Faculty Bibliography

Cross-sectional imaging has long been employed to examine swallowing in both the sagittal and axial planes. However, data regarding temporal swallow measures in the upright and supine positions are sparse, and none have employed the MBS impairment profile (MBSImP). We report temporal swallow measures, physiologic variables, and swallow safety of upright and supine swallowing in healthy subjects using videofluoroscopy (VFS). Twenty healthy subjects ages 21-40 underwent VFS study upright and supine. Subjects were viewed in the sagittal plane and swallowed 5 mL liquid and pudding barium. Oral transit time, pharyngeal delay time, pharyngeal response time, pharyngeal transit time, and total swallow duration were measured. Penetration/aspiration scores and 14 MBSImP variables were analyzed in both positions. All subjects completed swallows supine, although one aspirated on one liquid bolus. Temporal measures of swallowing were similar for pudding upright and supine. Pharyngeal phase swallow measures were longer for liquids in supine. MBSImP physiologic measures revealed a pharyngeal delay in both positions. Although Pen/Asp range was higher supine, more subjects penetrated upright. Temporal measures were increased for liquids in supine. Although Pen/Asp range was higher in supine, more subjects penetrated upright. These results provide support for cross-sectional supine imaging of swallowing for pudding, but perhaps not thin liquids for dysphagic patients. Slightly thicker liquids might prove reliable in supine without compromising swallow safety. Future research should examine swallow physiology in both positions in dysphagic and older healthy subjects.

Flexible laryngoscopes are common outpatient surveillance tools. Cleansing of these scopes between patients must be quick, effective, and safe. One sterilant that largely meets these criteria is ortho-phthalaldehyde (OPA); however, infrequently, patients may develop allergic reactions to it. We present three cases of patients who developed significant allergic reactions following repeated laryngoscopic examinations. Subsequent intradermal allergy testing confirmed sensitivity to OPA. In addition, we reviewed the current literature, which includes 17 similar reactions reported in nine patients across disciplines. Allergic reaction to OPA is uncommon, but a potentially under-reported severe complication of repeated endoscopy. LEVEL OF EVIDENCE: NA Laryngoscope, 2015.

OBJECTIVE: To introduce the otolaryngology community to the current state of research regarding electronic cigarettes, with special attention paid to mechanism, impact on health and addiction, and use in smoking cessation. DATA SOURCES: Review of Google Scholar and PubMed databases using the keywords electronic cigarettes, e-cigs, e-cigarettes, and vaping. In addition, information from media sources as well as news outlets was evaluated to gauge public perception of research findings. REVIEW METHODS: Recent research and randomized controlled trials were prioritized. CONCLUSIONS: The landscape of electronic cigarette devices is evolving, as is the research regarding their risks and benefits. Utilization is rapidly increasing. It appears that older users employ them as a smoking cessation tool compared to younger users. The data are generally inconclusive regarding the benefits of electronic cigarettes for smoking cessation compared with other methods. Furthermore, the safety profile of electronic cigarettes is dynamic and difficult to fully ascertain. IMPLICATIONS FOR PRACTICE: Patients with a variety of otolaryngologic conditions, including cancer, may benefit from frank discussion regarding electronic cigarettes. Furthermore, increasing patient inquiries regarding these devices are likely given their increasing popularity.

Age-related loss of muscle bulk and strength (sarcopenia) is often cited as a potential mechanism underlying age-related changes in swallowing. Our goal was to explore this phenomenon in the pharynx, specifically, by measuring pharyngeal wall thickness and pharyngeal lumen area in a sample of young versus older women. MRI scans of the neck were retrospectively reviewed from 60 women equally stratified into three age groups (20s, 60s, 70+). Four de-identified slices were extracted per scan for randomized, blinded analysis: one mid-sagittal and three axial slices were selected at the anterior inferior border of C2 and C3, and at the pit of the vallecula. Pixel-based measures of pharyngeal wall thickness and pharyngeal lumen area were completed using ImageJ and then converted to metric units. Measures of pharyngeal wall thickness and pharyngeal lumen area were compared between age groups with one-way ANOVAs using Sidak adjustments for post-hoc pairwise comparisons. A significant main effect for age was observed across all variables whereby pharyngeal wall thickness decreased and pharyngeal lumen area increased with advancing age. Pairwise comparisons revealed significant differences between 20s versus 70+ for all variables and 20s versus 60s for all variables except those measured at C2. Effect sizes ranged from 0.54 to 1.34. Consistent with existing sacropenia literature, the pharyngeal muscles appear to atrophy with age and consequently, the size of the pharyngeal lumen increases.

