Laser Versus Cold Steel for Endoscopic Management of Subglottic Stenosis.

OBJECTIVE: Endoscopic management of subglottic stenosis (SGS) includes a wide range of techniques. This 17-year review compares treatment outcomes between carbon dioxide (CO2) laser and cold steel. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care center. METHODS: A chart review was performed for all patients undergoing endoscopic treatment of SGS at Cleveland Clinic between July 12, 2000 and September 1, 2017. Data collected included demographics, stenosis etiology, stenosis severity, comorbidities, treatment modality, and airway procedure history. The primary endpoint was repeated treatment-free survival (RTFS) within 2 years using a Kaplan-Meier analysis and Cox proportional hazard model. RESULTS: A total of 139 patients (median [interquartile range] aged 48.7 [37.8, 57.0] years; 83.4% female) were included in the analysis, with etiologies including idiopathic (56.8%), granulomatosis with polyangiitis (25.2%), and intubation (16.5%). All patients underwent either cold steel (107 patients) or CO2 laser (32 patients) lysis of stenosis with concurrent dilation. RTFS within 2 years was 50.2% for CO2 laser and 31.9% for cold steel (hazard ratio [HR] and 95% confidence interval [CI]: 1.69, 0.96-2.97, P = .07). In patients with no prior airway procedures, there was no difference in RTFS between laser and cold knife (P = .41). However, in patients with prior airway procedures, RTFS was significantly greater in the laser group, even after adjusting for age, smoking history, and stenosis etiology (50.0% vs 16.8%, adjusted HR and CI: 2.82, 1.14-6.98, P = .025). CONCLUSION: Endoscopic lysis of SGS with CO2 laser should be considered in revision cases.

Reassessing the Role of Phonomicrosurgery and Smoking Status in the Management of Reinke's Edema.

OBJECTIVES: To elucidate recurrence patterns of Reinke's edema (RE) following phonomicrosurgery and compare current and former smokers' outcomes. METHODS: A retrospective chart review was performed for patients who underwent microflap excision for RE at our institution since 2008. Patient data were collected, including demographics, smoking history, and operative and voice outcomes during the available follow-up period. Descriptive statistics, student's t-tests, Chi-squared analyses, and Fischer's exact tests were used for the appropriate between-group comparisons utilizing JMP statistical software. RESULTS: Patients who quit smoking on the day of surgery or continued to smoke postoperatively were included in our group of current smokers (n = 56). Patients who quit smoking within the month of surgery or longer were included in our group of former smokers (n = 22). There was no significant difference in postoperative voice outcomes between groups. Eight patients in the entire cohort experienced recurrence during the available follow-up period. Fischer's exact test revealed no statistically significant association between smoking status and recurrence (two-tailed p > 0.05). The mean time to recurrence for current smokers who did recur was 69 and 54 months for former smokers. CONCLUSION: We report low overall recurrence rates after microflap excision of RE lesions compared with historical data, without any significant difference in recurrence or voice outcomes when comparing current and former smokers. Further prospective trials with larger sample sizes are warranted to guide the surgical management of RE patients and the implications of smoking status. LEVEL OF EVIDENCE: 3 Laryngoscope, 2023.

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.

Dysphonia in Performers: Prevalence of Vocal Lesions and Voice Emergencies in a Private Otorhinolaryngology Practice.

OBJECTIVE: To determine the prevalence of abnormal laryngeal findings during videostroboscopy in performers presenting to clinic or when having an acute vocal emergency. STUDY DESIGN: Retrospective study of professional singers and actors who presented for a vocal evaluation. SUBJECTS AND METHODS: A chart review of singers or professional actors who presented in a private otorhinolaryngology clinic between 2014 and 2016. The prevalence of laryngeal lesions noted on stroboscopy were reviewed. The RFS (reflux finding score) was calculated and the exams that presented RFS greater than or equal to seven were considered suspicious of laryngopharyngeal reflux (LPR). RESULTS: A total of 140 records of actors and singers were evaluated either for routine evaluation or for an acute emergency. Sulcus vocalis was the most prevalent lesion 36% (n = 33), followed by cyst 27% (n = 25) and acute laryngitis, 14% (n = 13). Thirty-seven (26.4%) performers were treated for emergence due to dysphonia, Emergency dysphonia, mostly due to viral infection, was treated with steroids and speech therapy, with improvement of symptoms after treatment. Of these professionals, 83.8% (31) presented with a structural lesion or infection in the vocal folds, while 16.2% presented with dysphonia, which required emergency care without a structural lesion in the vocal folds. (P<0.05) Eighty-nine percent (33) of the professionals presenting with a voice emergency with dysphonia (37) were treated with corticosteroids. Thirty-three percent (n = 47) of the professionals presented with RFS scores ≥7. Nineteen professionals (40%) with signs of LPR were treated for emergency due to dysphonia. The professionals with signs of LPR had more emergency dysphonia than those who did not suspect LPR. (19.4%) (P = 0.008). CONCLUSION: Vocal emergencies in professionals are common in a private laryngology practice and require specialized assessment. The most prevalent lesions in the study were vocal sulcus. LPR is common in this group as noted both by findings with videostroboscopy and the RFS.

