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To determine the prevalence of abnormal laryngeal findings during videostroboscopy in performers presenting to clinic or when having an acute vocal emergency.Retrospective study of professional singers and actors who presented for a vocal evaluation.A chart review of singers or professional actors who presented in a private otorhinolaryngology clinic between 2014 and 2016. The prevalence of laryngeal lesions noted on stroboscopy were reviewed. The RFS (reflux finding score) was calculated and the exams that presented RFS greater than or equal to seven were considered suspicious of laryngopharyngeal reflux (LPR).A total of 140 records of actors and singers were evaluated either for routine evaluation or for an acute emergency. Sulcus vocalis was the most prevalent lesion 36% (n = 33), followed by cyst 27% (n = 25) and acute laryngitis, 14% (n = 13). Thirty-seven (26.4%) performers were treated for emergence due to dysphonia, Emergency dysphonia, mostly due to viral infection, was treated with steroids and speech therapy, with improvement of symptoms after treatment. Of these professionals, 83.8% (31) presented with a structural lesion or infection in the vocal folds, while 16.2% presented with dysphonia, which required emergency care without a structural lesion in the vocal folds. (P0.05) Eighty-nine percent (33) of the professionals presenting with a voice emergency with dysphonia (37) were treated with corticosteroids. Thirty-three percent (n = 47) of the professionals presented with RFS scores ≥7. Nineteen professionals (40%) with signs of LPR were treated for emergency due to dysphonia. The professionals with signs of LPR had more emergency dysphonia than those who did not suspect LPR. (19.4%) (P = 0.008).Vocal emergencies in professionals are common in a private laryngology practice and require specialized assessment. The most prevalent lesions in the study were vocal sulcus. LPR is common in this group as noted both by findings with videostroboscopy and the RFS.

BACKGROUND: In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.METHODS: ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.RESULTS: ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.CONCLUSION: The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Bilateral vocal fold immobility (BVFI) has an impact on both the voice and breathing. Many procedures have been developed to manage BVFI including the use of a coblator to perform a unilateral posterior cordotomy. This study evaluated the use of unilateral coblator cordotomy for BVFI.Retrospective chart review.Ninety-four patients having undergone coblation cordotomies for BVFI performed by surgeons at two different institutions. Parameters evaluated were etiology of BVFI, prior tracheotomy, the number of revision procedures, postoperative decannulations, breathing outcomes as measured by Dyspnea Index, and voice outcomes as measured by the Voice Handicap Index.The main causes of immobility were thyroidectomy and prolonged endotracheal intubation. Twenty-one procedures were performed in patients who had a tracheotomy already in place, two required concurrent tracheotomy with cordotomy, and two underwent tracheotomy some time after cordotomy. The mean follow up was 16 months (1-38 months). Of the 25 patients who had a tracheotomy tube placed before or during the course of their care, we were unable to decannulate four of them after initial or revision cordotomy. Twenty of our 94 patients required a secondary revision unilateral cordotomy, usually on the previously un-operated vocal fold. This was more common in bilateral fixation than in paralysis. In 44 patients where Voice Handicap Index data was known both pre- and postoperatively, the median VHI scores improved from 62.2 to 37.4, while the VHI worsened in only four patients. Eight patients had a Dyspnea index performed both pre- and post-operatively and the median score dropped from 18.3 to 12.5.Coblation cordotomy is a reasonable option for vocal fold lateralization in BVFI. In our study, this method allowed for decannulation in 21 of 25 patients who had a tracheotomy. The initial coblator cordotomy was sufficient for the majority of patients, with 22% (20/94) requiring a revision procedure. Interestingly, our study also showed promising voice outcomes with improvements in VHI in all but four patients.

Background Allergy and asthma are often diagnosed concomitantly. Patients with both diagnoses might need to have a more targeted approach to reduce the symptomatic burden and severity of disease. Objective This study was designed to explore the relationship between specific allergen sensitization, and asthma diagnosis and severity with the hypothesis that patients who tested positive to a higher allergy class of response and to more allergens would be more likely to have severe asthma. Methods A retrospective review was performed on 1419 charts that had a positive IgE allergy class blood test between 2014 and 2018. A total of 701 patients had one or more positive tests and a diagnosis of asthma. Patient demographics and pertinent variables including all clinic and ED visits, specific allergy and class of response, and information related to their asthma treatment and severity were recorded. Logistic regression was used to analyze the likelihood of asthma diagnosis, concomitant diagnosis of asthma and allergic rhinitis, and measures of asthma severity. Results Higher class of response to cat dander 1.24 (1.09, 1.41), dog dander 1.29 (1.13, 1.47), lamb's quarter 1.35 (1.06, 1.70), house dust 1.41 (1.11, 1.82), Cladosporium herbarum 1.35 (1.07, 1.67) or cockroach 1.56 (1.00, 2.44) showed increased odds of hospitalizations. There was a statistically significant difference between the average number of classes for patients with and without asthma ( P Conclusions This study found that positivity to cat dander, dog dander, some fungus, and house dust was associated with more severe asthma.

Differences in skull-base angles between humans, other hominid species and apes might account for the ability of humans to develop complex speech. This study compared midline skull base angles, and angles related to insertion of skull base musculature between these species.126 human adult, 29 adolescent, 19 children, and 13 fetus skulls were compared to 32 ape and a subset of non-human antiquity hominid casts of skulls (13). Cranial base measurements were taken using an eMicroscribe 3d G2 digitizer. Midline and muscle insertion measurements were obtained.There were statistical differences in both the midline angles of the skull base (humans, 119

Objectives: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients. Methods: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence. Results: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression. Conclusions: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

Objectives/hypothesis Respiratory laryngeal dystonia (RLD) is poorly understood and rarely reported in the literature. Patients have atypical laryngeal movement resulting in airway obstruction. This motion is neurogenic in nature, is constant while awake, nonepisodic, and non-trigger dependent. Given its rarity, it is often misdiagnosed for inducible laryngeal obstruction; however, it is refractory to medical and behavioral management. Although this condition has been addressed in the literature, this report is the largest case series characterizing presenting symptomology, multimodal treatment outcomes, and longitudinal course of these patients, and proposes a set of diagnostic criteria to aid in clinical identification of RLD patients. Our objectives were to characterize RLD clinically and offer diagnostic guidelines to clinicians. Study design A prospective case series with a retrospective analysis at a tertiary referral center. Methods A review of clinical records and videostroboscopic analysis of 16 patients treated for respiratory laryngeal dystonia from October 2005 to October 2018 was performed. Results Sixteen patients with respiratory laryngeal dystonia were included. The common features of this group were persistent, nonepisodic dyspnea and stridor with laryngoscopic evidence of paradoxical vocal fold motion. Our patients had no structural neurologic abnormalities. These patients typically failed respiratory retraining therapy and medical management of laryngeal irritants. In our series, 100% of patients underwent respiratory retraining therapy, 68.8% received laryngeal botulinum toxin injection, and 31.3% required tracheostomy. Conclusions RLD is a rare and challenging condition. The disorder can be severely disabling, and treatment options appear limited. A multidisciplinary approach may be helpful. Some patients responded to laryngeal botulinum injection and medical management, whereas others required tracheostomy for symptom control. Laryngoscope, 2020.

