In-Office Superior Laryngeal Nerve Block for Paralaryngeal Pain and Odynophonia.

OBJECTIVES: Pain localized to the thyrohyoid region may be due to neuralgia of the superior laryngeal nerve (SLN), inflammation of the thyrohyoid complex, or a voice disorder. We present outcomes of treatment of paralaryngeal pain and odynophonia with SLN block. STUDY DESIGN: Retrospective Review. METHODS: A retrospective chart review of patients undergoing in-office SLN block for paralaryngeal pain between 2015 and 2018 at two tertiary care centers was conducted. Patient demographics, indications, and response to treatment were analyzed. RESULTS: Thirty-eight patients underwent blockade of the internal branch of the SLN for paralaryngeal pain, with 10 excluded for incomplete medical records. Eighty-two percent (23/28) reported an improvement in their symptoms. Patients underwent an average of 2.5 blocks (SD = 1.88, range 1-8), with 10 patients (36%) undergoing a single procedure. Of the 18 patients who underwent multiple blocks, nine had eventual cessation of symptoms (50%) compared to resolution in 6/10 undergoing a single injection. Eleven patients (39%) noted odynophonia related to vocal effort, and all of these patients had improvement in or resolution of their symptoms and were more likely to improve compared to those without odynophonia (P = .006). Of the four patients who had a vocal process granuloma (VPG) at presentation, three had complete resolution of the lesion at follow-up. CONCLUSION: In-office SLN block is effective in the treatment of paralaryngeal pain. It may be used as an adjunct in the treatment of vocal process granulomas, as well as voice disorders where odynophonia is a prominent symptom. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:401-405, 2022.

Treatment of Vocal Fold Polyps with In-Office Potassium Titanyl Phosphate (KTP) Laser Ablation in Professional Singers.

Vocal fold polyp (VFP) is an exophytic gelatinous lesion with an atrophic epithelium. After behavioral and conservative management, phonomicrosurgery is the treatment of choice for VFPs with excellent outcomes in terms of lesion resolution and postoperative vocal function. Office-based potassium titanyl phosphate (KTP) laser ablation is a new treatment modality for VFPs but its efficacy for professional singers has yet to be validated. Reported is a consecutive series of six professional singers (with seven episodes of VFP) who, based on patient and provider preference, underwent in-office KTP laser ablation of VFP. Two polyps required two ablation procedures; otherwise, a single treatment was successful in resolution of VFP at a mean resolution time of 44 days. Singing voice handicap index 10 improved from a mean of 30.8 (range 4-40) to 6.0 (range 0-22). All patients resumed their professional singing careers without vocal limitations. Posttreatment videos were reviewed by three blinded fellowship trained laryngologists, who were not able to accurately predict the laterality of the polyp (52% correct, p = 0.99).

Correlation of Glottic Gap and Voice Impairment in Presbyphonia.

OBJECTIVE/HYPOTHESIS: The objective of this study was to investigate the glottic gap area as a significant marker for the severity of presbyphonia as it relates to patient-reported outcome measures (Voice Handicap Index-10 [VHI-10]) and stroboscopic findings. STUDY DESIGN: Retrospective case-control study conducted in an academic tertiary voice center. METHODS: Patients seen at a tertiary voice clinic who were diagnosed with presbyphonia without other organic laryngeal pathology from January 2014 to December 2017 were included. Clinical data and laryngeal videostroboscopy videos were collected. Still images at the point of vocal process approximation during adduction were captured, and the glottic gap area was measured using ImageJ. These were compared to a control cohort. Correlations were made using Wilcoxon rank sum test, Mann-Whitney U test, and Pearson correlation coefficients. RESULTS: Thirty-three patients were included. Inter-rater reliability of glottic area measurement was strong (intraclass correlation coefficient = 0.73, P < .001). Compared to controls, presbyphonia patients had a larger glottic gap area (P < .001) and greater open-phase quotient on laryngeal videostroboscopy (P < .001). Larger glottic gap area did not correlate with patient-reported vocal function as measured by VHI-10 (P = .79) and did not correlate with presence of secondary muscle tension dysphonia (P = .99). In the presbyphonia cohort, the glottic gap area did not correlate with age (P = .29). CONCLUSIONS: Glottic gap area at the point of vocal process approximation during phonation can be reliably measured. Patients with presbyphonia have a larger glottic gap area and greater open-phase quotient on stroboscopy, but these do not correlate with patient-reported voice impairment or the presence of secondary muscle tension dysphonia (MTD). These data suggest that dysphonia severity in presbyphonia is not fully explained by a glottic gap or secondary MTD alone. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1594-1598, 2021.

