Faculty Bibliography

OBJECTIVES/HYPOTHESIS: To investigate the role of Smad3 as a regulator of transforming growth factor (TGF)-beta1-mediated cell activities associated with fibrosis in normal human vocal fold fibroblasts. We also sought to confirm the temporal stability of Smad3 knockdown via small inhibitor ribonucleic acid (siRNA). Vocal fold fibroblasts were employed to determine the effects of Smad3 knockdown on TGF-beta1-mediated migration and contraction, as well as regulation of connective tissue growth factor (CTGF). We hypothesized that Smad3 is an ideal candidate for therapeutic manipulation in vivo based on its role in fibrosis. STUDY DESIGN: In vitro. METHODS: Knockdown of Smad3 via siRNA was performed in our normal human vocal fold cell line. Three-dimensional collagen gel contraction and scratch assays were employed to determine the role of Smad3 on TGF-beta1-mediated contraction and migration, respectively. The role Smad3 in the induction of CTGF was characterized via sodium dodecyl sulfate polyacrylamide gel electrophoresis. The effects of Smad3 signaling on Smad7 messenger (m)RNA and protein were also quantified. RESULTS: Smad3 knockdown was temporally-stable up to 72 hours (P < 0.001), diminished TGF-beta1-mediated collagen gel contraction and migration, and blunted induction of CTGF, but it had no effect on TGF-beta1-mediated Smad7 mRNA or protein induction. CONCLUSION: Transforming growth factor-beta1 stimulated profibrotic cell activities in our cell line and these actions were largely reduced with Smad3 knockdown. These data provide continued support for therapeutic targeting of Smad3 for vocal fold fibrosis because it appears to regulate the fibrotic phenotype. LEVEL OF EVIDENCE: N/A. Laryngoscope, 2015.

OBJECTIVES/HYPOTHESIS: To optimize decellularization of porcine vocal folds (VF) and quantify human bone marrow-derived mesenchymal stem cell (BM-MSC) interactions with this matrix to provide a foundation for regenerative approaches to VF repair. STUDY DESIGN AND METHODS: Vocal folds were dissected from porcine larynges and three decellularization protocols were compared, each consisting of washes and mechanical agitations with different combinations of reagents. DNA content was analyzed via Quant-iT Picogreen assay and hematoxylin and eosin staining. Bone marrow-derived MSCs were then seeded onto the decellularized VF matrices. Morphology, metabolic activity, DNA content, and gene expression were assessed using LIVE/DEAD Cell Viability, alamarBlue Cell Viability Assay, Quant-iT Picogreen assay, and, respectively. RESULTS: The most successful decellularization protocol removed 95% DNA content within 1 day, compared to several days required for previously described protocols. Histology confirmed the retention of extracellular matrix (ECM) and its components, including glycosaminoglycans, collagen, and fibrin, while void of nuclear/cellular content. Decellularized scaffolds were then seeded with BM-MSCs. Similar DNA quantities were observed after 24 hours of seeding within the VF-ECM scaffold when compared to cells on tissue culture plastic (TCP). LIVE/DEAD staining of the seeded VF-ECM confirmed excellent cell viability, and the metabolic activity of BM-MSCs increased significantly on VF-ECM compared to TCP. Endoglin gene expression decreased, suggestive of differentiation. CONCLUSION: Porcine VFs can be efficiently decellularized within 5 hours using a combination of sodium deoxycholate and peracetic acid. Decellularized VF-ECM supported attachment and growth of human BM-MSCs, with evidence of differentiation. LEVEL OF EVIDENCE: N/A Laryngoscope, 2015.

We report a case of unilateral vocal fold immobility in a 57-year-old woman that occurred subsequent to a choking episode, which she resolved by removing impacted food with a finger sweep. Other than the unilateral immobility, no abnormality of the laryngeal mucosa or framework was detected on physical examination, laryngoscopy, and computed tomography. Weeks later, the patient underwent an unrelated surgical procedure necessitating laryngeal mask airway ventilation. When she emerged from the procedure, she noted full resolution of her voice symptoms. Office laryngoscopy confirmed the full return of vocal fold function. We discuss possible explanations for the return of function in the context of this unusual onset and resolution. We also review the literature regarding unilateral vocal fold immobility, including its etiology, presentation, workup, and treatment.

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.

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.

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.

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.

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.