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Objectives/hypothesis: To evaluate the efficacy of various techniques of laryngohyoid suspension in the elimination of aspiration utilizing a cadaveric ovine model of profound oropharyngeal dysphagia., Study Design: Animal study., Methods: The head and neck of a Dorper cross ewe was placed in the lateral fluoroscopic view. Five conditions were tested: baseline, thyroid cartilage to hyoid approximation (THA), thyroid cartilage to hyoid to mandible (laryngohyoid) suspension (LHS), LHS with cricopharyngeus muscle myotomy (LHS-CPM), and cricopharyngeus muscle myotomy (CPM) alone. Five 20-mL trials of barium sulfate were delivered into the oropharynx under fluoroscopy for each condition. Outcome measures included the penetration aspiration scale (PAS) and the National Institutes of Health (NIH) Swallow Safety Scale (NIH-SSS)., Results: Median baseline PAS and NIH-SSS scores were 8 and 6, respectively, indicating severe impairment. THA scores were not improved from baseline. LHS alone reduced the PAS to 1 (P = .025) and NIH-SSS to 2 (P = .025) from baseline. LHS-CPM reduced the PAS to 1 (P = .025) and NIH-SSS to 0 (P = .025) from baseline. CPM alone did not improve scores. LHS-CPM displayed improved NIH-SSS over LHS alone (P = .003)., Conclusions: This cadaveric model represents end-stage profound oropharyngeal dysphagia such as what could result from severe neurological insult. CPM alone failed to improve fluoroscopic outcomes in this model. Thyrohyoid approximation also failed to improve outcomes. LHS significantly improved both PAS and NIH-SSS. The addition of CPM to LHS resulted in improvement over suspension alone., Level of Evidence: NA. Laryngoscope, 127:E422-E427, 2017., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Endoscopic Zenker diverticulotomy (EZD) is a primary treatment for Zenker diverticulum (ZD). During EZD, the diverticulum is not excised, and interpretation of postoperative videofluoroscopic swallow study (VFSS) is challenging. The purpose of this investigation was to describe normal VFSS findings status post-successful EZD., Methods: The charts of all patients with ZD treated at our center between October 01, 2011, and May 30, 2014, were abstracted. Outcome measures included recidivistic diverticulum size, Eating Assessment Tool-10 (EAT-10), penetration aspiration scale, pharyngeal constriction ratio (PCR), and pharyngoesophageal segment (PES) opening., Results: Twenty patients met inclusion criteria. The mean age was 70.5 (± 13) years. Seventy percent of the patients were male. Mean EAT-10 decreased 72.1% from 17.9 (± 8.2) to 5 (± 6.9) (P < 0.0001), and diverticulum size decreased 50.9% from 1.96 cm (± 0.68) to 0.96 cm (± 0.57) (P < 0.001). The PCR improved 33.6% from 0.17 (± 0.13) to 0.11 (± 0.11) (P < 0.001). Mean PES opening increased 61.6% from 0.53 cm (± 0.3544) to 0.86 cm (± 0.29) in lateral view and increased 40.0% from 1.00 cm (± 0.54) to 1.39 cm (± 0.46) in anteroposterior view (P < 0.001)., Conclusion: VFSS following successful EZD demonstrates an approximate 50% reduction in diverticulum size and significant improvement in PCR and PES opening. These data provide a framework for the expected fluoroscopic outcomes of successful diverticulotomy., Level of Evidence: 4. Laryngoscope, 127:1762-1766, 2017., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To validate the ovine model of profound oropharyngeal dysphagia and compare swallowing outcomes of laryngotracheal separation with those of total laryngectomy., Methods: Under real-time fluoroscopy, swallowing trials were conducted using the head and neck of two Dorper cross ewes and one human cadaver, secured in lateral fluoroscopic orientation. Barium trials were administered at baseline, pre- and post-laryngohyoid suspension, following laryngotracheal separation, and following laryngectomy in the ovine model., Results: Mean pre-intervention Penetration Aspiration Scale and National Institutes of Health Swallow Safety Scale scores were 8 ± 0 and 6 ± 0 respectively in sheep and human cadavers, with 100 per cent intra- and inter-species reproducibility. These scores improved to 1 ± 0 and 2 ± 0 post-laryngohyoid suspension (p < 0.01). Aerodigestive tract residue was 18.6 ± 2.4 ml at baseline, 15.4 ± 3.8 ml after laryngotracheal separation and 3.0 ± 0.7 ml after total laryngectomy (p < 0.001)., Conclusion: The ovine model displayed perfect intra- and inter- species reliability for the Penetration Aspiration Scale and Swallow Safety Scale. Less aerodigestive tract residue after narrow-field laryngectomy suggests that swallowing outcomes after total laryngectomy are superior to those after laryngotracheal separation.

