Faculty Bibliography

INTRODUCTION/BACKGROUND:Foreign bodies in the aerodigestive tract pose a clinical challenge that must be addressed both swiftly and judiciously. Characteristics specific to both individual patients and to individual types of foreign bodies must be taken into consideration when planning for foreign body removal. OBJECTIVE:To discuss a scenario in which multidisciplinary decision-making was employed to remove a foreign body both quickly and safely. CASE SUMMARY/METHODS:We present a case of an adolescent girl who presented with throat pain and inability to manage her secretions after unintentionally swallowing a fork, which became lodged in her proximal esophagus. The position of the tines of the fork made intubation impossible. The fork was removed using direct laryngoscopy while the patient maintained spontaneous respirations. DISCUSSION/CONCLUSIONS:Complex decision-making, involving clinicians with expertise in various specialties, is often necessary to ensure a safe outcome. Careful planning and consideration of various details, specific to both foreign body characteristics and to patients themselves, are necessary to provide safe and efficient care for patients with foreign body ingestion.

PURPOSE/UNASSIGNED:Primary muscle tension dysphonia (pMTD) is a form of vocal hyperfunction with no preexisting tissue trauma to the vocal folds. There are no known structural or neurological causes of pMTD, and there is rarely obvious, confirmatory evidence to reliably diagnose individuals accurately. Furthermore, acoustic and aerodynamic measurements taken during voice assessments vary widely within this population. The purpose of this study was to find subgroups within a sample of pMTD patients based on acoustic and aerodynamic measurements. We use a computational approach to elucidate what has largely been observational in the past. METHOD/UNASSIGNED:-means clustering analysis was conducted. RESULTS/UNASSIGNED:The exploratory factor analysis grouped together variables across patients, which resulted in three principal axes. These three principal axes separately consisted of aperiodicity, fundamental frequency, and aerodynamic measurements. These principal axes explained 44.7% of the total variance. Four clusters of patients were identified across the three principal axes. These were characterized by (a) a high amount of aperiodicity in the voice, (b) lower fundamental frequency values, (c) higher fundamental frequency values, and (d) high aerodynamic values. CONCLUSIONS/UNASSIGNED:The clusters identified in the current study are reliable and moderately separated. Furthermore, these clusters align with previously identified subgroups in related work. The analysis presented here lays the groundwork for additional clustering analyses with new pMTD samples, as well as future work establishing subtype classifications of pMTD.

OBJECTIVE:Mentorship and training relationships shape the careers and influence of neurosurgeons. Network analysis can reveal structural characteristics and key individuals who support network connectivity and drive the field's development. This endeavor analyzed the U.S.-based neurosurgical training network derived from NeurosurGen.com. METHODS:A network graph was constructed representing neurosurgical training relationships, including chairperson-trainee, program director-trainee, and coresident connections. Graph- and node-level metrics, with a focus on centrality measures, were calculated for a trainer-trainee subgraph. RESULTS:The network consisted of 8840 neurosurgeons represented as nodes, and 382,143 relationships represented as edges. It evolved from an early small-world structure to a hierarchical and decentralized structure dominated by local clusters. Demographic shifts over time reflected increasing diversity and inclusion, with greater representation of female, Hispanic, Asian, and Black trainees across 285 training programs. Nodes were preferentially connected via residency, and the connectivity among underrepresented populations improved in concert with increased representation. Harvey W. Cushing was the quintessential neurosurgeon-influencer in the United States, ranking highly across most centrality measures over time. CONCLUSIONS:The neurosurgical training network is sparse but interconnected, typical of large real-world professional networks. While many small groups of neurosurgeons are closely tied within their immediate training hierarchy and peer group, in modern neurosurgery, each surgeon is only connected to a small fraction of the total network. Highly central individuals have played critical roles in linking disparate groups and shaping network structure. Increasing diversity in recent decades indicates progress toward inclusivity, although overall representation remains low.

