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Objective: Report outcomes of rapid implementation of telehealth across an academic otolaryngology-head and neck surgery department during the COVID-19 pandemic., Methods: This is a retrospective, single-institution study of rapid deployment of telehealth during the COVID-19 pandemic. Characteristics of patients were compared between those who agreed and those who declined telehealth care. Reasons for declining telehealth visits were ascertained. Characteristics of telehealth visits were collected and patients were asked to complete a post-visit satisfaction survey., Results: There was a 68% acceptance rate for telehealth visits. In multivariable analysis, patients were more likely to accept telehealth if they were being seen in the facial plastics subspecialty clinic (odds ratio [OR] 59.55, 95% confidence interval [CI] 2.21-1607.52; P = .015) compared to the general otolaryngology clinic. Patients with Medicare (compared to commercial insurance) as their primary insurance were less likely to accept telehealth visits (OR 0.10, 95% CI 0.01-0.77; P = .027). Two hundred and thirty one patients underwent telehealth visits; most visits (69%) were for established patients and residents were involved in 38% of visits. There was an 85% response rate to the post-visit survey. On a scale of one to ten, the median satisfaction score was 10 and 99% of patients gave a score of 8 or higher. Satisfaction scores were higher for new patient visits than established patient visits ( P = .020)., Conclusion: Rapid implementation of telehealth in an academic otolaryngology-head and neck surgery department is feasible. There was high acceptance of and satisfaction scores with telehealth., Level of Evidence: 3., Competing Interests: The authors declare no conflicts of interest., (© 2021 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objective: To develop and assess an otolaryngology-specific surgical priority scoring system that incorporates varying levels of mucosal involvement., Study Design: Retrospective cohort., Setting: Academic medical center., Methods: A novel mucosal score was developed based on best available evidence. This mucosal score was incorporated into the Medically Necessary, Time-Sensitive (MeNTS) score to generate a MeNTS-Mucosal (MeNTS-M) score. A retrospective cohort of patients was identified to assess the surgical priority scoring systems. Inclusion criteria included all scheduled surgical procedures between March 23, 2020, and April 17, 2020. Decisions about whether to proceed or cancel were made based on best clinical judgment by surgeons, without use of any surgical priority scores. The predictive value of the surgical priority scoring systems was assessed in this retrospective cohort., Results: The median MeNTS score was significantly lower in adult patients whose surgery proceeded compared to those for whom the surgery was cancelled (48 vs 56; P = .004). Mucosal and MeNTS-M scores were not statistically different based on whether surgery proceeded. Among adult patients, the highest area under the curve (AUC) was for the MeNTS scoring system (0.794); both the mucosal and MeNTS-M systems had lower AUC values (which were significantly lower than the AUC for the MeNTS scoring system)., Conclusion: This study represents development and assessment of the first otolaryngology-specific surgical priority score and incorporates varying levels of mucosal disruption. The combined MeNTS-M scoring system could be a valuable tool in appropriately triaging otolaryngology-head and neck surgery procedures., (© The Authors 2021.)

Purpose: Lymphedema associated with head and neck cancer (HNC) therapy causes adverse clinical outcomes. Standard treatment includes professionally administered complete decongestive therapy (CDT). Cost and availability of trained therapists are known barriers to therapy. Advanced pneumatic compression devices (APCD) may address these issues. A randomized, wait-list controlled trial was undertaken to evaluate an APCD in post-treatment HNC patients with lymphedema., Material and Methods: Eligible patients had completed treatment for HNC, were disease free, and had lymphedema at enrollment. Participants were randomized to wait-list lymphedema self-management (standard of care) or lymphedema self-management plus the use of the APCD bid. Safety (CTCAE V4.0) and feasibility were primary endpoints; secondary endpoints included efficacy measure by objective examination and patient reported outcomes (symptoms, quality of life, function), adherence barriers, and satisfaction. Assessments were conducted at baseline and weeks 4 and 8., Results: Forty-nine patients were enrolled (wait-list n = 25; intervention n = 24). In total, forty-three patients completed the study. No device-related Serious Adverse Events were reported. Most patients used the APCD once per day, instead of the prescribed twice per day, citing time related factors as barriers to use. APCD use was associated with significant improvement in perceived ability to control lymphedema (p = 0.003) and visible external swelling (front view p < 0.001, right view p = 0.004, left p = 0.005), as well as less reported pain., Conclusion: This trial supports the safety and feasibility of the APCD for the treatment of secondary lymphedema in head and neck cancer patients. In addition, preliminary data supports efficacy.

