Airway and Respiration Parameters Improve Following Vocal Fold Medialization: A Prospective Study.

OBJECTIVES/HYPOTHESIS: Laryngeal medialization procedures such as injection laryngoplasty (IL) and thyroplasty type 1 (TT1) are standard techniques for the treatment of glottic insufficiency related to unilateral vocal fold paralysis (UVFP). These procedures reliably improve the voice and may also improve swallowing function. Despite the association of laryngeal paralysis with airway regulation, there is little published on the effect of UVFP and its surgical treatment on respiration. The aim of this prospective study was to evaluate the aerodynamic outcomes of UVFP patients before and after vocal fold medialization, either by IL or TT1. METHODS: Consecutive patients with dysphonia due to UVFP were included in this prospective study between 2012 and 2014. Nineteen patients were investigated (5 females, 14 males) with a mean age of 37.05 ± 17.8 years. Eight patients were treated by IL while 11 patients received TT1. The patients were subjected to Modified Medical Research Council (MMRC) and Borg dyspnea scales, maximum phonation time (MPT) measurement, spirometry, and cycle ergometry, pre- and postoperatively at 2 months. RESULTS: There was a statistically significant increase in MPT from 5.5 ± 3 seconds to 11.2 ± 4.9 seconds postoperatively (P < .001). The MMRC and Borg dyspnea scales also showed significant improvement postoperatively (P < .001, P = .006, respectively). The change in spirometric parameters (peak expiratory flow, forced expiratory volume in 1 second, forced vital capacity, and peak inspiratory flow) were nonsignificant, while there was a significant improvement in cycle ergometry test postoperatively (P = .018). CONCLUSION: Laryngeal medialization procedures such as IL and TT1 improve UVFP patients' respiration-related quality of life and aerodynamic performance with no significant changes in spirometry.

Associations between laryngeal and cough dysfunction in motor neuron disease with bulbar involvement.

True vocal fold (TVF) dysfunction may lead to cough ineffectiveness. In individuals with motor neuron disease (MND), cough impairment in the context of dysphagia increases risk for aspiration and respiratory failure. This study characterizes differences and associations between TVF kinematics and airflow during cough in individuals with bulbar MND. Sequential glottal angles associated with TVF movements during volitional cough were analyzed from laryngeal video endoscopy examinations of adults with bulbar MND (n = 12) and healthy controls (n = 12) and compared with simultaneously collected cough-related airflow measures. Significant group differences were observed with airflow and TVF measures: volume acceleration (p ≤ 0.001) and post-compression abduction TVF angle average velocity (p = 0.002) were lower and expiratory phase rise time (p = 0.001) was higher in the MND group. Reductions in maximum TVF angle during post-compression abduction in the MND group approached significance (p = 0.09). All subjects demonstrated complete TVF and supraglottic closure during the compression phase of cough, except for incomplete supraglottic closure in 2/12 MND participants. A strong positive relationship between post-compression maximum TVF abduction angle and peak expiratory cough flow was observed in the MND group, though it was not statistically significant (r = 0.55; p = 0.098). Reductions in the speed and extent of TVF abduction are seen during the expulsion phase of cough in individuals with MND. This may contribute to cough impairment and morbidity.

Risk stratification in endoscopic airway surgery: is inpatient observation necessary?

PURPOSE: To compare post-operative complication rates between inpatient and outpatient endoscopic airway surgery in patients with laryngotracheal stenosis. Secondary objectives included characterization of a cohort of patients with this disease. METHODS: Retrospective review of patients with laryngotracheal stenosis in a tertiary care laryngology practice over a 5-year period. RESULTS: Ninety-one patients underwent 223 endoscopic airway surgeries. Of 114 outpatient interventions, 1 patient (0.8%) sought emergent medical care following discharge for respiratory distress. Of 109 procedures resulting in admission, no patients required transfer to a higher level of care, endotracheal intubation or placement of a surgical airway. There was no statistically significant difference in complication rates between patients treated as outpatients or inpatients (p=0.33, chi square). There were no cardiopulmonary events. There were no pneumothoraces despite frequent use of jet ventilation. The most common etiologic category was idiopathic (58%), followed by granulomatosis with polyangiitis (16%) and history of tracheotomy (12%). Most patients with idiopathic disease were female (p<0.001, Fisher's exact test). CONCLUSION: Patients undergoing endoscopic surgery for airway stenosis rarely have post-operative complications, and outpatient surgery appears to be a safe alternative to post-operative admission and observation.

