Characteristic Pressure Waveforms Can Distinguish Airway Collapse Patterns in Sleep Apnea Patients: A Pilot Study.

Objective: To use pharyngeal pressure recordings to distinguish different upper airway collapse patterns in obstructive sleep apnea (OSA) patients, and to assess whether these pressure recordings correlate with candidacy assessment for hypoglossal nerve stimulator (HGNS) implantation. Study Design: Prospective case series. Setting: Single tertiary-quaternary care academic center. Methods: Subjects with OSA prospectively underwent simultaneous drug-induced sleep endoscopy (DISE) and transnasal pharyngeal pressure recording with a pressure-transducing catheter. Pressure was recorded in the nasopharynx and oropharynx, and endoscopic collapse patterns were classified based on site, extent, and direction of collapse. Pressure recordings were classified categorically by waveform shape as well as numerically by inspiratory and expiratory amplitudes and slopes. Waveform shape, amplitude, and slope were then compared with the endoscopic findings. Results: Twenty-five subjects with OSA were included. Nasopharyngeal waveform shape was associated with the extent of collapse at the level of the palate (P = .001). Oropharyngeal waveform shape was associated with anatomical site of collapse (P < .001) and direction of collapse (P = .019) below the level of the palate. Pressure amplitudes and slopes were also associated with the extent of collapse at various sites. Waveform shape was also associated with favorable collapse pattern on endoscopy for HGNS implantation (P = .043), as well as surgical candidacy for HGNS (P = .004). Conclusion: Characteristic pharyngeal pressure waveforms are associated with different airway collapse patterns. Pharyngeal pressure is a promising adjunct to DISE in the sleep surgery candidacy evaluation.

Streamlining the Cochlear Implant Evaluation: Utility of Community Audiometry in Cochlear Implant Candidacy Assessment.

OBJECTIVE: To identify redundancy in the cochlear implant candidacy evaluation and assess its financial impact. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care academic cochlear implant center. PATIENTS: One hundred thirty-five patients referred for cochlear implant candidacy evaluation from 2004 through 2019. INTERVENTION: Community and academic audiometry were compared in a matched-pair analysis. MAIN OUTCOME MEASURES: Pure-tone audiometry and word recognition scores (WRS) were compared using the Wilcoxon signed-rank test. Cost of repeated audiometry was estimated using the Medicare Provider Utilization and Payment data. RESULTS: The majority of pure-tone thresholds (PTT) and pure-tone averages (PTA) had no statistically significant differences between community and academic centers. Only air PTT at 2000 Hz on the right and air PTA on the right demonstrated differences with α = 0.05 after Bonferroni correction. Despite statistical differences, mean differences in PTT and PTA were all under 3.5 dB. WRS were on average lower at the academic center, by 14.7% on the right (p < 0.001) and 10.6% on the left (p = 0.003). Repeating initial audiometry costs patients up to $60.58 and costs the healthcare system up to $42.94 per patient. CONCLUSIONS: Pure-tone audiometry between community and academic centers did not demonstrate clinically significant differences. Lower academic WRS implies that patients identified as potential cochlear implant candidates based on community WRS are likely suitable to proceed to sentence testing without repeating audiometry, saving patients and the healthcare system time and resources.

Voice Restoration after Radiation and Supracricoid Partial Laryngectomy by Injection Augmentation of the Arytenoid.

Supracricoid partial laryngectomy (SCPL) is an organ-preserving surgical technique intended to achieve oncologic control of laryngeal cancer while maintaining laryngeal functions. Most patients who undergo SCPL achieve a serviceable voice. However, several factors can affect the function of the neoglottis after SCPL. We report the case of a 53-year-old male referred for near aphonia after undergoing SCPL for recurrent laryngeal carcinoma initially treated with radiation. Calcium hydroxylapatite injection augmentation of the right arytenoid was performed to assist neoglottic closure. Flexible laryngoscopy demonstrated greatly improved neoglottic closure postoperatively, and the patient's voice was successfully restored. This case demonstrates a novel technique for voice restoration in patients who have undergone partial laryngectomy.

Base of Tongue Surgery for Obstructive Sleep Apnea in the Era of Neurostimulation.

Retroglossal collapse is commonly seen in patients with obstructive sleep apnea. The role of upper airway stimulation surgery for these patients continues to evolve. However, base of tongue reduction surgery continues to have usefulness for appropriately selected patients with obstructive sleep apnea. Specific tongue base approaches may vary in response to patient and surgeon preferences and be used in multilevel surgery where appropriate. Key factors include patient age, willingness to undergo device implantation, and preferences for outpatient versus inpatient procedure, single procedure versus multiple, and tolerance for various procedure-specific postoperative restrictions and potential complications.

