Chondronecrosis of the cricoid treated with hyperbaric oxygen therapy: A case series.

We present two cases of cricoid chondronecrosis treated with hyperbaric oxygen (HBO2) therapy. Both patients presented with biphasic stridor and dyspnea several weeks after an intubation event. Tracheostomy was ultimately performed for airway protection, followed by antibiotic treatment and outpatient HBO2 therapy. Both patients were decannulated within six months of presentation and after at least 20 HBO2 therapy sessions. Despite a small sample size, our findings are consistent with data supporting HBO2 therapy's effects on tissue edema, neovascularization, and HBO2 potentiation of antibiotic treatment and leukocyte function. We suggest HBO2 therapy may have accelerated airway decannulation by way of infection resolution as well as the revitalization of upper airway tissues, ultimately renewing the structural integrity of the larynx. When presented with this rare but significant clinical challenge, physicians should be aware of the potential benefits of HBO2 therapy.

The Role of the Modified Barium Swallow Study and Esophagram in Patients with Globus Sensation.

Globus sensation (GS) is a common benign finding that is often associated with frequent throat clearing and is commonly a result of laryngopharyngeal reflux. The primary objective of this investigation was to examine the role of the modified barium swallow study (MBSS) with esophagram in the diagnosis and management patients who present with chief complaints of a GS. We hypothesize that these radiographic swallow studies do not add clinically significant information in the investigation of this common complaint. Retrospective chart review of patients with chief complaints of GS between 2000 and 2009 who underwent both MBSS and esophagram was conducted. Of the 380 patients who underwent MBSS, only 68 patients were eligible for this study. Over 70 % of patients were on reflux medicines, 81 % of the MBSS studies were normal, 62 % of the esophagram results were normal, 18 % of patients had a hiatal hernia, and 10 % exhibited signs of reflux. Esophagoscopy was performed in 45 % of patients, of which 35 % were normal. One patient initially had a normal esophagogastroduodenoscopy and then was subsequently diagnosed with gastric CA. Fifty-nine percent of patients underwent CT Neck with IV contrast, of which 67 % had minor findings. Positive findings are often benign and can be treated with reflux medications. Esophagoscopy was often normal and most sensitive only for hiatal hernia. No hypopharyngeal cancer was noted. Therefore, MBSS and esophagram for patients with GS are most often negative and fail to add significant diagnostic information.

Transillumination of the occult submucous cleft palate.

Occult submucous cleft palate is a congenital deformity characterized by deficient union of the muscles that normally cross the velum and aid in elevation of the soft palate. Despite this insufficient muscle coverage, occult submucous cleft palate by definition lacks clear external anatomic landmarks. This absence of anatomic signs makes diagnosis of occult submucous cleft less obvious, more dependent on ancillary tests, and potentially missed entirely. Current diagnostic methodologies are limited and often are unrevealing in the presurgical patient; however, a missed diagnosis of occult submucous cleft palate can result in velopharyngeal insufficiency and major functional impairment in patients after surgery on the oropharynx. By accurately and easily diagnosing occult submucous cleft palate, it is possible to defer or modify pharyngeal surgical intervention that may further impair velopharyngeal function in susceptible patients. In this report, we introduce transillumination of the soft palate using a transnasal or transoral flexible endoscope as an inexpensive and simple technique for identification of submucous cleft palate. The use of transillumination of an occult submucous cleft palate is illustrated in a patient case and is compared to other current diagnostic methodologies.

Epistaxis Rates and Health Care Utilization in Patients With a Ventricular Assist Device.

Objective: Identify baseline epistaxis rates and epistaxis-related health care utilization trends in the ventricular assist device (VAD) population. Methods: Single center, retrospective cohort study consisting of chart review of adult VAD patients. Analysis of descriptive statistics was assessed using χ 2 tests, independent sample t tests, or Fisher's exact when expected counts were low. Logistic regression was used to assess associations between epistaxis and variables of interest. Results: Two hundred ninety patients were included in the analysis. Ninety-eight (33.8%) patients developed epistaxis and 84 (29.0%) received medical attention. Patients with gastrointestinal (GI) bleeding had increased rates of epistaxis (42.4% vs 29.0%). Logistic regression analysis found GI bleeding to have an adjusted odds of developing epistaxis of 1.94 (95% confidence interval [CI]: 1.12-3.37) and kidney disease to have an adjusted odds of 1.83 (95% CI: 1.06, 3.13). Discussion: VAD implantation improves survival and quality of life but also carries significant bleeding risks. At our institution, 29% of VAD patients received medical attention for epistaxis. GI bleeding and kidney disease were found to have increased adjusted odds of developing epistaxis. Fifty-nine percent of epistaxis events occurred while inpatient and 32.8% of events were seen in the emergency department. Implications for Practice: VAD patients are an at-risk group that could potentially benefit from preventative nasal hydration regimen.

