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Journal clubs are a fundamental part of medical training that allow residents and faculty to critically analyze literature, keep up-to-date with new advancements, and implement evidence-based medicine. The aim of this study was to describe one otolaryngology residency program's efforts towards reformatting its journal club, evaluate how well the re-designed format enabled participants to achieve journal club goals compared to the prior format, and assess faculty and resident qualitative perceptions of both formats.An 11-question survey was sent to all department faculty and residents to obtain feedback regarding the original journal club format. The results of this initial survey were then used to redesign the journal club format, which consisted of 3 rotating session types: evidence-based, deep-dive, and landmark. A 6-month pilot program using the redesigned format was implemented, and surveys were sent at the halfway mark and at the conclusion of the pilot to evaluate the effectiveness of these format changes.A single academic center with an otolaryngology residency program PARTICIPANTS: : Residents and faculty in the department of otolaryngology RESULTS: Compared to the original format, the 6-month pilot demonstrated a more consistent attainment of journal club goals and a near-unanimous preference for the new format. This preference was consistent among both faculty (90.9%) and residents (89%). All respondents agreed that the intended goals of journal club were more frequently met under the revamped format, and statistically significant differences in approval rate were observed in the specific areas of critically assessing the literature, highlighting new findings, and translating forefront knowledge. The overall time required to prepare for sessions was lower for faculty, and higher for residents.The findings from this study help to support programmatic efforts towards redesigning journal clubs with the goals of improving participant satisfaction and educational benefit. With the paucity of data in the literature evaluating journal club format overhauls, this study provides compelling evidence for programs to perform similar assessments and consider redesigns if warranted.

To assess the quality, readability, and understandability of posterior glottic stenosis (PGS) information available to patients online.The top 50 Google search results for "posterior glottic stenosis" were categorized based on website affiliation and target audience (patient or provider). Readability was assessed using the Flesch-Kincaid Grade Level (FKGL) and the Flesch Reading Ease (FRE) scores. The DISCERN tool was used to assess quality and the Patient Education Assessment Tool for Printed Materials (PEMAT-P) was used to assess understandability and actionability. Simple descriptive statistics were used to analyze the data.36 of the top 50 results were eligible for scoring. 17% (6 of 36) were classified as patient-focused while 83% (30 of 36) were provider-focused. Patient-focused materials had a higher mean FRE score (36.9) than provider-focused materials (15.5) (P0.001). Patient-focused materials had an average reading level of 12.5 compared to 15.8 for provider-focused materials (P0.001). There was a significant correlation between overall PEMAT-P and DISCERN (r = 0.63, P0.001), PEMAT-P understandability and DISCERN (r = 0.63, P0.001) and FRES and FKGL (r = -0.67, P0.001). From this, we can infer that higher quality sites are easier to understand but not necessarily tailored to a certain reading level.Shared decision making in PGS management is crucial as patients must be aware of how treatment modalities affect airway, voice, and swallowing. However, this study shows that patient targeted PGS information is limited, and the readability, quality, and understandability is generally low. We suggest the development of web pages with PGS information tailored for patient education and search optimization to make this information appear earlier in Google search results. Furthermore, future studies should seek to characterize the link between online health information and socioeconomic-based health disparities.

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.

The purpose of this review article is to summarize the existing literature surrounding wound healing mechanisms in laryngotracheal stenosis.A review of general wound healing pathophysiology, followed by a focused review of iatrogenic laryngotracheal stenosis (iLTS) and idiopathic subglottic stenosis (iSGS) as conditions of aberrant wound healing.iLTS is the scarring of the laryngotracheal complex, coming secondary to injury from prolonged intubation. iSGS is a chronic fibroinflammatory scarring and narrowing of the subglottic airway in the absence of any obvious preceding injury or trauma. They are both thought to result from a prolonged and dysregulated wound healing response that promotes the deposition of pathologic scar in the airway.Understanding the mechanisms that underlie wound healing will help identify and intervene on the process early in its development and discover future therapies that target individual wound healing mechanisms limiting the incidence of this recalcitrant disease process.