A Randomized, Double-Blind, Placebo-Controlled, Parallel-Group Phase 2b Trial of P2X3 Receptor Antagonist Sivopixant for Refractory or Unexplained Chronic Cough.

INTRODUCTION: To determine the optimal dose of sivopixant, a highly selective P2X3 receptor antagonist, for refractory or unexplained chronic cough (RCC/UCC). METHODS: In this phase 2b, randomized, double-blind, placebo-controlled, parallel-group, multicenter trial, patients received sivopixant 50, 150, or 300 mg or placebo once daily for 4 weeks. The primary endpoint was a change from baseline in 24-h cough frequency (coughs/h) with sivopixant vs placebo. RESULTS: Overall, 390/406 randomized patients completed the study. Placebo-adjusted changes in hourly cough count over 24 h were 13.17% (P = 0.3532), - 1.77% (P = 0.8935), and - 12.47% (P = 0.3241) and in cough severity (visual analog scale) were 1.75 mm (P = 0.5854), - 1.21 mm (P = 0.7056), and - 6.55 mm (P = 0.0433) with sivopixant 50, 150, and 300 mg, respectively. Placebo-adjusted changes from baseline in Leicester Cough Questionnaire total scores were - 0.37 (P = 0.4207), - 0.07 (P = 0.8806), and 0.69 (P = 0.1473) with sivopixant 50, 150, and 300 mg, respectively. Additionally, 61.3%, 78.3%, 86.8%, and 71.4% of patients receiving sivopixant 50, 150, and 300 mg and placebo, respectively, reported any improvements in Patient Global Impression of Change. The incidence of treatment-emergent adverse events (TEAEs) was 25.7%, 32.0%, 49.0%, and 20.6% in sivopixant 50, 150, and 300 mg and placebo groups, respectively; all TEAEs in the sivopixant group were mild-to-moderate. CONCLUSION: Sivopixant did not demonstrate a statistically significant difference vs placebo in change from baseline in 24-h cough frequency. The dose of 300 mg has potential for RCC/UCC, showing the greatest improvements in cough frequency and patient-reported outcomes and dose-related mild to moderate reversible taste disturbance, although further trials are needed. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT04110054; registered September 26, 2019.

To Tube, or Not to Tube: Comparing Ventilation Techniques in Microlaryngeal Surgery.

OBJECTIVES/HYPOTHESIS: The objective of this study was to compare ventilation techniques utilized in microlaryngeal surgery. STUDY DESIGN: Retrospective cohort study. METHODS: Two-hundred surgeries performed from May 1, 2018 to March 1, 2020 and stratified as intubated, intermittently intubated (AAIV) or apneic. Patient demographics, comorbidities, anesthetic agents, intraoperative parameters/events, and complications were studied and compared across the three groups using inferential analyses. RESULTS: Median body mass index in the AAIV group was significantly higher (33 vs. 29; P = .0117). Median oxygen nadirs were lower in AAIV cases (81% vs. 91-92%) while CO2 peak measurements were lower (33 mmHg vs. 48 mmHg) in the fully apneic cohort which were significantly shorter cases (P < .0001). CO2 peak measurements were comparable between AAIV and intubated cohorts (median 48.5 mmHg vs. 48.0 mmHg). Median apnea times were significantly prolonged by 2-5.5 minutes using nasal cannula and THRIVE/Optiflow in fully apneic cases when compared to no supplementary oxygenation (P = .0013). Systolic blood pressures following insertion of laryngoscope were higher (159.5 vs. 145 mmHg) and postoperative diastolic pressures were lower (68.5 vs. 76.5 mmHg) in fully apneic cases than intubated cases. No differences existed between frequencies of complications. CONCLUSIONS: This study compares intubated, intermittently apneic, and fully apneic surgeries. No statistically significant differences were noted in comorbid conditions. While intraoperative hemodynamic fluctuations were more pronounced in the fully apneic cohort, and oxygenation distributions were lower in the AAIV cohort, no significant differences existed between events and complications. Apneic techniques are as safe and effective as traditional intubation. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2773-2781, 2021.

