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Objectives/hypothesisTo objectively assess the initial and long-term retention of robotic surgical skills of otolaryngology residents.Study designThis study was performed in an academic otolaryngology residency training program. Between October 2015 and November 2016, residents were invited to complete a prospective, multiphase robotic surgical skills training course: 1) online da Vinci Surgical System Assessment and didactic, 2) faculty-supervised robotic simulator training, 3) robotic docking and draping training, 4) robotic dry-lab exercises. To optimize surgical skill retention, the training laboratory was repeated 2 weeks after the initial training session.MethodsTwenty otolaryngology residents were included. Primary outcome was measured as robotic skill assessment scores on three tasks: camera targeting, peg board, and needle targeting. Skill assessments were completed prior to training, between the two training sessions, and at 1 month and 6 months after training. Residents were also asked to complete a self-assessment questionnaire.ResultsCamera targeting scores were improved at midtraining (P

Objectives/hypothesisDetermine the rate, diagnoses, and risk factors associated with 30-day nonelective readmissions for patients undergoing surgery for oropharyngeal cancer.Study designRetrospective cohort study.MethodsWe analyzed the Nationwide Readmissions Database for patients who underwent oropharyngeal cancer surgery between 2010 and 2014. Rates and causes of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission.ResultsAmong 16,902 identified cases, the 30-day, nonelective readmission rate was 10.2%, with an average cost per readmission of $14,170. The most common readmission diagnoses were postoperative bleeding (14.1%) and wound complications (12.6%) (surgical site infection [8.6%], dehiscence [2.3%], and fistula [1.7%]). On multivariate regression, significant risk factors for readmission were major ablative surgery (which included total glossectomy, pharyngectomy, and mandibulectomy) (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.06-1.60), advanced Charlson/Deyo comorbidity (OR: 2.00, 95% CI: 1.43-2.79), history of radiation (OR: 1.58, 95% CI: 1.15-2.17), Medicare (OR: 1.34, 95% CI: 1.06-1.69) or Medicaid (OR: 1.82, 95% CI: 1.32-2.50) payer status, index admission from the emergency department (OR: 1.19, 95% CI: 1.02-1.40), and length of stay ≥6 days (OR: 1.57, 95% CI: 1.19-2.08).ConclusionsIn this large database analysis, we found that approximately one in 10 patients undergoing surgery for oropharyngeal cancer is readmitted within 30 days. Procedural complexity, insurance status, and advanced comorbidity are independent risk factors, whereas postoperative bleeding and wound complications are the most common reasons for readmission.Level of evidence4. Laryngoscope, 129:910-918, 2019.

ImportanceOptimal management of subglottic stenosis has not been established. Endoscopic techniques include balloon dilation, radial incisions with carbon dioxide laser or cold knife, and combinations of techniques. Adjunctive measures include mitomycin application and glucocorticoid injection.ObjectiveTo determine whether surgical technique or adjunctive measures are associated with duration between surgical procedures.Design, setting, and participantsAdult patients with subglottic stenosis treated endoscopically between 1995-2015 at a quaternary academic medical center were identified. Patients with isolated subglottic (cricotracheal) stenosis 18 years and older were included. Patients with prior open surgical procedures, prior laryngeal surgical procedures, glottic stenosis, or vocal fold paralysis were excluded.InterventionsPatients underwent endoscopic procedures including laser radial incisions, balloon dilation, or both, with some patients receiving topical mitomycin, glucocorticoid injection, or both.Main outcomes and measuresTime interval between endoscopic treatments.ResultsA total of 101 patients (mean [SD] age, 52.3 [15.9] years; 77.2% female) were included in the analysis, with etiologies including idiopathic (47 [46.5%]), intubation (31 [30.7%]), granulomatosis with polyangiitis (9 [8.9%]), and other autoimmune diseases (6 [5.9%]). Among the 219 operations, both laser and balloon dilation were used in 117 (53.4%), while balloon dilation alone was used in 96 (43.8%) and laser alone in 6 (2.7%). Mitomycin application and steroid injection were used in 144 (65.8%) and 93 (42.5%) cases, respectively. Mitomycin application was associated with improvement in the mean interval to next procedure from 317 to 474 days (absolute difference, 157 days; 95% CI, 15-299 days). Advanced grade of stenosis, dilation technique, and steroid injection did not significantly alter the surgical intervals.Conclusions and relevanceEndoscopic surgery for subglottic stenosis is a critical aspect of patient management. Neither surgical technique nor grade of stenosis was seen to alter the surgical intervals. Mitomycin application was associated with an extended time interval between endoscopic treatments.