In a subspecialty interdisciplinary voice and swallowing clinic, patient referrals come from a wide variety of disciplines for various reasons, which can make scheduling their initial evaluations challenging. Depending on the nature of complaints and symptoms, patients may best be evaluated either by a single provider (a laryngologist) or by an interdisciplinary team that includes a speech-language pathologist. If not scheduled appropriately, the provider and the patient may lose valuable time, resources, and money. This was a retrospective chart review of 76 patients who received an interdisciplinary evaluation in our Voice and Swallowing Center's first 7 months of operation. Two factors were examined for their predictive values: the most common reasons for referral and the disciplines that commonly refer to the clinic. The goal was to probe for any variables known at the time of referral that could inform us whether an interdisciplinary evaluation would be beneficial or not. This information informs resource planning for space, equipment, scheduling, and staffing. The results showed that the most common reasons for a referral to the Voice and Swallowing Center were dysphonia (34.8%), dyspnea/paradoxical vocal fold motion ("PVFM," 20.2%), and dysphagia (18%). Statistical analysis of the results indicated that certain reasons for referral were more likely to require an interdisciplinary evaluation than others: dysphonia, irritable larynx syndrome/chronic cough, and PVFM. Referrals most commonly came from providers with a background discipline of primary care (26%) and otolaryngology (22%). The discipline of a referring provider alone was not a strong enough indicator to reliably predict the type of evaluation needed. Examining the available data on referral patterns, as this study has done, has the potential to inform providers how to better anticipate their patients' needs and also improve clinic operations.

IntroductionGlottic insufficiency can result from neurologic injury, surgery, radiation, and the aging larynx. Treatment includes voice therapy, vocal fold injection augmentation, surgical medialization, or laryngeal reinnervation procedures. The objective of this study is to describe an in-vivo rabbit phonation model for glottic insufficiency that is simple and reproducible by means of unilateral cricothyroid muscle stimulation and high-speed video recordings of evoked phonation.MethodsA non-randomized controlled trial utilizing seven New Zealand white rabbits was performed via a single operation including evoked phonation with bilateral and unilateral cricothyroid muscle stimulation conditions. The effect of stimulation method on glottic cycle, pitch and loudness was compared. Endoscopic recordings using 5,000 frames-per-second image capture technology and audiologic recordings were obtained for all phonation conditions. Primary outcome measures included means of maximum glottal area (MGA)/length pixel ratio, right and left amplitude/length pixel ratios, calculated cycle frequency, auditory recorded frequency, and maximum auditory intensity. Measurements were obtained via pixel counts using imageJ. Paired t-tests compared the average values obtained over five consecutive glottic cycles for each unilateral and bilateral stimulation during evoked phonation.ResultsMean (median, IQR) MGA/length was significantly greater with unilateral, 20.30 (19.13, 10.97), vs bilateral, 9.62 (8.33, 2.58), stimulation (p=0.043). Mean frequency (median, IQR), 683.46 Hz (658.5, 197.1) vs 479.92 Hz (458.1, 112); (p=0.027) and mean maximum intensity, 83.5 dB (83.5, 1) vs 76.3 dB (74.5, 4); (p=0.013) were significantly reduced from bilateral to unilateral stimulation. There was no significant difference of mean right amplitude/length between bilateral and unilateral.ConclusionThe described model demonstrates a simple and reproducible means of producing glottic insufficiency and represents a pathway for better understanding the biomechanics and pathophysiology of glottic insufficiency and offers the potential to compare treatment modalities through in-vivo study.

Objective Vocal fold paresis or paralysis (VFP) may severely affect quality of life due to dysphonia and respiratory distress. As an increasing percentage of the United States population receives the COVID-19 vaccination, the objective of this study is to determine the correlation of COVID-19 post-vaccination recurrent laryngeal neuropathy and resulting VFP. Methods The Vaccine Adverse Event Reporting System database was queried for patients exhibiting symptoms of VFP following COVID-19 vaccination. Patient demographics and clinical information including presenting symptoms, time of symptom onset, time of diagnosis and laterality. Results Twenty patients were found to have laryngoscopy confirmed VFP following COVID-19 vaccination. Vaccinations for Pfizer-BioNTech, Moderna, and Janssen were reported. Of those reported, 13 patients were female (65.0%) and 7 were male (35.0%), with a mean age of 61.8 years. The most common presenting symptom was a hoarse voice (30.0%). A majority of these cases were unilateral in nature (64.0%). Mean time from vaccination to symptom onset was 12.1 days and mean time from vaccination to diagnosis was 37.6 days. Conclusion For patients presenting with voice or swallowing complaints after receiving the COVID-19 vaccine, prompt evaluation by an otolaryngologist should occur. However, the potential VFP side effect of vaccination is very rarely cited in the literature and largely outweighed by the benefits of vaccination. Further research is needed to delineate the exact pathophysiology of this complication and determine whether a causal relationship exists.