Botulinum toxin injection for the treatment of upper esophageal sphincter dysfunction.

OBJECTIVES: We sought to review the dysphagia-related outcomes and quality of life in a series of patients with upper esophageal sphincter (UES) dysfunction treated with cricopharyngeal (CP) botulinum toxin (BTX) injection, and to identify patient characteristics or CP muscle histologic features that predict efficacy of BTX injection. METHODS: A retrospective chart review was performed on patients with UES dysfunction who underwent CP BTX injection. Dysphagia-related quality-of-life questionnaires based on the Eating Assessment Tool (EAT-10) were mailed to patients. RESULTS: Forty-nine patients (30 female, 19 male; average age, 59 +/- 16 years) with UES dysfunction have been treated at our institution with CP BTX injection since 2000. Seventeen of these patients also underwent CP myotomy. Injections of BTX were occasionally repeated after the treatment effect subsided, and the BTX dose varied widely (average, 39 +/- 19 units). Improvement in symptoms was noted by 65% of patients. The overall complication rate was minimal, although many patients complained of transient worsening of dysphagia after CP BTX injection. Biopsy specimens of the CP muscle were evaluated in the subset of patients with CP BTX injection who proceeded to myotomy, with results of neuropathic, myopathic, and mixed histologic subtypes. The EAT-10 scores demonstrated a general trend toward improved swallowing outcomes after CP BTX injection. CONCLUSIONS: This study reviewed findings from the largest published series of BTX treatment of UES dysfunction and evaluated the efficacy, patient satisfaction, and complications of this procedure. Dysphagia-related quality-of-life outcomes appear to be improved after CP BTX injection.

Quantification of Vocal Fold Atrophy in Age-Related and Parkinson's Disease-Related Vocal Atrophy.

OBJECTIVE: Vocal fold atrophy (VFA) is associated with aging and Parkinson's disease (PD). Clinical diagnosis of VFA depends on several visual-perceptual laryngostroboscopy findings that are inherently subjective. The purpose of this study was to use quantitative measurements to; (1) examine the relationships between VFA and dysphonia severity and (2) evaluate differences in VFA in patients with age-related VFA versus PD. METHODS: Thirty-six patients >60 years of age with VFA were included in this retrospective cohort study. Demographic information, medical history, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), Voice Handicap Index-10 (VHI-10), and still images from the stroboscopic exam were obtained. Image J™ was used to measure VFA, including bowing index (BI), normalized glottal gap area, and normalized mucosal wave amplitude. Pearson's correlation was used to evaluate the relationship between VFA, CAPE-V, and VHI-10. t-Tests and multivariate linear regression were used to compare VFA measures by dysphonia severity (CAPE-V <30 vs. >30) and diagnosis (age-related vocal atrophy [ARVA] and PD). RESULTS: BI was positively correlated with CAPE-V. Patients with CAPE-V >30 had a significantly larger BI compared to those with CAPE-V <30. Patients with PD had significantly larger BI than those with ARVA. Diagnosis of PD also predicted a larger BI after controlling for age and CAPE-V. CONCLUSION: Quantitative measures supported an association between bowing severity and dysphonia severity in patients with PD and ARVA. A PD diagnosis significantly predicted more severe BI. These findings demonstrate the potential utility of BI. Quantitative VFA measures might also provide insight into the mechanisms of ARVA and dysphonia. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1462-1469, 2023.

Extreme Sawtooth-Sign in Motor Neuron Disease (MND) suggests Laryngeal Resistance to Forced Expiratory Airflow.

