Diagnosing Laryngopharyngeal Reflux: A Comparison between 24-hour pH-Impedance Testing and Pharyngeal Probe (Restech) Testing, with Introduction of the Sataloff Score.

OBJECTIVE: The purpose of this study was to compare the diagnostic utility of pH monitoring using 24-hour esophageal pH-Impedance (HEMII-pH) testing versus pharyngeal pH (Restech) testing (Respiratory Technology Corporation, Houston, Texas) for diagnosing laryngopharyngeal reflux (LPR). METHODS: Retrospectively, patients were reviewed who had completed a Reflux Symptom Index (RSI) survey and stroboscopy within 60 days before or after undergoing simultaneous esophageal pH-Impedance monitoring and Restech testing. Reflux Finding Score (RFS) was determined by 4 blinded observers. 80.45% of patients were on anti-reflux medications at the time of study and had incomplete response to treatment for reflux. Improvement on reflux treatment was determined by evaluating presenting pre-pH monitoring RFS, post treatment RFS, and improvement of symptoms. Pearson correlation coefficients were calculated to assess relationships among RSI, RFS, and test results from HEMII-pH and Restech tests. RESULTS: Eighty-seven patients were included in the analysis. The inter-rater reliability of the RFS determination was 74.57%, and the intra-rater reliability was 67.00%. Subjects who had a positive RYAN Score had a significant correlation with RFS (r of 0.222 and p-value of 0.0492). There was no correlation between RFS and number or percent time of reflux events, longest event, total number of events, or percent of time at alkaline pH for either HEMII-PH or Restech test. RSI correlated better with HEMII-pH test than with Restech for percent time spent in both upright (r of 0.226 and p-value of 0.029) and supine position (r of 0.261 and a p-value of 0.032). Restech correlated better with total patient symptom Scores including cough, heartburn, burping, and throat clearing, with a r of 0.242 and a p-value of 0.048. Restech detected more percent time in reflux for total reflux, supine reflux, and upright reflux (p-value less than 0.0001). Restech also detected longer event times than Impedance (p-value of less than 0.0001). When diagnosis of LPR is based on the definition of CRC, the Sataloff Score test had 70.45% sensitivity and 80.95% specificity. The RYAN Score had a sensitivity of 72%, and a specificity of 56.45%, and the Wu Score had a sensitivity of 62.16%, and specificity of 54.05%. When the Sataloff and Wu Score were used together, the sensitivity was 71.45%, specificity 100%, positive predictive value of 100%, and a negative predictive value of 59.46%. CONCLUSION: The amount of time of reflux events correlates with symptoms better than the number of events. The HEMII-pH test was able to detect more events of pH<4 than Restech, possibly because there might have been more acid events below than above the upper esophageal sphincter, while Restech detected more total events. Restech recorded longer event times than HEMII-pH test. Since length of time correlates with RFS (probably reflecting laryngeal inflammation), and since laryngeal clearance of acid is more similar to pharyngeal than esophageal clearance, this finding might prove valuable clinically. The Sataloff Score has a sensitivity of 70.45%, and a specificity of 80.95% and appears useful clinically to detect mild to moderate that is missed by the RYAN Score. A combination of Sataloff Score and Wu Score may be clinically valuable to identify LPR with an increased sensitivity of 71.45% and increased specificity of 100%. The Wu Score is not yet available for the general clinical use, but the Sataloff Score is.

The Lasting Impact of the COVID-19 Pandemic on Surgical Key Indicator Cases for Otolaryngology Residency Education.

OBJECTIVES: Early on during the COVID-19 pandemic, the US Centers for Medicare & Medicaid Services (CMS) and other government as well as medical institutions recommended that surgeons postpone nonessential surgeries. The aim of our study is to examine the impact of the COVID-19 pandemic on otolaryngology surgical training by evaluating changes in surgical volumes through various time points relative to the height of the pandemic. METHODS: We performed a retrospective review of all surgical cases performed by the Otolaryngology-Head and Neck Surgery department at a tertiary care academic center from 3 time periods: July 1st, 2018, to June 30th, 2019; July 1st, 2019, to June 30th, 2020; and July 1st, 2020, to June 30th, 2021. RESULTS: From the 2018-19 period to the 2020-21 period, the total number of overall cases decreased by 9.9%, from 2386 to 2148 cases. During this same time duration, the number of key indicator cases decreased by 13.4%, from 1715 to 1486 cases. Relative to other cases, ethmoidectomy, rhinoplasty, and stapes/OCR cases decreased the most during the 2019-20 period by 41.9%, 41.8%, and 29.5%, respectively. From the 2018-19 period to the 2020-21 period, thyroid/parathyroid cases decreased the most by 35.4%. Only ethmoidectomy and oral cavity cases showed increases during this period at 9.7% and 24.4%, respectively. CONCLUSIONS: Although case volumes have stayed relatively constant, key indicator case volumes at the present tertiary care academic center have not yet fully recovered from the COVID-19 pandemic. Efforts must be made to determine how this has impacted residency surgical education.