PURPOSE OF REVIEW: The role of transnasal esophagoscopy (TNE) in the evaluation and management of the head and neck cancer patient is evolving. This study reviews the most recent advances in the use of this technology in the head and neck patient population. RECENT FINDINGS: It appears that in-office, unsedated TNE is a useful alternative to conventional endoscopy in the evaluation and management of the head and neck patient. The current literature defines the feasibility and limitations of this technology for screening for the development of synchronous and metachronous primaries, diagnosing esophageal and upper gastrointestinal disorders, as well as performing certain office-based procedures. Perhaps most importantly, TNE is better able to navigate the anatomical and functional limitations common to the head and neck patient, which can prevent use of conventional transoral endoscopy. SUMMARY: TNE has a significant role in the evaluation and management of the head and neck cancer patient and it enables the otolaryngologist to provide improved quality of care.

INTRODUCTION: In-office laryngeal procedures present an alternative to the risks and costs associated with general anesthesia. However, the inherent control afforded by the operative theater is decreased potentially increasing the risk of complications. Many patients undergoing these procedures have traditional surgical risk factors, such as antithrombotic (AT) medical therapy. We sought to quantify complication rates for in-office procedures as a function of AT therapy. METHODS: A retrospective review of 127 diverse, in-office laryngeal procedures was performed and patients were then stratified based on AT medication status and type of procedure. The primary dependent variables were intraoperative and postoperative complications. Additionally, in those patients undergoing procedures with the goal of voice improvement, Voice Handicap Index (VHI)-10 scores were used to quantify the success of the procedure as a function of AT therapy. RESULTS: Of the 127 procedures, 27 procedures (21.2%) involved patients on some form of AT agent that was not ceased for the procedure. Across all patients, no intraoperative complications were encountered, irrespective of therapeutic status. Three postoperative complications were noted; all in patients not on AT therapy. A statistically significant improvement in VHI-10 scores was noted across all patients, irrespective of AT status. CONCLUSIONS: AT medications do not appear to increase the risk of complications associated with in-office laryngeal procedures. Furthermore, AT therapy seemed to have no negative impact on the voice outcomes of patients undergoing procedures for voice improvement.

Importance: A new diagnosis of adult-onset recurrent respiratory papillomatosis (AO-RRP) prompts many questions related to disease acquisition, course, and transmission. Recent attention to the human papillomavirus (HPV), along with emerging data on AO-RRP, provides a foundation for patient counseling. Objective: To provide a framework for these discussions, including an overview of the current literature on HPV-mediated disease across organs. Evidence Review: The peer-reviewed literature was culled to provide a comprehensive review encompassing AO-RRP and anogenital papilloma, as well as general HPV virology and pathophysiology. PubMed and Google Scholar databases were searched from 1975 to July 2014. Findings: Most HPV infections in healthy adults are cleared within 2 years without clinical significance. Adult-onset RRP is a rare manifestation of HPV and may be homologous to anogenital HPV, which is highly transmissible between sexual partners. Horizontal transmission of AO-RRP has not been characterized. Our laboratory, however, recently found that nearly 100% of patients with AO-RRP had concurrent oral cavity HPV infection. Historically, an increased number of oral sex partners was thought to be associated with AO-RRP, but recent data from our group did not corroborate this finding. Recent data also question the dogma that smoking and laryngopharyngeal reflux play a role in recidivistic disease. Management of AO-RRP is often symptom based and includes lesion excision or ablation with adjuvant therapies including cidofovir for refractory cases. Conclusions and Relevance: Recurrent respiratory papillomatosis may be related to a new or latent HPV infection, potentially obtained at birth, and the mechanism(s) underlying the progression from HPV infection to RRP remains unknown. Recommendations with regard to sexual practices in patients with AO-RRP cannot be made at this time. Unlike human immunodeficiency virus, patients with AO-RRP are not obligated to discuss infection status with partners. Despite the nebulous nature of the disease, clinicians should be a resource to discuss the current state of the literature with both the patient and partner.

