Laryngeal chondromas: Current knowledge and future directions.

Objective: Cartilaginous tumors of the larynx are rare, representing less than 1% of all laryngeal tumors. Chondromas are benign mesenchymal tumors characterized by a slow-paced growth, primarily originated in the cricoid cartilage, followed by the thyroid, arytenoid, and epiglottic cartilages. This scoping review aims to understand the extent of evidence on the epidemiology, clinical characteristics, morbidity, and recurrence of the laryngeal chondroma (LC). Data sources: MEDLINE (Ovid), Embase (Elsevier), Web of Science (Clarivate), Cochrane Central Register of Controlled Trials and Systematic Reviews, Lilacs, Scopus, and Google Scholar databases. Review methods: The scoping review was conducted from 1816 to 2023, for observational studies describing LC. Titles and abstracts were screened for relevance, followed by an evaluation of the full text for eligibility. The data were collected from the qualifying articles, and a narrative summary of the outcomes was prepared. Results: One hundred and nineteen studies met the inclusion criteria. Ninety-four case reports, 22 case series, and 3 cohorts. Two hundred and four participants with a diagnosis of LC were described. Male:female ratio was 2.8:1. The most common localization was the cricoid (113; 47.08%), followed by the thyroid (45; 18.75%), and the arytenoid cartilage (27; 11.25%). Dyspnea (78.85%) and hoarseness (74.28%) were the most reported symptoms. The recurrence rate was 11.25%, and complications were uncommon following the resection. Conclusion: This scoping review found a low-frequency rate over all the cartilaginous laryngeal tumors. Most patients were treated with resection, with a low rate of malignancy conversion. This population has low attributable mortality, morbidity, and recurrence according to the current literature.

Impact of BMI on Dyspnea and Need for Surgical Intervention in Bilateral Vocal Fold Immobility.

OBJECTIVE: Bilateral vocal fold paralysis (BVFP) and posterior glottic stenosis (PGS) are causes of bilateral vocal fold immobility (BVFI) and may cause shortness of breath, stridor, and need for surgical intervention. Although increased body mass index (BMI) is associated with restrictive breathing patterns in patients with normal upper airways, it is unclear how BMI impacts dyspnea and need for surgical intervention in BVFI patients. STUDY DESIGN: Retrospective cohort study. SETTING: Three tertiary academic centers in the United States. METHODS: Demographics, BMI, Dyspnea Index (DI), etiology, presence of tracheostomy and surgical intervention (dilation, tracheostomy, cordotomy, arytenoidectomy, open reconstruction) were collected. Primary outcomes included dyspnea measured by DI and need for surgery to improve airway. Linear regressions were performed to assess continuous outcomes. Mann-Whitney U-test was utilized to assess categorical outcomes. RESULTS: Among 121 patients, 52 presented with BVFP and 69 with PGS. Previous neck surgery was the most common cause of BVFI (40.2%). 44.3% of patients received a tracheostomy. Through multivariate linear regression, increased BMI was significantly associated with increased DI in the entire cohort (ß = .43, P = .016). Increased BMI was also associated with need for any surgical intervention (odds ratio [OR] = 1.07, 95% confidence interval [CI] = [1.01-1.13]) in the overall cohort. When stratifying our data, BMI was only significantly associated with DI in BVFP (ß = .496) and need for surgical intervention in PGS (OR = 1.11, 95% CI = [1.01-1.21]), although a positive trend was seen in all analyses. CONCLUSION: Increased BMI may correlate with worsening dyspnea symptoms and need for surgical intervention in patients with BVFI. Weight-loss-related counseling may benefit symptom management.

Submucosal Epstein-Barr Virus Positive Polymorphic B-cell Lymphoproliferative Disorder of the Larynx: A Case Report.

Epstein-Barr virus (EBV) belongs to the group of human herpes virus and can cause clinical and subclinical infections. Although EBV-related disease presentations are similar, they can lead to oncogenic transformation with various clinical manifestations. A thorough workup with morphology, immunohistochemistry, and molecular studies is crucial for the diagnosis of EBV-positive polymorphic B-cell lymphoproliferative disorder, not otherwise specified (NOS), which is a new entity introduced by International Consensus Classification in 2022. We describe an interesting presentation of EBV-positive polymorphic B-cell lymphoproliferative disorder with laryngeal involvement to bring awareness to this entity and we would like to address the need for more accessible treatment options.

Venous Thromboembolism Prophylaxis in Otolaryngologic Patients Using Caprini Assessment.

