Faculty Bibliography

The Dysphagia Handicap Index (DHI) is a 25-item questionnaire assessing the physical, functional, and emotional aspects of dysphagia patients' quality of life (QoL). The study goal was to translate and validate the Hebrew-DHI. 148 patients undergoing fiberoptic endoscopic examination of swallowing (FEES) in two specialized dysphagia clinics between February and August 2017 filled the Hebrew-DHI and self-reported their dysphagia severity on a scale of 1-7. 21 patients refilled the DHI during a 2-week period following their first visit. FEES were scored for residue (1 point per consistency), penetration and aspiration (1 point for penetration, 2 points for aspiration, per consistency). 51 healthy volunteers also filled the DHI. Internal consistency and test-retest reproducibility were used for reliability testing. Validity was established by comparing DHI scores of dysphagia patients and healthy controls. Concurrent validity was established by correlating the DHI score with the FEES score. Internal consistency of the Hebrew-DHI was high (Cronbach's alpha = 0.96), as was the test-retest reproducibility (Spearman's correlation coefficient = 0.82, p < 0.001). The Hebrew-DHI's total score, and its three subscales (physical/functional/emotional) were significantly higher in dysphagia patients compared to those in healthy controls (median 38 pts, IQR 18-56 for dysphagia patients compared to 0, IQR 0-2 for healthy controls, p < 0.0001). A strong correlation was observed between the DHI score and the self-reported dysphagia severity measure (Spearman's correlation coefficient = 0.88, p < 0.0001). A moderate correlation was found between the DHI score and the FEES score (Pearson's correlation coefficient = 0.245, p = 0.003). The Hebrew-DHI is a reliable and valid questionnaire assessing dysphagia patients' QoL.

BACKGROUND:Oral human papillomavirus (HPV) infection is the principal underlying cause of a dramatic increase in oropharyngeal cancer. Dentistry can play an important role in developing clinical algorithms for secondary prevention. METHODS:The authors conducted this cross-sectional pilot study with practices of The National Dental Practice-Based Research Network. The authors evaluated the feasibility and acceptability of screening and testing procedures as judged by practitioners and patients. The authors used tablet devices for patient screening, obtaining consent, and administering a confidential oral HPV risk factor survey. RESULTS:Most patients (85%) were comfortable being asked about their cigarette use and their sexual behavior (69%) and were interested in participating again (79%). More than 90% of practitioners were comfortable with study procedures except the extra time required for patient participation (75% comfortable). There were no problems with oral rinse collection as reported by patients or practitioners. CONCLUSIONS:It is feasible in community dental offices to collect oral rinses for HPV detection and to ask patients explicit questions about sexual history when using a tablet device for confidentiality. PRACTICAL IMPLICATIONS/CONCLUSIONS:Discussing high-risk types of HPV and appropriately assessing that risk are a challenge for oral health care professionals. These results are positive from a research perspective but do not address the advisability of routine HPV screening in dentistry.

OBJECTIVE:Radiobiological models have been used to calculate the outcomes of treatment plans based on dose-volume relationship. This study examines several radiobiological models for the calculation of tumor control probability (TCP) of intensity modulated radiotherapy plans for the treatment of lung, prostate, and head and neck (H&N) cancers. METHODS:Dose volume histogram (DVH) data from the intensity modulated radiotherapy plans of 36 lung, 26 prostate, and 87  H&N cases were evaluated. The Poisson, Niemierko, and Marsden models were used to calculate the TCP of each disease group treatment plan. The calculated results were analyzed for correlation and discrepancy among the three models, as well as different treatment sites under study. RESULTS:The median value of calculated TCP in lung plans was 61.9% (34.1-76.5%), 59.5% (33.5-73.9%) and 32.5% (0.0-93.9%) with the Poisson, Niemierko, and Marsden models, respectively. The median value of calculated TCP in prostate plans was 85.1% (56.4-90.9%), 81.2% (56.1-88.7%) and 62.5% (28.2-75.9%) with the Poisson, Niemierko, and Marsden models, respectively. The median value of calculated TCP in H&N plans was 94.0% (44.0-97.8%) and 94.3% (0.0-97.8%) with the Poisson and Niemierko models, respectively. There were significant differences between the calculated TCPs with the Marsden model in comparison with either the Poisson or Niemierko model (p < 0.001) for both lung and prostate plans. The TCPs calculated by the Poisson and Niemierko models were significantly correlated for all three tumor sites. CONCLUSION/CONCLUSIONS:There are variations with different radiobiological models. Understanding of the correlation and limitation of a TCP model with dosimetric parameters can help develop the meaningful objective functions for plan optimization, which would lead to the implementation of outcome-based planning. More clinical data are needed to refine and consolidate the model for accuracy and robustness. Advances in knowledge: This study has tested three radiobiological models with varied disease sites. It is significant to compare different models with the same data set for better understanding of their clinical applicability.

