Preoperative n-BCA embolization in the resection of submandibular lymphatic malformations refractory to sclerotherapy treatment: A pilot case series.

OBJECTIVE: Lymphatic malformations in the submandibular neck pose unique challenges to treatment that elevate their risk of recurrence. This case series provides a review of five patients, previously treated with sclerotherapy or with a history of multiple infections, who were treated in a novel fashion: single-stage resection using preoperative n-butyl cyanoacrylate (n-BCA) glue embolization. METHODS: We performed a retrospective medical record review of five patients who underwent single-stage n-BCA embolization by Interventional Radiology followed by surgical resection by Otolaryngology, including a review of their symptoms, previous treatments, and post-treatment surveillance, with follow-up ranging from 4 to 24 months after the treatment of interest. RESULTS: All study subjects had unremarkable perioperative courses, and four patients did not demonstrate any evidence of disease recurrence or persistence during the follow-up period. One patient was found to have a small area of persistent disease on post-treatment imaging, but has remained symptom free. CONCLUSIONS: Treatment of submandibular lymphatic malformations with n-BCA embolization followed by surgical resection can be performed in a single stage. This case series demonstrates that this approach can yield durable relief of symptoms, even in patients whose lesions were refractory to previous treatments.

Diagnostic Yield of Office-Based Laryngeal Biopsy in Patients With Leukoplakia; A Case Study With Review of the Literature.

OBJECTIVE: To review the authors experience in un-sedated office-based biopsies of patients with vocal fold leukoplakia and to review the literature. MATERIAL AND METHOD: A retrospective review of 29 patients was conducted. RESULTS: A total of 41 office-based procedures were performed (eight patients had bilateral vocal fold lesions and four patients had the procedure performed twice). In 26 out of the 41 biopsies, the pathology revealed benign lesion. In eight cases, the pathology showed dysplasia (four high-grade and four low-grade). Seven biopsies revealed squamous cell carcinoma. Five patients underwent suspension micro-laryngoscopy for definitive diagnosis. Four of whom had a change in their diagnosis. CONCLUSION: Un-sedated office-based biopsy of vocal fold leukoplakia is an alternative to suspension microlaryngoscopy in case of carcinoma or nonmalignant lesions.

Tolerance of Patients Using Different Approaches in Laryngeal Office-Based Procedures.

OBJECTIVE: To evaluate the tolerance, overall experience, procedure discomfort, and patient anxiety using different routes in office-based laryngeal procedures. SUBJECTS AND METHODS: We performed a retrospective analysis of patients undergoing office-based laryngeal procedures for the treatment or diagnosis of laryngeal lesions via transnasal, transoral, or percutaneous routes. Tolerability, overall experience, procedure discomfort, and patient's anxiety were evaluated and reported on a custom scale over 5. RESULTS: A total 178 procedures performed on 154 patients were reviewed. The video-recordings and data on 15 procedures were missing. A total of 163 procedures were included in this study. These were stratified as follows; 128 procedures via the transnasal fiberoptic approach, 16 procedures via the transoral fiberoptic approach, and 19 procedures via the percutaneous approach. There was no significant difference in the mean score of overall experience across the three different approaches (P= 0.926). The mean overall experience score for the transnasal approach was 1.85, vs 1.93 and 1.94 for the transoral and percutaneous approach, respectively. Similarly, there was no significant difference in the mean score of tolerability across the three different approaches. The mean tolerability score was 1.68 using the transnasal approach, compared to 1.6 using the transoral approach, and 1.84 using the percutaneous approach (P= 0.77). Anxiety scores, and procedure discomfort scores did not differ either among the three groups (P= 0.138 and P= 0.656, respectively). CONCLUSIONS: There was no significant difference in tolerability, anxiety, procedure discomfort, and overall experience regarding the different approaches employed.

Volumetric measures of the paralyzed vocal fold using computerized tomography; its clinical implication.