Differing Progression to Posterior Glottic Stenosis in Autoimmune and Idiopathic Subglottic Stenosis.

OBJECTIVES/HYPOTHESIS: We sought to characterize rates of progression to posterior glottic stenosis (PGS) from autoimmune or idiopathic subglottic stenosis. STUDY DESIGN: This was a retrospective review. METHODS: Patients from a tertiary-care laryngology practice over a 10-year period with autoimmune or idiopathic subglottic stenosis (SGS) were included. Patients with a history of prolonged intubation or other causes of iatrogenic stenosis were excluded. PGS was confirmed on videostrobolaryngoscopy recordings by a fellowship-trained laryngologist. PGS type (1-4) was also recorded. Demographic information was recorded, and if applicable, autoimmune disease type was specified. Time until PGS was recorded along with the number of interventions. Chi-squared analysis was used to compare PGS in autoimmune and idiopathic SGS. RESULTS: A total of 77 patients were identified with autoimmune (32 patients) or idiopathic (45 patients) subglottic stenosis. Autoimmune pathologies included systemic lupus erythematosus, granulomatosis with polyangiitis (GPA), rheumatoid arthritis, relapsing polychondritis, and sarcoidosis, with GPA the most common (14/32). Patients with autoimmune SGS had a higher rate of PGS (10 of 32) compared to idiopathic subglottic stenosis (1 of 45) for an odds ratio of 20 (95% CI: 2.4-166.4, P = .006). Patients with idiopathic SGS were more likely to be female (all 45 compared to 29/32 autoimmune, P = .07) and older (mean 53 (range 29-75) compared to 46 (20-82), P = .02). CONCLUSIONS: In this large patient cohort, autoimmune SGS patients were found to have a higher likelihood of developing PGS compared to their idiopathic counterparts, suggesting that counseling for this progression may be warranted. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1816-1820, 2021.

Impact of Fiberoptic Endoscopic Evaluation of Swallowing Outcomes and Dysphagia Management in Neurodegenerative Diseases.

OBJECTIVES/HYPOTHESIS: To determine the incidence of abnormal fiberoptic endoscopic evaluation of swallowing (FEES) findings in patients with progressive neurologic disorders and identify the most commonly implemented dysphagia management strategies. STUDY DESIGN: Retrospective Review. METHODS: A retrospective review was performed of patients with neurodegenerative disease who underwent FEES at a tertiary-care center between 2008 and 2019. Patient demographics, diagnosis, and Eating Assessment Tool-10 (EAT-10) scores were recorded. Rates of penetration, aspiration, and functional change in management (FCIM) to include dietary modifications, home exercises, swallow therapy, surgical intervention (injection augmentation or esophageal dilation), or alternative means of nutrition (i.e., percutaneous enteral gastrostomy [PEG] tube) were calculated. RESULTS: Two hundred nine FEES assessments were performed in 178 patients with a mean age of 64.8 years (standard deviation = ±14). The most common diagnoses were amyotrophic lateral sclerosis (32%) followed by Parkinson's disease or Parkinsonism (26%). FEES demonstrated penetration in 72.5% of patients and aspiration in 14.6%. Mean EAT-10 scores differed between patients with aspiration versus penetration versus normal FEES (24.7 vs. 14.9 vs. 13.9, respectively, P < .001). An FCIM was recommended in 88% of patients and most commonly included self-directed modifications (43%). Overall, 4.5% of patients underwent surgical intervention. A PEG tube was recommended for either supplemental or sole form of nutrition in 19% of the entire cohort. CONCLUSIONS: Most patients with neurodegenerative diseases presenting with dysphagia demonstrated abnormal FEES findings necessitating an FCIM, suggesting early dysphagia evaluation may be warranted in this cohort. These findings correlate with worsened EAT-10 scores in patients with aspiration or penetration on FEES. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:726-730, 2021.