Incidence, risk factors, and outcomes of endoscopic sinus surgery after endoscopic skull-base surgery.

BACKGROUND: Patients undergoing endoscopic resection of neoplasms with both sinonasal and skull base involvement can develop chronic rhinosinusitis (CRS) after treatment and may occasionally benefit from additional endoscopic sinus surgery (ESS). We investigate risk factors and outcomes associated with revision ESS (rESS) after endoscopic skull-base surgery (SBS) for neoplasms with combined sinonasal and skull base involvement. METHODS: A retrospective review of patients with neoplasms with both sinonasal and skull base involvement who underwent endoscopic resection at a single tertiary care academic institution from 2004 through 2017 was performed. Eighty-three patients were included. Main outcome measures included incidence and timing of revision surgery, Lund-Mackay (LM) scores, and 22-item Sino-Nasal Outcome Test (SNOT-22) scores. RESULTS: rESS was performed in 21 (25%) cases, 15 (18%) of which were due to CRS. Time between initial resection and rESS was an average of 42 months (range, 6 to 142 months). Pre-SBS and post-SBS LM scores were not significantly different (5.0 vs 4.7, p = 0.640), although pre-SBS and post-SBS SNOT-22 scores showed significant improvement (32.6 vs 24.5, p = 0.030). Malignant pathology correlated with need for rESS (odds ratio [OR] 5.07, p = 0.04), as well as treatment including chemotherapy (OR 5.10, p = 0.003) and radiation (OR 4.15, p = 0.013). CONCLUSION: A significant proportion of patients develop clinically significant sinusitis after endoscopic SBS for neoplasms with combined sinonasal and skull base involvement and may benefit from rESS. Intervention occurred, on average, 3.5 years after initial tumor resection. Malignant pathology, radiation therapy, and chemotherapy correlate with need for rESS.

Association of Type of Treatment Facility With Overall Survival After a Diagnosis of Head and Neck Cancer.

Importance: Patients with head and neck cancer receive care at academic comprehensive cancer programs (ACCPs), integrated network cancer programs (INCPs), comprehensive community cancer programs (CCCPs), and community cancer programs (CCPs). The type of treatment facility may be associated with overall survival. Objective: To examine whether type of treatment facility is associated with overall survival after a diagnosis of head and neck cancer. Design, Setting, and Participants: This population-based retrospective cohort study included patients from the National Cancer Database, a prospectively maintained, hospital-based cancer registry of patients treated at more than 1500 US hospitals. Participants were diagnosed with malignant tumors of the head and neck from January 1, 2004, through December 31, 2016. Data were analyzed from May 1 through November 30, 2019. Exposures: Treatment at facilities classified as ACCPs, INCPs, CCCPs, or CCPs. Main Outcomes and Measures: Overall survival after diagnosis and treatment of head and neck cancer was the primary outcome. The secondary outcome was the odds of receiving treatment at ACCPs and INCPs vs CCCPs and CCPs. Multivariable Cox proportional hazards regression and univariable and multivariable logistic regression models were used for analysis. Results: A total of 525 740 patients (368 821 men [70.2%]; mean [SD] age, 63.3 [14.0] years) were diagnosed with malignant tumors of the head and neck during the study period. Among them, 36 595 patients (7.0%) were treated at CCPs; 174 658 (33.2%), at CCCPs; 232 867 (44.3%), at ACCPs; and 57 857 (11.0%), at INCPs. The median survival for patients with aerodigestive cancers was 69.2 (95% CI, 68.6-69.8) months; salivary gland cancers, 107.2 (95% CI, 103.9-110.2) months; and skin cancers, 113.2 (95% CI, 111.4-114.6) months. Improved overall survival was associated with treatment at ACCPs (hazard ratio [HR], 0.89; 95% CI, 0.88-0.91), INCPs (HR, 0.94; 95% CI, 0.92-0.96), and CCCPs (HR, 0.94; 95% CI, 0.92-0.95) compared with CCPs. Compared with patients with private insurance, those with government insurance (odds ratio [OR], 1.35; 95% CI, 1.29-1.41), no insurance (OR, 1.12; 95% CI, 1.09-1.16), or Medicaid (OR, 1.17; 95% CI, 1.14-1.20) were more likely to receive treatment at ACCPs and INCPs, whereas patients with Medicare were less likely to receive treatment at ACCPs and INCPs (OR, 0.95; 95% CI, 0.94-0.97). Compared with white patients, black (OR, 1.55; 95% CI, 1.52-1.59) and Asian (OR, 1.56; 95% CI, 1.49-1.63) patients were more likely to receive care at ACCPs and INCPs. Compared with patients from lower-income areas, patients from high-income areas were more likely to receive treatment at ACCPs and INCPs (OR, 1.25; 95% CI, 1.22-1.28). Conclusions and Relevance: These findings suggest that treatment at ACCPs and INCPs was associated with a better overall survival rate in patients with head and neck cancer. Key social determinants of health such as race/ethnicity, socioeconomic status, and type of insurance were associated with receiving treatment at ACCPs and INCPs.