The Impact of Dermal Fillers on Perceived Personality Traits and Attractiveness.

BACKGROUND: Dermal fillers are increasingly popular for facial rejuvenation and enhancement, including effacement of nasolabial folds (NLFs) and marionette lines and lip augmentation. This study aimed to evaluate casual observer perception of physical and interpersonal traits of subjects who receive filler treatment. METHODS: An anonymous survey of 8 before/after treatment photographical sets was administered in Likert scale format (1-7) using online crowdsourcing. Three sets of photographs were before/after NLF/ marionette line treatment, three of lip augmentation, and two internal controls. Respondents were surveyed on personal demographics, as well as perceptions of subject photographs across nine domains (facial symmetry, confidence, likeability, youthfulness, trustworthiness, attractiveness, intelligence, approachability, happiness). RESULTS: In total, 260 respondents completed the survey. The majority were male (63.1%), Caucasian (58.1%), 18-34 years old (58.1%), and college graduates (66.2%). Respondents rated photographs with line filler treatment and lip filler treatment as significantly improved compared to the pre-treatment photographs across all nine trait domains [p < 0.001, for all]. No differences were found between the control photosets [p > 0.05, for all]. Middle-aged respondents (35-55 years) were more likely to perceive treated filler photographs as more youthful than younger respondents (18-34 years) [p < 0.006] Additionally, respondents with lower educational attainment (high-school graduate or less) were more likely to perceive treated patients as less intelligent compared to higher-educated respondents (college/postgraduates) [p < 0.05, for both]. CONCLUSION: The use of dermal fillers for treatment of NLF/marionette lines and lip augmentation have significant associations with the perception of improved attractiveness and several personality traits. Additionally, casual observer demographic subgroups may influence perceptions. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Osteoradionecrosis of the Midface and Mandible: Pathogenesis and Management.

Radiation therapy is an important and commonly used treatment modality for head and neck cancers. Osteoradionecrosis (ORN) is a potential debilitating complication of treatment, which most commonly affects the mandible. Management strategies are tailored to the severity of disease. Medical management including oral rinses, irrigations, antibiotics, and pharmacological treatments is viable for mild-to-moderate ORN. More severe disease is best addressed with a combination of medical management and surgical intervention aimed at aggressively removing devitalized tissue until bleeding bone is encountered and reconstructing the soft tissue and bone defect. Reconstruction with either regional vascularized flaps or vascularized osteocutaneous free flaps in case of larger full-thickness bone defects (greater than 6 cm) or anterior mandible (medial to mental foramen) is most appropriate. Maxillary ORN complications can present with a wide range of functional problems and facial disfigurement. Life-threatening and time-sensitive problems should be treated first, such as skull base bone coverage or correction of severe ectropion, to avoid blindness from exposure keratopathy. Then, less time-sensitive issues can be addressed next, such as nasal obstruction, velopharyngeal insufficiency, and chronic tearing. It may require a combination of specialists from different disciplines to address various issues that can arise from maxillary ORN.

Temporal Augmentation: A Systematic Review.

Clinicians employ various modalities in order to achieve temporal augmentation; however, no literature comprehensively describes these methods or provides perspective on available options. Understanding the available methodologies for cosmetic temporal augmentation allows for improved patient satisfaction with limited risk of complications. To synthesize the available literature on cosmetic temporal augmentation, including all available methodologies, patient satisfaction data, and complication rates, as well as to identify gaps in the available literature to encourage further research. A literature search was performed using the databases PubMed, Ovid Medline, Cochrane Library, and Web of Science. Using the key terms "temporal" or "temple" and "augmentation" or "rejuvenation," all article formats presenting primary literature data involving cosmetic temporal augmentation were included. Articles not presenting patient data or not discussing cosmetic indications were eliminated. A total of 12 articles were deemed appropriate for analysis. Of the 12 articles included, 6 (50%) evaluated filler techniques, 3 discussed fat grafting (25%), and 3 reviewed solid implant (25%) techniques. Eight (67%) of these were retrospective reviews, with the remaining being prospective trials (33%). All studies found high patient satisfaction rates and a small number of complications with their respective methodology. Several methods are employed for cosmetic temporal augmentation, including various types of injectable fillers, solid implants, and fat grafting, with all reporting successful satisfaction and complication outcomes. Further research is necessary to properly compare these modalities. Clinician discretion should guide procedural choice until future well-controlled studies are able to provide standardized outcomes.