ObjectiveWhen total laryngectomy is not required, organ preservation surgery or radiotherapy is considered the standard of care for primary glottic cancer. These accepted treatment options are available for early and advanced glottic cancers due to equivalent locoregional control and survival rates. However, in today's climate of accountable care, the financial burden of treatment choices continues to increase in significance. We therefore compared hospital charges and treatment-related morbidity between organ-preserving surgery and radiation with or without chemotherapy-herein, (chemo)radiation-in the primary treatment of glottic cancer.Study designNationwide Inpatient Sample Database was analyzed to assess clinical and financial information.SettingPopulation-based analysis.SubjectsPatients (N = 5499) with primary glottic cancer undergoing treatment with laryngeal preservation strategies.MethodsPatients were subdivided by ICD-9 codes into 3 treatment groups: endoscopic resection, open partial laryngectomy, and (chemo)radiation. Treatment-related outcomes, charges, and length of hospitalization were analyzed among treatment groups.ResultsWhen adjusting for sex, age, race, comorbidity, and primary payer, (chemo)radiotherapy was associated with increased direct charges (P < .001; coefficient, $23,658.99; 95% confidence interval [95% CI]: $10,227.15-$37,090.84) and length of hospitalization (P < .001; hazard ratio, 0.593; 95% CI: 0.502-0.702) when compared with endoscopic surgery. As compared with open surgery, endoscopic surgery was associated with reduced hospital charges (P = .012; coefficient, $11,967.01; 95% CI: $2,784.17-$21,249.85) and duration of hospitalization (P < .001; hazard ratio, 0.749; 95% CI: 0.641-0.876).ConclusionsThis analysis suggests that increased utilization of endoscopic surgery in patients with primary glottic cancer not requiring total laryngectomy may lead to reduced financial burden and duration of hospitalization when compared with open surgery or (chemo)radiation therapy.

Objectives/hypothesisThe direct study of human phonation is limited by the invasive and painful nature of human laryngeal neuromuscular manipulation. As a platform for the study of human phonation, indirect models have been utilized for decades such as animal, cadaveric, and computational. We sought to develop a research method allowing direct scientific control of virtually living larynges to expand our ability to understand human phonation.Study designCanine and porcine models.MethodsNineteen canine larynges were surgically removed and reperfused with progressively adapting methodologies to create ex vivo phonation.ResultsFull neuromuscular stimulation and phonation were ultimately achieved in the ex vivo larynx. As compared with alternative perfusate solutions, heparinized whole blood was found to result in the most robust neuromuscular response. Modification of the reperfusion technique from a continuous flow to a pulsatile pump system resulted in dramatic increases in neuromuscular response and longevity of the organ. The experimental findings were repeated to demonstrate reliability of the ex vivo model.ConclusionsThe ex vivo larynx model is demonstrated to be a repeatable platform for phonatory research. The process of development has been comprehensively described in the present report. Although the described experimental model was designed for phonatory research, this model can be readily adapted for investigations of organ transplant preservation techniques, effects of organ ischemia, and neuromuscular reinnervation capabilities.Level of evidenceNA.