Spontaneous Giant Laryngeal Granuloma in the Absence of Laryngeal Injury.

The etiology of laryngeal granuloma can typically be attributed to endotracheal intubation, vocal abuse, or gastroesophageal reflux disease. There is a strong male predominance, except in cases due to intubation, where incidence is higher in women. We report a case of spontaneous development of multiple granulomas in a female with no history of intubation who presented with hoarseness and massive bilateral supraglottic masses obscuring her glottis. The disparity between the massive lesions and asymptomatic reflux highlights the need for further research in the pathophysiology of laryngeal granulomas.

The evolution of presenting signs and symptoms of lateral skull base cerebrospinal fluid leaks.

PURPOSE OF REVIEW: To review the presenting signs and symptoms of spontaneous cerebrospinal fluid (CSF) leaks of the lateral skull base. RECENT FINDINGS: Research continues to demonstrate that CSF leaks from the lateral skull base are insidious, and present with subtle signs and symptoms. Patients commonly present with symptoms of aural fullness, middle ear effusion, and otorrhea following tympanostomy tube insertion that can be confused for chronic otitis media. More recently headache, pulsatile tinnitus, and dizziness/vertigo are being recorded as symptoms at presentation, which is likely a reflection of the association of spontaneous CSF leak with obesity, intracranial hypertension, and superior canal dehiscence. The presence of these less common symptoms in the setting of middle ear effusion should raise suspicion for CSF leak. The rate of meningitis in spontaneous CSF leak is not negligible, and patients should be counseled on this life-threatening risk. SUMMARY: Spontaneous CSF leak from the lateral skull base presents with subtle signs and symptoms and remains a diagnostic challenge. Less common symptoms may represent associations with underlying comorbidities, and awareness of the increasing coincidence of diseases that accompany spontaneous CSF leak is essential to prompt diagnosis and management.

The lamina push test: an alternative to the globe push test for identifying the medial orbit during endoscopic sinus surgery.

BACKGROUND: Aside from endoscopic and image guidance confirmation, the standard method of identifying the lamina involves the surgeon or an assistant applying gentle pressure on the globe externally. This globe push test requires the surgeon to remove one instrument from the endoscopic field or an assistant to press on the globe, and the test is most useful when either the periorbita or periorbital fat is exposed. We propose an alternative, equally accurate, and more efficient technique dubbed the lamina push test. METHODS: A blunt instrument is used to gently apply lateral pressure in the expected location of the medial orbital wall. If the lamina has been adequately skeletonized, the entire lamina will be seen to move as a unit. If residual ethmoid partitions are present, no movement or only localized movement is observed. RESULTS: Using the lamina push test, we have been able to safely identify the lamina papyracea in all patients undergoing endoscopic sinus surgery, without injury to the lamina or orbital contents. The use of direct pressure significantly increases the movement of an intact lamina. CONCLUSION: The lamina push test is a safe and effective technique for identification of the medial orbital wall, confirmation of removal of all lateral ethmoid partitions, and verification of lamina integrity. It enables more consistent identification of an intact lamina, allows the surgeon to keep both instruments in the endonasal surgical field, and does not require an assistant.

The effect of brief subway station noise exposure on commuter hearing.

OBJECTIVE: To demonstrate that brief exposure to subway noise causes temporary threshold shift and is preventable with noise protection. METHODS: The study was conducted as a randomized crossover trial. Twenty subjects were randomly assigned to two groups, one with hearing protection and one without. Subjects were exposed to subway platform noise for 15 minutes. Pre- and post-exposure pure tone audiometry (PTA) and otoacoustic emissions were compared. After a washout period, subjects switched hearing protection groups and repeated the process. RESULTS: A statistically significant reduction in PTA thresholds after subway noise exposure was identified, for subjects with and without hearing protection (P < .001). For exposure without hearing protection, the mean threshold was 5.19 dB pre-exposure and 3.91 dB post-exposure (decrease of 1.28 dB; 95% confidence interval, 0.82-1.74). For exposure with hearing protection, the mean threshold was 4.81 dB pre-exposure and 3.47 dB post-exposure (decrease of 1.34 dB; 95% confidence interval, 0.89-1.79). CONCLUSION: Brief exposure to subway noise did not cause hearing loss with or without noise protection. Though clinically insignificant, the unexpected finding of reduction in PTA suggests that there are complex heterogeneous short- and long-term cochlear responses to noise exposure that should be further explored. LEVEL OF EVIDENCE: 1b.