OBJECTIVE: To report the volumetric measures of the paralyzed vocal fold in patients undergoing injection laryngoplasty. MATERIAL AND METHOD: All the medical records of patients with unilateral vocal fold paralysis who had high resolution computerized tomography scan of the neck and chest prior to injection laryngoplasty between October 2015 and May 2018 were included. Volumetric evaluation of the vocal folds was performed by measuring the vocal fold height using coronal images and the vocal fold length and width using axial images. RESULTS: A total of 21 patients divided into 13 males and 8 females were identified. The mean age was 56.66 ± 20.94 years. The mean volume of the paralyzed vocal fold was significantly smaller than that of the non-paralyzed vocal fold (p < .05). Similarly, the mean length and height of the paralyzed vocal folds were smaller than those of the non-paralyzed vocal folds (p < .05). CONCLUSION: Volumetric measurements of the paralyzed vocal fold in comparison to the normal vocal fold in a group of 21 patients with unilateral vocal fold paralysis shows the presence of significant difference between the normal and affected site, and the presence of large inter-subject variation. Information on the volume difference between the two vocal folds may be used to better estimate the amount that needs to be injected in medialization procedures.

Application of Thulium Laser as Office-based Procedure in Patients With Vocal Fold Polyps.

PURPOSE: To report the voice outcome measures of thulium laser therapy as an office procedure in patients with vocal fold polyps. METHOD: This is a retrospective chart review of all patients with vocal fold polyps who underwent office-based thulium laser treatment between November 2016 and December 2017. Demographic data were collected. Objective voice outcome measures included extent of resolution, type of closure, and mucosal wave characteristics. Also, subjective outcome measures were reported, namely, Voice Handicap Index-10. RESULTS: A total of 20 patients were enrolled with a mean age of 50.95 ± 14.70 years. All patients had unilateral vocal fold polyps except for one who had bilateral polyps. Out of the 20 patients, 16 had complete regression of disease and 4 had partial regression. The number of patients with incomplete glottal closure decreased from 12 pretreatment to only 1 patient posttreatment, and the number of patients with impaired mucosal waves decreased from 13 to 5. There was also a significant decrease in the mean VHI-10 score before and after treatment (15.61 vs. 4.61 P value < 0.001). CONCLUSION: Thulium laser can be used as an office procedure for the treatment of vocal fold polyps.

Sexual Dimorphism in Laryngeal Volumetric Measurements Using Magnetic Resonance Imaging.

The objective of this study is to investigate the dimensional and volumetric measurements in the thyroarytenoid (TA) muscle in men and women using magnetic resonance imaging (MRI). The hypothesis is that there is a gender-related difference in these measurements. A retrospective chart review of 76 patients who underwent MRI of the neck at the American University of Beirut Medical Center was conducted. The dimension and volume of the right and left TA muscle were measured on axial and coronal planes short tau inversion recovery images. Male and female groups were compared with respect to demographic data and MRI findings using parametric and nonparametric tests. The mean length of the thyro-arytenoid muscle in males was larger than that in females on the right (males 2.44 [0.29] cm vs females 1.70 [0.22] cm) and on the left (males 2.50 [0.28] cm vs females 1.72 [0.24] cm) reaching statistical significance (P < .001). The mean width of the thyro-arytenoid muscle in males was larger than that in females on the right (males 0.68 [0.13] cm vs females 0.59 [0.11] cm) and on the left (males 0.68 [0.12] cm vs females 0.57 [0.12] cm) reaching statistical significance (P < .001). The mean height of the thyro-arytenoid muscle in males was larger than that in females on the right (males 1.05 [0.21] cm vs females 0.95 [0.12] cm) and on the left (males 1.05 [0.21] cm vs females 0.95 [0.12] cm) reaching statistical significance (P < .01 on the right and P < .05 on the left). The volume of the thyroarytenoid muscle in males was larger than that in females on the right (males 0.86 [0.25] mL vs females 0.48 [0.15] mL) and on the left (males 0.89 [0.27] mL vs females 0.48 [0.17] mL) reaching statistical significance (P < .001). The results of this investigation clearly indicate a significant difference in these measurements between men and women.