CNGA3 is expressed in inner ear hair cells and binds to an intracellular C-terminus domain of EMILIN1.

The molecular characteristics of CNG (cyclic nucleotide-gated) channels in auditory/vestibular hair cells are largely unknown, unlike those of CNG mediating sensory transduction in vision and olfaction. In the present study we report the full-length sequence for three CNGA3 variants in a hair cell preparation from the trout saccule with high identity to CNGA3 in olfactory receptor neurons/cone photoreceptors. A custom antibody targeting the N-terminal sequence immunolocalized CNGA3 to the stereocilia and subcuticular plate region of saccular hair cells. The cytoplasmic C-terminus of CNGA3 was found by yeast two-hybrid analysis to bind the C-terminus of EMILIN1 (elastin microfibril interface-located protein 1) in both the vestibular hair cell model and rat organ of Corti. Specific binding between CNGA3 and EMILIN1 was confirmed with surface plasmon resonance analysis, predicting dependence on Ca2+ with Kd=1.6×10-6 M for trout hair cell proteins and Kd=2.7×10-7 M for organ of Corti proteins at 68 µM Ca2+. Pull-down assays indicated that the binding to organ of Corti CNGA3 was attributable to the EMILIN1 intracellular sequence that follows a predicted transmembrane domain in the C-terminus. Saccular hair cells also express the transcript for PDE6C (phosphodiesterase 6C), which in cone photoreceptors regulates the degradation of cGMP used to gate CNGA3 in phototransduction. Taken together, the evidence supports the existence in saccular hair cells of a molecular pathway linking CNGA3, its binding partner EMILIN1 (and ß1 integrin) and cGMP-specific PDE6C, which is potentially replicated in cochlear outer hair cells, given stereociliary immunolocalizations of CNGA3, EMILIN1 and PDE6C.

The Multimodal Diagnostic Approach Necessary in Detecting Elusive Submucosal Laryngeal Cancer.

Submucosal laryngeal lesions have proven themselves to be a diagnostic challenge in the field of medicine, often presenting inconsistently between endoscopic visualization, various imaging modalities, and biopsy. The conflicting clinical picture can lead to a delay in definitive diagnosis and treatment. A variety of laryngeal imaging modalities exist that give a unique perspective of the tumor being evaluated and can be used in combination to clarify discrepancies in presentation.  This report describes the clinical course of an undiagnosed laryngeal squamous cell carcinoma (SCC) presenting with persistent dysphonia, dysphagia, and unilateral vocal fold immobility. A negative head and neck computerized tomography (CT) scan reduced the concern for cancer, so symptomatic treatment with vocal fold augmentation was performed. Augmentation curiously worsened the dysphonia and also may have delayed the process of definitive diagnosis. Upon presenting to the laryngology clinic, stroboscopy demonstrated no vibration of the affected vocal fold. Submucosal vascular irregularity was noted with narrow band imaging with a very subtle keratotic mucosal change raising suspicion for underlying malignancy. Despite two CT scans that failed to visualize the lesion initially, a biopsy revealed keratinizing SCC, which was subsequently staged as T3N0M0. The patient elected to receive radiation therapy alone given his medical comorbidities. This case showcases the elusive ability submucosal laryngeal cancers have in diagnostic workups. Heavy reliance on any single diagnostic modality may be misleading, resulting in delayed diagnosis and treatment. An early, thorough, and multimodal approach that analyzes the cumulative results of a variety of diagnostic tools is essential in identifying and treating these elusive cancers in a timely manner.

Transcervical intubation for massive self-inflicted neck wound transecting the epiglottis.

