Faculty Bibliography

Importance/UNASSIGNED:Esophageal perforations are difficult to diagnose and have a high mortality rate. Cervical esophageal perforations (CEPs) are the second most common anatomic type of esophageal perforations and are most often due to iatrogenic injury. They are often managed more conservatively than thoracic perforations. The current literature on CEPs is mostly observational, with a paucity of prospective controlled studies. In addition, there is scarce literature focusing specifically on iatrogenic CEPs (iCEPs) as an entity of their own. Observations/UNASSIGNED:The existing studies on esophageal perforations address treatment by anatomic location and by cause, but few focus specifically on iCEPs. The cricopharynx is the most common site for injury in diagnostic endoscopy. The standard treatment is generally conservative management with drainage unless the perforation is greater than 2 cm, the diagnosis is delayed, or the patient shows signs of sepsis, which would prompt surgical intervention, most commonly in the form of primary repair via open or endoscopic approach. An open approach has been the mainstay of therapy; however, use of endoscopic clips, stents, and suturing is increasingly on the rise. Guideline recommendations on the optimal therapeutic approach for iCEPs are lacking. The most consistent recommendation in the literature is immediate and individualized treatment. Conclusions and Relevance/UNASSIGNED:The management of iCEPs is controversial. There is a need for additional prospective studies comparing treatment options for iCEPs to establish a gold standard treatment and to assess for the expanding role of endoscopic interventions.

OBJECTIVES/UNASSIGNED:To evaluate volume changes within the tongue post chemoradiation therapy (CRT). STUDY DESIGN/UNASSIGNED:Retrospective review. SETTING/UNASSIGNED:Academic Medical Center. SUBJECTS AND METHODS/UNASSIGNED:Subjects included 19 patients that received CRT as the primary treatment for tonsillar or hypopharynx squamous cell carcinoma. Tongue volumes were calculated by three raters from thin slice computed tomography images collected before treatment and up to 29 months post-CRT. Body mass index (BMI) was also collected at each time point. RESULTS/UNASSIGNED: < .001) decreased by 0.11 units (SEM = 0.02) per month post radiation. CONCLUSION/UNASSIGNED:Tongue dysfunction and decreased tongue strength are significant contributors to the dysphagia that patients experience after receiving CRT. In this study, both tongue volume and BMI decreased post-CRT; therefore, BMI could potentially be used as a predictor of tongue volume post-CRT.

OBJECTIVE:We conducted a quality improvement project to increase the rate of discharges before noon (DBN) in the otolaryngology department at a tertiary care center. METHODS:Based on a Plan-Do-Study-Act framework, monthly discharge data and observed-to-expected (O:E) length of stay were collected and shared with the department members monthly. A target of 43% DBN was predetermined by the center (Plan). The following interventions were implemented (Do): discharge planning starting at the time of admission, focus on early attending-to-resident team communication, placement of discharge order prior to rounding, and weekly reminders to the entire department. RESULTS:Discharges were monitored for 3 years. For the year prior to this study, a minority of patients were discharged before noon (12 months: 75 of 190, 36%). During the first 6 months of monitoring (Study), no significant improvement was identified (34 of 95, 36%). After interventions, performance significantly improved (31 months: 250 of 548, 68%). The performance was consistently above the predetermined target of 43%. During the study time, O:E length of stay remained below the predetermined target (O:E ratio, 0.90; hospital target, 0.93). DISCUSSION/CONCLUSIONS:Comprehensive discharge planning beginning at the time of admission, weekly reminders, and improved communication (Act) can help to prioritize DBN and increase the percentage of discharges before noon. IMPLICATIONS FOR PRACTICE/CONCLUSIONS:By utilizing a quality improvement framework, significant improvements in timely discharge can be achieved and sustained with changes in workflow and departmental culture. These changes can be achieved without increases in resources or prolonging the length of stay.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:To assess the safety and efficacy of autologous cultured fibroblasts (ACFs) to treat dysphonia related to vocal fold scar and age-related vocal atrophy (ARVA). STUDY DESIGN/METHODS:Randomized, double-blinded, placebo-controlled, multi-institutional, phase II trial. METHODS:cells or placebo saline was performed at 4-week intervals for each vocal fold. Follow-up was performed at 4, 8, and 12 months. The primary outcome was improved mucosal waves. Secondary outcomes included Voice Handicap Index (VHI)-30, patient reported voice quality outcomes, and perceptual analysis of voice. RESULTS:Fifteen subjects received ACF and six received saline injections. At 4, 8, and 12 months after ACF treatments, a significant improvement in mucosal wave grade relative to baseline was observed in both vocal scar and ARVA groups. Relative to control group, mucosal waves were significantly improved in the ARVA group at 4 and 8 months. Perceptual analysis significantly improved in the vocal scar group 12 months after ACF treatments compared to controls. Vocal scar group reported significantly improved vocal quality from baseline. VHI and expert rater voice grade improved in both groups, but did not achieve significance. No adverse events related to fibroblast injections were observed. CONCLUSIONS:In this cohort, injection of ACFs into the vocal fold lamina propria (LP) was safe and significantly improved mucosal waves in patients with vocal scar and ARVA. ACF may hold promise to reconstruct the LP. LEVEL OF EVIDENCE/METHODS:1 Laryngoscope, 2019.