Postoperative Complications in Obese Patients After Tracheostomy.

OBJECTIVE: To determine the prevalence of varying classes of obesity in patients undergoing tracheostomy and the associated complication rates as compared with nonobese patients. STUDY DESIGN: A retrospective chart review was performed from 2012 to 2018 on all patients who underwent open tracheostomy by the Department of Otolaryngology-Head and Neck Surgery. SETTING: All tracheostomies were performed at a single tertiary care center. METHODS: Patients were classified by body mass index (BMI) according to the World Health Organization classification system: underweight (<18.5), normal-overweight (18.5-29.9), class I (30-34.9), class II (35-39.9), and class III (>40). Charts were reviewed for patient demographic information, Charlson Comorbidity Index score, surgical indication, operative time, tracheostomy tube type, and postoperative complications. RESULTS: A total of 387 patients (mean ± SD BMI, 31.3 ± 14.2) were identified per the inclusion/exclusion criteria. Of patients with BMI >30 (n=153), 34.6% were categorized as obesity class I, 29.4% as class II, and 35.9% as class III. The most common indication for tracheostomy was malignancy in nonobese patients (41.5%) and respiratory failure for obese patients (58.2%). Operative time was significantly longer in obese patients, and most of these patients required an extended-length tracheostomy tube. Patients with a BMI >40 had higher rates of multiple postoperative complications or death (P = .009). Underweight patients also had a higher rate of complication than normal-overweight patients (P = .016). CONCLUSION: Class III and underweight patients had higher rates of postoperative complications, which should be taken into consideration during perioperative counseling.

Jet Ventilation in the Pregnant Patient with Airway Stenosis: Surgical Safety and Outcomes.

OBJECTIVE: To review pregnancy outcomes and the safety of jet ventilation use in the gravid patient undergoing surgical airway intervention. METHODS: A multi-institutional retrospective review of medical records was performed to identify women who underwent low-frequency jet ventilation during pregnancy for surgical treatment of airway stenosis. Postoperative complications were noted, and patients were interviewed regarding pregnancy outcomes. RESULTS: Six women were included in this series. No immediate complications relating to anesthesia or surgical intervention were noted in five of the six women. One patient with a well-known history of uncontrolled seizures experienced seizure activity postoperatively. One patient returned to the operating room at a later date for debridement of tracheal crusts. Five mothers delivered via cesarean section and one via spontaneous vaginal delivery. The mean gestation age was 37.3 weeks. One of the six infants delivered prematurely and three were delivered at low birth weight. Three of the six infants required elevated care immediately post-delivery but, at present, all are in good health. CONCLUSION: Low-frequency jet ventilation and surgical management of airway stenosis should be recognized as a safe treatment option in the gravid patient. Surgical intervention should not be delayed in patients with severe symptoms, particularly given the potential risk associated with prolonged corticosteroid use. LEVEL OF EVIDENCE: 4.

Treatment of chronic neurogenic cough with in-office superior laryngeal nerve block.

OBJECTIVES: Neurogenic cough is believed to result from a sensory neuropathy involving the internal branch of the superior laryngeal nerve (SLN). We present our outcomes for the treatment of neurogenic cough with localized blockade of the internal branch of the SLN. METHODS: A retrospective chart review of patients who underwent in-office percutaneous SLN block for treatment of neurogenic cough between 2015 and 2017 was conducted. Patient demographics, indications for injection, and response to treatment were recorded and analyzed. Cough severity index (CSI) scores before and after treatment were compared. RESULTS: Twenty-three patients underwent percutaneous blockade of the internal branch of the SLN in the clinic setting, and five patients were excluded for incomplete records. The indication was neurogenic cough as a diagnosis of exclusion. The injectable substance used was a 1:1 mixture of a long-acting particulate corticosteroid and a local anesthetic. Unilateral injections were performed in 13 patients, and five patients underwent bilateral injections. Of the unilateral injections, 10 were left-sided. Patients underwent an average of 2.4 SLN block procedures (range 1-7). Mean follow-up time postinjection was 85.4 days (7-450 days). Cough severity index scores decreased significantly from an average of 26.8 pretreatment to 14.6 posttreatment (P < 0.0001). CONCLUSION: The SLN block is an effective treatment for neurogenic cough, with average CSI scores significantly improved following injection. Further study is necessary to determine the characteristics of patients' responses to treatment, long-term outcomes, and efficacy of the procedure when compared to placebo and other accepted treatments for neurogenic cough. LEVEL OF EVIDENCE: 4. Laryngoscope, 1898-1903, 2018.

