Faculty Bibliography

OBJECTIVES: We undertook to provide data regarding temporal measurements of swallow function obtained by dynamic magnetic resonance imaging in a midsagittal plane and to compare these values to normative fluoroscopy data. METHODS: Seventeen healthy female volunteers with no swallowing complaints underwent turbo-fast low-angle-shot magnetic resonance imaging with a 3-T scanner while swallowing liquid and pudding boluses delivered via syringe. Ninety sequential images were acquired with a temporal resolution of 113 ms per frame for each swallow. The imaging was performed in the midsagittal plane. The analyses focused on oral and pharyngeal transit times. RESULTS: All subjects tolerated the protocol without complaints or adverse events. The mean (+/- SD) oral transit times for liquids and pudding were measured as 0.25 +/- 0.09 second and 0.25 +/- 0.13 second, respectively. This difference was not statistically significant (p = 0.74). The mean pharyngeal transit times for liquids and pudding were measured as 0.84 +/- 0.16 second and 1.11 +/- 0.21 seconds, respectively. This difference achieved statistical significance (p < 0.0001). The intrarater and inter-rater reliabilities for the measurements were excellent. CONCLUSIONS: This sequence provided a high degree of temporal resolution of deglutition in the midsagittal plane. Furthermore, the temporal measurements acquired with dynamic magnetic resonance imaging were reliable and were relatively consistent with those of previous studies done with videofluoroscopy.

OBJECTIVES/HYPOTHESIS: We hypothesize that the KTP laser has the potential to augment wound healing in a rat model, and this modality may serve as a therapeutic tool for the management of vocal fold fibrosis. STUDY DESIGN: Prospective, laboratory animal study. METHODS: Rats were subjected to either vocal fold injury +/- KTP laser treatment at low energy to simulate clinically relevant endpoints. In addition, cohorts were subjected to therapeutic KTP laser alone. Endpoints included the analyses of gene expression data related to the acute inflammatory response and extracellular matrix deposition and organization. RESULTS: Therapeutic KTP treatment was associated with an additive effect on inflammatory gene expression in the context of the injured rat vocal fold mucosa. A similar additive effect was observed for matrix metalloproteinase gene expression, similar to data previously reported in the dermatology literature. However, histologically, the KTP had little effect on established vocal fold fibrosis. CONCLUSIONS: These data are the first to attempt to provide mechanistic insight into the clinical utility of angiolytic lasers for vocal fold scar. Similar to previous data obtained in the skin, it appears that these effects are mediated by MMPs. LEVEL OF EVIDENCE: NA. Laryngoscope, 123:2189-2194, 2013.

OBJECTIVES/HYPOTHESIS: Life-support training emphasizes the primacy of airway management. Acquiring these skills requires practice and exposure to events. Otolaryngology residents lack standardized training in advanced airway skills. This project aimed to create such a program by using simulation-based methodology evaluated using specific educationally based tools. STUDY DESIGN: Prospective cohort study. METHODS: The program consisted of lectures and simulation-based training sessions designed to impart competency in a set of defined airway skills to otolaryngology residents. Only participating residents who completed the course (n = 12) were evaluated both before and after the course for their fund of knowledge through multiple-choice examinations and for clinical reasoning and technical skills as assessed by a panel of otolaryngologists in simulated difficult airway situations. Self-assessment tools were also incorporated. RESULTS: The average multiple choice score was 12 of 27 (44%) before the course and 15 of 27 (55%) after the completion of the course (P = .001). Faculty assessment yielded a cumulative score of 80% and 91% pre- and postcourse, respectively (P = .002). Although all residents reported prior experience in a critical emergency airway situation, only one reported prior training in advanced airway skills. A significant increase in participants' self-perceived ability to carry out critical airway-related skills was observed. All respondents felt the course was effective. CONCLUSIONS: Simulation-based airway training courses can be effectively incorporated into existing educational curricula for otolaryngology residents, and their success can be measured using educationally based tools. With such a course, residents can be expected to demonstrate measurable improvement in clinical knowledge base, technical skills, and self-perceived ability to handle difficult airway situations. Laryngoscope, 2013.

OBJECTIVES: We utilized dynamic magnetic resonance imaging to visualize the pharynx and upper esophageal segment in normal, healthy subjects. METHODS: A 3-T scanner with a 4-channel head coil and a dual-channel neck coil was used to obtain high-speed magnetic resonance images of subjects who were swallowing liquids and pudding. Ninety sequential images were acquired with a temporal resolution of 113 ms. Imaging was performed in axial planes at the levels of the oropharynx and the pharyngoesophageal segment. The images were then analyzed for variables related to alterations in the area of the pharynx and pharyngoesophageal segment during swallowing, as well as temporal measures related to these structures. RESULTS: All subjects tolerated the study protocol without complaint. Changes in the area of the pharyngeal wall lumen and temporal measurements were consistent within and between subjects. The inter-rater and intra-rater reliabilities for the measurement tool were excellent. CONCLUSIONS: Dynamic magnetic resonance imaging of the swallow sequence is both feasible and reliable and may eventually complement currently used diagnostic methods, as it adds substantive information.

OBJECTIVES/HYPOTHESIS: Although clinical dogma suggests the value of laryngeal visualization (flexible laryngoscopy and stroboscopy) in dysphonic patients, recently published clinical guidelines suggest that, in many cases, history and/or physical examination are sufficient to guide clinical decision-making regarding the timing of such examinations. We sought to prospectively quantify the diagnostic accuracy of history, laryngoscopy, and stroboscopy using direct laryngoscopy as the gold standard. STUDY DESIGN: Expert survey. METHODS: Six laryngologists were presented with vignettes including history and physical examination (HPE), laryngosocpy, and stroboscopy. Questions regarding diagnosis, the certainty of diagnosis, and subsequent management plans were posed. Operative findings via direct laryngoscopy were employed as a comparator. RESULTS: The diagnostic accuracy of HPE was quite low (5%). The accuracy of diagnosis increased substantially following laryngeal imaging; 68.3% for both flexible laryngoscopy and stroboscopy. Particular diagnoses were more consistently identified; cancer, for example, was much more accurately identified on laryngoscopy (100%) and stroboscopy (100%) rather than HPE alone (33%). Cancer was selected as the diagnosis in 10 of 60 HPEs, though was only correct once and missed in five cases. In contrast, no diagnoses of cancer were missed following laryngoscopic and/or stroboscopic examinations. CONCLUSION: These findings confirm the value of laryngeal visualization (flexible laryngoscopy and stroboscopy) in dysphonic patients, and the lack of accuracy of history and physical examination in determining the diagnosis in patients with hoarseness. Laryngoscope, 2013.