OBJECTIVE: The aim was to determine the utilization of Caprini guideline-indicated venous thromboembolism (VTE) prophylaxis and impact on VTE and bleeding outcomes in otolaryngology (ORL) surgery patients. METHODS: Elective ORL surgeries performed between 2016 and 2021 were retrospectively identified. Logistic regression models were used to examine the association between patient characteristics and receiving appropriate prophylaxis, inpatient, 30- and 90-day VTE and bleeding events. RESULTS: A total of 4955 elective ORL surgeries were analyzed. Thirty percent of the inpatient cohort and 2% of the discharged cohort received appropriate risk-stratified VTE prophylaxis. In those who did not receive appropriate prophylaxis, overall inpatient VTE was 3.5-fold higher (0.73% vs. 0.20%, p = 0.015), and all PE occurred in this cohort (0.47% vs. 0.00%, p = 0.005). All 30- and 90-day discharged VTE events occurred in those not receiving appropriate prophylaxis. Inpatient, 30- and 90-day discharged bleeding rates were 2.10%, 0.13%, and 0.33%, respectively. Although inpatient bleeding was significantly higher in those receiving appropriate prophylaxis, all 30- and 90-day post-discharge bleeding events occurred in patients not receiving appropriate prophylaxis. On regression analysis, Caprini score was significantly positively associated with likelihood of receiving appropriate inpatient prophylaxis (odds ratio [OR] 1.05, confidence interval [CI] 1.03-1.07) but was negatively associated in the discharge cohort (OR 0.43, CI 0.36-0.51). Receipt of appropriate prophylaxis was associated with reduced odds of inpatient VTE (OR 0.24, CI 0.06-0.69), but not with risk of bleeding. CONCLUSION: Although Caprini VTE risk-stratified prophylaxis has a positive impact in reducing inpatient and post-discharge VTE, it must be balanced against the risk of inpatient postoperative bleeding. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:1169-1182, 2024.

Proximal Scar Progression in Idiopathic Subglottic Stenosis After Wedge Excision: Does it Happen?

OBJECTIVE: To compare the incidence of glottic stenosis in idiopathic subglottic stenosis (iSGS) patients with no prior surgical intervention to those with a history of endoscopic dilation and characterize the incidence of glottic involvement, changes in scar length, and progression of scar toward glottis following laser wedge excision (LWE). METHODS: A retrospective review of iSGS patients who underwent LWE between 2002 and 2021 was performed. Patients without prior airway surgery were labeled LWE primary (LWEP) and operative findings for LWEP patients were reviewed for glottic involvement, scar length (DL ), and distance from the glottis to superior-most aspect of scar (DGS ). Rates (in mm/procedure) of DΔL , reflecting an increase in length, and D-ΔGS , reflecting proximal migration, were calculated by dividing DΔL and D-ΔGS by the number of LWE procedures. RESULTS: 213 iSGS patients underwent LWE, with 132 being LWEP patients. LWEP had a lower incidence of baseline glottic involvement (n = 6, 4.5%) than LWE secondary (LWES; n = 6, 7.5%). Four new cases of glottic involvement were noted in LWEP patients following LWE, with only one being clinically significant resulting in permanently decreased vocal fold mobility. With each procedure, scar length increased by 1.0 mm and DGS decreased by 0.7 mm, reflecting a migration or decrease in DGS of 9.5% with each procedure with respect to initial DGS . Overall rates of glottic stenosis following operations were similar between LWEP and LWES cohorts, 7.6% and 7.5% respectively. CONCLUSION: There appears to be a low risk of glottic involvement resulting from the LWE procedure in iSGS patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:875-882, 2023.

Zenker Diverticulum: Does Size Correlate with Preoperative Symptoms?

Abstract Introduction Zenker diverticulum (ZD) usually affects adults after the 7th decade of life. Treatment for ZD is indicated for all symptomatic patients, but some patients prefer to defer surgical treatment until symptoms get worse and decrease their quality of life. Objective To evaluate the association of the preoperative symptoms in ZD patients with the size of the ZD. Methods A retrospective study design. Electronic medical records were used to identify patients diagnosed with ZD and treated over 11 years. Data collection included the chief complaints and symptoms, medical history, and findings on radiologic swallow evaluations of the patients. The diverticulum size was stratified into 3 groups: small (< 1 cm), moderate (1-3 cm), and large (> 3 cm). Results A total of 165 patients were enrolled and stratified by diverticulum size (48 small, 67 medium, and 50 large). Dysphagia, cough, and regurgitation were the most prevalent symptoms. Dysphonia was more frequent among patients with a small pouch. Logistic regression analysis showed that dysphagia and choking were associated with large and medium diverticulum size (p < 0.05). Additionally, dysphonia was significantly associated with the presence of a small-sized ZD (p < 0.04). Conclusion Upper gastrointestinal symptoms such as dysphagia and choking may be associated with a ZD > 1 cm and should always be evaluated. Additionally, the presence of dysphonia was found to be correlated with a ZD < 1 cm, suggesting that a prompt and appropriate fluoroscopic evaluation must be considered in those patients in whom no other clear cause of dysphonia is evident.

Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) in type 1 thyroplasty.

INTRODUCTION: Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) has been shown to benefit oxygenation, ventilation, and upper airway patency in laryngeal surgery. Its use in thyroplasty procedures has not been described. We hypothesized that the addition of THRIVE during type 1 thyroplasty procedures increases patient's safety and decreases the risk of an obstructive airway, while also decreasing the FiO2 with potential pooling of oxygen under the drapes. METHODS: This was a retrospective study of 80 patients carried out at Mayo Clinic Florida. Use of THRIVE for thyroplasty surgeries was introduced by the authors in 2016. All cases between 2016 and 2021 were analyzed. Patients who underwent thyroplasty surgery without the use of THRIVE were included as a control group. RESULTS: A total of 80 patients underwent elective thyroplasty procedures, and 46 of them used the THRIVE technique. Median age was 61 years and 34 % were men. Patients with and without THRIVE were similar at baseline, but THRIVE patients had higher min SPO2 and lower HR end compared to patients without THRIVE. Normal BMI patients had significantly higher min SPO2 compared to either underweight or overweight BMI patients, but there was no strong linear relationship between BMI and intraoperative parameters. CONCLUSION: Our study is the first to demonstrate the use of THRIVE in type 1 thyroplasty in the literature. THRIVE facilitates oxygenation and ventilation of both the spontaneously breathing and the apneic patient. We have demonstrated that thyroplasty can be performed using high flow Optiflow® as the sole mechanism for oxygenation and ventilation.

Clinical Symptoms Contributing to Zenker's Diverticulum Repair: A Retrospective Review.

OBJECTIVE: Zenker's diverticulum (ZD) is usually associated with dysphagia and other symptoms due to the interrelated functions of several systems. Surgical management of ZD is effective for all sizes of diverticula, but not all patients decide to undergo surgery. The purpose of this study was to determine the relationship between clinical presentation and patients' decision to undergo surgical repair. SUBJECTS AND METHODS: This is a retrospective study including 165 patients with ZD treated over the last 11 years. Data collection includes patients' chief complaints and symptoms, medical history, findings on radiologic swallow evaluations, and patients' decision to undergo surgery. Pearson correlation and logistic regression analysis were performed. RESULTS: Among our cohort, dysphagia was the most prevalent symptom (89.1%), followed by cough (65.5%) and regurgitation (58.8%). Dysphonia was prevalent among patients with a small-sized ZD. Our logistic regression model showed that patients' decision to undergo surgical repair could be predicted by diverticula size (ß=1.10, p=0.002) and the presence of dysphagia (ß=1.91, p=0.005), cough (ß=1.01, p=0.042), and dysphonia (ß=-1.37, p=0.024). CONCLUSION: Patients' decision to undergo surgery usually involves interrelated factors, including symptomatic burden, presence of comorbidities, and recommendation of the surgeon. This study has identified that diverticula size and the presence of dysphagia, cough, and dysphonia are significant factors influencing decision-making for surgical repair in patients with ZD.

Apneic Technique in Laryngotracheal Surgery.

Background Apneic oxygenation can be applied to select laryngotracheal procedures to improve operative visualization and avoid potential complications associated with intubation and jet ventilation.  Aims/objectives The authors sought to determine if apneic oxygenation using a high-flow nasal cannula could be used as a safe alternative airway management strategy for the duration of select laryngotracheal procedures. Methods Single institution, multi-site retrospective review of 38 adult (>18 years old) patients undergoing apneic oxygenation in the setting of various laryngotracheal procedures from January 2017 through January 2018. Humidified oxygen was delivered via a high-flow nasal cannula. The data was collected and analyzed using SAS version 9.4 (SAS Institute, Cary, NC). Results Twenty-four women and 14 men, mean age 60.0 years (SD 16.1; 36-89) and 70.1 years (SD 7.2; 56-81), respectively, underwent a mean total apneic time of 23.9 minutes (13-40). A statistically significant correlation existed between apneic time and minimum oxygen saturation (Pearson correlation coefficient 0.38; p=0.018). Twenty-one patients resumed spontaneous ventilation without the need for jet ventilation, mask ventilation, or placement of a definitive airway during the procedure.  Conclusions and significance Apneic oxygenation allows for extended periods of operating without the need for the placement of an endotracheal tube in patients undergoing general anesthesia for select laryngotracheal procedures.