Background: Penetrating trauma to the larynx is a rare phenomenon with a high risk of mortality and morbidity due to the density of vital structures in the area (Demetriades et al., 1996). Most commonly, this type of injury is due to a gunshot wound or knife injury (Snow and Ballenger, 2003). In cases of suicidal cutthroat injury, it is relatively rare to penetrate the airway (Symbas et al., 1976). Case report: We present a case of self-penetrating trauma to the anterior neck allowing access for direct laryngeal visualization and transcervical intubation in the field. We describe the immediate workup, surgical intervention, and postoperative management. We focus on managing postoperative cough, secretion management, decannulation, and resultant dysphagia. Conclusion: Penetrating laryngeal trauma resulting in airway transection is a rare but potentially fatal phenomenon in which airway management and aggressive post-operative care for severe coughing and dysphagia should be performed to help improve patient outcomes.

Rural-urban otolaryngologic observational workforce analysis: The state of Nebraska.

Objective: To analyze the rural-urban access to otolaryngology (OHNS) care within the state of Nebraska. Design: Cross-sectional study. Methods: Counties in Nebraska were categorized into rural versus urban status based upon the 2013 National Center for Health Statistics urban-rural classification scheme with I indicating most urban and VI indicating most rural. The information on otolaryngologists was gathered utilizing the Health Professions Tracking System. Otolaryngologists were categorized based on the county of their primary and outreach clinic location(s). Travel burden was estimated using census tract centroid distance to the nearest clinic location, aggregated to county using weighted population means to determine the average county distance to the nearest otolaryngologist. Results: Nebraska is a state with a population of 1.8 million people unequally distributed across 76,824 square miles, with rural counties covering 2/3 of the land area. Nebraska has 78 primary OHNS clinics and 70 outreach OHNS clinics distributed across 93 counties. More than half (54.8%) of the counties in Nebraska lacked any OHNS clinic. Overall, a statistically significant difference was found when comparing mean primary OHNS per 100,000 population and mean miles to a primary OHNS clinic with Level III counties being 5.17 linear miles from primary OHNS compared to Level V counties being 29.94 linear miles. Conclusion: Overall, a clear discrepancy between rural and urban primary OHNS clinics in Nebraska can be seen visually and statistically with rural Nebraskans having to travel at least 5.5 times farther to primary OHNS clinics when compared to urban Nebraskans.

Quality Versus Quantity: Using Scholarly Activity to Assess Otolaryngology Residency Candidates.

Selecting qualified candidates each year for residency positions has become more difficult in recent years, due to the sharp increase in Otolaryngology applicants. Although there are objective measures that can be used to directly compare medical students during the initial screening process, most information in the application is highly subjective and/or variable across institutions. Many programs count the total posters/presentations and publications to gauge scholarship. This measure of quantity may lead to negative bias toward those who have no home program, limited time outside of academics, and/or inadequate resources to engage in volunteer research. Evaluating the quality of research may be superior to quantity. A first-author publication is a viable proxy that demonstrates applicants have developed skills that set them apart from their peers. They likely possess non-clinical, translatable skills including internal motivation, self-regulation, curation of information, and task completion that map closely with qualities that make for excellent residents.

Ultrasound assessment of vocal fold paresis: a correlation case series with flexible fiberoptic laryngoscopy and adding the third dimension (3-D) to vocal fold mobility assessment.

BACKGROUND: Perioperative examination ofthe vocal folds with flexible fiberoptic laryngoscopy is not always feasible. Prior studies suggest vocal fold ultrasound may provide a useful screening tool, however, correlation to laryngoscopic findings is necessary. The purpose of the case series was to validate vocal fold ultrasound in the adult population and to correlate the ultrasound findings to the assessment provided by flexible fiberoptic laryngoscopy. MATERIALS AND METHODS: This IRB approved study accrued sixteen patients. Vocal fold ultrasound performed by the anesthesiologist was correlated with the laryngoscopy performed by the otolaryngologist. RESULTS: Assessment of vocal fold motion was congruent in thirteen patients with normal vocal fold mobility; however, there was discordance between the findings in three patients. CONCLUSION: Vocal fold ultrasound may be useful to screen for vocal fold motion abnormalities in the adult population. Abnormal findings on vocal fold ultrasound should be confirmed with subsequent laryngoscopy.

Recurrent Lingual Abscess in an Elderly Female With Bulbar Amyotrophic Lateral Sclerosis.