Introduction: Videofluoroscopic swallow studies (VFSS) are commonly requested by otolaryngologists to evaluate swallow function in patients with cough but no data exists on the utility of VFSS in this population. We aim to determine which history clinical exam and laryngoscopy findings correlate with abnormal VFSS findings in patients with cough.
Material(s) and Method(s): Ten items from flexible videolaryngoscopy were recorded including: motion abnormalities pooling of secretions pharyngeal asymmetry and glottal insufficiency. VFSS findings recorded included penetration aspiration delayed initiation and presence of residue after swallow. Nonparametric statistical analysis was performed to determine correlations between history and clinical exam observation and VFSS findings. A total of 405 patients with a chief complaint of cough were referred to speech language pathology. Of those 107 had a VFSS and 93 had an esophagram. Forty-five patients had a VFSS after referral and were included in the analysis.
Result(s): Age (p = 0.35) glottal insufficiency (p = 0.33) pooling of secretions (p = 0.10) any videolaryngoscopy abnormality (p = 0.07) cardiopulmonary history (p = 0.29) and other variables did not correlate VFSS abnormalities in patients with cough. Only gender (p = 0.02) was a predictor of an abnormal VFSS (86% males and 57% females).
Conclusion(s): This study found that videolaryngoscopy and clinical exam were not predictive of VFSS abnormalities in patients with cough

Recurrent Respiratory Papillomatosis (RRP) is a rare disease of the aerodigestive tract caused by the Human Papilloma Virus (HPV) that manifests as profoundly altered phonatory and upper respiratory anatomy. Current therapies are primarily symptomatic; enhanced insight regarding disease-specific biology of RRP is critical to improved therapeutics for this challenging population. Multiplex PCR was performed on oral rinses collected from twenty-three patients with adult-onset RRP every three months for one year. Twenty-two (95.6%) subjects had an initial HPV positive oral rinse. Of those subjects, 77.2% had an additional positive oral rinse over 12 months. A subset of rinses were then compared to tissue samples in the same patient employing HPViewer to determine HPV subtype concordance. Multiple HPV copies (60-787 per human cell) were detected in RRP tissue in each patient, but a single dominant HPV was found in individual samples. These data confirm persistent oral HPV infection in the majority of patients with RRP. In addition, three novel HPV6 isolates were found and identical HPV strains, at very low levels, were identified in oral rinses in two patients suggesting potential HPV subtype concordance. Finally, somatic heteroplasmic mtDNA mutations were observed in RRP tissue with 1.8 mutations per sample and two nonsynonymous variants. These data provide foundational insight into both the underlying pathophysiology of RRP, but also potential targets for intervention in this challenging patient cohort.