The objective of this study was to determine the prevalence of benign vocal fold lesions (BVFLs) in patients with chronic cough over a 1-year period.Case series with chart review.Tertiary academic medical center.A retrospective cohort study of patients with chronic cough seen in our tertiary multidisciplinary cough clinic from 2016 to 2017 was conducted. Patient characteristics, presence of BVFLs by laryngoscopy, and Leicester Cough Questionnaire (LCQ) were recorded.A total of 419 patients were included (average age: 61 years), and 67% of patients were female. Ten percent of patients had BVFLs: granuloma (5%), leukoplakia (3%), nodules (2%), and polyps (1%). Median cough duration was 2.9 years (interquartile range [IQR], 0.7-8.5); no significant difference in median cough duration was observed between patients with BVFLs and those with no lesions (2.6 vs 3.0 years,Prevalence of BVFLs in our cohort of patients with chronic cough was 10%, with posterior glottic lesions-granuloma-being the most common (5%). Prevalence of midmembranous lesions was as follows: vocal fold nodules (2%) and vocal fold polyps (1%). BVFLs were not associated with longer cough duration or more severe cough. We cannot determine a causative or noncausative relationship between BVFLs and chronic cough at this time due to lack of a control group.

OBJECTIVES/HYPOTHESIS The objective of this study was to compare ventilation techniques utilized in microlaryngeal surgery. STUDY DESIGN Retrospective cohort study. METHODS Two-hundred surgeries performed from May 1, 2018 to March 1, 2020 and stratified as intubated, intermittently intubated (AAIV) or apneic. Patient demographics, comorbidities, anesthetic agents, intraoperative parameters/events, and complications were studied and compared across the three groups using inferential analyses. RESULTS Median body mass index in the AAIV group was significantly higher (33 vs. 29; P = .0117). Median oxygen nadirs were lower in AAIV cases (81% vs. 91-92%) while CO2 peak measurements were lower (33 mmHg vs. 48 mmHg) in the fully apneic cohort which were significantly shorter cases (P

Objectives/hypothesis Vocal tremor is a neurologic disorder that can be treated with laryngeal botulinum toxin injections (LBTX). We sought to describe our experience with thyroarytenoid and concurrent strap muscle injection. Study design Retrospective chart review. Methods A chart review was performed of all patients with a primary diagnosis of vocal tremor treated with LBTX from 2012 through 2017. Results Twenty-one patients were included (mean age 69 years, 100% female). Thirteen patients (62%) had a minor component of spasmodic dysphonia in addition to their tremor. Fourteen patients had vertical and horizontal components to their tremor, and two had horizontal tremor alone. The remaining five patients did not have clear characterization of their tremor. A total of 49 injections were reviewed (25 thyroarytenoid [TA], 24 thyroarytenoid and strap muscle [TA+S]), and patients reported subjective voice benefit with 48 (96%) of these (92% TA, 100% TA+S). When available, the postprocedural change from baseline Voice Handicap Index-10 and Consensus Auditory Perceptual Evaluation of Voice scores were calculated (mean overall: -1.9, -7.8; TA: -2.7, -3.5; TA+S: -1.4, -10.3, respectively). Subjective patient improvement ratings (scale 0%-100%) were obtained for 46 injections, with a mean of 70% improvement per injection. Of patients with both horizontal and vertical tremor, outcomes were improved with TA+S injection versus TA alone (mean improvement 74% vs. 35%, P Conclusions There is utility in the characterization of vertical and horizontal components of vocal tremor. Patients with both appear to have increased benefit with injection of strap muscles in addition to thyroarytenoid muscles. Level of evidence 4 Laryngoscope, 129:1433-1437, 2019.

OBJECTIVE Microlaryngeal surgery typically requires oxygenation and ventilation via either an endotracheal tube (ETT), jet ventilation (JV), or intermittent apnea with an ETT. Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) delivered by high flow nasal cannula has been reported as an alternative technique. This method of apneic oxygenation and ventilation allows for stable, unobstructed visualization of immobile laryngeal structures. We aim to describe the technique and characterize intraoperative parameters related to its safety. STUDY DESIGN Case Series. METHODS The electronic medical record was reviewed for patients who underwent microlaryngoscopy using THRIVE technique. Patient demographics, procedural details, operative parameters, and anesthesia records were reviewed. Descriptive statistics were reported. RESULTS A total of 53 patients underwent microlaryngoscopy using THRIVE as the sole method of ventilation, with 62% female. Median age was 51 years, and median BMI was 25 kg/m2 . Most patients were ASA class 2, and most had a Mallampati score of 2. The most common surgical indications were subglottic stenosis, vocal fold lesions, and vocal fold paralysis. Median apnea time was 16 minutes. At the end of case, median end tidal CO2 was 50 mmHg, and median minimum SpO2 was 95. Six cases required supplementation of THRIVE with JV or tracheal intubation for sustained oxygen desaturation. There was an increase in end tidal CO2 of 0.844 mmHg/min of apneic time. CONCLUSIONS THRIVE is a safe and effective technique for oxygenation and ventilation in microlaryngeal, non-laser surgery in appropriately selected patients. To ensure safety, back-up plans such as jet ventilation and microlaryngeal ETT should be available. LEVEL OF EVIDENCE 4 Laryngoscope, 131:587-591, 2021.