A lingual abscess is a rare condition that was scarcely described in clinical textbooks. A lingual abscess recurrence is rare and has only been described twice in the literature. Typically, the tongue and oral cavity have multiple intrinsic properties which stave off intralingual infection; however, there may be situations in which these properties are compromised, as demonstrated in oro-motor disability. Lingual abscesses have the potential to develop into catastrophic obstructive airway issues; therefore, early detection and management are paramount. The following is a presentation of an elderly female with Bulbar Amyotrophic Lateral Sclerosis (ALS) treated conservatively for a lingual abscess with recurrence at eleven months post-treatment. Due to her baseline neuromuscular disorder and elevated anesthesia risk, she was treated in the interventional radiology suite with drain placement and Povidone-Iodine sclerotherapy under conscious sedation with excellent results.

Just-In-Time Simulation Training for Nasopharyngeal Specimen Collection During the SARS-CoV-2 Pandemic.

INTRODUCTION: Rapid and accurate detection of the novel coronavirus using a nasopharyngeal specimen requires training for professionals who may have limited experience. To respond to the urgent need, an interprofessional team created a just-in-time (JIT) module to provide only what was needed, precisely when needed, and rapidly deployed training sessions to a large group of health professionals. METHODS: In April and May 2020, health professionals from the hospital, ambulatory clinics, and public health attended training. Procedural comfort/knowledge and perception of the training were assessed with pre-survey and post-survey. RESULTS: Comfort level in collecting a nasopharyngeal specimen among participating health professionals increased from 2.89 (n = 338) on the pre-survey to 4.51 (n = 300) on the postsurvey on a 5-point scale. Results revealed a significant difference (P < .01) between pre-post knowledge questions regarding the correct angle and depth of the swab to obtain an adequate sample from the nasopharynx. DISCUSSION: This study demonstrates that a JIT intervention can improve knowledge and comfort regarding the nasopharyngeal swab procedure. In preparation for the prevention and mitigation of future viral outbreaks (ie, coronavirus and influenza), educators should consider creating JIT skills training for health care professionals who may be deployed to assist in mass testing efforts.

Integrated Comprehensive Care for Transcare and Gender Diverse Clinic Patients: An Assessment of Physical, Mental, and Social Needs.

Introduction There is a large body of research reporting the healthcare needs of groups identifying as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ); however, a gap exists in the research literature because many epidemiological studies focus on sexual orientation rather than gender identify/incongruence. To address the lack of specific data from transgender and gender diverse (TGD) individuals, our organization designed and deployed a survey to assess the gender-affirming physical, mental, and social care needs of current patients. Methods A group of subspecialty physicians currently working with TGD patients created a list of questions and requested feedback from medical professionals familiar with the healthcare needs of this population. In addition, patients reviewed the survey for content and clarity. The final 68-item survey was distributed in April 2020 to patients or patients' representatives with an email address on file at the Nebraska Medicine Transgender Care Clinic (NMTCC). Participants were asked to respond to questions regarding their gender identity, their transition-related medical decisions, and their interest in services. Results Invitations were sent to 690 patients and 168 surveys were completed (response rate: 24.3%). Over 90% (n = 153) of the participants were patients and 9% (n = 15) answered survey questions on the patient's behalf. A majority (77.2%) had started the medical transition (hormones or puberty blockers) in the past four years. Nearly half (46.4%) identified as trans women, 43.4% identified as trans men, and 10.2% indicated they were nonbinary or gender expansive. Participants' sex assigned at birth was 50.9% female and 46.1% male. Most patients (n = 149; 92%) reported currently receiving hormone treatment within the Nebraska Medicine healthcare system. Results indicated the highest level of clinical services interest was primary care (38.4%), gender-affirming surgery (73.5%), voice therapy (49.0%), and hair removal (37.5%). In addition, participants were very likely to participate in support groups with "people of similar gender identity" (32.9%), with "others around my age" (28.6%), and "including a mix of ages and identities" (26.9%). Discussion This study suggests that our TGD patients would utilize integrated services to access a variety of clinical and non-clinical services. Ongoing community engagement and direct feedback from patients are critical to the success and growth of our gender-affirming care clinic. The results of this study will inform the planning and further evolution of a program designed to build trust and address health inequities for TGD individuals throughout the region.