Objectives/hypothesis The purpose of this study was to develop and provide evidence of a novel permanent injectable biomaterial for vocal fold augmentation with the potential to treat glottic incompetence by evaluating its performance in two animal models. Study design Animal model. Methods Microporous annealed particle (MAP) hydrogel was fabricated using a water-in-oil emulsion method and synthetically tuned to match the stiffness modulus of native vocalis muscle. Thirty-two New Zealand White rabbits were administered unilateral injections of MAP (n = 16), saline (n = 8), and the clinical standard hyaluronic acid (Restylane-L) (n = 8), and evaluated at day 0, and 6-week, 4-month, and 6-month endpoints. Induced vocal fold vibration was recorded with a high-speed camera prior to euthanization, with glottic closure and mucosal wave characteristics assessed both quantitatively and qualitatively by an experienced voice clinician. Histologic analysis was performed to assess scaffold permanence, immunogenicity, and vascularization within the scaffold. Results Histologic analysis confirmed the MAP gel treatment group maintained its volume without migration for 6 months postimplantation. Immune staining showed minimal to nonexistent immunogenicity over the course of the implant lifetime. Extensive tissue integration and vascularization was observed histologically within the MAP gel group by immunofluorescence staining. Mucosal wave was not impaired by any of the injected materials, including the MAP gel augmentation. Conclusions MAP gel is a nonresorbable biostimulatory injectable implant that provides superior tissue integration, stiffness matching, and permanence compared to current injectable implants, with retained biomechanical function, suggesting its potential as a new therapeutic for glottic incompetence. Level of evidence NA Laryngoscope, 130:2432-2441, 2020.

To compare flexible distal-chip laryngoscopy (FDL) and rigid telescopic laryngoscopy (RTL) in image quality and diagnostic ability.Prospective cohort study; blinded comparison.Eighteen normal adult subjects were recruited to undergo both FDL and RTL and normalized videos were recorded. Three blinded laryngologists compared the videos for color fidelity, illumination, resolution, and vascularity, and indicated superiority with FDL, RTL, or no difference. Raters also reported if an abnormality was seen and in which video it was better visualized. Videos for two subjects were repeated to assess intra-rater reliability, making 20 video comparisons across 3 raters for a total of 60 ratings. Differences in responses were analyzed via Mann-Whitney U and Pearson ΧRTL was rated superior in all categories of image quality (47 vs 5 vs 8, P0.01; 47 vs 7 vs 6, P0.01; 51 vs 5 vs 4, P0.01; 44 vs 9 vs 7, P0.01, respectively). An abnormality was seen 33 times with both modalities and 6 times with RTL only. When seen with both modalities, visualization was superior in RTL compared with FDL (29 vs 4, P0.01).There was significant superiority of RTL in all categories of image quality, with slight inter-rater agreement for color fidelity, resolution, and vascularity. RTL was also significantly better for visualization of abnormalities. These findings suggest superior image quality in RTL compared with FDL, but further research is required to determine if this difference is clinically significant.

In this paper, a numerical approach combined with experiments is employed to characterize the airflow through the vocal cord. Rabbits are used to perform in vivo magnetic resonance imaging (MRI) experiments and the MRI scan data are directly imposed for the three-dimensional (3D) reconstruction of a 3D high-fidelity model. The vibration modes are observed via the in vivo high-speed videoendoscopy (HSVM) technique, and the time-dependent glottal height is evaluated dynamically for the validation of the 3D reconstruction model. 72 sets of rabbit in vivo high-speed recordings are evaluated to achieve the most common vibration mode. The reconstruction is mainly based on MRI data and the HSVM records are supporting and validate the 3D model. A sharp-interface immersed-boundary-method (IBM)-based compressible flow solver is employed to compute the airflow. The primary purpose of the computational effort is to characterize the influence of the vocal folds that applied to the airflow and the airflow-induced phonation. The vocal fold kinematics and the vibration modes are quantified and the vortex structures are analyzed under the influence of vocal folds. The results have shown significant effects of the vocal fold height on the vortex structure, vorticity and velocity. The reconstructed 3D model from this work helps to bring insight into further understanding of the rabbit phonation mechanism. The results provide potential improvement for diagnosis of human vocal fold dysfunction and phonation disorder.

Ear, nose, and throat procedures in intraoperative environments often involve surgeons' and anesthesiologists' use of shared and sometimes competing approaches to managing a patient's airway. Both clinicians have expertise in laryngoscopy and unique skill sets needed for advanced airway management. This article explores how joint decision making is best achieved despite disagreements and how collegial, collaborative relationships can be preserved to prioritize patients' safety during risk assessment and goal setting.

Summary Laryngeal botulinum toxin injection is an important treatment modality for spasmodic dysphonia and other laryngeal disorders. We sought to compare usage patterns of laryngeal botulinum toxin injections for voice disorders and to identify and quantify inefficiencies and barriers in providing this treatment. A 26 item survey was written and approved for distribution by the American Academy of Otolaryngology-Head and Neck Surgery and the National Spasmodic Dysphonia Association. It was distributed to Otolaryngologists who perform laryngeal botulinum toxin injections via the e-mail lists of the National Spasmodic Dysphonia Association provider database, American Academy of Otolaryngology-Head and Neck Surgery Voice Committee and the American Laryngological Association Neurolaryngology Study Group. There were 81 survey participants who collectively reported performing >1700 laryngeal botulinum toxin injections for voice disorders monthly (Mean = 21.5 pts/month). Regarding botulinum toxin A (BtxA) vial use, 54% of participants reported using multiple doses per vial for different patients during a single clinic day, while 14% reported using pharmacy predrawn single use aliquots. A combination of usage practices was reported by 7% of participants. Using an individual vial per patient and discarding the unused remainder was reported by 26% of participants with an associated annual cost in wasted BtxA of $84,300 per physician. There is wide variation in injection practices regarding management of BtxA vials and adherence to an individual vial per patient policy is associated with significant waste of health care resources. Alternative approaches to BtxA vial use could positively impact health care resource utilization.