Rates of allergy-test positivity vary by country and by regions within countries. Several studies have looked at allergy test results to determine the most common allergens. Many of these studies have been based on surveys or on studies of small numbers of tests. Positivity rates for allergy tests are poorly defined in the northern midwestern region of the United States. We conducted a study to identify the rates of positive allergy tests for both inhalant/respiratory allergens and food allergens in the upper Midwest. We extracted from our laboratory database the results of all test samples sent for one of eight allergen panels that had been analyzed between Sept. 1, 2014, and Sept. 1, 2015. All testing was performed at The Cleveland Clinic with the Phadia ImmunoCAP system. The percentage of positive tests, the distribution of the most frequently positive tests, and the class of in vitro responses were identified. A total of 148,628 test results for 63 different allergens were identified. Of the 125,190 tests for inhalant/respiratory allergens, the most frequently positive were dog dander (24% of tests), cat dander (23%), dust mites (23% for both Dermatophagoides pteronyssinus and Dermatophagoides farinae), and June grass (21%). Of the 23,438 food tests, the most frequently positive test results were for milk (18%), peanut (17%), wheat (16%), and egg white (15%). Most of the results fell into classes 1 through 3, although there was still a notable number of very high responses (class 5 and 6). These findings suggest that there is wide variability in the positivity of in vitro allergy tests and that the likelihood of a positive result in screening panels can be estimated. Evaluating such rates will help identify the most and least common allergens and will help to cost-effectively refine allergy screening panels.

Objective Laryngopharyngeal reflux (LPR) symptoms are often resistant to management and cause significant quality of life impairment to patients with this disease. This study assesses the utility of a sleep-positioning device (SPD) in treating LPR. Design Single center prospective cohort study. Setting Tertiary medical center Participants 27 adult patients with diagnosed laryngopharyngeal reflux. Intervention An SPD consisting of a two-component wedge-shaped base pillow and a lateral positioning body pillow (Medcline, Amenity Health Inc.) was given to patients with a diagnosis of LPR. Subjects slept using the device for at least 6 h per night for 28 consecutive nights. Main outcomes Primary outcomes were Nocturnal Gastroesophageal Reflux Symptom Severity and Impact Questionnaire (N-GSSIQ) and the Reflux Symptoms Index (RSI) survey instrument. Each was collected at baseline, after 14, and after 28 days of SPD use. Results 27 patients (19 female and 8 male; age 57.1 ± 12.8, BMI 29.0 ± 8.1) were recruited. At baseline mean N-GSSIQ was 50.1 ± 22.4 and mean RSI of 29.6 ± 7.7. Repeated measure analysis showed that subjects' total N-GSSIQ scores decreased by an average of 19.1 (p = 0.0004) points by two weeks and 26.5 points by 4 weeks (p Conclusions In patients with LPR, SPD treatment significantly improves self-reported symptoms of nocturnal reflux as well as symptoms specific to LPR. These results support the therapeutic efficacy of a SPD for patients with LPR.

Summary Objective Voice disorders are common conditions that may have a significant impact on patient quality of life, yet their prevalence and epidemiology are poorly documented. In this study, we estimated the prevalence, demographics, and occupation of patients with dysphonia. Methods Using the Commercial and Medicare MarketScan databases of 146.7 million lives (2008–2012), the prevalence of dysphonia was estimated. Patient demographics and industry occupation were evaluated. Prevalence estimates overall and by industry were made using Medical Expenditure Panel Survey. Industry estimates were compared with US government employment statistics to assess differences between dysphonia and the general population. Results A gradual increase in the diagnosis of dysphonia was noted from 1.3% to 1.7% of the population from 2008 to 2012, with an associated increase in the diagnosis of acute laryngitis, the largest diagnostic category. A strong correlation was present between diagnosis and age, with acute laryngitis more common in the younger populations and malignancies in older ages. Benign neoplasms were more prevalent in the service industry, with 2.6 times increased likelihood compared with the general population, and malignancies were more prevalent in the manufacturing industry, with 1.4 times increased likelihood. Almost 3 million laryngoscopies and stroboscopies were performed with $900 million in costs. Conclusion Prevalence rates of the diagnosis of dysphonia are increasing and are associated with large healthcare costs. Prevalence rates also differ somewhat between industries, and there appears to be a higher percentage of malignant neoplasms in the manufacturing industry and benign neoplasms in the service industry.

Objective To describe the profile and outcomes of elderly patients undergoing medialization laryngoplasty for vocal cord paralysis. Study Design Case series with retrospective review. Setting Tertiary care hospital. Subjects and Methods Patients were included in the study if they were65 years old at the time of medialization laryngoplasty between 2008 and 2015. Patient comorbidities, anticoagulation status, disease etiology, and physical examination findings were recorded with postoperative length of stay, complications, pre- and posttreatment voice outcomes with the Voice Handicap Index (at 6 weeks, 4 months, 8 months, and 1 year), and postprocedural interventions (revision injections, surgery, therapy). Results A total of 112 patients met the eligibility criteria. Iatrogenic injury to the recurrent laryngeal nerve (50%) was the most common etiology, followed by idiopathic (31%) causes. Sixty percent of patients were receiving long-term antiplatelet and/or anticoagulation therapy. All but 14 patients on aspirin therapy stopped their antiplatelet/anticoagulation therapy prior to surgery. Most patients were discharged on the day of surgery. Postprocedure Voice Handicap Index scores significantly improved ( P.001) by 47%, 53%, 64%, and 57% at each of the 4 measured postprocedure dates, respectively. Two patients had major nonsurgical complications postoperatively requiring inpatient hospitalization. Chi-square analysis revealed no differences between intraoperative aspirin use, sex, or comorbidities and the incidence of complications ( P.05). Conclusion The clinical profile and outcomes of our patients undergoing medialization laryngoplasty are comparable to those seen in younger cohorts. Medialization laryngoplasty is a safe and successful option for elderly patients with vocal cord paralysis and vocal handicap.

Background The objective of this work was to evaluate prevalence of eosinophilic esophagitis (EoE) in the United States, and analyze prevalence of atopic disease in patients with EoE. The study design was a retrospective administrative database analysis in U.S.-based outpatient settings. Methods A retrospective claims analysis in the inpatient and outpatient setting (using MarketScan) was conducted to analyze prevalence of atopic disease diagnoses in patients with EoE in 2012, and timing of those diagnoses vs EoE. Results From published evidence, prevalence of EoE was estimated at 1 to 5 patients per 10,000 and prevalence of asthma, allergic rhinitis (AR), and atopic dermatitis (AD) concurrent to EoE ranged from 20% to 50%, 50% to 75%, and 2% to 19% cases, respectively. From 2009 and 2013, the estimated prevalence of EoE in MarketScan increased from 2.7 to 5.6 per 10,000 enrollees age 34.5 ± 18.43 years (mean ± standard deviation). Age followed a bimodal distribution with peaks at 12 and 41 years. Women accounted for 35.6% cases. Prevalence of asthma, AR, AD, and food allergies up to 12 months post-EoE diagnosis reached 44.7%, 27.1%, 25.2%, and 16.9%, respectively, with 63.5% of all patients suffering from at least 1 of these 4 diseases and 3.0% suffering from all 4. Conclusion The diagnosis of EoE is associated with the diagnoses of asthma, AR, AD, and food allergies. The high prevalence of these conditions in EoE patients further strengthens the hypothesis of a common pathogenesis.

