Comparing cadaveric and 3D-printed laryngeal models in transcutaneous injection laryngoplasty.

Background: There is increasing focus on the development of high-quality simulation models for medical education. Cadaveric models, although considered more realistic, may be difficult to obtain and costly. The advent of three-dimensional (3D) printing has offered a low-cost, reliable, and reproducible alternative. This study sought to compare the utility of 3D-printed to cadaveric models for training in transcutaneous injection laryngoplasty (TIL). Methods: A simulation course with a cross-over design was employed. Video laryngoscopes were utilized for both the 3D and cadaveric models to assess the accuracy of injection into the vocal fold. Pre-procedure and post-procedure surveys were administered to evaluate understanding and comfort level on a Likert scale of 1-10. Each model was also rated on a 1-5 Likert scale for self-efficacy, fidelity, and educational value. Results: Pre- and post-survey data were completed by 15 otolaryngology residents and medical students. Mean pre-seminar understanding and comfort level were 3.7 and 2.2, respectively, compared to 6.9 and 5.9 (p < .05) following use of the 3D model and 6.4 and 4.7 (p < .05) following use of the cadaver model. When comparing 3D and cadaveric models, no significant differences were observed regarding self-efficacy, fidelity, and educational value. Conclusion: There was a similar mean increase in understanding and comfort following use of the 3D and cadaveric models. 3D-printing can provide an excellent adjunct to, and eventually a potential replacement for hands-on cadaveric training in medical education, particularly for TIL. Level of Evidence: Level III.

Vocal Fold Medialization Procedures in Previously Radiated Patients: A Survey of Practice Patterns.

BACKGROUND/OBJECTIVES: Head and neck radiation therapy (HNRT) has traditionally been considered a contraindication to vocal fold medialization procedures. Although safety has been demonstrated, we hypothesize that actual management varies. This study evaluates practice patterns of otolaryngologists regarding vocal fold medialization in patients after HNRT. METHODS: A 25-question survey evaluating respondents' management of patients status post HNRT with vocal fold paresis/paralysis was distributed to 357 otolaryngologists. Practice patterns regarding injection laryngoplasty (IL), medialization thyroplasty (MT), and arytenoid adduction (AA) were queried. RESULTS: Eight-two clinicians (23%) completed the survey. Ninety-one percent of respondents were laryngologists, 9% head and neck surgeons, 3% comprehensive otolaryngologists, and 3% "other." Eleven (15%) had been in practice <5 years, 19 (25%) for 5-10 years, and 46 (61%) for >10 years. No respondents considered HNRT a contraindication to IL, and 11 (14%) reported complications from the procedure. Hyaluronic acid (58, 75%) was most commonly injected. Twenty percent considered HNRT a contraindication to MT, and 37% considered it a contraindication to AA. Gore-Tex was used most commonly (65%). Twenty-seven percent reported major complications after MT. All complications occurred in the >10-year practice group, and this group was more likely to delay surgery after HNRT (p = 0.022). Respondents with complications were more likely to perform MT in HNRT patients (p = 0.0191). CONCLUSIONS: Otolaryngologists generally do not consider HNRT to be a contraindication to IL, but some consider it a contraindication to MT/AA. Previous complications do not appear to deter surgeons from performing MT. LEVEL OF EVIDENCE: N/A (Survey Study) Laryngoscope, 2024.

Retrograde Cricopharyngeus Dysfunction: The Jefferson Experience.

OBJECTIVES: To describe our center's experience with the identification and treatment of retrograde cricopharyngeus dysfunction (R-CPD), a syndrome involving the inability to belch previously described by only one institution. Additionally, because all patients initially learned of their condition and sought treatment as a result of social media posts, we queried their source and comfort with this form of medical referral. METHODS: Retrospective chart review of patients who underwent botulism toxin injection into the cricopharyngeus muscle for treatment of R-CPD from 2019 to 2022. Demographic data, most common symptoms at presentation, and response to treatment and complications were documented. Post-treatment questionnaires were reviewed. RESULTS: A total of 85 patients were identified. Mean age at surgery was 27 years. There were 54 (63.5%) females and 31 (36.5%) males. The inability to burp (98.8%), bloating (92.9%), gurgling noises (31.8%), and excessive flatulence (21.2%) were the most common symptoms. The minimum units of botox utilized were 25, whereas the maximum was 100. The majority of patients (88.2%) had a successful response at initial follow-up visit. The most common complication was mild dysphagia (30.6%), which was transient for all patients. Most patients learned of our practice through social media, with only one patient being referred by a medical provider. CONCLUSIONS: The majority of patients in our cohort were young and female. The inability to burp and bloating were the most common presenting symptoms. Social media was the primary source of referral. Our institution favors 80-100 units for an effective response. Laryngoscope, 133:1081-1085, 2023.

Combined Anterior Osteophytectomy and Cricopharyngeal Myotomy for Treatment of DISH-Associated Dysphagia.

