Esophageal Dysphagia in Adults: When It Sticks.

Esophageal dysphagia is a common yet difficult to diagnose condition. This article underscores the role of detailed patient history and physical examinations, including prompt endoscopic evaluation, for accurate differentiation between esophageal and oropharyngeal dysphagia. The authors discuss the heightened importance of early intervention in certain patient groups, such as elderly individuals and patients with head and neck cancer, to mitigate the risk of malnutrition and infection. The authors delve into etiologic factors highlighting the complexity of clinical presentations and the significance of tailored management strategies.

Can EAT-10 Become EAT-5? Improving Measurement Efficiency of Dysphagia with Item Response Theory.

OBJECTIVES: To assess: (1) the Eating Assessment Tool (EAT-10) with item response theory (IRT) to determine which individual items provide the most information, (2) the extent to which dysphagia is measured with subsets of items while maintaining precise score estimates, and (3) if 5-item scales have the differing discriminatory ability, as compared to the parent 10-item instrument. METHODS: Prospectively collected data from 2,339 patients who completed the EAT-10 questionnaire during evaluation at a tertiary care otolaryngology clinic were utilized. IRT analyses provided discrimination and location parameters associated with individual questions. Residual item correlations were also assessed for redundant information. Based on these results, three 5-item subsets were further evaluated using item information function curves. Areas under receiver-operator characteristic curves (ROC-AUC) were also calculated to evaluate the discriminatory ability for dysphagia-related clinical diagnoses. RESULTS: Item discrimination parameter estimates ranged from 1.71 to 5.46, with higher values indicating more information. Residual item correlations were determined within item pairs, and location parameters were calculated. Based on these data, in combination with clinical utility, three 5-item subsets were proposed and assessed. ROC-AUC analyses demonstrated no significant difference between the EAT-5-Alpha subset and the original 10-item instrument for discriminating dysphagia as a primary diagnosis (0.88, 0.88). The EAT-5-Clinical subset outperformed the original 10 instruments in ROC-AUC for aspiration. The EAT-5-Range subset was significantly associated with problems with thin liquids. CONCLUSIONS: IRT analyses distinguished three proposed 5-item subsets of the EAT-10 instrument, supporting shorter survey options, while still reflecting the impact of dysphagia without significant loss of discrimination. LEVEL OF EVIDENCE: 3 (Diagnostic testing with consistently applied reference standards, partial blinding). Laryngoscope, 133:3327-3333, 2023.

Predictive Outcomes of Deep Learning Measurement of the Anterior Glottic Angle in Bilateral Vocal Fold Immobility.

OBJECTIVE: (1) To compare maximum glottic opening angle (anterior glottic angle, AGA) in patients with bilateral vocal fold immobility (BVFI), unilateral vocal fold immobility (UVFI) and normal larynges (NL), and (2) to correlate maximum AGA with patient-reported outcome measures. METHODS: Patients wisth BVFI, UVFI, and NL were retrospectively studied. An open-source deep learning-based computer vision tool for vocal fold tracking was used to analyze videolaryngoscopy. Minimum and maximum AGA were calculated and correlated with three patient-reported outcomes measures. RESULTS: Two hundred and fourteen patients were included. Mean maximum AGA was 29.91° (14.40° SD), 42.59° (12.37° SD), and 57.08° (11.14° SD) in BVFI (N = 70), UVFI (N = 70), and NL (N = 72) groups, respectively (p < 0.001). Patients requiring operative airway intervention for BVFI had an average maximum AGA of 24.94° (10.66° SD), statistically different from those not requiring intervention (p = 0.0001). There was moderate negative correlation between Dyspnea Index scores and AGA (Spearman r = -0.345, p = 0.0003). Maximum AGA demonstrated high discriminatory ability for BVFI diagnosis (AUC 0.92, 95% CI 0.81-0.97, p < 0.001) and moderate ability to predict need for operative airway intervention (AUC 0.77, 95% CI 0.64-0.89, p < 0.001). CONCLUSIONS: A computer vision tool for quantitative assessment of the AGA from videolaryngoscopy demonstrated ability to discriminate between patients with BVFI, UVFI, and normal controls and predict need for operative airway intervention. This tool may be useful for assessment of other neurological laryngeal conditions and may help guide decision-making in laryngeal surgery. LEVEL OF EVIDENCE: III Laryngoscope, 133:2285-2291, 2023.