The upper aerodigestive tract is a complex region of human anatomy owing to the diverse and dynamic physiologic functions that it provides. A thorough anatomic understanding provides the basis for comprehending the physiology and pathophysiology of various neurologic laryngeal and pharyngeal diseases. As laryngoscopy, both flexible and direct, has become more common and produces higher resolution images, the importance of maintaining an in-depth understanding of laryngeal anatomy has increased significantly. We discuss pharyngeal and laryngeal anatomy from the luminal perspective to aid in interpreting the laryngoscopic exam. Anatomy is reviewed in a stepwise fashion beginning with the laryngeal skeleton and expanding to include all laryngeal structures. Particular detail is provided for vascular structures in planning microlaryngeal surgery and office-based procedures.

Purpose The purpose of this study was to perform a comprehensive systematic review of the literature on voice-related patient-reported outcome (PRO) measures in adults and to evaluate each instrument for the presence of important measurement properties. Method MEDLINE, the Cumulative Index of Nursing and Allied Health Literature, and the Health and Psychosocial Instrument databases were searched using relevant vocabulary terms and key terms related to PRO measures and voice. Inclusion and exclusion criteria were developed in consultation with an expert panel. Three independent investigators assessed study methodology using criteria developed a priori. Measurement properties were examined and entered into evidence tables. Results A total of 3,744 studies assessing voice-related constructs were identified. This list was narrowed to 32 PRO measures on the basis of predetermined inclusion and exclusion criteria. Questionnaire measurement properties varied widely. Important thematic deficiencies were apparent: (a) lack of patient involvement in the item development process, (b) lack of robust construct validity, and (c) lack of clear interpretability and scaling. Conclusions PRO measures are a principal means of evaluating treatment effectiveness in voice-related conditions. Despite their prominence, available PRO measures have disparate methodological rigor. Care must be taken to understand the psychometric and measurement properties and the applicability of PRO measures before advocating for their use in clinical or research applications.

Thyroglossal duct cysts (TGDCs) are the most common congenital neck mass and often present in the paediatric population as a painless mass in the midline. A lateralised neck mass presenting for the first time in an adult may raise more concern for malignancy or a laryngocele. A 50-year-old man presented with an asymptomatic right level II neck mass adjacent to the thyroid cartilage. Preoperative CT revealed a cystic mass right of the midline with an intralaryngeal component. Intraoperatively, the lesion tracked towards the central hyoid bone; a Sistrunk procedure was performed. Postoperative pathology revealed a small foci of thyroid tissue within the mass. Careful consideration of the origin of this unusually presenting TGDC enabled appropriate operative management.

Objectives/Hypothesis Idiopathic subglottic stenosis (iSGS) is a rare and devastating extrathoracic obstruction involving the lower laryngeal and upper tracheal airway. It arises without known antecedent injury or associated disease process. Persistent mucosal inflammation and a localized fibrotic response are hallmarks of the disease. Despite the initial clinical description of iSGS more than 40 year ago, there have been no substantive investigations into the pathogenesis of this enigmatic and progressive airway obstruction. In these studies, we present the initial characterization of the molecular pathogenesis underlying the fibrosing phenotype of iSGS. Methods Utilizing 20 human iSGS and healthy control specimens, we applied histologic, immunohistochemical, molecular, and immunologic techniques. Results We demonstrate significant activation of the canonical IL-23/IL-17A pathway in the tracheal mucosa of iSGS patients, as well as identify γδ T cells as the primary cellular source of IL-17A. Conclusion Our results suggest that aberrant mucosal immune activation is a component in of the pathogenesis of iSGS. Most critically, our work offers new targets for future therapeutic intervention. Level of Evidence NA Laryngoscope, 126:E356–E361, 2016

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.