The Prevalence of Dysphonia and Dysphagia Symptoms in Patients on Statin Therapy.

OBJECTIVE: To investigate the effect of statin therapy on swallowing and phonation. METHODS: A group of patients on statin therapy and another group not on statins (controls) presenting to the endocrinology clinic between January 2018 and April 2018 were asked to participate. All patients filled Voice Handicap Index (VHI-10), Eating Assessment Tool (EAT-10), and Likert scales for vocal fatigue and hoarseness. Demographic data included age, gender, allergy, and history of smoking. RESULTS: A total of 160 patients were recruited, 75 patients on statin therapy and 85 not on statin therapy. The mean age of the study group was 55.00 years, whereas that of the control group was 45.70 years. The mean duration of statin treatment was 74.92 months. The mean VHI-10 and EAT-10 scores were significantly higher in the statin group compared to the control group (P < 0.05). Although there was no significant difference in the mean Likert scale for vocal fatigue, the mean Likert scale for hoarseness was significantly higher in the statin group compared to the control group (P < 0.05). CONCLUSION: This investigation revealed a significantly higher prevalence of laryngopharyngeal symptoms in patients on statin therapy versus a control group.

The Prevalence of Dysphonia and Dysphagia in Patients with Vitamin D Deficiency.

OBJECTIVE: To investigate the prevalence of phonatory and swallowing symptoms in patients with hypovitaminosis D. METHODS/DESIGN: All patients presenting to the endocrinology clinic and investigated for vitamin D deficiency between January 2018 and April 2018 were asked to participate in this study. Demographic data included age, gender, allergy, and history of smoking. Patients filled Voice handicap Index (VHI-10) and Eating Assessment Tool (EAT-10). RESULTS: A total of 136 consecutive subjects presenting to the endocrinology clinic for vitamin D testing were included: 60 with hypovitaminosis D and 76 with no hypovitaminosis D. The mean vitamin D level in the study group and controls was 13.25 ng/mL and 31.91 ng/mL, respectively. There was no significant difference in the mean score of VHI-10, nor in the mean score of EAT-10 in patients with hypovitaminosis D versus those with no hypovitaminosis D (P value >0.05). CONCLUSION: There was no significant difference in the prevalence of phonatory and dysphagia symptoms using VHI-10 and EAT-10 questionnaires between subjects with hypovitaminosis D and those with normal serum vitamin D levels.

Pathogenic Role of Reinke's Edema in Snoring and Obstructive Sleep Apnea.

OBJECTIVE: To investigate the association between vocal fold Reinke's edema, snoring, and obstructive sleep apnea. DESIGN/METHODS: Twenty-five patients diagnosed with Reinke's edema and 25 patients with normal laryngeal examination, matched according to age, gender, and body mass index were recruited for this prospective study. Demographic data included age, gender, and body mass index. All patients filled the Berlin Questionnaire, STOP-BANG Sleep Apnea Questionnaire, and the Epworth Sleepiness Questionnaire. RESULTS: Out of 25 patients with Reinke's edema, 36% had Obstructive Sleep Apnea (OSA) as evidenced by having two or more positive categories in the Berlin Questionnaire. In the control group, only 4% had OSA.The difference between the two groups was statistically significant (P value = 0.005). With respect to Epworth Sleepiness Scale and the STOP-BANG Sleep Apnea Questionnaire (P value > 0.05), there was no statistically significant difference between the two groups. CONCLUSIONS: This investigation revealed higher prevalence of snoring and obstructive sleep apnea in patients with Reinke's edema as evidenced by the Berlin Questionnaire. The caring physician should be alert to symptoms of airway obstruction for possible early intervention.

Adverse Reaction to Restylane: A Review of 63 Cases of Injection Laryngoplasty.

