Faculty Bibliography

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.

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.

Purpose: Age-related loss of muscle bulk and strength has been documented in the tongue and geniohyoid. Our goal was to explore this phenomenon in the pharynx, specifically by measuring pharyngeal wall thickness (PWT) and pharyngeal lumen area (PLA) in a sample of young vs older women. Method(s): MRI scans of the neck were retrospectively reviewed from 60 women equally stratified by 3 age groups (20s, 60s, 70+). Exclusion criteria included dysphagia, c-spine surgery, neurological illness, head and neck malignancy and obstructive sleep apnea. Three de-identified axial slices were extracted per scan for randomized, blinded analysis: at the levels of the anterior inferior border of C2 and C3, and at the pit of the vallecula (Vpit). Pixel-based measures of PWT and PLA were completed using ImageJ and converted to metric units using the calibration markers on the original images. Measures of PWT and PLA (at three levels) were compared between age groups with one-way ANOVAs using Sidak adjustments for post-hoc pairwise comparisons. Result(s): A significant main effect of age was observed for all variables whereby PWT decreases and PLA increases with advancing age (Table 1). Pairwise comparisons revealed significant differences between 20s vs 70+ for all variables and 20s vs 60s for all variables except PWT and PLA at C2. Effect sizes ranged from 0.56-1.34. Conclusions (Including Clinical Relevance): Consistent with the existing sacropenia literature, the pharyngeal muscles appear to atrophy with age and consequently, PLA increases as well. Future work should explore the relationship between pharyngeal muscle size/ atrophy and functional swallowing outcomes. (Table Presented)

Purpose: Dynamic MRI has been used to examine swallowing in sagittal and axial planes with good temporal resolution. However, few studies have examined temporal measures and none have compared upright vs. supine swallowing in both positions with the MBSImP. We report physiologic variables and swallow safety upright and supine with MBSImP and Penetration/Aspiration scales in healthy subjects. Method(s): Twenty healthy subjects (mean = 28 years) underwent VFS study upright and supine with a C-Arm. Subjects were viewed in the sagittal plane and swallowed 5 mL liquid and pudding barium. Pen/Asp scores and 14 MBSImP variables were analyzed (overall Impression score) in both positions, with means and ranges across subjects upright and supine. Paired t-tests compared MBSImP scores upright vs. supine. Level of significance: p<.05. Result(s): All subjects tolerated the supine position while swallowing. Mean MBSImP scores were WNL across subjects for both positions, except Component 6, Initiation of the Pharyngeal Swallow (Table 1). Nosignificant differences were found for MBSImP scores upright vs. supine. Although the range of Pen/Asp scores was higher for supine, 3 subjects penetrated upright only, 1 penetrated supine only, and 1 aspirated on 1 supine swallow. Pearson coefficients for inter/intra-judge reliability:0.94, 0.91. Conclusions (Including Clinical Relevance): Physiologic measurse revealed a pharyngeal delay in both positions with scores not significantly different. Although Pen/Asp range was higher in supine, more subjects penetrated upright. Future research should examine swallow physiology in both positions in dysphagic and older healthy subjects. (Table Presented)

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.