Importance Because of the recurrent nature of idiopathic subglottic stenosis, routine follow-up is necessary for monitoring progression of stenosis. However, no easily accessible, standardized objective measure exists to monitor disease progression. Objective To determine whether peak expiratory flow (PEF) can be used as a reliable and easily accessible biometric indicator of disease progression relative to other validated spirometry measures in patients with idiopathic subglottic stenosis. Design, setting, and participants Prospectively collected data on PEF, expiratory disproportion index (EDI), and total peak flow (TPF) from 42 women with idiopathic subglottic stenosis without comorbid lower airway or parenchymal lung disease who were treated at a single tertiary referral center between 2014 and 2018 were analyzed. The mean follow-up period was 18.2 months (range, 2-40 months). Ten patients initially screened were not included in the analysis owing to comorbid glottic or supraglottic stenosis or nonidiopathic etiology. Main outcomes and measures Measurements of PEF, EDI, and TPF were taken at preoperative visits and at all other visits. Results Forty-two women (mean age, 51.5 years; 98% white [n = 41]) met the inclusion criteria. The area under the curve for PEF was 0.855 (95% CI, 0.784-0.926). The optimal cutoff value was 4.4 liters per second (264 L/min), with a sensitivity and specificity of 84.4% and 82.0%, respectively. The area under the curve for EDI was 0.853 (95% CI, 0.782-0.925). For TPF, this was 0.836 (95% CI, 0.757-0.916). Conclusions and relevance This study provides evidence supporting the use of PEF as a simple, efficient, and accessible way of monitoring progression of idiopathic subglottic stenosis and predicting receipt of surgical intervention. Sensitivity and specificity of PEF were comparable to those of the more complex measures of TPF and EDI.

Objective To characterize the associated symptoms of dysphagia and dyspnea among patients presenting with muscle tension dysphonia (MTD). Study Design Retrospective chart review performed over a 14-month period from October 2014 to December 2015. Setting Voice and swallowing center of a tertiary academic medical center. Subjects and Methods Thirty-eight patients with MTD were included for analysis. Clinical data were collected and analyzed, including perceptual voice evaluation and patient-reported outcomes measures. Results Among patients with a diagnosis of MTD, the incidence of reported dysphagia during clinical history and examination was 44.7%. Among patients with MTD, 60.5% had an EAT-10 (10-item Eating Assessment Tool) score ≥3 (ie, abnormal). Patients who reported dysphagia and/or had abnormal EAT-10 score (≥3) had significantly greater voice impairment than that of patients without dysphagia ( P = .02). Patients who reported dysphagia also had significantly higher Clinical COPD Questionnaire scores than those of patients who reported only dysphonia ( P = .002). Conclusions Patients presenting for dysphonia who are diagnosed with MTD have a high rate of comorbid dysphagia. Patients who reported dysphagia had significantly higher self-reported voice impairment and greater severity of breathing dysfunction as measured by the Clinical COPD Questionnaire. The coincidence of these symptoms in this patient cohort may suggest an underlying pathophysiology that has yet to be elucidated. Further prospective studies are needed to clarify the underlying cause of dysphagia and breathing dysfunction in the setting of MTD and to investigate diagnostic and therapeutic paradigms.

IntroductionIdiopathic subglottic stenosis (iSGS) is an unexplained progressive obstruction of the upper airway that occurs almost exclusively in adult, Caucasian women. The disease is characterised by mucosal inflammation and localised fibrosis resulting in life-threatening blockage of the upper airway. Because of high recurrence rates, patients with iSGS will frequently require multiple procedures following their initial diagnosis. Both the disease and its therapies profoundly affect patients’ ability to breathe, communicate and swallow. A variety of treatments have been advanced to manage this condition. However, comparative data on effectiveness and side effects of the unique approaches have never been systematically evaluated. This study will create an international, multi-institutional prospective cohort of patients with iSGS. It will compare three surgical approaches to determine how well the most commonly used treatments in iSGS ‘work’ and what quality of life (QOL) trade-offs are associated with each approach.Methods and analysisA prospective pragmatic trial comparing the ‘Standard of Care’ for iSGS at multiple international institutions. Patients with a diagnosis of iSGS without clinical or laboratory evidence of vasculitis or a history of endotracheal intubation 2 years prior to symptom onset will be included in the study. Prospective evaluation of disease recurrence requiring operative intervention, validated patient-reported outcome (PRO) measures as well as patient-generated health data (mobile peak flow recordings and daily steps taken) will be longitudinally tracked for 36 months. The primary endpoint is treatment effectiveness defined as time to recurrent operative procedure. Secondary endpoints relate to treatment side effects and include PRO measures in voice, swallowing, breathing and global QOL as well as patient-generated health data.Ethics and disseminationThis protocol was approved by the local IRB Committee of the Vanderbilt University Medical Center in July 2015. The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations and directly to patient with iSGS via social media-based support groups.Trial registration numberNCT02481817.

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

This case series assesses whether surgical technique or adjunctive measures are associated with duration between surgical procedures for subglottic stenosis.