Objective: The effect of vocal fold medialization (VFM) on vocal improvement in persons with unilateral vocal fold immobility (UVFI) is well established. The effect of VFM on the symptom of dysphagia is uncertain. The purpose of this study is to evaluate dysphagia symptoms in patients with UVFI pre- and post-VFM., Study Design: Case series with chart review., Setting: Academic tertiary care medical center., Subjects and Methods: The charts of 44 persons with UVFI who underwent VFM between June 1, 2013, and December 31, 2014, were abstracted from a prospectively maintained database at the University of California, Davis, Voice and Swallowing Center. Patient demographics, indications, and type of surgical procedure were recorded. Self-reported swallowing impairment was assessed with the validated 10-item Eating Assessment Tool (EAT-10) before and after surgery. A paired samples t test was used to compare pre- and postmedialization EAT-10 scores., Results: Forty-four patients met criteria and underwent either vocal fold injection (73%) or thyroplasty (27%). Etiologies of vocal fold paralysis were iatrogenic (55%), idiopathic (29%), benign or malignant neoplastic (9%), traumatic (5%), or related to the late effects of radiation (2%). EAT-10 (mean ± SD) scores improved from 12.2 ± 11.1 to 7.7 ± 7.2 after medialization (P < .01) with a follow-up of 119 ± 65 days., Conclusion: Patients with UVFI suffer from dysphagia and report significant improvement in swallowing symptoms following VFM. The symptomatic improvement appears to be durable over time., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

We conducted a retrospective review to identify the characteristics of cerebrospinal fluid (CSF) leak in patients who had undergone septoplasty and in selected patients who had experienced a spontaneous CSF leak. CSF leak is a known but infrequently reported complication of septoplasty; to the best of our knowledge, only 4 cases have been previously published in the literature. A review of our institution's database revealed 3 cases of postseptoplasty CSF leak. We reviewed all the available data to look for any commonalities among these 7 cases. In addition, we reviewed 6 cases of spontaneous CSF leak selected from our database for the same purpose. For all patients, we noted the side of the cribriform plate defect, its size and, for the postseptoplasty cases, the interval between the septoplasty and the leak repair. Overall, we found that leaks were much more common on the right side than on the left. The sizes of the leaks in the 2 postseptoplasty groups were comparable (mean: 14.0 × 6.4 mm). The interval between septoplasty and leak repair ranged from 2.5 to 20 years in our cases and from 3 days to 22 weeks in the previously published cases. All 3 of the postseptoplasty patients in our database presented with clear rhinorrhea. Two of the 3 patients had meningitis; 1 of these 2 also had pneumocephalus. Of the 6 cases of spontaneous CSF leaks, 4 occurred on the right and 2 on the left; the average size of the defect was 5.8 mm in the greatest dimension. The finding that cribriform plate defects after septoplasty were typically right-sided likely reflects the prevalence of left-sided surgical approaches. Also, the fact that the defects were larger in the postseptoplasty cases than in the spontaneous cases is likely attributable to the torque effect toward the thin skull base that occurs when the perpendicular plate is twisted during septoplasty.