The aim of this study is to review the prevalence of adverse reactions to cross-linked hyaluronic acid (HA) following injection laryngoplasty and discuss possible mechanisms. A retrospective chart review of patients who underwent injection laryngoplasty using HA was conducted. Demographic data included age, gender, etiology, site of injection, and amount injected. Adverse reaction was diagnosed by the presence of inflammatory reaction at the injection site. A total of 63 patients were included, divided into 41 males and 22 females with a mean age of 51.76 years. The most common etiology was vocal cord paralysis (n = 53), followed by postcordectomy, puberphonia, and vocal fold atrophy and bowing. The average amount injected was 0.56 (0.22) mL. Three cases out of 63 patients developed an adverse reaction and presented with airway symptoms, namely, progressive shortness of breath and globus 2 to 3 days postinjection. Adverse reactions following HA injection laryngoplasty may occur with life-threatening symptoms.

Laser Partial Arytenoidectomy as an Office Procedure.

Bilateral vocal fold paralysis is a disabling condition that results in airway symptoms, dysphonia, and sometimes difficulty swallowing. Various types of glottal widening procedures have been described in the literature, all of which are performed in the operating room under general anesthesia. The aim is to report laser partial arytenoidectomy as an office-based treatment modality in a patient with bilateral vocal fold paralysis. Using Thulium laser fiber introduced through the working channel of fiberoptic nasopharyngoscope, a posterior cordectomy followed by resection of the vocal process of the right arytenoid was performed. The laser was used in a pulsed mode, power range 3.5 to 4.5 W, duration 70 to 300 milliseconds, repetition 2 to 4 Hz, and aiming beam 65%. The procedure was well tolerated and the patient was successfully decannulated 3 weeks later. Unsedated office-based laser arytenoidectomy might be considered a safe alternative to the commonly practiced glottal widening procedures in patients with a preexisting tracheotomy.

Prevalence of Dysphagia in Patients With Non-neoplastic Vocal Fold Pathology.

OBJECTIVES: To examine the prevalence of dysphagia in patients presenting with dysphonia and diagnosed with non-neoplastic vocal fold pathology. METHODS: A total of 45 patients presenting with dysphonia and diagnosed with non-neoplastic vocal fold pathology and a control group matched according to age and gender were included. Patients with recent history of respiratory tract infection, laryngeal surgery or manipulation, neurologic disorders, head and neck tumors, or history of chemotherapy/radiotherapy were excluded. The primary outcome measure for dysphagia was Eating Assessment Tool-10. Patients with a score above three were considered to have dysphagia. RESULTS: The 45 patients were stratified as 18 males and 27 females, with an overall mean age of 48.23 ± 14.65 years. The most common vocal fold pathology was Reinke edema (28.8%), followed by laryngitis (24.4%), and vocal fold nodules (17.7%) and polyps (13.33%). Out of 45 patients with dysphonia, 37.7% had dysphagia and out of 25 controls, 8% had dysphagia as evidenced by an Eating Assessment Tool-10 score of above three. This prevalence is higher than normative values reported in the literature (16%-22%). CONCLUSIONS: The high prevalence of dysphagia in patients with non-neoplastic vocal fold pathology alludes to the pathogenic role of laryngeal behavior in the development of obstructive swallowing symptoms. The potential benefit of voice and swallowing therapy in the treatment of these patients should be considered.

Predictive value of globus pharyngeus in patients with functional dysphonia versus organic dysphonia.

OBJECTIVES/HYPOTHESIS: This is a retrospective study investigating the prevalence of globus pharyngeus in patients with dysphonia. STUDY DESIGN: Retrospective chart review. METHODS: The study examined the prevalence of globus pharyngeus in patients presenting with history of dysphonia at the American University of Beirut Medical Center Voice Center was performed. The etiology of dysphonia was categorized as organic in the presence of laryngeal pathology versus functional in the absence of any laryngeal pathology on laryngeal videostroboscopic examination. Functional dysphonia was further stratified as muscle tension dysphonia (MTD) and non-MTD based on the presence or absence of supraglottic muscle tension patterns. RESULTS: The medical records of 300 patients were reviewed. Total prevalence of globus pharyngeus was 14.33%. There was a significant difference in the prevalence of globus pharyngeus between patients with organic dysphonia and patients with functional dysphonia (P < .001). Out of 43 patients with globus, 41.86% had organic voice disorders versus 58.14% who had functional voice disorders. Among those with functional voice disorders, globus pharyngeus was more prevalent in patients with MTD versus non-MTD patients (P = .19). Out of 25 patients with functional voice disorders and globus, 72% had MTD versus 28% who had no MTD (P = .19). CONCLUSIONS: Globus pharyngeus is significantly more prevalent in patients with functional dysphonia versus patients with organic dysphonia. Moreover, in patients with functional dysphonia, the prevalence of globus was higher in those with MTD despite not reaching statistical significance. Globus pharyngeus may be either the cause or the result of laryngeal aberrant functional behavior. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:930-934, 2019.

