Laryngeal Blastomycosis, an Unexpected Diagnosis: A Case Report.

Isolated laryngeal blastomycosis is an extremely rare entity with few cases described in the medical literature. Nonspecific and chronic presenting symptoms such as dysphonia, dyspnea, dysphagia, and/or cough are described, with isolated reports requiring urgent management related to respiratory distress. We present a case report of a 63-year-old immunocompetent female diagnosed with isolated laryngeal blastomycosis, document the treatment regimen and subsequent clinical course. In view of the rarity of this diagnosis, isolated laryngeal blastomycosis has the potential for clinical and pathologic misdiagnosis. Without an accurate diagnosis, blastomycosis remains untreated and the risk for airway disease progression increases.

Telemedicine and the Interdisciplinary Clinic Model: During the COVID-19 Pandemic and Beyond.

The emergence of the novel coronavirus disease 2019 (COVID-19) and the subsequent need for physical distancing have necessitated a swift change in health care delivery. Prior to the COVID-19 outbreak, many institutions utilized an interdisciplinary clinic model including both a laryngologist and a speech-language pathologist for the evaluation of patients with voice, swallowing, and upper airway disorders. To improve access, many providers are pursuing the use of interdisciplinary telemedicine to provide individualized patient-centered care while allowing for physical distancing. The purpose of this commentary is to review the current literature regarding telemedicine in laryngology and speech-language pathology as well as the current and future states of practice for interdisciplinary tele-evaluations.

Upper Esophageal Sphincter Dilation for Recalcitrant Dysphagia Secondary to Dermatomyositis.

Dermatomyositis is a rare multisystem autoimmune disorder occasionally accompanied by dysphagia. It is typically treated with immune modulating agents; however, dysphagia is often unresponsive to these. Previous reports have demonstrated the utility of videoflouroscopy and manometry in understanding the etiologies of dysphagia to inform a procedural target, historically the cricopharyngeus muscle. We present a case of dermatomyositis and dysphagia resistant to medical management in a patient found by videoflouroscopy and manometry to have severe oropharyngeal dysphagia, esophageal dysmotility and a cricopharyngeal web. We demonstrate the utility and safety of upper esophageal sphincter dilation by transnasal esophagoscopy even in the setting of multifactorial dysphagia.

Smoking status and symptom burden in surgical head and neck cancer patients.

OBJECTIVES/HYPOTHESIS: Head and neck squamous cell carcinoma (HNSCC) patients who smoke are at risk for poor treatment outcomes. This study evaluated symptom burden and clinical, sociodemographic, and psychosocial factors associated with smoking in surgical patients to identify potential targets for supportive care services. STUDY DESIGN: Cross-sectional survey. METHODS: Individuals with HNSCC of the oral cavity, larynx, or pharynx were recruited from two cancer centers and completed questionnaires assessing smoking status (never, former, current/recent), patient characteristics, and symptoms before surgery. RESULTS: Of the 103 patients enrolled, 73% were male, 52% were stage IV, 41% reported current/recent smoking, and 37% reported former smoking. Current/recent smokers were less likely than former smokers to have adequate finances (53% vs. 89%, P = .001) and be married/partnered (55% vs. 79%, P = .03). Current/recent smokers were also more likely than both former and never smokers to be unemployed (49% vs. 40% and 13%, respectively, all P = .02) and lack health insurance (17% vs. 5% and 13%, respectively, all P ≤.04). Fatalistic beliefs (P = .03) and lower religiosity (P =.04) were more common in current/recent than never smokers. In models adjusted for sociodemographic/clinical factors, current/recent smokers reported more problems than former and never smokers with swallowing, speech, and cough (P ≤.04). Current/recent smokers also reported more problems than never smokers with social contact, feeling ill, and weight loss (P ≤ .02). CONCLUSIONS: HNSCC patients reporting current/recent smoking before surgery have high-risk clinical and sociodemographic features that may predispose them to poor postoperative outcomes. Unique symptoms in HNSCC smokers may be useful targets for patient-centered clinical monitoring and intervention. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:127-133, 2017.

