinical practice among members of the American Broncho-Esophagological Association (ABEA). METHODS: A web-based survey was distributed to ABEA members, composed of four sections: 1) background and demographics; 2) information regarding the appropriate length of time that new-onset dysphonia may be managed before laryngeal visualization, given particular comorbidities; 3) the frequency and risks of office-based flexible transnasal laryngoscopy; and 4) the overall value of laryngoscopy and stroboscopy. RESULTS: Seventy-one ABEA members completed the survey; they had a combined 1,468 years of post-residency experience. Approximately 75% of respondents were involved in a fully academic practice. Across all respondents, an average of 11 patients with new voice complaints were seen per week. Overall, 98.6% of respondents believe that laryngoscopy is very valuable. Stridor in a neonate and potential foreign bodies were both conditions necessitating laryngoscopy on the day of presentation. In patients with no serious underlying condition(s), the mean duration until laryngoscopy was 12.96 days (range, 0 to 30 days). CONCLUSIONS: These data suggest that the current practice patterns among experts in the field are divergent from the recently published Guideline.

BACKGROUND: Dysphagia is a potential consequence of treatment for head and neck cancer. Neuromuscular electrical stimulation (NMES) has evolved as a treatment option, with the goal of improved swallow function in patients with chronic dysphagia. However, the effects of NMES on tumorigenicity are unknown and often confound the initiation of this therapy, potentially limiting its efficacy in treating patients with head and neck cancer. METHODS: Squamous cell carcinoma was grown in the flank of athymic, nude mice. Mice were randomized into treatment and control groups; the experimental group received daily NMES directly to the flank for 8 days. RESULTS: Tumor volumes, recorded on days 0, 3, 7, and 10, demonstrated no significant differences between groups on each day of measurement. Immunohistochemical analysis of apoptosis, proliferation, and vascularization also failed to demonstrate statistically significant differences between treated and untreated groups. CONCLUSIONS: NMES does not promote the growth of underlying tumor in our model. These data may provide preliminary evidence that applying electrical stimulation over the muscles of the anterior neck does not increase the risk of tumorigenicity. Early initiation of NMES in this challenging population may be feasible from an oncologic standpoint. (c) 2011 Wiley Periodicals, Inc. Head Neck, 2011.

OBJECTIVES/HYPOTHESIS: In this article we describe a methodology for obtaining high-quality dynamic magnetic resonance imaging (MRI) sequences of the swallow sequence in healthy volunteers. The study includes comparison to previous work done in our lab using a 1.5 Tesla (T) magnet. STUDY DESIGN: Case series. METHODS: Three healthy volunteers underwent turbo-fast low angle shot MRI at 3T while swallowing liquid boluses delivered via intravenous tubing to the oral cavity. Imaging was performed in the sagittal and axial planes. RESULTS: Imaging provided by this sequence provided high temporal resolution, with the ability to depict deglutition in the axial and sagittal planes. Comparison with imaging at 1.5T demonstrated benefits in temporal resolution and signal-to-noise. Anatomic information provided differed from comparative videofluoroscopy. CONCLUSIONS: MRI of swallowing using the described technique is reliable and provides a unique evaluation of the swallowing sequence. Laryngoscope, 2012.

OBJECTIVES/HYPOTHESIS: No studies to date have examined the clinical safety and efficacy of carboxymethylcellulose (CMC) for vocal fold injection. The current study investigates the voice outcomes and complications of CMC injection. STUDY DESIGN: Retrospective review. METHODS: All patients who underwent CMC injection from three independent sites in a 1-year period were reviewed. Voice outcomes in the form of voice handicap index-10 (VHI-10) and complications from injection were recorded. RESULTS: Seventy-eight patients with VHI-10 results from 1 to 8 weeks after CMC injection were evaluated. Thirty-eight patients were treated for vocal fold immobility, and 15 patients underwent treatment for hypomobility, 15 for vocal fold atrophy, seven for scar/sulcus, one for previous laryngeal fracture, one for functional dysphonia, and one for persistent granuloma. In 60 patients with available VHI-10 data, overall improvement in voice was seen. There was a mean decrease in VHI-10 of 7.48 (26.4 to 18.9, P < .05), correlating to a 19.9% decrease. Forty-five patients (75%) showed a decrease in VHI-10, nine (15%) showed an increase, and six (10%) showed no change. Statistically significant differences were seen for patients with immobility (decrease of 8.6, or 31%) and hypomobility (decrease of 10.7, or 37.8%). There were no complications of vocal fold stiffness, inflammatory reaction, or scar in the 78 patients during the total follow-up period. CONCLUSIONS: CMC is a viable, safe, and efficacious material for the temporary treatment of glottic insufficiency in vocal fold immobility and hypomobility, with minimal risk of permanent adverse voice outcomes.

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

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