The influence of subway station design on noise levels.

OBJECTIVES/HYPOTHESIS: To investigate the impact of subway station design on platform noise levels. STUDY DESIGN: Observational. METHODS: Continuous A-weighted decibel (dBA) sound levels were recorded in 20 New York City subway stations, where trains entered on either a straight track or curved track in 10 stations each. Equivalent continuous noise levels (Leq ) at various locations on the boarding platform (inbound end, midplatform, and outbound end) during train entry and exit were compared between the straight and curved stations in broadband as well as narrow one-third octave bands. RESULTS: Overall, curved stations trended louder than straight stations, although the difference in broadband Leq did not reach statistical significance (curve, 83.4 dBA; straight, 82.6 dBA; P = .054). Noise levels were significantly louder at the inbound end of the platform during train entry (inbound, 89.7 dBA; mid, 85.5 dBA; outbound, 78.7 dBA; P < .001) and at the outbound end during train exit (inbound, 79.7 dBA; mid, 85.3 dBA; outbound, 89.1 dBA; P < .001). Narrow band analysis showed that curved stations were significantly louder than straight stations at 100 Hz and high frequencies from 8 to 20 kHz. Peak impact levels ranged from 104 to 121 dBA. CONCLUSIONS: Curved stations have a different noise profile compared to straight stations and are significantly louder than straight stations at high frequencies. Designing stations with straight tracks within the platform can help reduce commuter noise exposure. LEVEL OF EVIDENCE: NA Laryngoscope, 127:1169-1174, 2017.

EphA4 deficient mice maintain astroglial-fibrotic scar formation after spinal cord injury.

One important aspect of recovery and repair after spinal cord injury (SCI) lies in the complex cellular interactions at the injury site that leads to the formation of a lesion scar. EphA4, a promiscuous member of the EphA family of repulsive axon guidance receptors, is expressed by multiple cell types in the injured spinal cord, including astrocytes and neurons. We hypothesized that EphA4 contributes to aspects of cell-cell interactions at the injury site after SCI, thus modulating the formation of the astroglial-fibrotic scar. To test this hypothesis, we studied tissue responses to a thoracic dorsal hemisection SCI in an EphA4 mutant mouse line. We found that EphA4 expression, as assessed by beta-galactosidase reporter gene activity, is associated primarily with astrocytes in the spinal cord, neurons in the cerebral cortex and, to a lesser extent, spinal neurons, before and after SCI. However, we did not observe any overt reduction of glial fibrillary acidic protein (GFAP) expression in the injured area of EphA4 mutants in comparison with controls following SCI. Furthermore, there was no evident disruption of the fibrotic scar, and the boundary between reactive astrocytes and meningeal fibroblasts appeared unaltered in the mutants, as were lesion size, neuronal survival and inflammation marker expression. Thus, genetic deletion of EphA4 does not significantly alter the astroglial response or the formation of the astroglial-fibrotic scar following a dorsal hemisection SCI in mice. In contrast to what has been proposed, these data do not support a major role for EphA4 in reactive astrogliosis following SCI.

Generation of an EphA4 conditional allele in mice.

Ephrins and Eph receptor tyrosine kinases are cell-surface molecules that serve a multitude of functions in cell-cell communication in development, physiology, and disease. EphA4 is a promiscuous member of the EphA subclass of Eph receptors and can bind to both EphrinAs and EphrinBs. In addition to its well-established roles in guiding the development of neuronal connectivity, EphA4 has been implicated for a role in synaptic plasticity, vascular formation, axon regeneration, and central nervous system repair following injury. However, the study of its role in the adult stage has been hampered by confounding developmental defects in EphA4 germline mutants. Here, we report the generation and molecular characterization of an EphA4 conditional allele along with a novel null allele with a knockin fluorescent reporter gene (mCFP). The conditional allele will be useful in ascertaining postdevelopmental and/or cell type-specific function of EphA4 in physiology, injury, and disease.