Impact of Perioperative Voice Therapy on Outcomes in the Surgical Management of Vocal Fold Cysts.

INTRODUCTION: Vocal fold cysts are benign mid-membranous lesions of the true vocal fold, classified as mucus retention or epidermal inclusion cysts. Treatment is surgical excision with or without postoperative voice therapy. METHODS: A retrospective review was performed of the demographics, treatment approach, and outcomes of patients treated for vocal fold cysts between 2009 and 2014. Voice Handicap Index (VHI)-10 scores before and after treatment were compared using the Wilcoxon Rank-Sum test and the two-tailed Student's t test. Videostroboscopy examinations were reviewed for posttreatment changes in vibratory characteristics of the vocal folds. RESULTS: Twenty-five patients were identified, and one was excluded for incomplete records. Mean age was 41.9 years (66.7% female), and mean follow-up time was 5.58 months. Microflap excision was pursued by 21/24 (87.5%) patients, with 14 patients (58.3%) undergoing perioperative voice therapy. One cyst recurred. Two patients elected for observation, and their cysts persisted. VHI-10 decreased from 23.8 to 6.6 (P < 0.001) overall. There was a statistically significant reduction in VHI-10 in patients undergoing surgery with and without postoperative voice therapy (P < 0.004 and 0.001), but there was no significant difference between these two groups. Mucosal wave was classified as normal or improved in the majority. Cysts were characterized as mucus retention cysts in 19/21 (90%) and as epidermal inclusion cysts in 2/21 (10%). CONCLUSIONS: Vocal fold cysts impact mucosal wave and glottic closure. Surgical excision resulted in low rates of recurrence, and in improvement in the mucosal wave and VHI-10. Perioperative voice therapy did not offer a significant benefit. Mucus retention cysts were the majority, in contrast to other published studies.

Treatment Outcomes of In-Office KTP Ablation of Vocal Fold Granulomas.

OBJECTIVE: To determine the effectiveness of in-office potassium-titanyl-phosphate (KTP) treatment of vocal fold granulomas and identify any predictors of complete lesion resolution. METHODS: A retrospective review of patients who underwent in-office KTP ablation of vocal fold granulomas between 2007 and 2016 was performed. Medical records were reviewed for use of acid suppression medication, prior surgical treatment, voice therapy, laser settings, number of treatments, follow-up time, and Voice Handicap Index-10 (VHI-10) scores. RESULTS: Twenty-six patients underwent a total of 43 laser treatments. Eighty percent of patients were previously on acid suppression medication, and 42.3% had failed previous endoscopic treatments. Patients underwent a mean number of 1.65 ± 1.16 in-office treatments with decrease in size in 96.2% of cases. The VHI-10 was not significantly affected. Complete resolution occurred in 73.1% of cases with follow-up time ranging from 1 to 86 months (median = 9.5 months). No recurrences occurred in patients with complete resolution. Other than undergoing a single KTP treatment, no variable was found to be predictive of complete lesion resolution. Granuloma etiology was not predictive of lesion resolution but did correlate with symptom improvement. CONCLUSION: In-office pulsed KTP laser is an effective treatment option for vocal fold granulomas as the lesion resolves in the majority of cases.

Mid-membranous Vocal Fold Webs: Case Series.