We investigated the timeline of tissue repair of vocal fold epithelium after acute vibration exposure using an in vivo rabbit model. Sixty-five New Zealand white breeder rabbits were randomized to 120 min of modal- or raised-intensity phonation. After the larynges were harvested at 0, 4, 8, and 24 h, and at 3 and 7 days, the vocal fold tissue was evaluated using electron microscopy and quantitative real-time polymerase chain reaction. There was an immediate decrease in the microprojection depth and height following raised-intensity phonation, paired with upregulation of cyclooxygenase-2. This initial 24-h period was also characterized by the significant downregulation of junction proteins. Interleukin 1β and transforming growth factor β1 were upregulated for 3 and 7 days, respectively, followed by an increase in epithelial cell surface depth at 3 and 7 days. These data appear to demonstrate a shift from inflammatory response to the initiation of a restorative process in the vocal fold epithelium between 24 h and 3 days. Despite the initial damage from raised-intensity phonation, the vocal fold epithelium demonstrates a remarkable capacity for the expeditious recovery of structural changes from transient episodes of acute phonotrauma. While structurally intact, the return of functional barrier integrity may be delayed by repeated episodes of phonotrauma and may also play an important role in the pathophysiology of vocal fold lesions.

Objectives/Hypothesis The ideal animal experimental tracheostomy technique is one that is 1) safe and easy to perform, 2) requires no tracheostomy tube, and 3) requires minimal cleaning or suctioning to maintain patency. The leporine model for airway injury has been well established and offers an inexpensive and practical animal model for experimental evaluation. However, previous research has demonstrated a high mortality rate with survival airway surgery in rabbits. This study demonstrates the feasibility of airway management in the leporine model using a simple maturing suture tracheostomy that avoids a tracheostomy tube. Study Design Tracheostomy was performed in six New Zealand white rabbits in the setting of survival surgery over a 2-week study period. Methods A vertical tracheal incision was made from the second to the sixth tracheal ring. The anterior portion of the tracheal rings was removed and the skin surrounding the stoma was sutured down to the tracheal wall. The lateral tracheal wall was then suspended to the soft tissue in the lateral neck. Results All six rabbits survived the study period with minimal care and maintained stoma patency until sacrifice. Granulation tissue and edema were noted during the first week and largely resolved by the second week. An average of 5-mm-diameter stoma was measured 14 days after surgery without intraluminal stenosis or laryngeal edema. Conclusions This method meets the defined criteria for the ideal experimental tracheostomy, demonstrating potential benefit in a laryngotracheal stenosis model and a rabbit model of evoked phonation. Level of Evidence NA Laryngoscope, 125:680–684, 2015

Laryngeal framework surgery is the current gold standard treatment for unilateral vocal fold paralysis. It provides a permanent solution to glottic insufficiency caused by injury to the recurrent laryngeal nerve. Various modifications to the original Isshiki type I laryngoplasty procedure have been described to improve voice and swallowing outcomes. The success of this procedure is highly dependent on the experience of the surgeon as it epitomizes the intersection of art and science in the field. The following article reviews the evidence, controversies, and complications related to laryngoplasty for unilateral vocal fold paralysis. It also provides a detailed analysis of how and when arytenoid-positioning procedures should be considered, and summarizes the literature on postoperative outcomes.

Background Children with severe asthma have frequent exacerbations despite guidelines-based treatment with high-dose corticosteroids. The importance of refractory lung inflammation and infectious species as factors contributing to poorly controlled asthma in children is poorly understood. Objective To identify prevalent granulocyte patterns and potential pathogens as targets for revised treatment, 126 children with severe asthma underwent clinically indicated bronchoscopy. Methods Diagnostic tests included bronchoalveolar lavage (BAL) for cell count and differential, bacterial and viral studies, spirometry, and measurements of blood eosinophils, total IgE, and allergen-specific IgE. Outcomes were compared among 4 BAL granulocyte patterns. Results Pauci-granulocytic BAL was the most prevalent granulocyte category (52%), and children with pauci-granulocytic BAL had less postbronchodilator airflow limitation, less blood eosinophilia, and less detection of BAL enterovirus compared with children with mixed granulocytic BAL. Children with isolated neutrophilia BAL were differentiated by less blood eosinophilia than those with mixed granulocytic BAL, but greater prevalence of potential bacterial pathogens compared with those with pauci-granulocytic BAL. Children with isolated eosinophilia BAL had features similar to those with mixed granulocytic BAL. Children with mixed granulocytic BAL took more maintenance prednisone, and had greater blood eosinophilia and allergen sensitization compared with those with pauci-granulocytic BAL. Conclusions In children with severe, therapy-resistant asthma, BAL granulocyte patterns and infectious species are associated with novel phenotypic features that can inform pathway-specific revisions in treatment. In 32% of children evaluated, BAL revealed corticosteroid-refractory eosinophilic infiltration amenable to anti-TH2 biological therapies, and in 12%, a treatable bacterial pathogen.