OBJECTIVE: The impact of laryngeal dysfunction on airflow has not been well characterized in motor neuron disease (MND). This study aimed to detect and characterize extreme airflow oscillations informally observed during volitional cough and forced vital capacity (FVC) tasks in individuals with MND who demonstrated neurolaryngeal impairments including reduced speed and extent of vocal fold abduction compared to healthy controls during volitional cough expulsion. The extreme airflow oscillations in the MND group, when viewed as a flow-volume loop, appeared similar to the "sawtooth-sign." If the airflow oscillations are periodic in a range similar to phonation, they may reflect reduced laryngeal patency. METHODS: Volitional cough and FVC airflow data (3 trials each) from 12 participants with MND with bulbar/laryngeal involvement (3 F; ages 45-76) and 12 healthy controls (6 F; ages 41-68) were analyzed for periodicity. Percent and absolute durations of periodicity of the flow oscillations were calculated by an algorithm applied to the airflow signals. In addition, the frequency, magnitude, and kurtosis of the periodic airflow oscillations were described and compared between groups. RESULTS: In both volitional cough and FVC trials, the percent of airflow periodicity during forced expiration was significantly higher (z = 3.54) in individuals with MND, adjusted for age and sex. Periodic airflow accounted for on average 28% of the total time in participants with MND and was within a frequency range similar to phonation. Magnitude of the airflow oscillations was also larger for participants with MND (z = 3.46), and kurtosis of airflow was smaller (z = -4.70) during forced expiration, indicating persistent airflow oscillations throughout exhalation. CONCLUSIONS: The significantly larger-magnitude, lower-kurtosis, and more prominent presence of sawtooth-like airflow periodicity within a frequency range similar to phonation observed in individuals with MND with neurolaryngeal impairments suggests glottic airflow resistance during forced expiration.

Treatments for Age-related Vocal Atrophy: A Systematic Review.

OBJECTIVE: Age-related vocal atrophy (ARVA) can dramatically affect voice, communication, and quality of life. The objectives of this systematic review were to (1) determine whether treatments for ARVA were superior to controls (2) compare the relative efficacy of procedural and behavioral treatments (3) review the various types of outcome measures, and (4) evaluate the quality of studies. REVIEW METHODS: The literature was searched using strategies designed by a medical librarian (2/18/21, updated 3/9/22). Studies investigating treatments for bilateral vocal atrophy were included. Studies involving unilateral atrophy, presbyphonia (without endoscopic findings), or an absent comparator group were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist was used to guide this study. RESULTS: After applying the inclusion/exclusion criteria, 8 articles remained, including 4 randomized trials and 4 cohort studies, and a narrative synthesis was performed. Surgical and behavioral treatments for ARVA appeared to be superior to control groups, based on specific outcome measures. However, the superiority of these treatments over controls was not uniformly observed across multiple outcome measures. When comparing different treatments, superiority could not be established based on the quality and completeness of the studies included in the systematic review. Outcome measures also varied between individual studies. Finally, the risk of bias was analyzed and scored. Consistent point deductions among reviewed studies were noted. CONCLUSIONS: When comparing treatments for ARVA. Surgery and voice therapy were both superior to control groups based on specific outcome measures from different domains. Superiority of one treatment could not be established. LEVEL OF EVIDENCE: N/A Laryngoscope, 133:2846-2855, 2023.

Defining the Performance of Clinician's Ability to Screen for Laryngeal Mass From Voice.

OBJECTIVE: Defining a clinician's ability to perceptually identify mass from voice will inform the feasibility, design priorities, and performance standards for tools developed to screen for laryngeal mass from voice. This study defined clinician ability of and examined the impact of expertise on screening for laryngeal mass from voice. STUDY DESIGN: Task comparison study between experts and nonexperts rating voices for the probability of a laryngeal mass. SETTING: Online, remote. METHODS: Experts (voice-focused speech-language pathologists and otolaryngologists) and nonexperts (general medicine providers) rated 5-s/i/voice samples (with pathology defined by laryngoscopy) for the probability of laryngeal mass via an online survey. The intraclass correlation coefficient (ICC) estimated interrater and intrarater reliability. Diagnostic performance metrics were calculated. A linear mixed effects model examined the impact of expertise and pathology on ratings. RESULTS: Forty clinicians (21 experts and 19 nonexperts) evaluated 344 voice samples. Experts outperformed nonexperts, with a higher area under the curve (70% vs 61%), sensitivity (49% vs 36%), and specificity (83% vs 77%) (all comparisons p < .05). Interrater reliability was fair for experts and poor for nonexperts (ICC: 0.48 vs 0.34), while intrarater reliability was excellent and good, respectively (ICC: 0.9 and 0.6). The main effects of expertise and underlying pathology were significant in the linear model (p < .001). CONCLUSION: Clinicians demonstrate inadequate performance screening for laryngeal mass from voice to use auditory perception for dysphonia triage. Experts' superior performance indicates that there is acoustic information in a voice that may be utilized to detect laryngeal mass based on voice.

Comparative Treatment Outcomes for Idiopathic Subglottic Stenosis: 5-Year Update.