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.

Utility of Transnasal Humidified Rapid Insufflation Ventilatory Exchange for Microlaryngeal Surgery.

OBJECTIVE: Microlaryngeal surgery typically requires oxygenation and ventilation via either an endotracheal tube (ETT), jet ventilation (JV), or intermittent apnea with an ETT. Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) delivered by high flow nasal cannula has been reported as an alternative technique. This method of apneic oxygenation and ventilation allows for stable, unobstructed visualization of immobile laryngeal structures. We aim to describe the technique and characterize intraoperative parameters related to its safety. STUDY DESIGN: Case Series. METHODS: The electronic medical record was reviewed for patients who underwent microlaryngoscopy using THRIVE technique. Patient demographics, procedural details, operative parameters, and anesthesia records were reviewed. Descriptive statistics were reported. RESULTS: A total of 53 patients underwent microlaryngoscopy using THRIVE as the sole method of ventilation, with 62% female. Median age was 51 years, and median BMI was 25 kg/m2 . Most patients were ASA class 2, and most had a Mallampati score of 2. The most common surgical indications were subglottic stenosis, vocal fold lesions, and vocal fold paralysis. Median apnea time was 16 minutes. At the end of case, median end tidal CO2 was 50 mmHg, and median minimum SpO2 was 95. Six cases required supplementation of THRIVE with JV or tracheal intubation for sustained oxygen desaturation. There was an increase in end tidal CO2 of 0.844 mmHg/min of apneic time. CONCLUSIONS: THRIVE is a safe and effective technique for oxygenation and ventilation in microlaryngeal, non-laser surgery in appropriately selected patients. To ensure safety, back-up plans such as jet ventilation and microlaryngeal ETT should be available. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:587-591, 2021.

Benign Vocal Fold Lesions in Patients with Chronic Cough.

OBJECTIVE: The objective of this study was to determine the prevalence of benign vocal fold lesions (BVFLs) in patients with chronic cough over a 1-year period. STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic medical center. SUBJECTS AND METHODS: A retrospective cohort study of patients with chronic cough seen in our tertiary multidisciplinary cough clinic from 2016 to 2017 was conducted. Patient characteristics, presence of BVFLs by laryngoscopy, and Leicester Cough Questionnaire (LCQ) were recorded. RESULTS: A total of 419 patients were included (average age: 61 years), and 67% of patients were female. Ten percent of patients had BVFLs: granuloma (5%), leukoplakia (3%), nodules (2%), and polyps (1%). Median cough duration was 2.9 years (interquartile range [IQR], 0.7-8.5); no significant difference in median cough duration was observed between patients with BVFLs and those with no lesions (2.6 vs 3.0 years, P = .86). In total, 178 patients (42%) had available LCQ data: median score of 10.2 (IQR, 7.9-13.9); no significant difference in median LCQ was observed between patients with BVFLs and those with no lesions (10.5 vs 10.1, P = .54). CONCLUSION: Prevalence of BVFLs in our cohort of patients with chronic cough was 10%, with posterior glottic lesions-granuloma-being the most common (5%). Prevalence of midmembranous lesions was as follows: vocal fold nodules (2%) and vocal fold polyps (1%). BVFLs were not associated with longer cough duration or more severe cough. We cannot determine a causative or noncausative relationship between BVFLs and chronic cough at this time due to lack of a control group.

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.

Vocal fold scars: a common classification proposal by the American Laryngological Association and European Laryngological Society.