Objective Reinke's edema (RE) is a pathologically benign structural change of the vocal folds with a wide spectrum of clinical severity. We aim to propose and validate a clinical grading system based on size of the lesion to facilitate effective universal communication of disease severity. Study Design Retrospective review. Methods Patients diagnosed with RE exclusive of other glottic pathology between December 2010 and December 2014 were included. Sixty laryngoscopy photographs were extracted from recorded archived laryngeal videostroboscopy exams, blinded and graded by four laryngologists with experience diagnosing RE. Results A high degree of agreement among all four raters was demonstrated by high interclass correlation coefficients with a 95% confidence interval. Similarly, high intra-rater reliability was seen across all raters. Forty-nine (33%) lesions were grade 1. Thirty-five lesions (29.17%) were grade 2; 18 (15%) lesions were grade 3; and nine (7.5%) lesions were grade 4. Contralateral vocal fold was not graded in cases of grade 4. Conclusion This clinical grading for RE is a reliable tool for conveying severity of disease. High inter- and intra-rater reliability strongly suggest that RE similarly can be graded by different raters, and that a single rater is expected to grade RE similarly at different times. Level of Evidence 4. Laryngoscope, 127:2310–2313, 2017

Purpose: Vocal fold scar is one the most challenging benign laryngeal pathologies. The purpose of this paper is to propose a classification that will allow for a common description of this entity between laryngologists, prevent discrepancies in interpretation, allow for comparison of related studies, and offer a training tool for young laryngologists. Methods/Results: Based on the depth and laterality of scarring, we propose 4 types: type I, characterized by atrophy of lamina propria with/without affected epithelium; type II, where the epithelium, lamina propria, and muscle are affected; type III, where the scar is located on the anterior commissure; type IV, which includes extended scar formation in both anteroposterior and rostro-caudal axis with significant loss of vocal fold mass. Conclusion: We believe that our proposal is comprehensive and encompasses all existing iatrogenic and non-iatrogenic etiologies in a simple and concise manner. It also serves its purpose as a descriptive, comparative, and training tool.

Chronic laryngitis commonly presents with dysphonia, and infectious causes include tuberculosis and endemic mycoses. We present a 58-year-old female with laryngitis for 5 years, fevers, chills, fatigue, malaise, myalgias, anterior neck pain, and night sweats after multicontinent exposure. Bronchoscopy cultures were negative. Bilateral microflap excision of vocal fold lesions demonstrated thickened epithelium and a deep vocal fold mass. Biopsy showed necrotizing granulomatous inflammation with acid-fast bacilli. Mycobacterium kansasii was identified. Treatment led to improvement in dysphonia, systemic symptoms, and vocal fold irritation. To our knowledge, this is the first case of isolated nontuberculous mycobacterial vocal fold infection. Laryngoscope, 129:2534-2536, 2019.

Objectives The application of laser (light amplification by stimulated emission of radiation) energy in the larynx relies on thermal injury. The impact of this injury on adjacent tissue can be undesirable. Attempts have been made to limit the extent and range of injury to adjacent tissue. The O-Pel Surgical System (Precise Light Surgical, Inc., Campbell, CA), a new technology, utilizes kinetic energy through Pressure Induced Tissue Resection (PITR) (Precise Light Surgical, Inc.) to cut tissue, theoretically eliminating injury to adjacent tissue. The purpose of this study was to evaluate the PSL in canine vocal folds. Methods Four dogs underwent PITR incisions (4 mJ pulses at 200 Hz) on their vocal folds, through mucosa into the muscle. The animals were sacrificed at days 0, 3, 7, and 21 days postsurgery. The larynges were harvested and histology was performed with hematoxylin and eosin, Masson trichrome, and Verhoeff-van Gieson. Results At day 0, focal denudation of the epithelium and coagulation necrosis in the lamina propria and adjacent connective tissue are noted. On days 3 and 7, an inflammatory infiltrate of neutrophils is seen within the lamina propria and surrounding connective tissue with minimal edema and early deposition of collagen. At day 21, the mucosa is completely regenerated with the area of previous PITR into the muscle replaced with thick bundles of collagen. Conclusion The unique PITR characteristics offer a potentially unique cutting technology for laryngeal microsurgery. The current canine study suggests appropriate and rapid healing. With refinements of the tip size of the probe and adjustment of energy, PITR will likely be an appropriate alternate to traditional lasers in laryngeal surgery. Level of evidence NA. Laryngoscope, 129:2557-2562, 2019.

Previous research has shown that office-based laryngoscopic procedures can induce hemodynamic changes, including tachycardia and severe hypertension, calling into question the safety of these procedures. However, comparison between office and operating room (OR) procedures has not been carried out. Therefore, we prospectively measured hemodynamic variables in both settings to compare hemodynamic changes between office and OR procedures.Prospective cohort study.Single academic center.Subjects undergoing office and OR laryngoscopic procedures were prospectively identified, and 92 OR and 70 office subjects were included. Heart rate and blood pressure were measured at established time points before, during, and after the procedures. Descriptive and comparative statistical analyses were conducted.Severe hemodynamic events, either tachycardia or severe hypertension (blood pressure180 mm Hg systolic or110 mm Hg diastolic), occurred significantly more frequently in OR than office procedures (41% vs 20%; P = .006). OR severe hemodynamic events occurred more commonly than previously reported rates in the office (41% vs 28%; P = .012). Regression analyses showed that the odds of having a severe hemodynamic event were 3.66 times higher in OR versus office procedures.Severe hemodynamic events are more likely to occur in the OR than in the office during laryngologic procedures. While larger studies will be required to establish rates of dangerous cardiovascular events in laryngoscopic procedures, hemodynamic parameters indicate that office-based procedures have a safety benefit for procedures that can be conducted in either setting.

Vocal fold paresis is a complex, controversial, and unique clinical entity. Guidance in assessing and evaluating these patients is provided in this comprehensive review of the current literature discussing the varying clinical presentation, the broad differential and general prognosis.Patients with vocal fold paresis can present with elements of hyperfunction, which can often mask an underlying paresis. As such, repetitive phonatory tasks and videostroboscopic examination are critical for the assessment of patients with a suspected paresis. When analyzing stroboscopic findings, anatomical and motion asymmetries can strongly suggest the presence of a paresis. However, it is important to remember that other disorders can sometimes mimic or create a visual asymmetry when a true paresis may not be present. Laryngeal electromyography (LEMG) can serve as a valuable adjunct to confirm a paresis with the most reliable indicator being a decreased recruitment pattern. The differential is vast, including infectious, iatrogenic, systemic rheumatologic, and neurologic conditions. LEMG along with time of onset and the underlying cause of the paresis can be valuable prognostic indicators.Patients with paresis often present with symptoms of a hyperkinetic voice disorder. Regardless of the myriad of causes, their assessment hinges upon close clinical evaluation with videostroboscopy aided with LEMG.