Laryngeal Manifestations of Intractable Singultus.

Hiccup is a common phenomenon experienced by almost everyone in life. Although the exact physiology of this phenomenon remains unknown, it is associated with multiple central and peripheral etiologic causes. Vocal fold granulomas are benign laryngeal lesions typically caused by iatrogenic trauma, voice misuse, or chronic irritation. We present, for the first time, an association between intractable hiccups and vocal fold granulomas with good response to acupuncture and voice therapy in a 62-year-old male patient. This is an important contribution to the literature as the first report describing the co-occurrence of these pathologies in the context of a patient with several treatment failures, including vagal nerve stimulator.

Clinicopathologic Aspects of Vocal Fold Leukoplakia in Smokers and Nonsmokers.

BACKGROUND: We aimed to investigate possible causes of leukoplakia and squamous cell carcinoma. We particularly sought to characterize the effect of smoking history because leukoplakia has been observed in nonsmokers. METHODS: We retrospectively identified patients with a diagnosis of leukoplakia who were treated at Mayo Clinic (Jacksonville, Florida), in the Department of Otorhinolaryngology, from 1/1/2006 through 8/31/2019. Each patient was age- and sex-matched (1:2 ratio) to control patients without leukoplakia. Information about possible risk factors, chief symptoms, and social history with smoking and alcohol use was obtained from health records. Nine risk factors were analyzed independently with multivariate analysis. Continuous risk factors were compared between cases and controls with the Wilcoxon rank sum test; categorical variables were compared with the χ2 test. RESULTS: The final cohort consisted of 72 patients with leukoplakia (mean [SD] age, 66 [11] years; 61 men [85%]) and 144 age- and sex-matched controls. Compared with the control group, significantly more cases were current smokers (26% vs. 5%) and fewer were never-smokers. (17% vs. 51%) (P < 0.001). Cases also had a significantly longer duration of smoking history compared with controls (median, 30 vs. 0 years; P < 0.001). Alcohol consumption was not significantly different between cases and controls (53% vs. 54%; P > 0.99). When assessing never-smokers and those who had not smoked for more than 25 years, a history of smoking (P = 0.002) and the number of years smoked (P = 0.002) were significantly different for cases and controls. CONCLUSION: Most vocal fold leukoplakia lesions have a low risk of malignancy. It is important to evaluate the characteristics of the lesion and assess the patient's risk factors. Follow-up is a key factor in patient management, but for patients with recurrent leukoplakia, the duration and frequency of surveillance is still controversial and varies among medical centers. Future prospective studies with advanced analyses are warranted because they may strengthen the ability to identify clinical factors that influence the development of squamous cell carcinoma.

Fiddler's neck: A review.

Fiddler's neck is a common dermatologic condition associated with instrument use in violin and viola players. It typically manifests as a submandibular and/or supraclavicular lesion. It is a benign condition, but it may be mistaken for lymphedema or a salivary gland malignancy. Otolaryngologists who treat patients with fiddler's neck should be aware of appropriate management protocols and the need to avoid surgical excision. We obtained informed consent from 3 violinists to present their cases as specific examples of fiddler's neck. In addition, we present a literature review based on our PubMed search for articles about this instrument-induced dermatitis. The literature suggests that submandibular fiddler's neck is caused by mechanical pressure and shear stress on the skin and that it can present as erythema, scarring, edema, and lichenification. Supraclavicular fiddler's neck, on the other hand, is caused by allergic contact dermatitis, and it can present as an eczematous, scaly, and/or vesicular lesion. In most cases, a good history (especially of string instrument use), physical examination, and a patch test are sufficient to diagnose this condition. Management of fiddler's neck includes a topical steroid, proper instrument handling, neck padding, changing the instrument's materials, and/or reducing the amount of playing time. Surgical excision is usually not advisable.

Sulcus Vocalis (Type III): Prevalence and Strobovideolaryngoscopy Characteristics.