Injection Laryngoplasty in Patients With Puberphonia.

Puberphonia is a common vocal disorder characterized by the persistence of high vocal pitch postpuberty. Affected individuals may suffer from social impediments that can markedly affect their quality of life. Voice therapy is invariably offered as a main treatment modality with a successful outcome. Other treatment modalities include laryngeal framework surgery, cricothyroid muscle chemodenervation, and injection laryngoplasty. The authors of this manuscript report the impact of injection laryngoplasty on the average fundamental frequency in three cases of puberphonia.

Risk of post-operative hemorrhage after adenoidectomy and tonsillectomy: Value of the preoperative determination of partial thromboplastin time and prothrombin time.

INTRODUCTION: Tonsillectomy and adenoidectomy (T& A) are the most common pediatric surgical procedures performed world-wide. Bleeding remains the most common complication of these procedures with 1-5.7% prevalence. METHODS: We recruited 1269 patients who were scheduled for either tonsillectomy, adenoidectomy or both. All patients had preoperative CBC, PT, and aPTT ordered. According to the results, patients were labelled as either "abnormal group" or "normal group". RESULTS: 35 patients had abnormal lab results 18 of these patients were diagnosed with coagulation disorders on further laboratory testing.9 of these patients had no pertinent history of bleeding. Even though an association is noted between abnormal lab tests and preoperative history of risk of bleeding, the correlation did not have high sensitivity (28.6%). CONCLUSION: This study provides evidence that preoperative history can give some information on patients with abnormal coagulation profile but may underestimate the prevalence of such diseases. In addition, patients with abnormal coagulation profile have more risk of postoperative bleeding even after adequate medical treatment perioperative. Thus, identifying these patients will help the clinician in providing the best surgical management with the least morbidity and mortality.

Voice outcome measures after flexible endoscopic injection laryngoplasty.

OBJECTIVE: To report voice outcome measures after injection laryngoplasty using the transnasal or transoral flexible endoscopic technique. METHODS: A retrospective review of all patients who underwent flexible endoscopic injection laryngoplasty between June 2010 and August 2016 was carried out. Only those patients who had pre- and post-injection voice outcome measures recorded were included. Voice outcome measures recorded included perceptual voice evaluation using GRBAS, Voice Handicap Index-10 (VHI-10), maximum phonation time (MPT) and closed quotient (CQ) before and after treatment. RESULTS: Forty-six patients were identified, of which 32 had pre- and post-injection voice outcome measures recorded. There were 19 males and 13 females. The mean age was 56.97 years (range 20-86 years) and the most common indication was unilateral vocal fold paralysis. Thirteen patients had a transnasal flexible endoscopic injection), while 19 patients were injected transorally. Following injection laryngoplasty, there was significant improvement in the mean grade of dysphonia (2.81 vs. 1.22, P < 0.01, roughness (2.44 vs. 1.34, P < 0.01), breathiness (2.72 vs. 1.13, P < 0.01), asthenia (2.78 vs. 1.06, P < 0.01), and strain (2.44 vs. 1.19, P < 0.01), MPT (3.85 s vs. 9.85 s, P < 0.01) and mean CQ (0.19 vs. 0.46, P < 0.01). There was also a decrease in the mean VHI-10 score (33.31 vs. 7.94, P < 0.01). CONCLUSION: s: Patients achieved significant improvement in both subjective and objective voice measures after flexible endoscopic injection laryngoplasty via the nasal or transoral route. Voice outcomes were comparable to those reported for other approaches. This technique provides an alternative approach for the management of patients with vocal fold paralysis or glottal insufficiency.