ImportanceThis study reviews a single center's experience of performing staged laryngotracheoplasty (LTP) for the treatment of laryngotracheal stenosis with the ultimate goal of attaining long-term airway patency without restenosis.ObjectiveTo identify staged LTP as an efficacious surgical treatment option for laryngotracheal stenosis.Design, setting, and participantsFrom January 2000 to January 2012, patients at a tertiary care academic institution presenting with diagnoses of laryngeal or laryngotracheal stenosis were retrospectively identified. Medical records from adult patients were inspected, and patient demographics, clinical data, and clinical outcomes were recorded. All patients undergoing staged LTP were initially included. Patients with history of head and neck malignant neoplasm were excluded.InterventionsStaged LTP.Main outcomes and measuresThe primary outcome was long-term decannulation, defined as decannulation for duration of at least 6 months.ResultsSixty-one patients were included in this study. The mean (SD) patient age was 47.1 (16.7) at the time of first-stage LTP and had a mean (range) follow-up of 5.32 (0.5-17.3) years from the first-stage reconstruction. Etiology of stenosis included prolonged intubation in 27 patients (44%), autoimmune disease in 9 (15%), idiopathic causes in 11 (18%), blunt laryngeal trauma in 10 (16%), and other causes in 4 (7%). Forty-nine patients (80%) were successfully decannulated, while to date 12 (20%) remain tracheostomy or tympanostomy tube dependent. Univariate analyses showed no significant association between decannulation and age (P = .35), sex (P = .52), history of intubation (P = .22), surgeon (P = .20), etiology of stenosis (P = .91), or length of stenosis (P = .31). Multivariate logistic regression analysis showed a significant inverse relationship between grade of stenosis and probability of decannulation (P = .01).Conclusions and relevanceStaged LTP is an option for the reconstruction laryngotracheal stenosis. Our experience shows excellent decannulation rates in the selected patients with stenosis, many of whom have failed treatment with other surgical modalities.

BackgroundPreliminary case series have reported clinical feasibility and safety of a transoral minimally invasive technique to approach parapharyngeal space masses. With the assistance of the surgical robotic system, tumors within the parapharyngeal space can now be excised safely without neck incisions. A detailed technical description is included.MethodsAfter developing compressive symptoms from a parapharyngeal space lipomatous tumor, the patient was referred by his primary otolaryngologist because of poor open surgical access to the nasopharyngeal component of the tumor.ResultsTransoral robotic assisted resection of a 54- × 46-mm parapharyngeal space mass was performed, utilizing 97 minutes of robotic surgical time. Pictorial demonstration of the robotic resection is provided.ConclusionParapharyngeal space tumors have traditionally been approached via transcervical skin incisions, typically including blunt dissection from tactile feedback. The transoral robotic approach offers magnified 3D visualization of the parapharyngeal space that allows for complete and safe resection.

ObjectiveAlthough high-speed imaging (HSI) has been identified as a valuable tool in phonatory biomechanics research, to date, there have only been a selected number of reports investigating the clinical utility of HSI. We aim to elucidate the role of HSI in the diagnosis of the dysphonic patient.MethodsThe video files from 28 consecutive dysphonic patients with concurrently acquired videostroboscopy and HSI were retrospectively collected. Stroboscopy video files were edited to include vibratory motion only. Videos were then anonymously and randomly presented to four academic laryngologists. Experts were asked to assign a single best diagnosis for each video file. Assigned diagnoses were then compared with treatment diagnoses conferred based on medical history, phonatory evaluation, laryngeal examination, and response to treatment.ResultsInterrater analysis for the four laryngologists demonstrated significant and meaningful correlations for the diagnoses of polyps, cysts, nodules, and normal examination using stroboscopy (kappa > 0.40, P < 0.001). The experts demonstrated significant and meaningful correlations for the diagnoses of polyps, presbyphonia, and normal examination using HSI (kappa > 0.40, P < 0.001). Combined intrarater analysis performed by comparing single rater's diagnosis for single patient across both modalities resulted in poor correlation without statistical significance (kappa = 0.30, P = 0.07). Both stroboscopy- and HSI-assigned diagnoses matched the treatment diagnoses at equal predicted frequencies (32.3%), as demonstrated through multivariate logistic regression analysis (P < 0.001).ConclusionOverall, HSI did not improve the diagnostic accuracy above stroboscopy alone. Although specific laryngeal states such as presbyphonia may be better diagnosed with HSI, further studies are required to define HSI's precise role in the clinical setting.