Extraesophageal reflux disease, commonly called laryngopharyngeal reflux disease (LPRD), continues to be an entity with more questions than answers. Although the role of LPRD has been implicated in various pediatric diseases, it has been inadequately studied in others. LPRD is believed to contribute to failure to thrive, laryngomalacia, recurrent respiratory papillomatosis, chronic cough, hoarseness, esophagitis, and aspiration among other pathologies. Thus, LPRD should be considered as a chronic disease with a variety of presentations. High clinical suspicion along with consultation with an otolaryngologist, who can evaluate for laryngeal findings, is necessary to accurately diagnose LPRD., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: Tonsillectomy is a common procedure performed in children with the main complication being post-operative hemorrhage. It is uncertain if patients with hematological abnormalities face a higher risk of post-operative hemorrhage., Study Design: Retrospective chart review., Setting: Tertiary referral hospital., Patients Selected: All patients with a known hematologic disorder as well as children without a hematologic abnormality undergoing tonsillectomy with or without adenoidectomy in the past two years at our institution were included in this study., Main Outcome Measure: We sought to determine whether children with hematologic disorders are at an increased risk of post-operative hemorrhage after surgery., Results: Four-hundred and sixty-two patients were identified who underwent a tonsillectomy during this time period. Fourteen patients with hematological abnormalities were identified with only one patient suffering a post-tonsillectomy hemorrhage. All patients with abnormal laboratory values prior surgery underwent medical treatment in conjunction with pediatric hematology and did not suffer a post-tonsillectomy hemorrhage. Despite a small study group, the low incidence (1/14) of post-tonsillectomy hemorrhage in patients with hematological abnormalities suggests that these patients may not be at an increased risk, especially if appropriately evaluated and treated pre-operatively., Conclusion: Despite small sample size the results of our study suggest that patients with coagulation disorders may not have an increased risk of post-tonsillectomy hemorrhage when evaluated and corrected pre-operatively., (Published by Elsevier Ireland Ltd.)

Recurrent respiratory papillomatosis (RRP) is a rare, benign disease with no known cure. RRP is caused by infection of the upper aerodigestive tract with the human papillomavirus (HPV). Passage through the birth canal is thought to be the initial transmission event, but infection may occur in utero. HPV vaccines have helped to provide protection from cervical cancer; however, their role in the prevention of RRP is undetermined. Clinical presentation of initial symptoms of RRP may be subtle. RRP course varies, and current management focuses on surgical debulking of papillomatous lesions with or without concurrent adjuvant therapy., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Botulinum toxin (Botox) injections into the thyroarytenoid muscles are the current standard of care for adductor spasmodic dysphonia (ADSD). Reported adverse effects include a period of breathiness, throat pain, and difficulty with swallowing liquids. Here we report multiple cases of bilateral abductor paralysis following Botox injections for ADSD, a complication previously unreported., Study Design: Retrospective case series., Methods: Patients that received Botox injections for spasmodic dysphonia between January 2000 and October 2009 were evaluated. Patients with ADSD were identified. The number of treatments received and adverse effects were noted. For patients with bilateral abductor paralysis, age, sex, paralytic Botox dose, prior Botox dose, and course following paralysis were noted., Results: From a database of 452 patients receiving Botox, 352 patients had been diagnosed with ADSD. Of these 352 patients, eight patients suffered bilateral abductor paralysis, and two suffered this complication twice. All affected patients were females over the age of 50 years. Most patients had received treatments prior to abductor paralysis and continued receiving after paralysis. Seven patients recovered after a brief period of activity restrictions, and one underwent a tracheotomy. The incidence of abductor paralysis after Botox injection for ADSD was 0.34%., Conclusions: Bilateral abductor paralysis is a rare complication of Botox injections for ADSD, causing difficulty with breathing upon exertion. The likely mechanism of paralysis is diffusion of Botox around the muscular process of the arytenoid to the posterior cricoarytenoid muscles. The paralysis is temporary, and watchful waiting with restriction of activity is the recommended management.