INTRODUCTION: Laryngeal webs are a rare clinical entity, with those in the mid-membranous region occurring even less commonly. This is the first case series describing this condition. CASE REPORT: We describe the clinical course of four patients with mid-glottic webs and propose the possible pathophysiology. DISCUSSION: Trauma to the vocal folds followed by an inflammatory reaction is the likely event leading to the development of this lesion. Endoscopic division of this type of web has shown good postoperative voice outcomes without any recurrences. CONCLUSION: The mid-glottic web is a rare clinical entity for which there is no defined etiology. It is likely that trauma results in an inflammatory reaction and, ultimately, web formation. Further studies are needed to identify risk factors for this condition.

Inflammatory reaction to hyaluronic acid: A newly described complication in vocal fold augmentation.

OBJECTIVES/HYPOTHESIS: To establish the rate of inflammatory reaction to hyaluronic acid (HA) in vocal fold injection augmentation, determine the most common presenting signs and symptoms, and propose an etiology. STUDY DESIGN: Retrospective chart review. METHODS: Patients injected with HA over a 5-year period were reviewed to identify those who had a postoperative inflammatory reaction. Medical records were reviewed for patient demographic information, subjective complaints, Voice Handicap Index-10 (VHI-10) scores, medical intervention, and resolution time. Videolaryngostroboscopy examinations were also evaluated. RESULTS: A total of 186 patients (245 vocal folds) were injected with HA over a 5-year period, with a postoperative inflammatory reaction rate of 3.8%. The most common complaints in these patients were odynophagia, dysphonia, and dyspnea with vocal fold erythema, edema, and loss of pliability on videolaryngostroboscopy. All patients were treated with corticosteroids. Return of vocal fold vibration ranged from 3 weeks to 26 months, with VHI-10 scores normalizing in 50% of patients. CONCLUSIONS: This reaction may be a form of hypersensitivity related to small amounts of protein linked to HA. Alternatively, extravascular compression from the HA could lead to venous congestion of the vocal fold. The possibility of equipment contamination is also being investigated. Further studies are needed to determine the etiology and best treatment. LEVEL OF EVIDENCE: 4 Laryngoscope, 2016 127:445-449, 2017.

Viral laryngitis: a mimic and a monster - range, presentation, management.

PURPOSE OF REVIEW: The purpose of this review is to highlight recent literature relating to the diagnosis and treatment of some less common forms of viral laryngitis. The main conditions addressed in this review are chronic cough or postviral vagal neuropathy, varicella zoster infection of the larynx, and a condition increasingly suspected as being virally induced, idiopathic ulcerative laryngitis. RECENT FINDINGS: Diagnosis of these conditions requires a thorough history and physical exam, and in certain cases referral to other subspecialties such as gastroenterology and pulmonology. Chronic cough due to postviral vagal neuropathy is a diagnosis of exclusion; however, recent literature does suggest that certain studies such as laryngeal electromyography can be of use in reaching a diagnosis. Treatment of this neuropathy has focused on use of neuromodulators. Treatment of laryngeal shingles and idiopathic ulcerative laryngitis has not been well defined because of the rarity of these conditions. SUMMARY: Recent studies regarding these conditions and potential future treatment options will be discussed.

Delayed lower cranial neuropathies following primary radiotherapy for oropharyngeal squamous cell carcinoma.

OBJECTIVES/HYPOTHESIS: Delayed lower cranial neuropathy is a rare complication following primary radiotherapy for head and neck cancer, and has been most associated with nasopharyngeal carcinoma with minimal data regarding this outcome in the treatment of the oropharynx. No reports, to the authors' knowledge, have described this complication following intensity modulated radiation therapy (IMRT) for oropharyngeal primaries. Once encountered, this adverse outcome can have serious impacts on speech and swallowing. We present here our institution's experience with delayed cranial neuropathies following primary radiation therapy for oropharyngeal squamous cell carcinoma, as well as document the only reported case following IMRT.

Risk factors associated with unilateral hearing loss.