Background: The reconstruction of major skull base, scalp and calvarial defects with microvascular free flaps has revolutionized the predictable and safe conduct of multidisciplinary oncologic surgery of this region. While extended resections can be more confidently completed, this has not necessarily been accompanied by increased local control or cure. This is due to limitations of radiation tolerance of surrounding tissues, necessary acceptance of involved microscopically close or involved margins, tolerable morbidity, and the lack of specific medical oncologic agents for benign and malignant CNS tumors. Use of coupler devices in routine head and neck defects evolved into use in skull base, calvarial, and intracranial settings where flap loss can be catastrophic.
Method(s): Mechanical microvascular anastomosis became increasingly widely used in head and neck reconstruction in the late 1980s and 1990s as a method to speed the process, and perhaps patency over hand-sewn anastomoses. These have been incorporated primarily in venous interposition graft and end-to-end, and end-to side venous configurations facilitated by vessel pliability and the ability to evert vessel walls over coupler pins. The coupler itself is constructed of 2 polyethylene rings and staggered ferromagnetic pins which match holes on the opposing ring through a friction fit, thus joining the vessels. Because of its construction, and the increased use and preference of MRI for perioperative evaluation early concern for heating and/or rotation, torquing or disruption of new anastomoses, it was studied in a relevant model and found in clinical experience, to be irrelevant.[1]
Conclusion(s): The use of the superficial temporal vessels for recipients is often preferred to save pedicle length, minimize the need for interposition vein grafts (doubling the number of anastomoses and thrombotic opportunity/risk), and often influenced by prior treatment (bicoronal flaps) in which ligation and scar may limit suitability. Additionally, the vein is often thin-walled and technically unusable. The incision for access to these vessels is usually placed immediately in the junctional creases of the ear and cheek, and thus several millimeters removed from the actual course of the vessels. In a broad and significant experience spanning 25 years including 40 skull base microvascular reconstructions, 15 of which used temporal recipient vessels, there have been 2 cases (one calvarial, one intracranial) where the coupler rings have eroded through the temporal skin, and self-ejected, without flap loss, and implying the acquisition of adequate venous supply to support flap survival. Given this observation, unique to this region, hand-sewn anastomoses are specifically recommended when using these vessels so as to minimize potentially catastrophic flap loss. Our experience in microvascular skull base reconstruction in this context is reviewed in support of this recommendation

Tissue inelasticity and the hair-bearing nature of the scalp and forehead pose unique challenges during reconstruction. A thorough understanding of the surgical anatomy of the scalp and forehead is paramount for optimal reconstructive outcomes. Primary wound closure is usually preferred over secondary intention healing and skin grafting. Use of dermal alternatives and tissue expansion are adjunctive therapies to facilitate scalp wound closure. Local skin and soft tissue flaps are commonly used for most small to medium defects; however, microsurgical free tissue transfer can be considered for large full-thickness skin defects of the forehead and scalp.

Pharyngeal lumen volume is prone to increase as a consequence of pharyngeal muscle atrophy in aging. Yet, the impact of this on swallowing mechanics and function is poorly understood. We examined the relationship between pharyngeal volume and pharyngeal swallowing mechanics and function in a sample of healthy community-dwelling seniors. Data were collected from 44 healthy seniors (21 male, mean age = 76.9, SD = 7.1). Each participant swallowed 9 boluses of barium (3 × 5 ml thin, 3 × 20 ml thin, 3 × 5 ml nectar). Pharyngeal shortening, pharyngeal constriction, pyriform sinus and vallecular residue were quantified from lateral view videofluorosopic swallowing studies. Pharyngeal lumen volume was captured during an oral breathing task with acoustic pharyngometry. In addition, within-participant measures of strength and anthropometrics were collected. Four linear mixed effects regression models were run to study the relationship between pharyngeal volume and pharyngeal constriction, pharyngeal shortening, pyriform sinus residue, and vallecular residue while controlling for bolus condition, age, sex, and posterior tongue strength. Increasing pharyngeal lumen volume was significantly related to worse constriction and vallecular residue. In general, larger and thicker boluses resulted in worse pharyngeal constriction and residue. Pharyngeal shortening was only significantly related to posterior tongue strength. Our work establishes the utility of acoustic pharyngometry to monitor pharyngeal lumen volume. Increasing pharyngeal lumen volume appears to impact both pharyngeal swallowing mechanics and function in a sample of healthy, functional seniors.