The purpose of the study was to define the impact of Zenker’s diverticula on voice and potential benefit from repair. Retrospective chart review of prospectively collected data from eleven patients with a Zenker’s diverticulum treated surgically in a tertiary care center from November 2014 through January 2016. The voice handicap index-10 (VHI-10) and eating assessment tool-10 (EAT-10) questionnaires were collected as part of pre- and post-operative evaluation, with an average post-operative follow-up of 69 days. Surgical techniques included: trans-oral endoscopic diverticulotomy with laser assistance, or trans-cervical approach with diverticulopexy or diverticulectomy. The primary outcome was subjective voice improvement. Secondary outcome was swallowing function improvement. Statistical analysis was performed using Wilcoxon Signed-Ranks and Mann–Whitney U tests. In patients undergoing surgical treatment of Zenker’s diverticula, there is a statistically significant improvement (p = 0.001) in patient-reported dysphagia symptoms measured by the EAT-10. There is also a clinically relevant improvement in subjective voice quality (average pre-operative total 6.55, post-operative 2.09, p = 0.022) as measured by the VHI-10. Many patients suffering from Zenker’s diverticula experience subjective voice handicap. Most note improvement in voice quality post-operatively, which we were able to quantify using the voice handicap index. We consider this a relevant consideration in pre-operative evaluation.

Objectives/Hypothesis Idiopathic subglottic stenosis (iSGS) is an unexplained obstruction involving the lower laryngeal and upper tracheal airway. Persistent mucosal inflammation is a hallmark of the disease. Epithelial microbiota dysbiosis is found in other chronic inflammatory mucosal diseases; however, the relationship between tracheal microbiota composition and iSGS is unknown. Given the critical role for host defense at mucosal barriers, we analyzed tissue specimens from iSGS patients for the presence of microbial pathogens. Methods Utilizing 30 human iSGS, 20 intubation-related tracheal stenosis (iLTS), and 20 healthy control specimens, we applied molecular, immunohistochemical, electron microscopic, immunologic, and Sanger-sequencing techniques. Results With unbiased culture-independent nucleic acid, protein, and immunologic approaches, we demonstrate that Mycobacterium species are uniquely associated with iSGS. Phylogenetic analysis of the mycobacterial virulence factor rpoB suggests that, rather than Mycobacterium tuberculosis, a variant member of the Mycobacterium tuberculosis complex or a closely related novel mycobacterium is present in iSGS specimens. Conclusion These studies identify a novel pathogenic role for established large airway bacteria and provide new targets for future therapeutic intervention. Level of Evidence NA Laryngoscope, 127:179–185, 2017

Otitis media is the most common reason for antibiotic prescription in the United States. Whether due to disease virulence or growing antimicrobial resistance, complications of otitis media seem to be seen more frequently. These complications may be difficult to identify and treat. This article focuses on the pathophysiology of these complications and address medical and surgical approaches to safe treatment.

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.Medical record abstraction.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.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 (chi(2) = 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.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.4. Laryngoscope, 126:1390-1396, 2016.

The ideal animal experimental tracheostomy technique is one that is 1) safe and easy to perform, 2) requires no tracheostomy tube, and 3) requires minimal cleaning or suctioning to maintain patency. The leporine model for airway injury has been well established and offers an inexpensive and practical animal model for experimental evaluation. However, previous research has demonstrated a high mortality rate with survival airway surgery in rabbits. This study demonstrates the feasibility of airway management in the leporine model using a simple maturing suture tracheostomy that avoids a tracheostomy tube.Tracheostomy was performed in six New Zealand white rabbits in the setting of survival surgery over a 2-week study period.A vertical tracheal incision was made from the second to the sixth tracheal ring. The anterior portion of the tracheal rings was removed and the skin surrounding the stoma was sutured down to the tracheal wall. The lateral tracheal wall was then suspended to the soft tissue in the lateral neck.All six rabbits survived the study period with minimal care and maintained stoma patency until sacrifice. Granulation tissue and edema were noted during the first week and largely resolved by the second week. An average of 5-mm-diameter stoma was measured 14 days after surgery without intraluminal stenosis or laryngeal edema.This method meets the defined criteria for the ideal experimental tracheostomy, demonstrating potential benefit in a laryngotracheal stenosis model and a rabbit model of evoked phonation.