Laboratory Evaluation of Spasmodic Dysphonia.

OBJECTIVES: To evaluate the utility of comprehensive laboratory evaluation in patients with spasmodic dysphonia (SD). STUDY DESIGN: Retrospective chart review. METHODS: A review of the medical records of 40 patients diagnosed with spasmodic dysphonia from 2009-2018 was preformed to evaluate abnormal test results that were significant when compared with abnormal results of the general population and for any other clinically relevant pathology. RESULTS: Erythrocyte sedimentation rate, ceruloplasmin levels, and anti-AChR were found to be elevated at levels considered statistically significant (p <0.05). Furthermore, we found levels of cholesterol, thyroid-stimulating hormone (TSH), T3, fasting blood glucose, creatine kinase, immunoglobulin, antinuclear antibody (ANA), and alpha-fetoprotein (AFP) levels to be abnormal at a greater rate in our population, but these were not statistically significant. Workup revealed several underlying conditions including thyroid neoplasms, hypothyroidism, and laryngopharyngeal reflux. Additionally, brain MRI revealed age-related ischemic pathology in an elevated number of patients, but with no obvious clinical sequalae. CONCLUSION: There is an association between serological values and spasmodic dysphonia that can aid in diagnosing pathology, as well as establishing a directed workup. Additionally, our study shows the utility of comprehensive evaluation in identifying undetected disease.

Multilevel Sleep Surgery Including the Palate in Nonsyndromic, Neurologically Intact Children with Obstructive Sleep Apnea.

OBJECTIVE: To examine the effects of multilevel sleep surgery, including palate procedures, on obstructive sleep apnea parameters in the pediatric population. STUDY DESIGN: A case series with chart review was conducted to identify nonsyndromic, neurologically intact pediatric patients who underwent either uvulectomy or uvulopalatopharyngoplasty as part of multilevel sleep surgery from 2011 through 2017. SETTING: A tertiary care, university children's hospital. SUBJECTS AND METHODS: Unpaired Student t test was used to compare average pre- and postsurgical apnea-hypopnea index (AHI) and oxygen saturation nadir (OSN). Paired Student t test was used to compare the mean pre- and postsurgical AHI and OSN within the same patient for the effects of adenotonsillectomy (T&A) vs multilevel sleep surgery. RESULTS: In patients who underwent T&A previously, multilevel sleep surgery, including palate procedures, resulted in improved OSA severity in 6 (86%) patients and worsened OSA in 1 (14%) patient. Multilevel sleep surgery, including palate procedures, significantly decreased mean AHI from 37.98 events/h preoperatively to 8.91 events/h postoperatively (P = .005). However, it did not significantly decrease OSN. CONCLUSION: This study includes one of the largest populations of children in whom palate procedures as a part of multilevel sleep surgery have been performed safely with no major complications and a low rate of velopharyngeal insufficiency. Therefore, palatal surgery as a part of multilevel sleep surgery is not necessarily the pariah that we have traditional thought it is in pediatric otolaryngology.

Speech and Language Outcomes in Patients with Ankyloglossia Undergoing Frenulectomy: A Retrospective Pilot Study.

Ankyloglossia is a controversial topic with no standardized treatment guidelines. A retrospective chart review was conducted to identify children who underwent lingual frenulectomy for speech and language impairment. Impairment severity was recorded pre- and postoperatively as mild, mild to moderate, moderate, moderate to severe, or severe. Variables were tested with chi-square analysis for their statistical relationship to improvements in speech and language. Children with preoperative moderate and moderate-to-severe speech and language impairment attained better speech and language outcomes after frenulectomy as compared with children with mild and mild-to-moderate impairment (100% vs 82%, P = .015). Sutured closure after frenulectomy was associated with better speech and language improvements (100% vs 83%, P = .033). One could consider observation of patients with mild and mild-to-moderate speech and language impairments. Sutured closure might result in better improvements in speech and language impairments. This pilot study sheds light on the potential impact of a larger study currently underway.

Caregiver perception of speech quality in patients with ankyloglossia: Comparison between surgery and non-treatment.