A Novel Just-In-Time-Online-Training for Nasopharyngeal Swab Specimen Collection During the COVID-19 Pandemic.

INTRODUCTION:  The spread of coronavirus disease 2019 (COVID-19) is controlled by timely detection of infected patients using a nasopharyngeal (NP) swab test, followed by isolation and treatment. One challenge encountered with NP swab collection was to train healthcare providers (HCPs) with different training backgrounds and experience for collecting NP swab specimens across Nebraska, including a sizeable rural area. In-person training for NP swab collection skills was challenging due to social distancing. We developed a Just-In-Time-Online Training (JITOT) and delivered it using Facebook Live (TM) to meet our HCPs' training needs. METHODS:  Online training was held on April 21, 2020, and attended by 453 HCPs. A quasi-experimental study based on a survey and a multiple choice questionnaire (MCQ) was conducted to evaluate its effectiveness in improving the participants' knowledge and attitudes. RESULTS:  Group mean knowledge score increased from a pre-test score of 57%-95% in the post-test showing a large effect size (Hedges' g = 0.976877). On a five-point Likert scale, the majority (86.21%) of the survey respondents agreed/strongly agreed that this training increased their overall comfort for nasal swab specimen collection as compared to their pre-training comfort (37.93%) with this procedure. The majority of respondents (96.55%) in the post-training evaluation agreed/strongly agreed that "the delivery method was appropriate." CONCLUSION:  A JITOT session is helpful to teach, demonstrate, clarify doubts, and improve the knowledge and comfort of the participants. It can be quickly delivered using a free social media platform for broader outreach during public health emergencies.

Resident Education in Laryngeal Stroboscopy: Part II-Evaluation of a Multimedia Training Module.

OBJECTIVE: To evaluate the efficacy of a web-based training module for teaching interpretation of laryngeal stroboscopy in a cohort of otolaryngology residents. STUDY DESIGN: Randomized controlled trial. SETTING: Academic tertiary center. SUBJECTS AND METHODS: Residents from three training programs were invited to complete an assessment consisting of a survey and five stroboscopic exams. Subsequently, participants were randomized to receive teaching materials in the form of (1) a handout (HO) or (2) a multimedia module (MM) and asked to complete a post-training assessment. Responses were compared to responses provided by three fellowship-trained laryngologists. RESULTS: Thirty-five of 47 invited residents (74.4%) completed both assessments. Overall mean postassessment scores were 64.3% ± 7.0, with the MM group (67.0% ± 7.6, n = 17) scoring higher (P = 0.03) than the HO (61.6% ± 5.4, n = 18) cohort. Postassessment scores did not differ by postgraduate year (P = 0.75) or institution (P = 0.17). Paired analysis demonstrated an overall mean improvement of 7.4% in the handout (HO) cohort (P = 0.03) and 10.3% in the MM cohort (P = 0.0006). Subset analysis demonstrated higher scores for the MM cohort for perceptual voice evaluation (HO = 68.8% ± 11.0; MM = 77.3% ± 10.6, P = 0.03) and stroboscopy-specific items (HO = 55.5% ± 8.2; MM = 61.9% ± 10.8, P = 0.06). On a five-point Likert scale, residents reported improved confidence in stroboscopy interpretation (P < 0.0001), irrespective of cohort (P = 0.62). Residents rated the MM (median = 5) more favorably as a teaching tool compared to the HO (median = 4, P = 0.001). CONCLUSION: Use of both the written HO and MM module improved scores and confidence in interpreting laryngeal stroboscopy. The MM was more effective in perceptual voice evaluation and stroboscopy-specific items. The MM was also rated more favorably by residents and may be an ideal adjunct modality for teaching stroboscopy.

Resource Utilization and Billing in a Resident-Managed Inpatient Consult Service.