STUDY DESIGN: Retrospective observational case series. OBJECTIVE: To assess the outcome of patients with diffuse idiopathic skeletal hyperostosis (DISH) with dysphagia who underwent cricopharyngeal myotomy (CPM) in conjunction with anterior osteophytectomy (OP). METHODS: This is a retrospective observational study of 9 patients that received combined intervention by neurosurgeons and otolaryngologists. Inclusion criteria for surgery consisted of patients who failed to respond to conservative treatments for dysphagia and had evidence of both upper esophageal dysfunction and osteophyte compression. We present the largest series in literature to date including patients undergoing combined OP and CPM. RESULTS: A total of 88.9% (8/9) of the patients who underwent OP and CPM showed improvement in their symptoms. Of the aforementioned group, 22.2% of these patients had complete resolution of their symptoms, 11.1% did not improve, and only 2 patients showed recurrence of their symptoms. None of the patients in whom surgery was performed required reoperation or suffered serious complication related to the surgical procedures. CONCLUSION: Based on the literature results, high rate of improvements in dysphagia, and low rate of complications, combined OP and CPM procedures may be beneficial to a carefully selected group of patients.

Safety of Outpatient Type 1 Thyroplasty.

OBJECTIVE: Type 1 thyroplasty is an established procedure for the treatment of vocal fold paralysis to improve voice and swallowing outcomes. At our institution, we commonly perform this procedure on an outpatient basis in medically stable patients. With this study, we assess the safety of outpatient thyroplasty by examining complication and readmission rates, need for revision surgery, and predictors of these outcome measures. METHODS: We performed a retrospective review of patients undergoing outpatient type 1 thyroplasty for vocal fold paralysis between 2013 and 2018 at our institution. We documented the etiology of paralysis, comorbidities, and demographic data. Our primary outcome measures were complications, need for readmission, and need for revision surgery. RESULTS: During the study period, 160 patients met our inclusion criteria. Mean age at time of surgery was 62.1 ± 13.9 years; there were 82 (51%) males and 78 (49%) females. Nine (5.6%) patients experienced major complications after surgery and 7 (4.4%) patients required unplanned readmission. Mean time to complication was 6.9 ± 9.7 days. There were no instances of postoperative airway compromise requiring intervention. There were no mortalities. Of those who underwent primary surgery, 22 (14%) patients required revision surgery. CONCLUSION: Given that complications tend to occur in a delayed fashion rather than in the acute postoperative period, same-day discharge seems reasonable as compared to overnight observation in medically stable patients undergoing type 1 thyroplasty. LEVEL OF EVIDENCE: IV.

Feasibility of Early Discharge after Open Hypopharyngeal Surgery for Dysphagia.

OBJECTIVE: To determine the rate of surgical complications, unplanned readmission, and functional status after open hypopharyngeal surgery for dysphagia with early return to oral diet and hospital discharge. METHODS: Retrospective chart review of patients who underwent open hypopharyngeal surgery for management of dysphagia from March 2013 to June 2018 at a single academic institution. A clear liquid diet is restarted the day of surgery and is advanced to a soft diet on postoperative day one. Univariate and multivariate logistic regression was performed to identify risk factors for postoperative complications and unplanned readmission. RESULTS: Ninety patients met eligibility criteria; 62 patients underwent open cricopharyngeal myotomy, 13 underwent Zenker's diverticulectomy, 15 had a Zenker's diverticulopexy. Mean inpatient length of stay was 2.0 ± 2.0 days (range 0-11 days); 57 patients (63.3%) were discharged on the same day as surgery or on postoperative day one. Seven patients (7.8%) had postoperative complications; the most common complication was esophageal leak (n = 6). Six patients (6.7%) had unplanned readmissions within 30 days. Mean time to unplanned readmission was 12 days (range 2-19 days). Open diverticulectomy was associated with an increased risk of unplanned readmission with an OR = 7.63 (95% CI 1.29, 45.45, P = .025). At last follow-up, 70% of patients had an increased functional oral intake by at least one scale score (FOIS) after surgery (mean follow-up 0.8 ± 1.1 years, range 0.02-5.1 years). CONCLUSION: An early diet and discharge may be safe for patients undergoing open surgery without a mechanical or suture closure of their esophageal mucosa, whereas in those undergoing diverticulectomy, NPO status and a radiological check before resuming drinking and eating are advised. LEVEL OF EVIDENCE: 4.

The Role of Cricopharyngeal Myotomy After Anterior Cervical Decompression and Fusion Operations.