OBJECTIVE:Patients with globus, the sensation of something stuck in the throat, are evaluated by otolaryngologists, gastroenterologists, and speech pathologists and often undergo multiple tests and interventions. We hypothesize that a videofluoroscopic swallow study (VFSS) is useful to characterize globus etiology and correlate subjective globus location to atypical VFSS findings. METHOD/METHODS:Retrospective chart review of all patients undergoing VFSS over a 24-month period with a primary complaint of globus. Globus was characterized by the patient as above the thyroid notch, between the thyroid notch and sternum, or substernal. VFSS findings were categorized as oropharyngeal, pharyngoesophageal, or esophageal based on nine VFSS abnormalities and then further broken out for subgroup analyses. RESULTS:Of 216 patients meeting study criteria, 109 patients localized globus above the thyroid notch, 74 between the thyroid notch and sternum, and 33 substernal. One hundred ninety-five patients (90.3%) had at least one finding on VFSS that could account for symptoms, and the majority had multiple. In fact, 21 patients (9.7%) with dysphagia localized above the thyroid notch had evidence of distal esophageal abnormalities, and 15 (6.9%) with dysphagia localized substernal had oropharyngeal abnormalities. CONCLUSION/CONCLUSIONS:Whereas VFSS was likely to identify abnormalities, these areas relate poorly overall with the patient's subjective globus location, and the clinical utility of the study is questionable. LEVEL OF EVIDENCE/METHODS:4. Laryngoscope, 2018.

Background: Large anterior skull base meningiomas with significant extension through the floor of the anterior fossa into the ethmoid and sphenoid sinuses pose a surgical dilemma. Radical resection of these tumors as well as the skull base and sinus component can be curative. This can be achieved through either a transcranial approach or a combined transcranial/endonasal approach depending on the involvement of the sinuses. However, in doing so, patients are at significant risk for postoperative cerebrospinal fluid leak as well as infection. Given these risks and the benign nature of these tumors, especially WHO grade I meningiomas, many surgeons will choose not to resect the portion going through the skull base. The residual tumor can then be observed or radiated if there are signs of growth.
Objective(s): We propose the use of a staged combined approach to maximize resection and minimize risk of CSF leak or infection. Case Presentation: We present the case of a 55-year-old male, BMI of 37, who presented with 3 weeks of left eye blurry vision, 2 years of anosmia, and personality changes. The patient was found to have a 7.3x5.9x4.6 cm anterior skull base meningioma with significant surrounding parenchymal edema in the bilateral frontal lobes as well as extension through the floor of the anterior skull base and into the ethmoid and sphenoid sinuses ([Fig. 1a], b). He was taken for a bifrontal craniotomy and resection of the intracranial component with planned amputation of the tumor at the skull base which was covered with a pericranial flap. He recovered well with return of his vision to normal. Pathology demonstrated a WHO grade II atypical meningioma. Follow-up imaging demonstrated persistent residual tumor within the ethmoid and sphenoid sinus ([Fig. 2]). We discussed an endoscopic endonasal resection of the residual tumor and anterior skull base in a delayed fashion once the pericranial graft healed versus radiation. The patient preferred to proceed with resection. He underwent an endoscopic endonasal resection of the residual tumor within the sinus and remaining anterior skull base. At the time of surgery the tumor was easily separated from the pericranial graft which was well healed. No CSF was observed but a nasoseptal flap was placed for protection. He was discharged on POD2. Postoperative imaging demonstrated gross total resection of the residual tumor ([Fig. 3]).
Conclusion(s): The use of a delayed combined transcranial and endoscopic endonasal approach for anterior skull base meningiomas with significant intracranial and sinus tumor component potentially maximizes surgical resection while reducing the risk of CSF leak and infection. (Figure Presented)

OBJECTIVES/HYPOTHESIS/OBJECTIVE:We describe the clinical features of granulomas of the membranous vocal fold secondary to endotracheal intubation, bronchoscopy or esophagogastroduodenoscopy. STUDY DESIGN/METHODS:Retrospective case series. METHODS:Review of cases at a single tertiary institution with evaluation of patient demographic characteristics, time to presentation, time to treatment, and clinical outcomes. RESULTS:Thirteen adult patients were identified with postintervention granuloma of the membranous vocal fold. All patients were female, with a mean age of 60 years (range, 28-81 years). None noted hoarseness prior to the intervention, and all noted significant hoarseness postoperatively. Conservative treatment with proton pump inhibitors and vocal rest was initially implemented in all patients. Four cases resolved without further intervention. Nine underwent surgical management because of airway symptoms, failure to improve, or patient request. One patient had injury to the contralateral vocal fold upon intubation. None experienced recurrence. Five had complete recovery of voice postoperatively, four did not. CONCLUSION/CONCLUSIONS:Iatrogenic granulomas of the membranous vocal fold after intubation or other upper airway instrumentation are rare complications presenting in the early postprocedure period with worsening hoarseness. Initial conservative treatment may be sufficient to yield resolution, and surgical treatment is effective for those failing medical management. Permanent voice damage may result from the original injury. LEVEL OF EVIDENCE/METHODS:4. Laryngoscope, 2018.