OBJECTIVE: Patient care delivered by residents is an educational opportunity to foster autonomy. These services, however, may not be billed without direct faculty supervision. This quality improvement project analyzes descriptive data, procedures, and billing from an academic otolaryngology-head and neck surgery department's inpatient consult service. METHODS: This prospective cohort study collected descriptive and billing data on all consults over 30 consecutive days. Data collected described bedside procedures and operative interventions. Encounters were Current Procedural Terminology coded and equivalent work relative value unit (wRVU) calculated. Codes submitted for billing were reviewed to identify opportunities for inpatient billing improvement. RESULTS: Ninety-eight new consults were included, and 105 bedside procedures were performed. Flexible laryngoscopy (n = 27), I&D (incision and drainage; n = 11), and suturing (n = 11) were the most performed bedside procedures. Operative intervention was required in 15 encounters. The inpatient consult team provided the equivalent of 391.39 wRVU. Seventy-three percent of operative compared to 3% of bedside procedures were submitted for billing. DISCUSSION: The productivity of our team approximated 61.8% of a full-time general otolaryngologist but with decreased billing submissions. Balance between resident autonomy, education, quality patient care, and the ability to capture service revenue is complex. Strategies other institutions have used to capture missed billing opportunities have included a hospitalist model, mid-level providers, and resident billing. IMPLICATIONS FOR PRACTICE: This study characterizes an academic inpatient consult service. Results describe a case for improving the structure of the inpatient consult service, caution that studies collecting data via department billing may underrepresent services, and suggest alternative service structures to overcome identified billing limitations.

Diffuse Spontaneous Laryngeal Hemorrhage with Trastuzumab.

Drug-induced epithelial hemorrhage of the endolarynx is an unusual etiology of hemoptysis. We present a case of hemoptysis in a young female patient undergoing treatment for metastatic breast cancer with trastuzumab emtansine. Though previously associated with diffuse spontaneous hemorrhage of the gingiva, there have not been reports of laryngeal hemorrhage with trastuzumab emtansine treatment. In this case report, we suggest that trastuzumab emtansine played a contributory role in the development of diffuse epithelial laryngeal hemorrhage and describe the pathophysiology, history, laryngoscopic findings, and management of this condition.

Examining the Otolaryngology Match and Relationships Between Publications and Institutional Rankings.

This study examines associations among publication number, National Institutes of Health (NIH) funding rank, medical school research rank, and otolaryngology department ranks of otolaryngology applicants during the 2018-2019 match cycle. Information regarding 2018-2019 otolaryngology applicants was collected from Otomatch.com and verified via department websites. Information was also collected regarding 2018 NIH funding rank and 2020 US News & World Report research rank of medical schools and otolaryngology departments. T tests and chi-square analyses were performed. Top 40 NIH funding rank, top 40 medical school research rank, and home institution department rank were separately associated with more publications and higher rates of matching into highly reputed otolaryngology departments (all P < .01). Furthermore, applicants who matched into ranked otolaryngology departments averaged significantly more publications (P < .01). Prospective otolaryngology applicants should take into account NIH funding rank, medical school research rank, and otolaryngology department rank, as they are associated with matching into high-ranking institutions.

Resident Education in Laryngeal Stroboscopy and Perceptual Voice Evaluation: An Assessment.

OBJECTIVES: To evaluate otolaryngology residents' level of confidence and understanding in interpreting laryngeal stroboscopy. METHODS: Otolaryngology residents from three residency programs with fellowship-trained laryngologists on faculty were invited to participate. An assessment consisting of a survey and five stroboscopic exams was administered. Each exam consisted of questions on perceptual voice evaluation, laryngoscopic findings, and stroboscopic findings. Scores were compared to answers provided by three fellowship-trained laryngologists. RESULTS: Thirty-eight of 47 invited residents (80.8%) enrolled in the study. On a five-point likert scale, residents reported low confidence (median = 2, range = 1-4) in interpreting stroboscopy, regardless of training program (P = 0.81). Mean assessment scores were 56.5% ± 11.9, with scores in perceptual voice evaluation = 68.5% ± 10.6; laryngoscopy = 70.2% ± 12.8; and stroboscopy = 45.3% ± 17.8. Residents performed worse on stroboscopy questions compared to laryngoscopy questions (P < 0.0001). There was a significant difference in scores by postgraduate year (P = 0.03), but not by institution (P = 0.34). A moderately positive correlation between reported level of confidence and overall scores (ρ = .47, P = 0.003) was demonstrated. CONCLUSIONS: Despite didactic and clinical exposure, residents report low confidence in interpreting stroboscopy and scored lower on stroboscopy-specific questions compared to other assessment items. Additional resources and learning opportunities are needed to improve resident confidence and comprehension of stroboscopy.