Tobacco use and surgical outcomes in patients with head and neck cancer.

BACKGROUND: Tobacco use is a risk factor for head and neck cancer, but effects on postoperative outcomes are unclear. METHODS: Patients with head and neck cancer (n = 89) were recruited before surgery. We assessed self-reported tobacco use status (never, former, or current) at study entry and recent tobacco exposure via urinary cotinine on surgery day. Outcomes included hospital length of stay (LOS) and complications. RESULTS: Most participants reported current (32.6%) or former (52.8%) tobacco use; 43.2% were cotinine-positive on surgery day. Complications occurred in 41.6% and mean LOS was 4.0 and 8.8 days in patients who received low and high acuity procedures, respectively. Current and former smokers were over 6 times more likely to have complications than never smokers (p = .03). For high acuity procedures, LOS was increased in current (by 4.4 days) and former smokers (by 2.3 days; p = .02). CONCLUSION: Tobacco use status is associated with postoperative complications and may distinguish at-risk patients.

Botulinum toxin treatment of false vocal folds in adductor spasmodic dysphonia: Functional outcomes.

OBJECTIVES/HYPOTHESIS: Supraglottic injection of botulinum toxin (Botox) has been described as an effective treatment for adductor spasmodic dysphonia (ADSD). Anecdotal evidence suggests that the patients have little to no breathiness after injection, but no formal longitudinal studies have been carried out to date. The purpose of this study was to examine the voice outcomes in patients with ADSD after supraglottic Botox injection. STUDY DESIGN: Retrospective case series. METHODS: Patients with ADSD who were treated with supraglottic Botox injections completed a qualitative self-evaluation of voice function after injection using the percentage of normal function (PNF) scale, a validated, quantitative scale from 0% (no function) to 100% (normal function). Posttreatment voice improvement after injection was determined using a Voice Handicap Index-10 (VHI-10) questionnaire. RESULTS: A total of 198 supraglottic injections were performed between July 2011 and October 2014. Twenty-five questionnaires were completed. Mean postinjection PNF was 95.0% ± 8.4% and was significantly increased from the preinjection mean PNF (62.5%) ± 22.6% (P < 0.001). The mean best VHI-10 for all injections was 7.23. In 19 of 25 patients (76%), there was no reduction in PNF in the early postinjection period. In the remaining six patients (24%), the decline in mean vocal function was 9.2%. CONCLUSIONS: Supraglottic Botox injection is an effective treatment for ADSD. Postinjection voice is significantly improved, and the majority of patients do not experience breathy voice/decline in vocal function after injection.

The Validity of Self-reported Recent Smoking in Head and Neck Cancer Surgical Patients.

OBJECTIVE: In cancer patients, cigarette smoking causes poorer response to treatment, treatment toxicity, increased risk of recurrence, higher surgical complication rates, and poorer overall survival. As such a significant determinant of patient prognosis, accurate classification of current smoking status is important. Self-reported smoking status may lead to misclassification if patients conceal their true status. The purpose of this study was to assess the validity of self-reported tobacco use during the previous 48 hours in head and neck cancer patients on the day of surgery. STUDY DESIGN: Cross-sectional. SETTING: Two academic medical centers in the southeastern United States. SUBJECTS AND METHODS: On the day of surgery, 108 head and neck cancer patients completed a survey asking about tobacco use during the past 48 hours and had semi-quantitative levels of urinary cotinine measured to biochemically validate self-reported recent smoking. RESULTS: Self-reported smoking yielded a sensitivity of 60.9% (95% CI, 45.4%-74.9%) and a specificity of 98.4% (95% CI, 91.3%-100.0%). The sensitivity increased to 76.1% (95% CI, 61.2%-87.4%) when allowing for the possibility that exposure to secondhand smoke or use of nicotine-containing products could have caused a positive cotinine test. CONCLUSION: In this patient population, self-reported recent smoking yielded a high (39%) proportion of false-negatives, and even 24% remained false-negatives after allowing for other sources of nicotine exposure. This magnitude of underreporting combined with the importance of tobacco use to patient prognosis supports the need for routinely biochemically verifying recent tobacco use in self-reported nonsmokers within the clinical setting.