Diabetes, which is present in 4 to 8% of adults in the United States, is a risk factor for surgical failure in laryngotracheal airway operations. We conducted a retrospective study to characterize a population of patients with subglottic stenosis-including the prevalence of diabetes, which has not been widely reported. We performed a retrospective chart review of 30 patients--22 women and 8 men, aged 17 to 77 years (mean: 47.5)--with subglottic stenosis who had presented to our facility between July 2001 and June 2004. Diabetes was present in 5 patients (16.7%); the prevalence of diabetes in our study was not significantly different from regional population-adjusted norms (8%). Although higher-grade stenosis was significantly more common in the diabetic patients than in the nondiabetic patients (p < 0.05), we were unable to conclude that diabetes plays an independent role in the development of subglottic stenosis. We intend to conduct a meta-analysis to assess the role that diabetes plays as both a risk factor for and an obstacle to the treatment of airway stenosis.

Objectives: To characterize the perceptual assessment of vocal quality in subglottic stenosis (SGS) patients and to identify risk factors for dysphonia., Study Design and Setting: Retrospective review, academic center., Methods: Perceptual voice assessment using GRBAS scale (Grade, Roughness, Breathiness, Asthenia, Strain); patient characteristics determined for 31 SGS cases., Results: The mean GRBAS (0 to 3 scale, 0 = normal quality) for SGS patients at their initial visit was G(1.4)R(1.2)B(0.5)A(0.5)S(1.1). For males vs females: G(2.1 vs 1.1)R(2.0 vs 0.8)B(1.0 vs 0.4)A(1.0 vs 0.3)S(1.7 vs 0.9). The Grade (P < 0.03), Breathiness (P < 0.04), and Asthenia (P < 0.02) assessments were significantly more dysphonic in patients with multilevel stenosis; vocal fold motion impairment (VFMI) also impacted overall Grade (P < 0.01). Overall Grade (P < 0.002), Roughness (P < 0.007), and Breathiness (P < 0.006) were significantly worse in patients with prior airway surgery., Conclusion: SGS patients demonstrate a mild to moderate change in perceptual voice characteristics with males in this series being more affected than females. Negative risk factors include multiple stenoses, VFMI, and previous airway surgery., Significance: This is the first systematic report of perceptual voice assessment in subglottic stenosis. SGS patients have notable degrees of dysphonia with identifiable risk factors.

Objectives: The study objective is to characterize the airway abnormalities in a series of patients with subglottic stenosis (SGS) as they relate to etiology and risk factors., Study Design and Setting: Retrospective review, academic medical center. Airway characteristics, patient demographics, and suspected risk factors were recorded from a database of SGS cases from 2001 to 2004., Results: Thirty-seven patients with SGS were identified; 22 of 37 had isolated SGS (59%). Intubation (10 of 37, 27%), high tracheotomy (4 of 37, 11%), and reflux (5 of 37, 14%) comprised the bulk of cases; 13 of 37 (35%) were considered idiopathic. Of 22 patients with isolated SGS, the majority 18 of 22 (P = 0.06) were women, 59% of which were idiopathic. Multiple-level cases (0 of 15) were idiopathic (P < 0.001). Intubation was the most common cause of multiple site stenosis (6 of 15, 40%)., Conclusions: The majority of patients in this study had isolated lesions. These patients tend to have no apparent risk factors. Multi-level cases are associated with prolonged intubation and known injuries. The nature of "idiopathic" stenoses is discussed., Significance: Clinical examination of SGS may be meaningful in understanding the etiology of the stenosis.