Benefits of Side-Firing Optical Fibers in Endoscopic Laser Treatment of the Larynx.

OBJECTIVE: To elucidate potential tissue coverage of side-firing optical fibers in office-based endoscopic laser treatment of larynx, as well as to demonstrate their enhanced ability to address challenging anatomic areas. METHOD: We performed a comparative study of four different fiber designs: a traditional forward-facing fiber, and three side-firing fibers that emit light at an angle of 45°, 70°, and 90°, respectively. The study was conducted in simulation, using eight three-dimensional models of the human larynx generated from microtomography x-ray scans. A computer program simulated the insertion of the endoscope into the larynx, and the Möller-Trumbore algorithm was used to simulate the application of laser light. RESULTS: Side-firing laser fibers increased potential tissue coverage by a mean of 50.2 (standard deviation [SD] 25.8), 73.8 (SD 41.3), and 84.0 (SD 47.6) percent for angles of 45°, 70°, and 90°, respectively, compared to forward-facing fibers. Angled fibers provided access to areas of the larynx considered difficult to address by traditional methods, including the infraglottis, laryngeal ventricle, and right vocal fold. CONCLUSION: Simulation results suggest that side-firing optical fibers have the potential to enhance anatomical access during in-office endoscopic laser procedures in the larynx. Further research is needed to better understand the benefits and any potential risks or contraindications of side-firing optical fibers. LEVEL OF EVIDENCE: NA Laryngoscope, 133:1205-1210, 2023.

National Variation of Insurance Coverage for Gender-Affirming Facial Feminization Surgery.

Background: Gender-affirming surgery may be pursued by individuals experiencing gender dysphoria. Although genital and chest procedures are classified as medically necessary, facial feminization surgeries (FFSs) are often considered cosmetic. Insurance companies may limit coverage of these procedures, especially in states less supportive of transgender individuals. Objectives: To determine insurance coverage and ease of finding policy information for FFSs, and to analyze differences based on state advocacy. Methods: Insurance policies for the top three commercial health plans per state were reviewed. Coverage status was determined by web-based search and telephone interviews. Ease of gathering policy information was assessed using a post-task questionnaire graded on a 7-point Likert scale, with higher numbers (e.g., 7) representing relative ease. State advocacy was determined by the number of state laws and policies affecting the transgender community. Results: Of the 150 insurance policies, only 27 (18%) held favorable policies for FFS. Most favorable companies covered chondrolaryngoplasty, with 78% (n = 21) offering preauthorization. Mean ease of use was rated 6, with 12 companies requiring a telephone interview. Insurance policies in states with laws driving transgender equity covered more FFS procedures (p = 0.043), whereas those in restrictive states offered less overall coverage (p = 0.023). Conclusions: FFS is rarely covered by commercial insurance companies, especially in states with less legal support for transgender individuals. Policy information remains difficult to obtain, with variable coverage by employer and no standardized medical necessity criteria. Limited coverage, lack of easily accessible information, and absence of universal criteria may act as barriers to FFS.

Does the Reflux Symptom Index Predict Increased Pharyngeal Events on HEMII-pH Testing and Correlate with General Quality of Life?

OBJECTIVES: To determine the ability of the reflux symptom index (RSI) to predict objective impedance and pH-probe testing, and to examine the relationship between disease-specific and general health status in patients diagnosed with laryngopharyngeal reflux (LPR). METHODS: Adults presenting to a tertiary care academic center with a primary voice complaint completed the RSI and the Patient-Reported Outcomes Measurement Information System 10-item global health instrument (PROMIS). An RSI score ≥13 was considered abnormal. Objective testing for LPR was performed using hypopharyngeal-esophageal multichannel intraluminal impedance catheter with dual pH (HEMII-pH) testing; a positive test was defined as more than one pharyngeal impedance events over 24 hours. Spearman rho analyses were applied, and the sensitivity and specificity of the RSI to detect HEMII-pH findings were determined. RESULTS: One hundred four patients underwent HEMII-pH testing. Mean scores were 16.7 (95%CI 15.1-18.3) for RSI. Sixty-three (60.6%) patients were diagnosed with LPR by HEMII-pH testing. RSI scores were moderately correlated with PROMIS physical (Spearman rho 0.43, P < 0.0001), social (Spearman rho 0.33, P < 0.0001) and mental health (Spearman rho 0.33, P < 0.0001) scores. The RSI has a sensitivity and specificity of 66.7% and 31.7%, respectively, for detecting pharyngeal events on HEMII-pH testing. CONCLUSIONS: There is moderate sensitivity and lack of specificity of the RSI for detecting increased pharyngeal reflux events. Reflux-specific and general health status instruments are correlated. Further investigation could assess the diagnostic ability of RSI compared proximal reflux events on HEMII-pH, as well as whether health status instruments can be used to detect clinically meaningful change in the LPR population.