OBJECTIVES: Our objective was to determine if there are differences in caregiver perception of speech for patients that undergo frenulectomy compared to patients that were not surgically treated. INTRODUCTION: Ankyloglossia is a controversial topic without standardized treatment guidelines. Although there have been several studies suggesting that breastfeeding does improve after frenulectomy, there is a paucity of literature that investigates the relationship between ankyloglossia and speech. METHODS: A retrospective chart review was conducted to identify patients with ankyloglossia. Patients were categorized into surgical treatment (frenulectomy) and non-treatment groups. Caregivers of both groups were contacted by phone and surveyed on speech quality and tongue mobility using Likert scores. Mann Whitney-U testing was used to determine if there were significant differences in perceived speech quality between the surgical and non-surgical groups. RESULTS: The caregivers of seventy-seven patients participated in the phone survey: 46 (60%) children in the surgical group and 31 (40%) children in the non-surgical group who participated in the phone survey. There were no differences in difficulty with speech (p = 0.484) and tongue mobility (p = 0.064) between the two groups. However, patients that underwent surgical intervention for ankyloglossia reported less difficulty with tongue tasks (p < 0.001) compared to those who were not surgically treated. Additionally, 50% of patients that underwent surgery had a documented family history of ankyloglossia which was significantly higher than 16.1% in the non-surgical group (p = 0.002). CONCLUSIONS: It appears that children with ankyloglossia might have similar speech quality following frenulectomy in comparison to speech quality without treatment. Children who undergo frenulectomy may experience improvements in tongue tasks. This data should encourage further research on the management of speech concerns in children with ankyloglossia.

Vocal Fold Paresis: Incidence, and the Relationship between Voice Handicap Index and Laryngeal EMG Findings.

OBJECTIVE: To determine whether there is a correlation between Voice Handicap Index 10 (VHI-10) and degree of vocal fold paresis as determined by laryngeal EMG. Secondary objective was to determine the incidence of vocal fold paresis in a tertiary laryngology practice. METHODS: A retrospective chart review of all new voice patients seen by the senior author (RTS) from January 1, 2016 to December 31, 2017. Subjects completed VHI at their initial visit. Patients were examined with flexible and rigid laryngoscopy and videostroboscopy and referred for laryngeal electromyography (LEMG) if neuromuscular weakness was suspected. LEMG was used to identify the affected nerves and to quantify subjectively the degree of paresis. Patients who did not complete LEMG and or handicap index were excluded from the correlation analysis. The prevalence of vocal fold paresis was determined by reviewing the records of each subject. The number of patients diagnosed clinically with paresis or paralysis and referred for LEMG was documented. RESULTS: The subjects, who had paresis confirmed on LEMG (n = 210) were grouped according to the nerves involved and by the degree of paresis. The unilateral superior laryngeal nerve and ipsilateral recurrent laryngeal nerve paresis group (n = 29) had a reasonably even distribution of patients in each sub-group (n = 11; 12; 6) and was analyzed for correlation. There was a strong positive correlation between the degree of paresis and the VHI score (r = 0.59, P < 0.001). Other groups did not have an even distribution among sub-groups and could not be to be analyzed for correlation. The senior author examined 344 new voice patients during years of 2016 and 2017. Based on laryngoscopy, 335 patients were referred for LEMG (97.4%). Two hundred thirty-seven patients had LEMG performed, and 234 patients confirmed to have vocal fold paresis were confirmed (98.7%.). The incidence of vocal fold paresis in subjects who underwent LEMG or who had normal motion during laryngoscopy was 95.1% (234 out of 246). The incidence in the 98 subjects who did not complete the recommended LEMG is unknown. CONCLUSION: The unilateral superior laryngeal nerve with ipsilateral recurrent laryngeal nerve paresis was the only group that allowed for analysis whether patient's perception of their voice problem as measured VHI-10 correlated with increasing degree of vocal fold paresis. A strong significant positive correlation in this group was identified. Additional studies with a larger patient cohort are recommended.

Acute infectious laryngitis: A case series.

Although acute laryngitis is common, it is often managed by primary physicians. Therefore, video images documenting its signs are scarce. This series includes 7 professional voice users who previously had undergone baseline strobovideolaryngscopy (SVL) during routine examinations or during evaluations for other complaints and who returned with acute laryngitis. Sequential SVL showed not only the expected erythema, edema, cough, and dysphonia, but also new masses in 5 of the 7 subjects. All the signs returned to baseline. This series is reported to highlight the reversible structural changes that can be expected in patients with acute laryngitis and the value of conservative management.