PURPOSE: Vocal fold scar is one the most challenging benign laryngeal pathologies. The purpose of this paper is to propose a classification that will allow for a common description of this entity between laryngologists, prevent discrepancies in interpretation, allow for comparison of related studies, and offer a training tool for young laryngologists. METHODS/RESULTS: Based on the depth and laterality of scarring, we propose 4 types: type I, characterized by atrophy of lamina propria with/without affected epithelium; type II, where the epithelium, lamina propria, and muscle are affected; type III, where the scar is located on the anterior commissure; type IV, which includes extended scar formation in both anteroposterior and rostro-caudal axis with significant loss of vocal fold mass. CONCLUSION: We believe that our proposal is comprehensive and encompasses all existing iatrogenic and non-iatrogenic etiologies in a simple and concise manner. It also serves its purpose as a descriptive, comparative, and training tool.

Chronic laryngitis caused by Mycobacterium Kansasii in a traveler.

Chronic laryngitis commonly presents with dysphonia, and infectious causes include tuberculosis and endemic mycoses. We present a 58-year-old female with laryngitis for 5 years, fevers, chills, fatigue, malaise, myalgias, anterior neck pain, and night sweats after multicontinent exposure. Bronchoscopy cultures were negative. Bilateral microflap excision of vocal fold lesions demonstrated thickened epithelium and a deep vocal fold mass. Biopsy showed necrotizing granulomatous inflammation with acid-fast bacilli. Mycobacterium kansasii was identified. Treatment led to improvement in dysphonia, systemic symptoms, and vocal fold irritation. To our knowledge, this is the first case of isolated nontuberculous mycobacterial vocal fold infection. Laryngoscope, 129:2534-2536, 2019.

Pressure induced tissue resection in the larynx: A preliminary canine study.

OBJECTIVES: The application of laser (light amplification by stimulated emission of radiation) energy in the larynx relies on thermal injury. The impact of this injury on adjacent tissue can be undesirable. Attempts have been made to limit the extent and range of injury to adjacent tissue. The O-Pel Surgical System (Precise Light Surgical, Inc., Campbell, CA), a new technology, utilizes kinetic energy through Pressure Induced Tissue Resection (PITR) (Precise Light Surgical, Inc.) to cut tissue, theoretically eliminating injury to adjacent tissue. The purpose of this study was to evaluate the PSL in canine vocal folds. METHODS: Four dogs underwent PITR incisions (4 mJ pulses at 200 Hz) on their vocal folds, through mucosa into the muscle. The animals were sacrificed at days 0, 3, 7, and 21 days postsurgery. The larynges were harvested and histology was performed with hematoxylin and eosin, Masson trichrome, and Verhoeff-van Gieson. RESULTS: At day 0, focal denudation of the epithelium and coagulation necrosis in the lamina propria and adjacent connective tissue are noted. On days 3 and 7, an inflammatory infiltrate of neutrophils is seen within the lamina propria and surrounding connective tissue with minimal edema and early deposition of collagen. At day 21, the mucosa is completely regenerated with the area of previous PITR into the muscle replaced with thick bundles of collagen. CONCLUSION: The unique PITR characteristics offer a potentially unique cutting technology for laryngeal microsurgery. The current canine study suggests appropriate and rapid healing. With refinements of the tip size of the probe and adjustment of energy, PITR will likely be an appropriate alternate to traditional lasers in laryngeal surgery. LEVEL OF EVIDENCE: NA. Laryngoscope, 129:2557-2562, 2019.

Positivity rates of in vitro inhalant/respiratory and food allergy tests in the northern midwestern United States.

Rates of allergy-test positivity vary by country and by regions within countries. Several studies have looked at allergy test results to determine the most common allergens. Many of these studies have been based on surveys or on studies of small numbers of tests. Positivity rates for allergy tests are poorly defined in the northern midwestern region of the United States. We conducted a study to identify the rates of positive allergy tests for both inhalant/respiratory allergens and food allergens in the upper Midwest. We extracted from our laboratory database the results of all test samples sent for one of eight allergen panels that had been analyzed between Sept. 1, 2014, and Sept. 1, 2015. All testing was performed at The Cleveland Clinic with the Phadia ImmunoCAP system. The percentage of positive tests, the distribution of the most frequently positive tests, and the class of in vitro responses were identified. A total of 148,628 test results for 63 different allergens were identified. Of the 125,190 tests for inhalant/respiratory allergens, the most frequently positive were dog dander (24% of tests), cat dander (23%), dust mites (23% for both Dermatophagoides pteronyssinus and Dermatophagoides farinae), and June grass (21%). Of the 23,438 food tests, the most frequently positive test results were for milk (18%), peanut (17%), wheat (16%), and egg white (15%). Most of the results fell into classes 1 through 3, although there was still a notable number of very high responses (class 5 and 6). These findings suggest that there is wide variability in the positivity of in vitro allergy tests and that the likelihood of a positive result in screening panels can be estimated. Evaluating such rates will help identify the most and least common allergens and will help to cost-effectively refine allergy screening panels.