OBJECTIVES/OBJECTIVE:To determine the relationships between the number and class of xerogenic medications on whole stimulated salivary flow rates and oral health-related quality of life (OH-QOL) measures in patients who received high-dose external beam radiation therapy (RT) for head and neck cancer (HNC). STUDY DESIGN/METHODS:Complete medication lists were generated using patient electronic health records from every attended study visit for 146 HNC patients. Whole stimulated salivary flow was measured before RT, and 6 and 18-months after RT. Ten single-item questions and two composite scales of swallowing problems and senses problems (taste and smell) were assessed at baseline and at 6-month intervals up to 24 months after RT. Linear mixed-effects models examined associations between the total number and class of medications and stimulated salivary flow and OH-QOL. RESULTS:There was no detected association between the total number of medications and stimulated salivary flow (p-value = .18). Only antidepressant usage was significantly associated with stimulated salivary flow (P = .006). Number of medications, narcotic analgesic, and antidepressant usage were significantly associated with a clinically meaningful decrease in OH-QOL. CONCLUSION/CONCLUSIONS:Antidepressants were associated with reduced stimulated salivary flow, but no cumulative negative effect on whole stimulated salivary flow was identified. Polypharmacy was associated with worse OH-QOL.

INTRODUCTION/BACKGROUND:The COVID-19 pandemic necessitated a rapid restructuring of the clinical management of voice and upper airway disorders by speech-language pathologists (SLPs). As in-person therapy sessions were suspended, voice-specialized SLPs across healthcare settings shifted to online teletherapy. In this survey study, we queried voice therapists on their experiences with and opinions regarding the adoption of teletherapy into routine clinical practice. METHODS:Voice-specialized SLPs were recruited nationwide to complete an online survey which included questions about the usability of software and hardware, patient management, the effectiveness of therapy, overall satisfaction, and suggestions for improvement. RESULTS:48 participants completed the survey. The majority of respondents reported frequent technical difficulties and poor access to or understanding of appropriate equipment. Overall, participants endorsed better patient access, attendance, and compliance, as well as increased scheduling flexibility. While 95% of the respondents stated they would recommend teletherapy to another SLP, only 20% supported a shift to exclusively virtual sessions. Forty percent of respondents endorsed a hybrid model consisting of initial in-person sessions followed by virtual ones. DISCUSSION/CONCLUSIONS:Incorporating teletherapy into clinical voice practice has, for the most part, followed Carl May's normalization process theory framework, in that clinicians have invested understanding, training, time and effort, and appraisal into its implementation. However, the unusually rapid pace of change necessitated by the pandemic has presented its own set of challenges. Given the inherent conveniences of virtual therapy, the online modality is likely here to stay. It is critical that we understand the facilitators and barriers to its successful adoption.

OBJECTIVE:To evaluate the long-term safety and clinical effect of INO-3107 immunotherapy in adults with recurrent respiratory papillomatosis (RRP). METHODS:RRP-002 was a retrospective, observational extension study that followed patients enrolled in the 52-week RRP-001 study. Patients with moderate to severe juvenile or adult-onset RRP who had undergone ≥ 2 surgical interventions in the year preceding dosing were eligible for enrollment in RRP-001. Participants underwent surgical debulking within 14 days prior to initial dosing and then received INO-3107 on Day 0, Weeks 3, 6, and 9. Efficacy assessments during RRP-002 follow-up were the frequency of surgical interventions and alternative medication use. The safety evaluation included reported severe adverse events (SAEs). RESULTS:Twenty-eight (28) of 32 participants from the 52-week RRP-001 study were enrolled in RRP-002. The median follow-up time for RRP-002 was 1.8 years (range: 1.2-2.4 years) for a total median assessment time of 2.8 years (range: 1.0-3.5 years). There were no SAEs or long-term safety concerns identified. The mean number of surgeries was reduced from 4.1 in the pre-treatment period to 1.7 in the first year post-INO-3107 treatment (Year 1) to 0.9 in the second year (Year 2). The complete response rate (0 surgeries per year) increased from 28% (9/32) in Year 1 to 50% (14/28) in Year 2. CONCLUSION/CONCLUSIONS:INO-3107 is well tolerated and provides a continued clinical effect against HPV-6 and 11 RRP that results in further reduction of the surgical burden observed in Year 1. These data support the role of INO-3107 immunotherapy for adult patients with RRP. LEVEL OF EVIDENCE/METHODS:III.