Understand real-world prescription patterns for patients presenting with a first diagnosis of ARS and evaluate adherence to published medical guidelines.Retrospective administrative database analysis.US-based outpatient settings.From a US claims database (MarketScan), 99,033 patients were identified with acute rhinosinusitis (ARS) in 2012 ("index"), with a complete medical and prescription history for 12 months preindex and 18 months postindex and no diagnoses of asthma or chronic rhinosinusitis. Of these, a random 10,000-patient sample was generated matched for age and sex to the initial cohort. Prescriptions and procedures at index, as well as complications up to 12 months postindex, were analyzed.Nearly 90% of all patients received a prescription at index. Antibiotics were prescribed for 84.8% patients, followed by antitussives (16.2% for adults, 6.2% for pediatrics), nasal corticosteroids (15.5% adults, 7.5% for pediatrics), and systemic corticosteroids (10.3% for adults, 5.5% for pediatrics), with 49% adults and 29% children receiving1 medication at first visit. Macrolides were the most frequently prescribed antibiotics (35.6% adults, 28.6% pediatrics), followed by amoxicillin/clavulanate and amoxicillin. Within 12 months of index, 3 patients presented with meningitis and 3 with orbital cellulitis.Significant variability in ARS treatment was observed, highlighting the need for heightened awareness of existing guidelines.

Bilateral vocal fold paralysis most commonly results from iatrogenic trauma to the recurrent laryngeal nerve during surgical procedures in the anterior neck. Patients may require tracheostomy because of acute or gradual onset of dyspnea and airway compromise. The intralaryngeal injection of Botox has been considered as a possible therapy for these airway symptoms of bilateral vocal fold paralysis. Chronic unopposed activity of intact cricothyroid muscles could potentially result in gradual medialization of the vocal folds in patients with bilateral recurrent laryngeal nerve paralysis. This case series describes three patients who successfully underwent injections of botulinum toxin into the bilateral cricothyroid muscles to offer sustained relief of dyspnea resulting from bilateral vocal fold paralysis.

Background The long-term impact of chronic rhinosinusitis (CRS) with or without allergic rhinitis (AR) on asthma is poorly documented. This study analyzed potential associations of ongoing CRS and AR on asthma. Methods Using the MarketScan™ claims database, patients with CRS and endoscopic sinus surgery (ESS) in 2010 were identified. The date of first sinusitis was determined for all. Patients with asthma at time of first sinusitis diagnosis were excluded. The remaining patients were grouped based on duration of sinusitis, from first diagnosis to surgery—group 1: 1 to

Objectives/Hypothesis Idiopathic subglottic stenosis (iSGS) is a rare and potentially life-threatening disease marked by recurrent and progressive airway obstruction frequently requiring repeated surgery to stabilize the airway. Unknown etiology and low disease prevalence have limited the ability to characterize the natural history of iSGS and resulted in variability in surgical management. It is uncertain how this variation relates to clinical outcomes. Study Design Medical record abstraction. Methods Utilizing an international, multi-institutional collaborative, we collected retrospective data on patient characteristics, treatment, and clinical outcomes. We investigated variation between and within open and endoscopic treatment approaches and assessed therapeutic outcomes; specifically, disease recurrence and need for tracheostomy at last follow-up. Results Strikingly, 479 iSGS patients across 10 participating centers were nearly exclusively female (98%, 95% confidence interval [CI], 96.1–99.6), Caucasian (95%, 95% CI, 92.2–98.8), and otherwise healthy (mean age-adjusted Charlson Comorbidity Index 1.5; 95% CI, 1.44–1.69). The patients presented at a mean age of 50 years (95% CI, 48.8–51.1). A total of 80.2% were managed endoscopically, whereas 19.8% underwent open reconstruction. Endoscopic surgery had a significantly higher rate of disease recurrence than the open approach (chi2 = 4.09, P = 0.043). Tracheostomy was avoided in 97% of patients irrespective of surgical approach (95% CI, 94.5–99.8). Interestingly, there were outliers in rates of disease recurrence between centers using similar treatment approaches. Conclusion Idiopathic subglottic stenosis patients are surprisingly homogeneous. The heterogeneity of treatment approaches and the observed outliers in disease recurrence rates between centers raises the potential for improved clinical outcomes through a detailed understanding of the processes of care. Level of Evidence 4. Laryngoscope, 2015

Botulinum toxin has several noncosmetic uses in otolaryngology. It is the primary treatment for spasmodic dysphonia and may be effective in select patients who have essential tremor of the voice. It may also be used to treat swallowing difficulties caused by cricopharyngeal dysfunction.

Importance Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score–matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

Burnout in modern medicine is becoming more recognized and researched. The objective in this study is to evaluate burnout in a tertiary care academic institution and compare results among faculty, trainees, and advanced practice practitioners (APPs) in a cross-sectional survey using the Maslach Burnout Inventory. Fifty-two surveys were distributed; 44 participants completed the survey (85%): 25 staff physicians (57%), 14 resident physicians (32%), and 5 nurse practitioners (11%). Staff physicians had low emotional exhaustion, moderate depersonalization, and low result for reduced personal accomplishments; trainees reported low emotional exhaustion, high depersonalization, and moderate reduced personal accomplishment; and nurse practitioners reported moderate on all 3 dimensions. There is overall low burnout in this tertiary care academic center of otolaryngologist providers and no difference in rates among the different groups (trainees, APPs, staff). Measures addressing specific deficiencies among dimensions of burnout would be helpful to prevent disintegration of physician satisfaction into burnout.