Tachyphylaxis and Dependence in Pharmacotherapy for Unexplained Chronic Cough.

Objective Unexplained chronic cough (UCC) is a perplexing condition treated with neuromodulators. Although previous literature describes the effectiveness of neuromodulators, there is little on the development of tachyphylaxis or dependence to neuromodulators over time. Our objective is to capture the experience of a large cohort of patients with UCC over an extended period, looking for these 2 phenomena. Study Design Case series with chart review. Setting Tertiary care hospital. Subjects and Methods We performed a retrospective review of patients diagnosed with UCC from 2010 to 2014. Patient outcomes were measured through percentage improvement scores. Treatment failures were attributed to no benefit, intolerable side effects, or tachyphylaxis. Tachyphylaxis was defined as the need for higher doses of medication following diminishing therapeutic benefit, while dependence was defined as a failure to stop therapy following attempted de-escalation or resurgence following drug cessation. Results Sixty-eight patients were included in the study. Tachyphylaxis was observed among 35% of patients while dependence was observed among 27% of successfully treated patients, together effecting >50% of the cohort. Sixty-eight percent of patients ultimately experienced successful treatment with neuromodulators, demonstrating strikingly distinct responses to different neuromodulator drug classes. Conclusion Tachyphylaxis and dependence occur frequently during UCC treatment and have a major impact on treatment outcomes. Patients sometimes demonstrate distinct responses to different neuromodulator classes. The majority of patients will experience successful treatment for their cough, although several trials may be required.

Burnout in Otolaryngology-Head and Neck Surgery: A Single Academic Center Experience.

Burnout in modern medicine is becoming more recognized and researched. The objective in this study is to evaluate burnout in a tertiary care academic institution and compare results among faculty, trainees, and advanced practice practitioners (APPs) in a cross-sectional survey using the Maslach Burnout Inventory. Fifty-two surveys were distributed; 44 participants completed the survey (85%): 25 staff physicians (57%), 14 resident physicians (32%), and 5 nurse practitioners (11%). Staff physicians had low emotional exhaustion, moderate depersonalization, and low result for reduced personal accomplishments; trainees reported low emotional exhaustion, high depersonalization, and moderate reduced personal accomplishment; and nurse practitioners reported moderate on all 3 dimensions. There is overall low burnout in this tertiary care academic center of otolaryngologist providers and no difference in rates among the different groups (trainees, APPs, staff). Measures addressing specific deficiencies among dimensions of burnout would be helpful to prevent disintegration of physician satisfaction into burnout.

Short- and Long-term Effects of Neuromodulators for Unexplained Chronic Cough.

Objective To evaluate the short- and long-term effects of tricyclic antidepressants (TCAs) and gabapentin in the treatment of unexplained chronic cough (UCC). Study Design Prospective cohort. Setting Tertiary care hospital. Subjects and Methods Patients seen between July 2016 and March 2017 were included following a formal workup and clinical evaluation indicative of UCC. Patients were placed on either a TCA (amitriptyline or nortriptyline) or gabapentin. Leicester Cough Questionnaire (LCQ) and percentage improvement scores were obtained prior to treatment initiation and at 2 and 6 months of neuromodulator treatment. A linear mixed model assessed the change in LCQ score between the 2 treatment time points and baseline scores. Results Twenty-eight patients completed a total of 37 neuromodulator trials. Gabapentin demonstrated statistically significant improvement in LCQ scores at 2 months (2.48 points, P≤ .01) and 6 months (5.40 points, P = .01) of treatment as compared with baseline. Patients taking TCAs demonstrated statistically significant improvement of LCQ scores at 2 months of treatment (3.46 points, P≤ .01). However, the majority of patients discontinued treatment, most commonly secondary to the development of tachyphylaxis after 2 months, precluding analysis at 6 months. Conclusion While both neuromodulator classes demonstrated short-term benefit, the majority of patients discontinue treatment prior to 6 months, with patients taking TCAs discontinuing more frequently than patients on gabapentin. Future investigations are warranted evaluating tachyphylaxis and the utility of dual treatment therapies designed to address peripheral and central sensory pathways involved in UCC.