OBJECTIVE:Previous investigations demonstrated voice changes corresponding to menstrual cycle phases, but few explored longitudinal cycle-to-cycle variations. The aim of this longitudinal case study was to describe changes in acoustics, laryngeal kinematics, vocal effort, and ability to produce high soft phonation in relation to menstrual cycle phases over the course of multiple cycles in a single normally cycling individual. METHODS:Data were obtained from a 34-year-old professional voice user who had self-collected daily videostroboscopy, acoustics, vocal effort rating, and high soft phonation tasks for 394 days. Data were analyzed by cycle phase and across time for all cycles. RESULTS:Cycle length ranged from 24-32 days. All metrics demonstrated high cycle-to-cycle variability (±2 standard deviation or more). Greatest variability was during menses and luteal phases. The fertile window was the least variable and showed decreased glottal area index (GAI), asymmetry quotient, perceived vocal effort, and increased smoothed cepstral peak prominence, consistent with previous literature suggesting "best" voice quality during the periovulatory period. Perceived vocal effort and fundamental frequency were highest during the luteal phase. GAI was lowest during the luteal phase, and higher during estimated day of ovulation, which contradicts previous findings. CONCLUSION/CONCLUSIONS:This case study represents a unique, longitudinal data set demonstrating changes in phonatory characteristics across repeated menstrual cycles. In general, there was increased variability during rapid hormonal changes (menses, luteal phases) and less variability during hormonal stability (fertile window), suggesting that voice changes are sensitive to the rapid hormonal shifts. Future prospective studies should include multiple participants and concurrent hormone-level tracking. LEVEL OF EVIDENCE/METHODS:Level 4.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Hypofractionated Gamma Knife radiosurgery (hfGKRS) is increasingly considered for treating large or near-critical structure meningiomas because of potential safety advantages. However, data on optimal fractionation and long-term outcomes remain limited. This study evaluated the longer-term tumor control and toxicity after hfGKRS for intracranial meningiomas at 2 large centers, supplemented by a systematic review and meta-analysis of existing literature. METHODS:The analysis included 34 patients (site 1 = 25, site 2 = 9, median age 62.6 years) with 40 tumors (median volume 11.2 cm3). 62% was low-grade (World Health Organization grade 0-1) and 38% was high-grade (World Health Organization grade 2-3). The most common fractionation schemes were 20 Gy in 5 fractions for low-grade and 21 Gy in 3 fractions for high-grade tumors. The mean follow-up was 28.8 months. RESULTS:Only 6 of 34 patients did not have any previous treatment including surgery and/or radiotherapy. 82% of patient patients had neurological deficits before stereotactic radiosurgery. The estimated rate of 5-year tumor progression for low-grade and high-grade tumors was 7.7% (95% CI 0.41%-30%) and 36% (95% CI 12%-62%). Symptoms improved in 12 patients (35%) and worsened in 6 patients (16%), with 1 case attributed to tumor progression and no significant visual deterioration in 16 tumors within 3 mm of the optic apparatus. There was no statistically significant association between fractionation (3 vs 5) scheme and tumor control (P = .07) or survival (P = .12). Karnofsky Performance Status performance was a significant predictor of death (HR 0.89, P = .012) and tumor progression (HR 0.93, P = .048). The combined meta-analysis revealed a 5-year tumor control rate of 91.6% for low-grade and 37.9% for high-grade meningiomas. CONCLUSION/CONCLUSIONS:hfGKRS demonstrates durable control and acceptable safety for low-grade intracranial meningiomas. High-grade tumors showed less favorable outcomes comparable with single-session Gamma Knife radiosurgery historical data. Further prospective data are needed to confirm these findings and optimize fractionation strategies.