The North American Airway Collaborative (NoAAC) previously published a 3-year multi-institutional prospective cohort study showing variation in treatment effectiveness between 3 primary surgical techniques for idiopathic subglottic stenosis (iSGS). In this report, we update these findings to include 5 years of data evaluating treatment effectiveness. Patients in the NoAAC cohort were re-enrolled for 2 additional years and followed using the prespecified published protocol. Consistent with prior data, prospective observation of 487 iSGS patients for 5 years showed treatment effectiveness differed by modality. Cricotracheal resection maintained the lowest rate of recurrent operation (5%), followed by endoscopic resection with adjuvant medical therapy (30%) and endoscopic dilation (50%). These data support the initial observations and continue to provide value to providers and patients navigating longitudinal decision-making. Level of evidence: 2-prospective cohort study.

The ram sign: detecting previously undiagnosed congenital laryngeal clefts in adults.

OBJECTIVES: We present the clinical characteristics of a case series of adult patients with type III laryngeal clefts according to the classification of Benjamin and Inglis, in an attempt to make practitioners aware of the "ram sign," a clinical finding associated with laryngeal clefts in adults. Laryngeal clefts are uncommon defects that are nearly universally identified during infancy as a result of persistent aspiration and pneumonia. Undiagnosed laryngeal clefts in adults are extremely rare. METHODS: Three type III laryngeal clefts were identified in adults (29, 48, and 60 years of age) from one clinic over an 18-month period. The existing literature features only one type III cleft, to our knowledge. The 60-year-old patient represents the oldest person in the English-language literature to have a newly diagnosed laryngeal cleft. All three cases presented with various degrees of aspiration over an extended period. RESULTS: The computed tomographic imaging and endoscopic findings from these three patients were reviewed. The videolaryngoscopic images demonstrated that the "ram sign"--an endoscopic finding associated with redundant soft tissue overlying the arytenoid cartilages that prolapses into the cleft, creating the appearance of ram's horns--was a consistent and striking feature in all three patients. CONCLUSIONS: Although rare, laryngeal clefts may represent an underdiagnosed entity in the adult population. With increased awareness, they may be identified more frequently as a treatable cause of aspiration and recurrent pneumonia.

Endoscopic assessment of vocal fold movements during cough.

OBJECTIVES: Little is known about the function of the true vocal folds (TVFs) during cough. The objective of this study was to determine the reliability of measuring TVF movements during cough and to obtain preliminary normative data for these measures. METHODS: Sequential glottal angles associated with TVF adduction and abduction across the phases of cough were analyzed from laryngeal videoendoscopy records of 38 young healthy individuals. RESULTS: The intraobserver and interobserver reliability of 3 experienced measurers was high (intraclass correlation of at least 0.97) for measuring sequential and maximum glottal angles. The TVF abduction velocity during expulsion was significantly higher than the precompression adduction velocity (p = 0.002), but there were no significant differences in maximum angle. No statistically significant differences were seen in maximum TVF angle and velocity when they were compared between the sexes and between the levels of cough strength. True vocal fold closure following expulsion occurred in 42% of soft coughs and in 57% of moderate to hard coughs. CONCLUSIONS: The TVF abduction angles during cough can be reliably measured from laryngeal videoendoscopy in young healthy individuals. The TVF movements are faster for expulsion abduction than for precompression adduction, but the extents of abduction are similar. To validly determine the cough phase duration, simultaneous measures of airflow are needed.

Update on Tracheostomy and Upper Airway Considerations in the Head and Neck Cancer Patient.

Patients with head and neck cancer account for a large proportion of perioperative airway events. Further, these patients frequently require tracheostomy placement, which is one of the most common surgical procedures. This article reviews updated techniques in managing a difficult airway in patients with head and neck cancer, such as strategies for intubation/extubation, methods of tubeless laryngeal surgery, and techniques and relevant topics in tracheostomy management.

Assessing the Clinical Utility of the Early Postoperative Pharyngogram in Hypopharyngeal Surgery for Dysphagia.