Importance Bilateral vocal fold immobility (BVFI) can result in considerable voice and airway impairment. Although the carbon dioxide (CO2) laser is commonly used in transverse cordotomy, the coblator, a minimally invasive, low-thermal technology, has been increasingly used in otolaryngology. Objective To investigate outcomes associated with coblation to treat BVFI. Design, Setting, and Participants A retrospective case series was conducted between January 2012 and June 2017 including 19 patients with BVFI who underwent cordotomy by coblation in a single tertiary care institution. Main Outcomes and Measures Clinical, operative, and health status data for all patients were reviewed. Quality of life was measured by the EuroQol 5-Dimensions (EQ-5D), and the Voice Handicap Index (VHI) was used to measure vocal cord function. Results Nineteen patients were eligible for inclusion, 15 of which underwent cordotomy by coblation for BVFI without stenosis. Mean age was 57 years with 13 (68%) women. The etiology of BVFI included thyroidectomy in 8 (42%) patients and prolonged intubation in 7 (37%). Mean length of surgery for BVFI without stenosis was 17 minutes; mean operating room (OR) time was 63 minutes compared with 88 scheduled OR minutes (effect size, 25 minutes; 95% CI, 9 to 40 minutes). During follow-up, 4 (27%) of these patients developed granulation tissue postoperatively. Following surgery, patient-reported shortness of breath significantly improved, with 10 of 14 (71%; 95% CI, 45% to 88%) patients with some level of preoperative breathing difficulty experiencing improvement in their breathing. Stridor also significantly improved, with 10 of 12 (83%; 95% CI, 55% to 95%) patients with some level of preoperative stridor improved after surgery. The EQ-5D results trended toward improvement postoperatively (0.67 to 0.80; effect size, 0.13; 95% CI, −0.10 to 0.34). The functional (22 to 12; effect size, −10; 95% CI, −19 to −2), emotional (23 to 11; effect size, −12; 95% CI, −23 to −3), and total VHI all significantly improved (68 to 39; effect size, −29; 95% CI, −49 to −8). Conclusions and Relevance Initial outcomes of cordotomy by coblation revealed that this technique was a safe and efficient approach to treating BVFI. Coblation was associated with significant reduction in OR time compared with scheduled time, and patients experienced significant improvement in shortness of breath, stridor, and vocal cord function.

Objective A recent study reported decreasing trends in tracheotomy procedures by its otolaryngology service. We set out to determine whether the previously reported decrease in otolaryngology performed tracheotomies by one institution is a local or generalizable phenomenon. Design Retrospective cohort study from 2010 to 2015. Setting Tertiary care hospital and affiliated regional hospitals. Subject and methods All patients who received tracheotomy during the period of analysis were included. Performing specialty, surgical technique, and procedure location were recorded. Procedures were stratified by year and specialty to generate incidence rate ratios for otolaryngologists and non-otolaryngologists. Incidence rate ratios were estimated with negative binomial regression across services. Results The otolaryngology service demonstrated a yearly decrease of 3.4% in the total number of tracheotomies (95% CI − 7.9% to + 1.4, P = 0.17). While the thoracic service remained constant (+ 0.3%, 95% CI − 2.6% to + 3.3%, p = 0.83), general surgery demonstrated the greatest increase in procedures (+ 4.4%, 95% CI − 6.0% to + 15.8%, P = 0.42). Thoracic and general surgery both dramatically increased the number of percutaneous tracheotomies performed, with general surgery also performing a greater number of bedside procedures. Conclusions and relevance We observed a similar decline in the number of tracheotomies otolaryngology over six years. Our trend is likely due to changes in consultations patterns, increasing use of the percutaneous method, and an increase in adjunctive gastrostomy tube placements. Investigations on the impact of a greater number of non-otolaryngology performed tracheotomies on follow up care is warranted.

Summary Objective Unilateral vocal fold paralysis can be treated with surgical medialization with a carved silastic implant. One challenge to this approach is anticipating the dimensions of the implant for adequate medialization. The purpose of this study was to develop a predictive model for implant design based on a patient's unique laryngeal anatomy and considering compression of the vocal fold. Study Design Retrospective chart review, prospective cadaver study, and prospective patient study. Methods A retrospective chart review was performed on patients who received silastic medialization laryngoplasty with favorable outcome and who had preoperative computed tomography. Data including Voice Handicap Index, maximum phonation time, and implant dimensions were collected from medical records, and laryngeal measurements were taken from preoperative imaging. Measurements were taken from computed tomography scans of three cadavers who underwent laryngoplasty for this study. Tissue compression (TC) was calculated and analyzed. A model to predict successful implant dimensions was developed and applied prospectively in 16 patients. Results Eleven patients from the chart review and three cadavers were included. Of all laryngeal metrics, width of the vocal fold at maximal medialization was most strongly correlated to TC ( r = 0.728). Linear regression was performed ( y = 0.50 x − 1.2, R 2 = 0.53, P = 0.005, F = 12.39). Of the prospective patients, 15 of 16 demonstrated complete glottis closure with the premeasured silastic implant. Conclusions Vocal fold compression by silastic implants is linearly correlated with vocal fold-width at maximal medialization. A predictive formula was generated to anticipate TC and was successful in designing custom implants for patients.

Background Allergen immunotherapy (AIT) has been in practice for more than 100 years. However, research in novel routes and delivery methods of immunotherapy to treat allergic rhinitis (AR) and conjunctivitis has only recently occurred in the United States, where the predominant form of AIT provided is largely via a subcutaneous immunotherapy (SCIT) route. AIT may prevent new sensitizations, improve symptoms, decrease medication usage, and prevent allergic asthma. Although AIT is the only potentially curative treatment for AR, access and adherence continue to be problematic. Only a fraction of eligible patients actually undergo treatment, and attrition rates are high. An obvious limitation of SCIT includes the requirement of regular injections to be provided in the physician's office due to the potential for anaphylaxis. Sublingual immunotherapy (SLIT) for home administration has been investigated as a potential alternative to address this limitation of SCIT. Methods A literature review was performed including the current findings from randomized clinical trials and meta-analyses with a discussion of the most recent evidence for the efficacy, safety, and dosing of allergen SLIT. Results The current data suggest that SLIT is effective for treatment of seasonal allergies, can potentially prevent asthma, and has a favorable safety profile. Head-to-head studies, however, are few, and comparative effectiveness still remains to be answered. Optimal treatment algorithms for SLIT have not yet been established, with wide variation in dosage selection and schedules. Similarly to SCIT, only a few allergens such as ragweed and grass pollen have been found to be effective in large clinical trials. Conclusion Recent data indicate that SLIT is an effective treatment modality for seasonal AR, improve quality of life, and can potentially prevent asthma but head-to head studies comparing SLIT to SCIT are needed.