Does Ibuprofen Increase Bleed Risk for Pediatric Tonsillectomy?

OBJECTIVE: To evaluate risk factors for pediatric posttonsillectomy hemorrhage (PTH) and the need for transfusion using a national database. STUDY DESIGN: Retrospective cohort study. SETTING: The study was conducted using the Pediatric Health Information System (PHIS) database. METHODS: Children ≤18 years who underwent tonsillectomy with or without adenoidectomy (T±A) between 2004 and 2015 were included. We evaluated the risk of PTH requiring cauterization according to patient demographics, comorbidities, indication for surgery, medications, year of surgery, and geographic region. RESULTS: Of the 551,137 PHIS patients who underwent T±A, 8735 patients (1.58%) experienced a PTH. The risk of PTH increased from 1.33% (95% confidence interval [CI]: 1.15%, 1.53%) in 2010 to 1.91% (95% CI: 1.64%, 2.24%) in 2015 (P < .001). Older age (≥12 vs <5 years old: adjusted odds ratio [aOR] 3.17; 95% CI: 2.86, 3.52), male sex (aOR 1.11; 95% CI: 1.05, 1.17), medical comorbidities (aOR 1.18; 95% CI: 1.08, 1.29), recurrent tonsillitis (aOR 1.15; 95% CI: 1.07, 1.24), and intensive care unit admission (aOR 1.74; 95% CI: 1.55, 1.95) were significantly associated with an increased risk of PTH. Use of ibuprofen (aOR 1.36; 95% CI: 1.22, 1.52), ketorolac (aOR 1.39; 95% CI: 1.14, 1.69), anticonvulsant (aOR 1.23; 95% CI: 1.03, 1.76), and antidepressants (aOR 1.35; 95% CI: 1.03, 1.76) were also associated with an increased risk of PTH. The need for blood transfusion was 2.1% (181/8735). CONCLUSION: The incidence of PTH increased significantly between 2011 and 2015, and ibuprofen appears to be one contributing factor. Given the benefits of ibuprofen, it is unclear whether this increased risk warrants a change in practice.

Assessment of Gender Differences in Clinical Productivity and Medicare Payments Among Otolaryngologists in 2017.

Importance: Women comprise an increasing proportion of the otolaryngology workforce. Prior studies have demonstrated gender-based disparity in physician practice and income in other clinical specialties; however, research has not comprehensively examined whether gender-based income disparities exist within the field of otolaryngology. Objective: To determine whether diversity of practice, clinical productivity, and Medicare payment differ between male and female otolaryngologists and whether any identified variation is associated with practice setting. Design, Setting, and Participants: Retrospective cross-sectional analysis of publicly available Medicare data summarizing payments to otolaryngologists from January 1 through December 31, 2017. Male and female otolaryngologists participating in Medicare in facility-based (FB; hospital-based) and non-facility-based settings (NFB; eg, physician office) for outpatient otolaryngologic care were included. Main Outcomes and Measures: Number of unique billing codes (diversity of practice) per physician, number of services provided per physician (physician productivity), and Medicare payment per physician. Outcomes were stratified by practice setting (FB vs NFB). Results: A total of 8456 otolaryngologists (1289 [15.2%] women; 7167 [84.8%] men) received Medicare payments in 2017. Per physician, women billed fewer unique codes (mean difference, -2.10; 95% CI, -2.46 to -1.75; P < .001), provided fewer services (mean difference, -640; 95% CI, -784 to -496; P < .001), and received less Medicare payment than men (mean difference, -$30 246 (95% CI, -$35 738 to -$24 756; P < .001). When stratified by practice setting, women in NFB settings billed 1.65 fewer unique codes (95% CI, -2.01 to -1.29; P < .001) and provided 633 fewer services (95% CI, -791 to -475; P < .001). In contrast, there was no significant gender-based difference in number of unique codes billed (mean difference, 0.04; 95% CI, -0.217 to 0.347; P = .81) or number of services provided (mean difference, 5.1; 95% CI, -55.8 to 45.6; P = .85) in the FB setting. Women received less Medicare payment in both settings compared with men (NFB: mean difference, -$27 746; 95% CI, -$33 502 to -$21 989; P < .001; vs FB: mean difference, -$4002; 95% CI, -$7393 to -$612; P = .02), although the absolute difference was lower in the FB setting. Conclusions and Relevance: Female sex is associated with decreased diversity of practice, lower clinical productivity, and decreased Medicare payment among otolaryngologists. Gender-based inequity is more pronounced in NFB settings compared with FB settings. Further efforts are necessary to better evaluate and address gender disparities within otolaryngology.