Voice outcomes after endoscopic treatment of laryngotracheal stenosis.

OBJECTIVE: This study aimed to assess vocal disability in patients with laryngotracheal stenosis who are managed with endoscopic surgery, comparing patients with posterior glottic stenosis (PGS) to those with subglottic or tracheal stenosis (SGS/TS). METHODS: Patients who underwent endoscopic treatment for laryngotracheal stenosis with voice outcomes data from 2005 to 2013 were studied. The mean Voice Handicap Index-10 (VHI-10) was compared over the study period. Of those with SGS/TS, the distance from the vocal folds to the proximal portion of the stenosis was obtained and compared to VHI-10. RESULTS: Forty-four patients met inclusion criteria. The mean VHI-10 for all patients was 14.6. Fifty percent were dysphonic (VHI-10>11). The mean VHI-10 for PGS patients was 22.4, and for SGS/TS patients, 10.9 (P=.004). Of those with PGS, 78.6% were dysphonic compared to only 36.7% of those with SGS/TS. Voice Handicap Index-10 improved from 14.1 for those with proximal stenosis to 4 for those with stenosis more than 2 cm distal to the vocal folds. CONCLUSION: Following endoscopic management of stenosis, those with PGS have poorer voice outcomes compared to those with SGS/TS. The majority of those with SGS/TS are not dysphonic. Vocal outcomes are greatest for those with stenosis beginning at least 2 cm distal to the vocal folds.

Safety and efficacy of multiuse botulinum toxin vials for intralaryngeal injection.

OBJECTIVES/HYPOTHESIS: Centers for Disease Control and Prevention guidelines maintain that single-use vials cannot be used for multiple patients. Botox product labeling states that the reconstituted toxin should be used within 4 hours on a single patient based on concerns of reduced potency, contamination, and consequent infections. The purpose of this study was to determine the safety and efficacy of using single-use vials in a multidose fashion. STUDY DESIGN: Prospective study and cohort chart review. METHODS: A multi-institutional three-part study was performed between May 2013 and October 2013: 1) a summation of subjects' recall of their past experiences (symptoms/response) with previous multidose Botox injections, 2) a prospective study of intralaryngeal injections, and 3) a chart review of injection responses in a subset of the cohort. RESULTS: Seven hundred forty-three subjects receiving 6,216 injections demonstrated zero infection-related complications on retrospective chart review. One hundred seventy-nine subjects recalled 24.0% overall adverse events, 10.6% redness, 7.3% pain and swelling at the injection site, and 0% fever. One hundred seventy-four subjects prospectively reported 12.6% overall adverse events. The self-reported efficacy rate of Botox injection was 96.6%. CONCLUSIONS: The low rates of adverse events following the use of Botox in a multipatient fashion are consistent with other percutaneous injections. No evidence of infection was found with multidose Botox use. Given the low incidence of side effects and high success rate, Botox can be used both safely and effectively in a multipatient fashion. LEVEL OF EVIDENCE: 4

Recognition and treatment of non-infectious hyaluronic acid reactions.

OBJECTIVE: To differentiate a non-infectious inflammatory reaction following hyaluronic acid injection for facial rejuvenation from other reported complications, and describe appropriate treatment. METHODS: Using a review of the literature and information available from the manufacturer, recommendations for management of non-infectious hyaluronic acid reactions are made. RESULTS: Patients who are afebrile with a normal white blood cell count and negative cultures, who appear to have an infectious process following hyaluronic acid injection are in fact having an inflammatory response. The inflammation may worsen with antibiotic therapy. Treatment should be systemic and/or local steroids, which may need to be for up to 6 months. CONCLUSION: After reviewing the literature, non-infectious inflammatory reaction following hyaluronic acid injection is exceedingly rare with only one other reported case. Erythematous skin in the week following injection without other infectious markers, such as fever or elevated serum white blood cell count, is an inflammatory reaction and should be treated with steroid therapy.