OBJECTIVE Hypoglossal nerve stimulation is an effective treatment for a subset of patients with Obstructive Sleep Apnea (OSA). Although multiple clinical trials demonstrate its efficacy, no previous literature explores the potential impact the stimulator has on swallowing and voice. Our primary objective is to evaluate patient reported post-operative changes in voice or swallowing following hypoglossal nerve stimulator placement. STUDY DESIGN Prospective cohort study. SETTING Tertiary care hospital. SUBJECT AND METHODS Patients scheduled to receive a hypoglossal stimulator were enrolled. Participants completed baseline Voice Handicap Index-10 (VHI-10) and Eating Assessment Tool-10 (EAT-10) questionnaires preoperatively and again at 1week, 3months, and 6months post-operatively following placement of a hypoglossal nerve stimulator. RESULTS 9 males and 5 females completed the study. The mean pre-operative VHI-10 and EAT-10 score was 3 and 0.8 respectively. Using linear mixed models, a clinically and statistically significant increase in the mean EAT-10 score was observed post-operatively at 1week (p=0.007), which was not observed at the time points the stimulator was active. A clinically and statistically significant decrease in VHI-10 score was observed following 2months of active stimulator use (p=0.02), which was not observed at any other time point. CONCLUSION The implantation and use of the hypoglossal nerve stimulator over 5months did not demonstrate any sustained, patient reported changes in voice handicap and swallowing function. While larger studies are warranted, our findings can be used to provide further informed consent for hypoglossal nerve stimulator implantation.

Analyze health care needs and outcomes-defined by changes in health care utilization-in cohorts of patients with respiratory comorbidities and requiring sinus surgery for the treatment of chronic rhinosinusitis (CRS).Retrospective database analysis.US-wide claims database (MarketScan).All patients with endoscopic sinus surgery (CPT 31254-31288) in 2008 and at least 2 years of continuous enrollment prior and post surgery were analyzed for concurrent comorbidities (asthma, polyps, aspirin sensitivity, and allergies). Inpatient and outpatient events as well as prescriptions related to the treatment of CRS were analyzed for frequency and cost, based on respiratory comorbidities.A total of 9105 patients were included and subdivided as following: no respiratory comorbidity (N = 4780), asthma only (N = 1167), polyps and asthma (N = 721), Samter's triad (N = 91), and additional subgroups based on various combinations of concurrent comorbidities. Before surgery, costs were flat, ranging from $296.4 (95% CI, $263.1-$329.8) per patient per year for patients in the no comorbidity group to $2189 (95% CI, $1449.2-$2930.1) for patients with Samter's triad. Surgery was preceded by at least 6 months of increased health care utilization (outpatient care and prescriptions). Following surgery, health care needs declined rapidly and reached baseline levels within 3 to 4 postoperative months. Patients with asthma received significantly more health care for CRS than patients without asthma through the entire study.Patients with CRS incur continuous costs and health care needs, due to the chronic nature of their disease. All patients, regardless of comorbidity, experienced significant decline in health care needs following sinus surgery from their preoperative state.

Objectives/Hypothesis To evaluate the endoscopic surgical management of adult subglottic stenosis and describe treatment outcomes. Study Design Retrospective review. Methods Ten-year review of adult patients with subglottic stenosis. Results Ninety-two adults (23 male, 69 female) with subglottic stenosis underwent 247 endoscopic dilations between 2001 and 2010. The mean age was 48 years at time of first surgery. Etiology was GPA (granulomatosis with polyangiitis, formerly Wegener's granulomatosis) (45%), intubation (25%), or idiopathic (33%). Forty-one patients (45%) underwent a single procedure; 51 patients (55%) required multiple surgeries. The average interval for patients requiring a subsequent procedure was 13.7 months. Variations in surgical technique did not show differences in time to next procedure, and the use of mitomycin-C did not result in longer intervals between procedures. No significant complications were encountered after dilation. Conclusions Subglottic stenosis remains a treatment challenge. Although patients are often symptomatically improved after endoscopic dilation, recurrence rates remain high. Level of Evidence 4. Laryngoscope, 124:736–741, 2014

Summary Objectives Most voice self-rating tools are disease-specific measures and are not suitable for use with healthy voice users. There is a need for a tool that is sensitive to the subtleties of a singer's voice and to perceived physical changes in the singing voice mechanism as a function of load. The aim of this study was to devise and validate a scale to assess singer's perceptions of the current status of their singing voice. Methods Ninety-five vocal health descriptors were collected from focus group interviews of singers. These were reviewed by 25 currently performing music theater (MT) singers. Based on a consensus technique, the number of descriptors was decreased to 42 items. These were administered to a sample of 284 professional MT singers using an online survey to evaluate their perception of current singing voice status. Results Principal component analysis identified two subsets of items. Rasch analysis was used to evaluate and refine these sets of items to form two 10-item subscales. Both subscales demonstrated good overall fit to the Rasch model, no differential item functioning by sex or age, and good internal consistency reliability. The two subscales were strongly correlated and subsequent Rasch analysis supported their combination to form a single 20-item scale with good psychometric properties. Conclusions The Evaluation of the Ability to Sing Easily (EASE) is a concise clinical tool to assess singer's perceptions of the current status of their singing voice with good measurement properties. EASE may prove a useful tool to measure changes in the singing voice as indicators of the effect of vocal load. Furthermore, it may offer a valuable means for the prediction or screening of singers “at risk” of developing voice disorders.

Objectives/Hypothesis: Open bedside tracheotomy (OBT) in the intensive care unit (ICU) has been advocated as a safe and more cost-effective alternative to tracheotomy performed in the operating room. The objective of this study is to determine predictive factors for postoperative outcomes, including decannulation and in-hospital mortality following OBT. Study Design: Retrospective chart review. Methods: The charts of 330 consecutive adult patients who underwent OBT at a tertiary care medical center between January, 2005, and April, 2011, were reviewed. Perioperative variables including demographics, comorbidities, serological markers, and time to tracheotomy were collected and analyzed in relation to the endpoints of in-hospital mortality and decannulation rate. Results: A total of 218 patients were included in the final analysis. The decannulation rate was 26.1% and inpatient mortality was 24.2%. On multivariate analysis, the inpatient mortality rate was significantly increased and the decannulation rate was significantly decreased among patients with concomitant cardiac or respiratory disease, or a coincident diagnosis of malignancy. ICU length of stay was increased by 4.5 days for each unit increase in cardiac comorbidity count. Conclusions: Admitting diagnosis and serological markers did not predict the rates of decannulation or in-hospital mortality. However, the presence of cardiac disease and/or oncologic comorbidities played a significant role in predicting hospital mortality or eventual decannulation. Several comorbidity combinations resulted in a greater than 60% likelihood of inpatient mortality. In this population, the overall benefit of an OBT may be debatable. Despite very high overall acuity levels, there were no serious procedural complications, indicating that bedside tracheotomy is safe in ill patients.