OBJECTIVES/HYPOTHESIS: To evaluate the clinical utility of postoperative contrast x-ray pharyngograms (XRP) for detecting pharyngoesophageal leaks following hypopharyngeal dysphagia surgery. STUDY DESIGN: Retrospective cohort study. METHODS: Medical records were reviewed of patients undergoing endoscopic (E-) or open (O-) Zenker's diverticulectomy (-ZD) with cricopharyngeal myotomy (-CPM) and CPM alone from 2008 to 2020 at one academic institution. Exclusion criteria were patients who were fed enterally or underwent repair of epiphrenic diverticula or O-CPM during laryngectomy. XRP clinical indication, impact on clinical care, and factors associated with use patterns were examined using descriptive statistics and logistic regression (LR). RESULTS: Of 152 subjects, 52% underwent O-ZD, 30% O-CPM, 15% E-ZD, and 3% E-CPM. An XRP was ordered for 65% of subjects, mostly routinely (94%). Among the four clinically apparent leaks observed in this cohort, early postoperative XRP confirmed one. It did not identify any clinically silent leaks. In univariate LR, undergoing XRP was associated with increasing day of diet advancement (odds ratio [OR] 4.7, 95% confidence interval [CI] 2.5-10.5) and hospital stay duration (OR 3.2, 95% CI 2.1-5.2), as well as surgeon specialty of otolaryngology compared to general surgery (OR 12.8, 95% CI 4.8-40.8) and procedure sub-type (O-CPM: OR 0.03, 95% CI 0.002-0.16). In multivariate LR, the following variables were significantly associated with XRP use: hospital stay (OR 1.7; 95% CI 1.1-3.0), otolaryngology (OR 105; 95% CI 15.4-2193), O-CPM (OR 0.03; 95% CI 0.002-0.16), and E-CPM (OR 0.04, 95% CI 0.002-0.60). CONCLUSIONS: Prospective, multi-institutional studies are needed to confirm the low clinical utility we observed of early, postoperative XRP following hypopharyngeal surgery for dysphagia. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:272-277, 2022.

Does Dysphagia Improve Following Laryngeal Reinnervation for Treatment of Hoarseness in Unilateral Vocal Fold Paralysis?

PURPOSE: There are many reports of the efficacy of laryngeal reinnervation on voice, but there is a paucity of literature regarding its impact on swallowing function. The goal of this study was to explore the impact of laryngeal reinnervation on swallowing outcomes among unilateral vocal fold paralysis (UVFP) patients. METHODS: We reviewed 22 UVFP cases treated with laryngeal reinnervation at our institution. Ten patients had complete datasets, including Eating Assessment Tool (EAT-10) scores and appropriate follow-up. Wilcoxon signed-rank test was used to compare pre- and postoperative scores. RESULTS: Over the study period, 10 cases (mean age 45.7 ± 13.3 years; 6/10 men) with UVFP underwent ansa cervicalis to recurrent laryngeal nerve anastomosis (6/10) or nerve-muscle pedicle procedure (4/10). The median time between injury and surgical reinnervation was 12.4 months (range 2.7-88.5 months). Based on EAT-10 scores 6/10 patients were found to have dysphagia. Of these, four improved their score after surgery, one remained stable, and one deteriorated. The median EAT-10 score of these patients improved from 13 to 7 after surgery, but this difference was not statistically significant (P = 0.138). CONCLUSION: Laryngeal reinnervation procedure has the potential for restoring a near normal voice in UVFP. Laryngeal reinnervation of the vocal fold may be associated with a tendency toward improvement in the EAT-10 score in patients after surgery for hoarseness in the setting of UVFP.

Sensitivity of the Communicative Participation Item Bank for Measuring Patient-Reported Outcomes After Treatment of Unilateral Vocal Fold Immobility.

Importance: The Communicative Participation Item Bank (CPIB) is a patient-reported outcome measure assessing the association between communication disorders and participation in daily communication. To our knowledge, no prior research has examined whether CPIB scores change after treatment of unilateral vocal fold immobility (UVFI). Objective: To compare CPIB scores before and after treatment of UVFI and with patient-defined target treatment outcomes and other common clinical outcomes after UVFI intervention. Design, Setting, and Participants: This single-group case series recruited a convenience sample of community-dwelling patients aged 18 years or older from an urban academic medical center who had a diagnosis of UVFI and planned to receive intervention for UVFI. The study was conducted from March 2014 to March 2019. Exposures: Intervention for UVFI according to clinicians' recommendations. The treatment type was not controlled for this study. Main Outcomes and Measures: Patients' self-reported communicative participation was assessed by obtaining CPIB scores before and after treatment of UVFI, with scores calibrated to the standardized T scale. Pearson correlations between the CPIB general short form and computerized adaptive format, the Voice Handicap Index-10 (VHI-10), and self-rated and clinician-rated voice severity were also evaluated. Results: The sample included 25 participants, of whom 17 (68%) were male, 8 (32%) were female, and the mean (SD) age was 54.9 (17.0) years. Significant changes after treatment were observed in all quantitative outcomes including the primary outcome of the CPIB; the mean T score before treatment was 40.95 (95% CI, 37.49-44.41) and after treatment was 53.23 (95% CI, 48.41-58.04) (mean difference, -13.04 [95% CI, -7.30 to -18.79]; Cohen d, 0.96). The Pearson correlation between the CPIB general short form and computerized adaptive testing scores at pretreatment was r = 0.93 and at posttreatment, r = 0.95. Computerized adaptive testing showed efficiency advantages, with typically 5 to 6 items required for administration compared with 10 items for the short form. The correlation between the CPIB and VHI-10 was moderate before treatment (r = -0.70) and strong after treatment (r = -0.91). Moderate correlations were observed between the CPIB and clinician-rated voice quality before (r = -0.52) and after (r = -0.46) treatment and between CPIB and self-rated voice quality before (r = -0.56) and after (r = -0.62) treatment. Conclusions and Relevance: The results of this case series suggest that the CPIB is relevant for clinical use to assess changes in communicative participation among patients with UVFI before and after they receive treatment.