OBJECTIVES: The reported prevalence of sulcus vocalis (SV)/type III, a pathologic groove in the vibratory margin of the vocal fold, varies greatly in the literature. Difficulties in visualizing the defect and a variety of descriptions have complicated the evaluation of SV. The objective of this study was to determine the prevalence of SV by reviewing strobovideolaryngoscopy (SVL) examinations in subjects with and without dysphonia. STUDY DESIGN: Retrospective chart review. METHODS: Charts and SVL images were reviewed for subjects with and without dysphonia and analyzed using standard statistical techniques. RESULTS: SVL images were reviewed for 94 nondysphonia subjects and 100 dysphonia subjects. For all subjects, 19.6% had type I, 2.1% had type II, and 5.7% had type III/SV. Per vocal fold, 14.7% had type I, 1.3% had type II, 3.1% had type III/SV and 13.1% had scar. The prevalence of SV per subject was not significantly different between the two groups (8% of dysphonia subjects, 3.2% of nondysphonia subjects). Male gender, decreased amplitude, decreased waveform, and hypodyamic motion were significantly higher in the dysphonia SV subjects compared with the non-SV subjects. All other SVL characteristics were not significantly different in subjects with SV compared with non-SV subjects. CONCLUSIONS: We report a prevalence of SV/type III at 3.1% (per vocal fold) and 5.7% (per subject). Higher frequencies of male gender and waveform abnormalities were seen in the dysphonia SV subjects only. There were no significant differences in nondysphonia subjects with or without SV.

Atraumatic intubation: experience using a 5.0 endotracheal tube without a stylet for laryngeal surgery.

OBJECTIVES/HYPOTHESIS: Vocal fold injury is a well-know complication of intubation, with rates reported as high as 69%. Laryngology textbooks recommend the use of a small endotracheal tube (ETT) to help avoid these complications and optimize visualization. Case reports have suggested that the rigid stylet can lead to laryngeal injury. Given the additional risks, intubation without the stylet is our preferred practice. There is limited documentation in the literature regarding this viewpoint. Our study investigated the feasibility of and potential barriers to intubation using 5.0 ETT without a stylet. STUDY DESIGN: Prospective study. METHODS: Consecutive adult patients undergoing laryngeal surgery were recruited for intubation with a 5.0 ETT without a stylet. Demographic data, specialty and training level of the intubator, and factors that would predict a difficult intubation were recorded. Descriptive statistical analysis was performed. RESULTS: Findings of the participants (n = 67) included average American Society of Anesthesiologists (ASA) physical status classification (2.2), average Mallampati score (1.7), average Cormack-Lehane grade (1.5), and average body mass index (28.0). Five patients (7.4%) required intubation using a stylet, and one of these five participants was intubated initially with a stylet. Of these five participants, 80% required use of a GlideScope (P < .001), and they had significantly higher ASA classification (P = .047) and number of intubation attempts (P = .042). One patient sustained an oropharyngeal injury during intubation with a stylet. No participants had laryngeal injury. CONCLUSIONS: Most patients can be intubated successfully using a 5.0 ETT without a stylet. There were no cases of laryngeal trauma with this technique. LEVEL OF EVIDENCE: 2b.

Spindle cell carcinoma of the larynx presenting as a vocal fold cyst.

Spindle cell carcinoma (SPCC) is a rare, malignant variant of squamous cell carcinoma (SCC), which shows biphasic proliferation of the conventional SCC component and malignant spindle shape cells with sarcomatous appearance. We present two cases of SPCC of the true vocal fold that presented as a benign appearing subepithelial mass. We discuss the patient presentation, voice assessment, surgical treatment, and a review of the literature.

NUT midline carcinoma mimicking tonsillitis in an eight-year-old girl.

We review a unique case of NUT midline carcinoma that presented in a young girl with an initial diagnosis of tonsillar abscess. We stress the importance of assaying poorly differentiated carcinomas in young patients for the t(15;19) translocation. Our patient presented with tonsillar enlargement and cervical lymphadenopathy mimicking acute tonsillitis. The clinical suspicion for malignancy arose after an aspirate from the tonsil did not yield any pus, and biopsy of a cervical lymph node demonstrated undifferentiated carcinoma. Further analysis by fluorescence in situ hybridization was positive for rearrangements in both BRD4 and NUT genes consistent with NUT carcinoma. In addition, fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed a very high standard uptake value in both the primary tumor and metastatic foci, suggesting that FDG-PET could be a useful tool in the staging and follow-up of NUT midline carcinoma.