Disposition of elderly patients after head and neck reconstruction.

IMPORTANCE: A patient's needs at discharge, particularly the need for nursing facility placement, may affect hospital length of stay and health care costs. The association between age and disposition after microvascular reconstruction of the head and neck has yet to be reported in the literature. OBJECTIVE: To determine whether elderly patients are more likely to be discharged to a nursing or other care facility as opposed to returning home after microvascular reconstruction of the head and neck. DESIGN, SETTING, AND PARTICIPANTS: From January 1, 2001, through December 31, 2010, patients undergoing microvascular reconstruction at an academic medical center were identified and their medical records systematically reviewed. During the study period, 457 patients were identified by Current Procedural Terminology codes for microvascular free tissue transfer for a head and neck defect regardless of cause. Seven patients were excluded for inadequate data on the postoperative disposition or American Society of Anesthesiologists (ASA) score. A total of 450 were included for analysis. MAIN OUTCOMES AND MEASURES: Demographic and surgical data were collected, including the patient age, ASA score, and postoperative length of stay. These variables were then compared between groups of patients discharged to different posthospitalization care facilities. RESULTS: The mean age of participants was 59.1 years. Most patients (n = 386 [85.8%]) were discharged home with or without home health services. The mean age of those discharged home was 57.5 years; discharge to home was the reference for comparison and odds ratio (OR) calculation. For those discharged to a skilled nursing facility, mean age was 67.1 years (OR, 1.055; P < .001). Mean age of those discharged to a long-term acute care facility was 71.5 years (OR, 1.092; P = .002). Length of stay also affected the disposition to a skilled nursing facility (OR, 1.098), as did the ASA score (OR, 2.988). CONCLUSIONS AND RELEVANCE: Elderly patients are less likely to be discharged home after free flap reconstruction. Age, ASA score, and length of stay are independent factors for discharge to a nursing or other care facility.

Total serum immunoglobulin E as a marker for missed antigens on in vitro allergy screening.

BACKGROUND: The diagnosis of inhalant allergies involves a medical history, physical exam, and allergen sensitivity testing; allergen sensitivity can be assessed by a specific immunoglobulin E (IgE) screen for inhalant allergens. Some patients with clinical suspicion for inhalant allergies have a negative specific IgE screen, but high total IgE. We theorize that elevated total IgE may indicate a false-negative screen caused by "missed allergens" not initially identified. METHODS: Study patients with a negative allergy screen and elevated IgE (>116 kU/L) were identified (n = 26). Control patients (n = 26) were defined as having a negative screen and an IgE <2.95 kU/L. Both groups were tested with an expanded specific IgE panel and completed a questionnaire about other causes of elevated IgE. RESULTS: The expanded panel was positive for inhalant allergens in 4 study patients (15%) and 0 control patients (p = 0.037). Within the study patients, 50% had asthma and 76.9% had chronic sinusitis. Only 2 control patients had asthma (11.5%), p = 0.003; 4 (19.2%) reported chronic sinusitis, p < 0.0001. Food allergen sensitivity was identified in 5 study patients and 1 control, p = 0.083. CONCLUSION: This pilot study evaluated patients clinically suspected of allergy with a negative inhalant IgE screen. Those with a high total IgE were more likely to have a missed inhalant allergen on expanded testing, as well as asthma and chronic sinusitis, compared to those with a low total IgE. Further investigation of "missed antigen" and the role of chronic respiratory inflammatory disease in patients with elevated total IgE is warranted.