INTRODUCTION Type I laryngoplasty has become the most dependable procedure for the management of anterior and midglottic incompetence since its classification by Isshiki in 1974. Many procedure variations have emerged, including the development of numerous techniques, implants, and prefabricated systems increasing the utilization of medialization laryngoplasty. Sharp dissection of the cartilage window becomes difficult with calcified thyroid cartilages, often encountered in older men. The surgical drill with a small cutting or diamond burr is used adjunctively to overcome this frequent anatomic variant. Halum et al. first described ultrasonic surgical system thyroplasty window creation in cadavers. The Sonopet ultrasonic surgical aspirator—developed by Synergetics USA, Inc. (O’Fallon, MO) and distributed by Stryker, Inc. (Kalamazoo, MI)—consists of a main control unit (Fig. 1), handpiece, ultrasonic tip, and foot control. This device produces ultrasonic vibrations that selectively grade rigid structures such as cartilage and bone while sparing adjacent soft tissue. The handpiece provides concurrent irrigation and suction (Fig. 2) while a piezoelectric element vibrates the tip at 25 kHz. The ultrasonic vibration moves in two planes, creating longitudinal and torsional forces without grabbing or kicking typical of rotary drill motion. This motion emulsifies tissue without excess heat production and requires minimal downward pressure. This ultrasonic surgical aspirator, initially created for neurosurgical applications, is now being used by a broader group of surgical subspecialties such as plastic surgery, ophthalmology, and oralmaxillofacial surgery. We now describe the first invivo series of the ultrasonic surgical aspirator for laryngeal framework surgery.

To determine the frequency and clinical relevance of unanticipated histopathologic results in routine sinonasal surgery and evaluate the necessity for histologic processing of nasal septal cartilage, bone, and inferior turbinate specimens.Case series with chart review.Tertiary care academic medical center.A retrospective review of surgical pathology reports on adult patients undergoing sinonasal surgery during a 5-year period from 2005 to 2010 was performed. All cases with the preoperative diagnosis of sinonasal neoplasia, autoimmune disease, or directed septal biopsies were excluded from review.A total of 1194 pathology reports were reviewed from 1172 individual patients. This included histopathologic evaluation of 1194 septal cartilage and bone specimens and 714 inferior turbinate specimens. None of the patients had unanticipated histopathologic findings that were clinically significant.Many surgeons obtain histopathologic diagnoses on all tissue removed from a patient. Based on our institutional case series, histopathology of the septum and inferior turbinates in routine sinonasal cases may not be necessary. A value-based approach to processing grossly unremarkable septal and turbinate tissue by waiving histologic processing and subsequent microscopic evaluation could provide significant cost savings.

Objective: 1) Determine the frequency and clinical relevance of unanticipated histopathologic results in routine sinonasal surgery. 2) Evaluate the necessity for histopathologic processing of septal cartilage, bone, and inferior turbinate specimens during routine sinonasal surgery.Method: A retrospective review of histopathologic reports on all adult patients undergoing sinonasal surgery at a tertiary care hospital during a 5-year period from 2005 to 2010 was performed. All cases with the preoperative diagnosis of sinonasal neoplasia, autoimmune disease, or directed septal biopsies were excluded from review.Results: A total of 1198 pathology reports were reviewed from 1175 individual patients. This included histopathologic evaluation of 1194 septal cartilage and bone specimens and 715 inferior turbinate specimens. None of the patients had an unanticipated histopathology finding other than squamous metaplasia and inflammation.Conclusion: Many surgeons obtain histopathologic diagnoses on all tissue removed ...

This case report demonstrates a novel technique for image-guided choanal atresia repair in the undersized neonate. A surgical navigation system (Stryker, Inc., Kalamazoo, MI) face mask was applied in an “inch-worm” technique facilitating a registration “work-around,” also detailed here, to permit intraoperative image guidance despite the patient's small head size. At age 10 days, the premature neonate underwent successful image-guided endoscopic repair of bilateral choanal atresia, permitted by a unique adaptation of face mask application and registration technique. This report presents the smallest weight patient in the literature to date to undergo image guidance during transnasal bilateral choanal atresia repair.

Objectives/Hypothesis: To investigate patient outcomes with large-diameter bougienage in isolated cricopharyngeal dysfunction and understand how esophageal dilatation can be used as an effective diagnostic and therapeutic modality in treating dysphagia. Study Design: Retrospective review. Methods: A retrospective chart review was performed on 46 patients meeting the criteria for cricopharyngeal dysphagia from 2004 to 2008 presenting in the outpatient setting. Patients were treated with 60 French esophageal dilators. Outcomes were analyzed as a function of symptomatology, manometry, duration of benefit, and safety. Results: Over the period reviewed, 59 dilatations were performed on 46 patients with cricopharyngeal dysfunction. Eight patients were dilated more than once. Four patients were lost to follow-up. The average starting Functional Outcome Swallowing Score (FOSS) was 2.07. Of the patients reviewed, 64.29% experienced an improvement in their FOSS with a median duration of 741 days. There were five minor complications and no major complications. Conclusions: In the largest series of esophageal dilatation for cricopharyngeal dysfunction in the literature, we found large-bore bougienage to have significant utility due to its efficacy, ease of use, and safety when compared to other modalities such as botulinum injection, balloon dilatation, and cricopharyngeal myotomy.