Vocal tract symptoms: Severity and frequency in patients on statins.

The objective of the study was to analyze the frequency and severity of vocal tract symptoms in patients on statins. A total of 73 patients were enrolled in this study, 44 patients who were taking statins and 29 controls not taking statins. The severity and frequency of vocal tract discomfort was assessed using the Vocal Tract Discomfort scale. The most frequent vocal tract symptom in patients on statins was dryness followed by tightness and lump sensation. The difference in the mean of the total score and in the mean frequency of any vocal tract symptom was not significant between patients taking statins and controls. The most severe (highest mean values) vocal tract symptom in patients taking statins also was dryness followed by tightness and lump sensation. The difference in the mean of the total score and in the mean severity of any vocal tract symptom between patients taking statins and controls was not significant. This study failed to demonstrate a higher prevalence or severity of vocal tract symptoms in patients receiving statins. Despite the lack of a significant difference in the means of vocal tract discomfort symptom frequency and severity, this study carries clinical significance when considering that a higher prevalence and severity of vocal tract discomfort symptoms should alert physicians to the possible development of statin-induced myotoxicity in the laryngopharyngeal complex.

Prevalence of MTD among Patients with Functional Dysphagia.

OBJECTIVE: To assess the prevalence of laryngeal muscle tension patterns among patients with functional dysphagia. STUDY DESIGN: Retrospective study. SETTING: The study took place at a university medical center. MATERIAL AND METHODS: The medical charts and laryngeal video recordings were reviewed for all patients who presented with dysphagia and who were referred for barium swallow between 2012 and 2017. A total of 170 cases were identified. Only those with normal findings on barium swallow and the absence of vocal fold pathology (exudative lesions, masses or tumors, paresis, and paralysis), referred to as functional dysphagia, were included in this study. Information retrieved included swallowing and phonatory symptoms in addition to patterns of laryngeal muscle tension. RESULTS: The mean ± SD age of the total group was 41.90 ± 15.10 years with a male:female ratio of 4:1. Seventy-five percent had evidence of at least 1 type of laryngeal muscle tension pattern. The most common pattern was type III, characterized by supraglottic anteroposterior compression (13 of 20), followed by type II, characterized by medial compression of the false vocal folds (5 of 20); only 1 patient had muscle tension pattern type IV, characterized as sphincter-like closure of supraglottic structures. The most common laryngopharyngeal symptom was throat discomfort when swallowing (35%), followed by throat clearing and choking/coughing when eating and drinking (25%). CONCLUSION: The high prevalence of laryngeal muscle tension pattern among patients with functional dysphagia supports the notion that laryngeal tension may be one of the underlying causes of dysphagia.

Unilateral Vocal Fold Paralysis in Parkinson Disease: Case Report and Review of the Literature.

OBJECTIVE: The objective of this study was to report the first case of unilateral vocal fold paralysis in a patient with Parkinson disease (PD) and to review the literature. METHODS: This is a case report and literature review following PubMed search using the keywords "Parkinson," "vocal fold paralysis," "vocal fold palsy," "vocal fold immobility," "vocal fold adductor palsy," "airway obstruction," and "stridor." RESULTS: A total of 18 subjects diagnosed with PD and vocal fold paralysis were described. In all cases, the vocal fold paralysis was bilateral and the main presenting symptoms were stridor and shortness of breath necessitating intubation and tracheostomy. This article describes the first case of PD presenting with dysphonia secondary to unilateral vocal fold paralysis (left). The management consisted of injection laryngoplasty for medialization of the paralyzed vocal fold. CONCLUSIONS: Patients with PD can present with unilateral vocal fold paralysis. Early treatment is advocated in view of the advent of injection laryngoplasty as a safe office procedure.