Objective: This study describes a large series of patients receiving topical mitomycin-c (MMC) during airway surgery, including complications, and carries out a cost analysis for its use in laryngotracheal stenosis., Study Design and Setting: Retrospective review, tertiary center. Airway patients receiving MMC are reviewed for demographics, stenosis characteristics, and MMC usage. A basic cost analysis is carried out., Results: Fifty patients underwent 93 MMC applications (mean = 50.8 years, 25 male, 25 female). In 89 of 93 applications (96%), the concentration of MMC was 0.4 mg/ml. One major complication occurred (1.1%). The expense for MMC is $455; the mean cost for airway surgery is $7,840. It is estimated that if 1 of 17 MMC treated patients requires one less operation, the cost ratio is favorable., Conclusions: This large series contributes to literature that MMC is a safe adjunct to laryngotracheal surgery. The marginal cost for MMC application is favorable based on our basic cost analysis and existing efficacy data., Significance: Mitomycin-c seems to be safe and cost-effective in endoscopic airway surgery., Ebm Rating: C-4.

Pterygoid fossa neoplasms in children are rare. Management of these neoplasms has been challenging because of tumor vascularity, difficult surgical access and complex anatomy from which these tumors arise. Surgical approach depends upon tumor extension and ability to obtain adequate exposure for successful tumor excision. We present three cases of an approach to the pterygopalatine fossa not previously described. The technique is cosmetically superior to the lateral rhinotomy approach and it preserves blood supply by leaving a portion of the periosteum attached to the maxilla. Furthermore, it avoids permanent hypesthesia/anesthesia of the midface with mobilization of the infraorbital nerve.

Objective: To explore the application of magnetic resonance imaging (MRI) in the evaluation of patients with cleft palate before and after primary palatoplasty with particular attention focused on the levator veli palatini muscle., Design: Prospective study using MRIs of subjects before and after primary cleft palate surgery., Setting: Hospital and university based., Patients: One female infant with normal anatomy. Three male and four female infants with cleft palate of varying severity., Intervention: Furlow double-opposing Z-plasty and V-Y palatoplasty., Main Outcome Measures: Magnetic resonance images., Results: It was found that the levator veli palatini muscle can be imaged before and after palatal surgery in infants using MRI. The muscle may have sufficient volume, proportionate to a normal infant or adult, in infants born with cleft palate. If retrodisplaced properly, the muscle is likely to be steeper (more vertical) from its origin at the base of the skull to its insertion into the velum following palatoplasty, thus providing a more favorable angle for elevating the velum. Following palatal surgery, the levator muscle mass may not be as cohesive across the velar midline, compared with normal musculature., Conclusion: MRI is a viable imaging modality for the evaluation of the anatomy of the levator veli palatini muscle before and after primary palatoplasty in infants born with cleft palate.

Options in the management of laryngoceles include observation, endoscopic resection, and resection via an external approach. We introduce a combined endoscopic and external approach that we have employed on several occasions to ensure complete removal of the laryngocele and the saccule from which it originated. A case is presented to help define the technique.

Objective: To obtain detailed anatomic information on the levator veli palatini (LVP) muscle from magnetic resonance imaging (MRI). Quantitative measures of the configuration of the LVP muscle at rest and during speech activities were obtained., Design: Prospective study using MRI of adult subjects with normal velopharyngeal mechanisms to determine anatomic and physiologic parameters of the levator muscle. The levator veli palatini muscle was imaged at rest and during speech activities consisting of nasal and non-nasal sounds mixed with vowels, consonants, or both (e.g., /ansa, asna, amfa, afma/)., Participants: Ten normal healthy adults (five men, five women) between 21 and 53 years of age and free of oropharyngeal abnormalities., Main Outcome Measures: Two-dimensional spin echo static images and dynamic fast gradient echo images of the levator muscle in both the sagittal and oblique/coronal planes., Results: On average across female (F) and male (M) subjects: distance between LVP muscle origin points, 52.6 mm (F), 54.6 mm (M); angle of levator muscle origin at rest, 64.5 degrees (F), 60.4 degrees (M); length of the levator muscle at rest, 44.1 mm (F), 46.4 mm (M); width of levator muscle at lateral margin of velum, 5.5 mm (F), 6.6 mm (M). Both the levator muscle angle of origin and length became progressively smaller from rest, nasal consonants, low vowels, high vowels, and fricatives for both female and male subjects. Across all subjects, there was a 19% reduction in length of the LVP muscle from rest position to fricative production., Conclusions: MRI is an effective method of imaging and measuring the LVP muscle and related structures in living subjects. Understanding the normal tissue distribution and quantification of the LVP muscle provides important information for development of a functional biomechanical model of the velopharynx and for improved surgical treatment.