OBJECTIVE: To analyze the presence of Joint Committee on Infant Hearing (JCIH) risk factors and co-occurring birth defects (CBDs) in children with unilateral hearing loss (UHL). DESIGN: Retrospective review. SETTING: Statewide registry of universal newborn hearing screen data for all children born in Virginia from 2002 through 2008. PATIENTS: The study population comprised 371 children with confirmed UHL. MAIN OUTCOME MEASURES: Universal newborn hearing screen status, presence or absence of JCIH risk factors, and CBDs RESULTS: Of the 371 children with confirmed unilateral hearing loss, 362 (97.5%) were identified through a failed universal newborn hearing screen. Of these 362 children, 252 (69.6%) had no JCIH risk factors and 110 (30.3%) had 1 or more risk factor reported. Nine children (2.5%) with 1 or more risk factors passed the universal newborn hearing screen but had later-onset UHL. Craniofacial anomaly was the most commonly reported JCIH risk factor in 48 children (43.6%). A family history of permanent childhood hearing loss was present in 24 children (21.8%). Twenty children (18.2%) had stigmata associated with a syndrome including hearing loss. Of the 110 children with UHL and a JCIH risk factor, additional CBDs were identified in 83 (75.5%). An ear-specific anomaly was most prevalent in 37 infants (44.6%), followed by cardiovascular anomalies in 34 infants (41.0%). CONCLUSIONS: Thirty percent of children with confirmed UHL had a JCIH risk factor, most commonly craniofacial anomalies, family history of hearing loss, and stigmata of syndromes associated with hearing loss. However, the absence of JCIH risk factors does not preclude the development of UHL. Further studies assessing the etiology of UHL and risk factor associations are warranted.

Granular cell tumor of the cervical esophagus: case report and literature review of an unusual cause of Dysphagia.

Granular cell tumors (GCT) of the head and neck are not uncommon; however, involvement of the cervical esophagus is rare. Characterized by an infiltrative growth pattern, these benign tumors are historically difficult to surgically excise and are radioresistant. We present here a case of dysphagia caused by a GCT of the cervical esophagus. Work up with ultrasound-guided fine needle aspiration was suggestive of a GCT due to the presence of cohesive cells with granular cytoplasm that were S-100 and CD68 positive with immunostaining, and PAS positive with histochemistry. Resection required removal of a portion of the muscular wall of the esophagus sparing the overlying mucosa. The patient is currently asymptomatic and without recurrence after 10 month follow-up. Review of the literature revealed 19 reports of cervical esophageal GCTs. There is a female preponderance (75%), with an average age of 41 years. Dysphagia and weight loss are the most common presenting symptoms. The average tumor size on presentation was 2.7 cm, with symptomatic tumors being significantly larger than asymptomatic lesions; the latter was present in 25% of patients. Concurrent GCTs in the upper aerodigestive tract were identified in 35% of cases. Approximately 30% of tumors required segmental cervical esophageal resection. The purpose of this report is to describe the epidemiology and treatment of GCTs of the cervical esophagus. Lesions should be addressed early with complete surgical excision to prevent growth necessitating more morbid surgery. Due to the high rate of concurrent GCTs, upper endoscopy is advised in the workup of these patients.

Genetics of hearing loss: focus on DFNA2.

The purpose of this review is to assess the current literature on deafness nonsyndromic autosomal dominant 2 (DFNA2) hearing loss and the mutations linked to this disorder. Hearing impairment, particularly nonsyndromic hearing loss, affects multiple families across the world. After the identification of the DFNA2 locus on chromosome 1p34, multiple pathogenic mutations in two genes (GJB3 and KCNQ4) have been reported. The overwhelming majority of pathogenic mutations linked to this form of nonsyndromic hearing loss have been identified in the KCNQ4 gene encoding a voltage-gated potassium channel. It is believed that KCNQ4 channels are present in outer hair cells and possibly inner hair cells and the central auditory pathway. This form of hearing loss is both phenotypically and genetically heterogeneous and there are still DFNA2 pedigrees that have not been associated with changes in either GJB3 or KCNQ4, suggesting that a possible third gene exists at this locus. Further studies of the DFNA2 locus will lead to a better understanding of progressive hearing loss and provide a better means of early detection and treatment.