The human vocal fold is a complex structure made up of distinct layers that vary in cellular and extracellular matrix composition. Elucidating the mechanical properties of vocal fold tissues is critical for the study of both acoustics and biomechanics of voice production, and essential in the context of vocal fold injury and repair. Both quasistatic and dynamic behavior in the 10-300Hz range was explored in this preliminary investigation. The resultant properties of the lamina propria were compared to that of the nearby thyroarytenoid muscle. Er, quantified via quasistatic testing of the lamina propria, was 609+/-138MPa and 758+/-142MPa in the muscle (p=0.001). E' of the lamina propria as determined by dynamic testing was 790+/-526MPa compared to 1061+/-928MPa in the muscle. Differences in E' did not achieve statistical significance via linear mixed effect modeling between the tissue types (p=0.95). In addition, frequency dependence was not significant (p=0.18).

OBJECTIVES/HYPOTHESIS: To determine oral human papilloma virus (HPV) colonization in patients with adult-onset recurrent respiratory papillomatosis (AO-RRP) and their long-term partners. STUDY DESIGN: Prospective, cohort study METHODS: Patients with pathology-confirmed AO-RRP and a small cohort of their long-term partners were subjected to a standardized oral rinse and swab protocol to obtain oral epithelial cells. DNA from these samples was extracted and subjected to both qualitative analyses via multiplex polymerase chain reaction as well as to a commercially available linear array assay for the determination of specific HPV subtypes. RESULTS: Samples were collected from 27 patients with AO-RRP and six long-term sexual partners. Qualitative analysis of agarose gel products using a multiple genotype primer cocktail suggested the presence of HPV DNA in oral rinse or swabs in 26 patients (96%) and four partner samples (67%). A subset of these positive patient samples was then subjected to genotyping; a spectrum of HPV subtypes was observed. Interestingly, HPV81 was identified in many samples. CONCLUSION: Recent data suggest that less than 7% of the general population is HPV positive in the oral cavity. Our data suggest that the oral colonization rate is much higher in patients with AO-RRP. Additionally, long-term sexual partners of patients with RRP had a much higher rate of HPV positivity. These preliminary data may have implications for viral transmission and provide a framework for enhanced patient education as well as further investigation. LEVEL OF EVIDENCE: 4. Laryngoscope, 2014.

OBJECTIVE: The effortful swallow was designed to improve posterior mobility of the tongue base and increase intraoral pressures. We characterized the effects of this maneuver via dynamic magnetic resonance imaging (dMRI) in healthy patients. METHODS: A 3-T scanner was used to obtain dMRI images of patients swallowing pudding using normal as well as effortful swallows. Ninety sequential images were acquired at the level of the oropharynx in the axial plane for each swallow; 3 series were obtained for each swallow type for each patient. Images were acquired every 113 ms during swallowing. The images were analyzed with respect to oropharyngeal closure duration, anteroposterior and transverse distance between the oropharyngeal walls, and oropharyngeal area before and after closure. RESULTS: Preswallow reduced pharyngeal area was observed (P = .02; mean = 212.61 mm2 for effortful, mean = 261.92 mm2 for normal) as well as prolonged pharyngeal closure during the swallow (P < .0001; mean = 742.18 ms for effortful, mean = 437.31 ms for normal). No other differences were noted between swallow types. Interrater and intrarater reliability of all measurements was excellent. CONCLUSION: This preliminary investigation is the first to evaluate the effects of effortful swallows via dMRI. In our cohort, consistent physiologic changes were elicited, consistent with clinical dogma regarding this maneuver.