Objective: To explore the application of magnetic resonance imaging (MRI) in the evaluation of patients with occult submucous cleft palate and to use the MRI information obtained to aid in the treatment decision to perform surgery versus behavioral speech therapy., Design: Prospective study with magnetic resonance (MR) images of subjects suspected of having occult submucous cleft palate., Setting: Hospital and university-based., Patients: Two girls who were 4 years old at the time of palatal surgery., Intervention: Furlow double-opposing Z-plasty., Main Outcome Measures: MR images and clinical speech evaluations., Results: MR images provided evidence of an interruption of levator veli palatini muscle tissue in the midline and a substantial attachment of levator muscle tissue to the posterior border of the hard palate. In addition, MR images for both subjects demonstrated remarkably similar bilateral encapsulating sheaths that contained nonmuscular tissue, as confirmed subsequently during surgery. The encapsulating sheaths interrupted the normal progression of the levator muscle sling across the midline. The MR images led to the decision to perform surgery instead of speech therapy. Hypernasality was markedly reduced in both subjects after surgery., Conclusions: MRI is an effective technique for diagnosing occult submucous cleft palate and may be an important aid in the treatment decision regarding surgery versus behavioral speech therapy for patients diagnosed with occult submucous cleft palate.

Background: This study developed and used a new, noninvasive approach to quantify cross-sectional area and tissue composition within the geniohyoid (GH) muscle in normal adults and head and neck cancer patients., Methods: B-mode ultrasound was used to measure GH cross-sectional area at rest and during four speech gestures and GH tissue composition at rest in normal young adults, patients with SCC head and neck cancer treated with primary radiotherapy, and normal older adults age matched with the patients., Results: Patients exhibited significantly greater GH cross-sectional area than young subjects at rest and in effortful conditions. Significantly greater muscle tissue variability across GH quadrants was observed in patients compared with normal subjects and in older compared with younger subjects., Conclusions: B-mode ultrasound area analyses and tissue classification techniques can be used to quantify muscle changes, such as those resulting from age, radiotherapy, or rehabilitation for head and neck cancer., (Copyright 2001 John Wiley & Sons, Inc.)

In order to advance our understanding of the relation between respiration and deglutition, simultaneous videofluoroscopy and respirodeglutometry was performed. Fifteen normal, healthy, young adults (20-29 years of age) were connected to a respirodeglutometer and positioned for simultaneous videofluoroscopic assessment in the lateral plane. Subjects performed three swallows each of a 5-ml and a 10-ml bolus of liquid barium and a 5-ml bolus of paste barium, for a total of nine swallows per subject. Location of the bolus head as identified with videofluoroscopy was associated with eight respirodeglutometric variables. In addition, temporal relations for seven respirodeglutometric variables were calculated as a function of bolus volume and viscosity. Significant temporal differences were found for five of the variables by volume. No significant temporal differences were noted by viscosity. Expiration occurred before 79% and after 96% of the swallows. The number of inspirations preceding a swallow suggested a possible effect resulting from the need to hold a bolus in the mouth before receiving instructions to swallow during videofluoroscopic assessment. This effect may be important during patient evaluation. For a significant number of swallows, respiratory flow ceased before the velum was fully elevated.

This study was designed to re-examine the same soft palates studied qualitatively in a previous investigation (Kuehn and Kahane, 1990), using a true-color image analysis system. The quantified measures of the areas of specific tissue types are reported. The results indicate that: (a) tendinous tissue is prominent anteriorly and comprises about 10% of total tissue in that region, (b) the relative proportion of glandular and connective tissue is fairly uniform across the length of the soft palate, averaging 22% and 36% respectively, (c) muscle tissue shows a pattern of increasing then decreasing amount from anterior to posterior with a maximum proportion of 23% in the midportion of the soft palate, (d) adipose tissue comprises 22% of total tissue area in the anterior segment and 17% of total tissue area in the posterior segment of the soft palate, (e) other tissue, primarily epithelium and vascular tissue, was found to be fairly constant anteriorly and increased in relative proportion to almost 30% of the total tissue area at the uvular base. The functional implications of these findings are discussed.