Evidence-based guidelines for the diagnosis and initial management of suspected acute bacterial rhinosinusitis in adults and children were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America comprising clinicians and investigators representing internal medicine, pediatrics, emergency medicine, otolaryngology, public health, epidemiology, and adult and pediatric infectious disease specialties. Recommendations for diagnosis, laboratory investigation, and empiric antimicrobial and adjunctive therapy were developed.

Bilateral immobility of the vocal folds can have a dramatic impact on both airway and voice. The diagnosis is based on history and physical examination and is supported by some objective tests such as computed tomography or magnetic resonance imaging evaluations. Although airway management is often the first consideration, a critical determination that is important both to an assessment of prognosis and to surgical planning is the differentiation between fixation and paralysis. The focus of surgical therapy has predominantly been directed at vocal fold lateralization, although there is growing interest in reinnervation and laryngeal pacing. There are a number of reliable lateralization and traditional techniques that are best performed with a tracheostomy in place. A lateralization procedure that removes the vocal process with a CO 2 laser and a portion of the body of the arytenoids with preservation of the medial mucosa and with/without an external stitch lateralization is described. It can usually be performed without a tracheostomy. A unilateral lateralization procedure is highly successful in the management of bilateral vocal fold paralysis, since the wound healing will pull the vocal fold in a lateral position. In bilateral fixation, however, bilateral lateralization procedures are usually required since the defect will partially fill back in, narrowing the surgically created defect.

To evaluate the utility of intrathecal fluorescein (IF) for intraoperative localization and successful repair of cerebrospinal fluid (CSF) leaks.Case series with chart review.Tertiary-care medical center.Subjects included those undergoing endoscopic CSF leak repair with or without the use of IF. Informed consent was obtained from all patients undergoing the administration of IF (total dose 10 mg).A total of 103 patients underwent CSF leak repair, and in 47 cases (45.6%), IF was used. Patients who were administered IF were more likely to have spontaneous CSF leak etiology (61.7% vs 16.1%; P0.001). Of the 47 cases with IF use, fluorescein was visualized at the skull base in 31 cases (66.0%), 11 (23.4%) had visible CSF leak without fluorescein coloration, and five (10.6%) had neither clear nor fluorescein-colored CSF visualized. Sensitivity and specificity for fluorescein detection was 73.8 percent (95% confidence interval [CI] 57.7%-85.6%) and 100 percent (95% CI 46.3%-100%), respectively. The false-negative rate was 26.2 percent (95% CI 15.8%-43.5%). Localization of the leak site was greater when fluorescein-colored CSF was visualized (100% vs 81.3%; P = 0.035). When fluorescein-colored CSF was not visualized intraoperatively, recurrence rates were 31.3 percent versus 9.7 percent when fluorescein coloration was seen, although this finding was not statistically significant (P = 0.10).The use of IF facilitates the accurate localization of CSF leaks and may assist the surgeon in confirming a watertight closure. The lack of intraoperative fluorescein visualization should not rule out the presence of CSF leak, as evidenced by a false-negative rate of 26.2 percent.

Objective: Spontaneous cerebrospinal fluid (CSF) leaks represent a significant challenge due to frequent association with elevated intracranial pressure (ICP) and higher risk of surgical failure. The study objective was to review management strategy and identify factors associated with need for acetazolamide and/or ventriculoperitoneal shunt (VPS) placement. Study Design: Retrospective data analysis. Methods: Chart review performed from 1999 to 2009 at a tertiary-care medical center. Results: A total of 105 patients underwent CSF leak repair; 39 patients (37.1%) were treated for spontaneous CSF leaks. Mean age was 57.7 years and 33 were female (85%). Average body mass index (BMI) was 38.5 kg/m2. The most common sites were cribriform plate (51%), sphenoid lateral pterygoid recess (31%), and ethmoid roof (8%). All patients underwent endoscopic repair utilizing image guidance with multilayered closure in most cases. Five patients (12.8%) developed recurrent CSF leak with mean ICP of 27.0 cm H2O, compared to 25.0 cm H2O for those without recurrence (P = .33). All had successful rerepair at mean follow-up of 2.8 years. Acetazolamide was used in nine patients, whereas six patients underwent VPS placement for elevated ICP management. Diagnosis of benign intracranial hypertension (BIH) was statistically associated with need for acetazolamide or VPS (P < .001), whereas elevated ICP reached borderline significance (P = .049). Conclusions: Management of spontaneous CSF leaks requires a comprehensive strategy after endoscopic repair. Diagnosis of BIH may be associated with requirement of further ICP treatment. Close ICP monitoring, coupled with selective use of acetazolamide and VPS, may decrease risk of failure. Laryngoscope, 2010

The purpose of this review is to describe the potential use of lasers in the treatment of benign superficial lesions of the larynx and discuss possible roles for vocal nodules.Although there are many articles that describe the use of lasers in benign laryngeal lesions, there have not been much recent data with CO2 lasers for such lesions and very little to describe the use in vocal nodules. Most recent data have been related to other lasers such as the pulse-dye or potassium titanyl phosphate lasers.Lasers can be used safely in the larynx to remove benign superficial laryngeal lesions. The safety and efficiency of microdissection techniques and the lack of evidence to support the use of newer lasers for vocal nodules would suggest selective laser use for removing vocal nodules.

Background Bipolar radiofrequency can be used surgically to excise and cauterize tissue simultaneously. It has potential for use in endoscopic sinus surgery (ESS). This study was performed to determine the extent and pattern of injury in the paranasal sinuses with bipolar radiofrequency and evaluate wound healing. Methods Eight rabbits underwent Coblation of maxillary sinus mucosa with biopsy immediately, on postoperative day (POD) 3, 7, 14, or 29. Maxillary mucosa was exposed through the nasal dorsum, and a Coblator PROciseXP wand used on a power setting of 7 for 2 seconds. Three of the rabbits also had Coblation of ethmoid mucosa over the lamina papyracea, after extending the maxillary ostomy, with biopsy immediately. Results Coblation resulted in immediate loss of surface respiratory epithelium and thermal-type injury to the underlying seromucinous glands. On POD 3, the site showed reepithelialization with squamous metaplastic epithelium. The seromucinous glands underwent coagulative necrosis. At POD 7, there was partial replacement of overlying epithelium by respiratory epithelium. The underlying seromucinous glands were lost and replaced by fibroblastic proliferation, with less fibrosis than the mechanically created ostomy site. The underlying bone had reactive, regenerative changes. On PODs 14 and 29, there was further regeneration of respiratory epithelium. Fibrosis was mild. Coblation resulted in gross violation of the bony wall in one maxillary sinus. There were no histological changes in the orbit. Conclusion Rabbit paranasal sinus mucosa heals appropriately after Coblation injury.