Importance/UNASSIGNED:Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective/UNASSIGNED:To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants/UNASSIGNED:In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures/UNASSIGNED:The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results/UNASSIGNED:Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance/UNASSIGNED:In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:To describe recurrence patterns in patients with recurrent respiratory papillomatosis (RRP) following surgical intervention. STUDY DESIGN/METHODS:Single-center, retrospective, longitudinal case series. METHODS:Initial and follow-up laryngoscopic examinations of seven previously untreated adult-onset RRP patients were reviewed. Patients were followed longitudinally for periods ranging from 3 months to 7 years. Lesion locations were recorded using a twenty-one region laryngeal schematic, and maps were generated to illustrate the distribution of disease before and after cold-knife or potassium-titanyl-phosphate laser intervention. Univariate and multivariate analyses were employed to examine variables affecting recurrence patterns. RESULTS:Across all patients, a statistically significant correlation between initial distribution and primary recurrence was observed. Seventy-five percent of new lesions were adjacent to regions with preexisting disease; 83% of new glottic lesions were adjacent to preexisting glottic lesions, and 66% of supraglottic lesions were adjacent to preexisting supraglottic regions. No statistically significant differences in recurrence rate were observed across sites. CONCLUSIONS:In previously untreated patients with adult-onset recurrent respiratory papillomatosis, lesions tended to recur either in the same regions or regions adjacent to those affected at the time of initial surgery. LEVEL OF EVIDENCE/METHODS:4 Laryngoscope, 2019.

OBJECTIVE:To determine adverse events after endoscopic flexible vs endoscopic rigid cricopharyngeal myotomy for treatment of Zenker's diverticulum (ZD). DATA SOURCES/METHODS:Systematic review of MEDLINE, Web of Science, CINAHL, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for all years according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional studies were identified from review citations and a by hand search of manuscripts referencing ZD. REVIEW METHODS/METHODS:A structured literature search was conducted to identify studies for this systematic review. Methodological Index for Non-randomized Studies (MINORS) criteria were applied to assess study quality. For inclusion, each study had to provide data for at least 10 adult patients who had undergone endoscopic ZD repair reporting clear association with the postprocedure course in each case. Data extracted included all reported adverse events, recurrences, follow-up, and operative times. RESULTS:In total, 115 studies were included. All but 8 were retrospective case series. Sixty-one reported series of patients after rigid endoscopic stapler repair, 31 after rigid laser repair, and 13 with other rigid endoscopic instruments. Twenty-nine flexible endoscopic studies were included. Mortality, infection, and perforation were not significantly more likely in either the rigid or the flexible group, but bleeding and recurrence were more likely after flexible endoscopic techniques (20% vs <10% and 4% vs 0%, respectively). Dental injury and vocal fold palsy were reported rarely in the rigid endoscopic groups. CONCLUSIONS:Adverse events are rare after endoscopic Zenker's repair. The flexible approach minimizes exposure limitations and can be completed in some patients without general anesthesia. Transoral rigid approaches result in fewer revision surgeries compared with flexible diverticulotomy.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:Various animal models have been employed to investigate vocal fold (VF) and phonatory function. However, biomechanical testing techniques to characterize vocal fold structural properties vary and have not compared critical properties across species. We adapted a nondestructive, automated indentation mapping technique to simultaneously quantify VF structural properties (VF cover layer and intact VF) in commonly used species based on the hypothesis that VF biomechanical properties are largely preserved across species. STUDY DESIGN/METHODS:Ex vivo animal model. METHODS:Canine, leporine, and swine larynges (n = 4 each) were sagittally bisected, measured, and subjected to normal indentation mapping (indentation at 0.3 mm; 1.2 mm/s) with a 2-mm spherical indenter to quantify normal force along the VF cover layer, structural stiffness, and displacement at 0.8 mN; two-dimensional maps of the free VF edge through the conus elasticus were created for these characterizations. RESULTS:Structural stiffness was 7.79 gf/mm (0.15-74.55) for leporine, 2.48 gf/mm (0.20-41.75) for canine, and 1.45 gf (0.56-4.56) for swine. For each species, the lowest values were along the free VF edge (mean ± standard deviation; leporine: 0.40 ± 0.21 gf/mm, canine: 1.14 ± 0.49 gf/mm, swine: 0.89 ± 0.28 gf/mm). Similar results were obtained for the cover layer normal force at 0.3 mm. On the free VF edge, mean (standard deviation) displacement at 0.08 gf was 0.14 mm (0.05) in leporine, 0.11 mm (0.03) in canine, and 0.10 mm (0.02) in swine. CONCLUSIONS:Automated indentation mapping yielded reproducible biomechanical property measurement of the VF cover and intact VF. Divergent VF structural properties across canine, swine, and leporine species were observed. LEVEL OF EVIDENCE/METHODS:NA. Laryngoscope, 2018.