Association of Social Determinants of Health with Time to Diagnosis and Treatment Outcomes in Idiopathic Subglottic Stenosis.

OBJECTIVES: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients. METHODS: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence. RESULTS: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression. CONCLUSIONS: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

Dysphagia, stricture, and pneumonia in head and neck cancer patients: does treatment modality matter?

OBJECTIVES: Dysphagia-related sequelae are common after head and neck cancer treatment. Our aims were 1) to document overall and site-specific dysphagia, stricture, and pneumonia rates in a Medicare population, 2) to calculate treatment-specific rates and adjusted odds of developing these complications, and 3) to track changes in rates between 1992 and 1999. METHODS: Head and neck cancer patients between 1992 and 1999 were identified in combined Surveillance Epidemiology and End Results (SEER) registry and Medicare databases. Multivariate analyses determined odds of dysphagia, stricture, and pneumonia based on modality. RESULTS: Of 8,002 patients, 40% of experienced dysphagia, 7% stricture, and 10% pneumonia within 3 years of treatment. In adjusted analyses, patients treated with chemoradiation had more than 2.5-times-greater odds of dysphagia than did those treated with surgery alone. Combined therapy was associated with increased odds of stricture (p<0.05). The odds of pneumonia were increased in patients treated with radiation with or without chemotherapy. Temporally, the dysphagia rates increased 10% during this period (p<0.05). CONCLUSIONS: Sequelae of head and neck cancer treatment are common and differ by treatment regimen. Those treated with chemoradiation had higher odds of experiencing dysphagia and pneumonia, whereas patients treated with any combined therapy more commonly experienced stricture. These sequelae represent major sources of morbidity and mortality in this population.

Current Opioid Prescribing Patterns after Microdirect Laryngoscopy.

BACKGROUND: The prevalence of opioid abuse has become epidemic in the United States. Microdirect laryngoscopy (MDL) is a common otolaryngological procedure, yet prescribing practices for opioids following this operation are not well characterized. OBJECTIVE: To characterize current opioid-prescribing patterns among otolaryngologists performing MDL. METHODS: A cross-sectional survey of otolaryngologists at a national laryngology meeting. RESULTS: Fifty-eight of 205 physician registrants (response rate 28%) completed the survey. Fifty-nine percent of respondents were fellowship-trained in laryngology. Respondents performed an average of 13.3 MDLs per month. Thirty-four percent of surgeons prescribe opioids for over two-thirds of their MDLs, while only 7% of surgeons never prescribe opioids. Eighty-eight percent of surgeons prescribed a combination opioid and acetaminophen compound, hydrocodone being the most common opioid component. Many surgeons prescribe non-opioid analgesics as well, with 70% and 84% of surgeons recommending acetaminophen and ibuprofen after MDL respectively. When opioids were prescribed, patient preference, difficult exposure and history of opioid use were the most influential patient factors. Concerns of opioid abuse, the physician role in the opioid crisis, and literature about postoperative non-opioid analgesia were also underlying themes in influencing opioid prescription patterns after MDL. CONCLUSIONS: In this study, over 90% of practicing physicians surveyed are prescribing opioids after MDL, though many are also prescribing non-opioid analgesia as well. Further studies should be completed to investigate the needs of patients following MDL in order to allow physicians to selectively and appropriately prescribe opioid analgesia postoperatively.

Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis.

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.