Can voice disorders matter as much as life-threatening comorbidities to patients' general health?

OBJECTIVE: National initiatives and funding agencies may deprioritize voice disorders relative to conditions such as malignancy, pulmonary, or cardiac disease. It is unknown whether the impact of voice problems is outweighed by other potentially more serious disease states. Our objective was thus to quantify the extent to which voice contributes to general health status when adjusting for concurrent, more life-threatening comorbidities. METHODS: Adults (n = 430) presenting to a tertiary care academic center with a primary voice complaint completed the Voice Handicap Index-10 (VHI-10) and the Patient-Reported Outcomes Measurement Information System global health short-form instrument (PROMIS). Medical comorbidities were categorized via the Deyo modification of the Charlson Comorbidity Index. The influence of voice and comorbid conditions on general health scores was assessed through multivariate ordinal regression. The potential for effect modification was also evaluated. RESULTS: VHI-10 mean scores were 11.4 (95% confidence interval [CI], 10.5 to 12.4). PROMIS physical and mental health t scores were 49.0 (95% CI, 48.0 to 49.9) and 51.6 (95% CI, 50.6 to 52.5), respectively. Global and social item scores were 3.4 (95% CI, 3.3 to 3.5) and 3.7 (95% CI, 3.6 to 3.8), respectively. The most prevalent comorbid conditions were pulmonary disease, malignancy, and connective tissue disorders. In all analyses, voice handicap was a significant predictor of general health, even when adjusting for comorbid conditions (VHI-10 ß = -1.349, P < 0.001 for physical health; ß = -1.278, P < 0.001 for mental health; ß = -1.691, P < 0.001 for social health; ß = -0.956, P < 0.001 for the global overview item). CONCLUSION: In the observed population, voice health has a significant, multi-dimensional impact on general health, which is not subsumed by the presence of comorbidities. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2405-2411, 2020.

Is a voice-specific instrument more indicative of stroboscopy results than common clinical queries?

OBJECTIVES: To determine whether the Voice Handicap Index-10 (VHI-10) predicts diagnoses made via laryngoscopy/stroboscopy, as compared to common clinical inquiries about vocal characteristics. METHODS: We prospectively collected data from a cohort of 204 consecutive patients newly presenting for ambulatory laryngology evaluation. Each patient completed the VHI-10 and 16 concurrent mainstream queries about vocal characteristics such as weakness, breathiness, fatiguability, or inability to shout. Using the objective diagnoses made by laryngoscopy/stroboscopy as a gold standard, the area under the receiver operating characteristic curves (AUC), sensitivity, and specificity were determined. RESULTS: For unilateral vocal fold paralysis, VHI-10 scores had an AUC of 0.78 (95% CI, 0.68-0.88) and had better discrimination than 12 common clinical queries. At a threshold score of ≥11, VHI-10 sensitivity was 0.94; at a threshold of ≥31, specificity was 0.91. For laryngeal stenosis, the VHI-10 score demonstrated moderate discrimination, with an AUC of 0.79 (95% CI, 0.56-1.00) and higher discrimination than three common clinical queries. At a threshold score of ≥11, VHI-10 sensitivity was 1.00; at a threshold of ≥31, specificity was 0.89. Both VHI-10 scores and common clinical queries had low diagnostic ability for vocal fold paresis, laryngopharyngeal reflux (LPR), paradoxical vocal fold motion, and vocal fold scar or atrophy. CONCLUSIONS: The VHI-10 score is an effective diagnostic indicator of laryngoscopy/stroboscopy findings of vocal fold paralysis and laryngeal stenosis, performing better than multiple mainstream queries about vocal characteristics. VHI-10 scores and common clinical queries are limited in their ability to indicate paresis, reflux, paradoxical motion, and vocal fold scar or atrophy. LEVEL OF EVIDENCE: 2c Laryngoscope, 130:992-999, 2020.