BACKGROUND: Anterior cervical spine surgeries have low morbidity, sufficient surgical corridor, and quick recovery times. Although largely considered a safe and effective procedure to address cervical myelopathy, radiculopathy, and deformity, dysphagia is a frequent yet poorly understood adverse event. One treatment is cricopharyngeal myotomy (CPM), which aids in swallowing for patients with refractory issues after anterior cervical decompression and fusion (ACDF). CASE DESCRIPTION: Here we describe our experience with 6 patients requiring revision ACDF with preoperative dysphagia who were treated with concurrent revision and CPM. Our series demonstrated that CPM is an effective and safe procedure used in combination with an ACDF. In our series, we had 6 patients with dysphagia preoperatively who were all able to undergo ACDF without worsening of their dysphagia despite having risk factors predisposing them to this complication. In our series, 83% of patients either improved or experienced resolution of their symptoms with only 1 patient failing to improve. CONCLUSIONS: Given its efficacy and safety, patients planned for ACDF with preoperative dysphagia should be evaluated by ENT for potential CPM.

Safety and efficacy of functional laryngectomy for end-stage dysphagia.

OBJECTIVES/HYPOTHESIS: To evaluate functional outcomes and complication rate after total laryngectomy (TL) for dysfunctional larynx with end-stage dysphagia. STUDY DESIGN: Retrospective chart review. METHODS: Chart review was performed on all patients who underwent TL from January 2008 to July 2016 at a single tertiary academic medical center. Patients who underwent TL for dysfunctional larynx without preoperative evidence of malignancy were included. Main outcome measures were post-TL functional swallowing and speech outcomes, and complication rate. RESULTS: The study included 19 patients from a cohort of 278 consecutive patients. All patients were previously treated with radiotherapy (RT), whereas 13/19 (68%) previously received chemoradiotherapy. The median time from RT to TL was 10.98 years (range, 0.67-23.94 years). Aspiration was evident preoperatively in 17/19 (89%) patients, with 11 experiencing recurrent aspiration pneumonia. Seventeen of 19 (89%) patients were nil per os (NPO) requiring enteral nutrition. Six of 19 (32%) patients had surgical complications, including three (16%) pharyngocutaneous fistulas. At 3-month and 1-year postoperative follow-up, there was significant improvement in mean Functional Oral Intake Scale (FOIS) score and aspiration, recurrent pneumonia, enteral nutrition, and NPO status rates (P < .05). At 1-year follow-up, no patients were NPO, and only one patient required gastrostomy tube supplementation. Mean FOIS score increased from 1.3 to 6.1 (P = .001). Eight of 13 patients (62%) were actively using a tracheoesophageal prosthesis at 1-year follow-up. CONCLUSIONS: Laryngectomy for dysfunctional larynx eliminates the morbidity of aspiration while improving diet and reducing gastrostomy tube dependence with an acceptable complication rate. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:597-602, 2018.

Open vs. endoscopic cricopharyngeal myotomy; Is there a difference?

INTRODUCTION: The upper esophageal sphincter (UES) is composed largely of the cricopharyngeus muscle (CP) and acts as the gatekeeper to the esophagus. There are multiple methods of treating UES dysfunction, but myotomy has been shown to be the most definitive means. We aim to evaluate the difference between open and endoscopic CP myotomy (CPM). METHODS: A retrospective review of all patients undergoing endoscopic and open CPM was undertaken. We recorded demographic, clinical, operative, hospital, and postoperative data for both groups from January 2010-March 2015. The endoscopic and open CPM groups were directly compared. RESULTS: Our cohort consisted of 38 open and 41 endoscopic CPM patients. There were 22 males and 16 females in the open group and 9 males and 32 females in the endoscopic group. The primary diagnosis for both groups was cricopharyngeal hyperfunction. We found a significant improvement in surgical time and symptomatic outcomes in the endoscopic group (p=0.008 and p=0.010). There was no difference in UES preop pressure, hospital stay, complication rate, time to oral intake, or length of follow-up between cohorts. CONCLUSION: Endoscopic CPM is a safe and effective alternative to the open approach. Patients undergoing endoscopic CPM have shorter operative times and improved outcomes when compared to the open approach.

A Rare Case of Carcinoma Cuniculatum Involving the Larynx in Association with a Saccular Cyst.

Carcinoma cuniculatum (CC), a rare, well-differentiated variant of squamous cell carcinoma, is uncommon in head and neck sites but when it does occur is most common in the oral cavity. Here we report a rare case of CC involving the larynx. A 49-year-old man presented with 10 months of worsening hoarseness and, despite multiple biopsies, no diagnosis of malignancy could be established. Eventual partial excision of the lesion and histologic review of prior specimens confirmed the diagnosis of CC. Focally, a transition to respiratory epithelium indicated the presence of an associated saccular cyst. Total laryngectomy was performed and 6 months later the patient is free of disease. Only two prior cases of CC have been reported in the larynx. Diagnosis of CC is challenging given the low grade histologic features and awareness of this entity for both treating physicians and the pathologist is important to reach a diagnosis of malignancy. This case highlights the challenges in diagnosis of CC, especially in unusual locations and when associated with other lesions such as a saccular cyst. Awareness of this rare tumor type combined with close communication between treating clinicians, radiologists and pathologists should allow earlier diagnosis and treatment.