Mucosal emphysematous head and neck infections: Scoping review and a case of emphysematous tonsillitis.

Objective: This scoping review seeks to understand the existing research in otolaryngological mucosal emphysematous infections and to elucidate gaps in knowledge in the field. We also present a case of bilateral necrotizing tonsillitis in an immunocompromised patient with the first reported imaging findings of emphysematous abscess of the tonsils. Data Sources: PubMed, Embase, Web of Science. Review Methods: We conducted our review according to the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews. Patient presentation, management, and outcomes were summarized. We also describe the case of a patient with aplastic anemia found to have emphysematous tonsillitis, managed with intubation, broad spectrum intravenous antibiotics and bilateral tonsillectomy. Results: We identified seven case reports or series, involving nine total patients, who presented with emphysematous epiglottitis, supraglottitis, or tonsillitis. The hallmark imaging characteristic was submucosal "gas bubble" on computed tomography. Presenting symptoms included dysphagia, odynophagia, dysphonia, cough, and fever. Both immunocompetent and immunocompromised patients were affected. All patients were treated with broad spectrum antibiotics, and most with steroids. Patients at risk of airway compromise also underwent intubation and surgical drainage or debridement of the emphysematous infection. Conclusion: Emphysematous pharyngeal infections are rare but potentially life-threatening infections that can progress rapidly, resulting in airway compromise and sepsis in both immunocompetent and immunocompromised individuals. We highlight the importance of swift intervention, with intubation and surgical intervention often required for severe cases. More research is needed on common pathogens and patient risk factors to guide future medical and surgical management.

Improving HPV-Related Oropharyngeal Cancer Knowledge and HPV Vaccination Rates via Virtual Workshops.

OBJECTIVE: To validate the efficacy of a virtual, interdisciplinary workshop in improving HPV knowledge, and vaccination practices among primary care and dental trainees. METHODS: A virtual platform was utilized to hold HPV educational workshops with primary care and dental trainees. Online surveys were distributed before and after the 1-h interactive workshop, led by otolaryngology residents. Surveys included the workshop's impact on (a) improving knowledge of HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) and (b) affecting change in HPV vaccination practices. The vaccination rates of trainees were recorded prior to and after workshop attendance. RESULTS: After the workshop, participants demonstrated significantly improved scores related to knowledge of HPV in the head and neck (p = 0.003) and showed an increased comfort level with counseling on HPV vaccination (p = 0.002). Respondents were also more aware that the HPV vaccine is approved to prevent OPSCC (61% vs. 95%, p < 0.05). Ninety-seven percent of respondents stated that the workshop changed their HPV vaccination practices, and 95% of those not fully vaccinated stated they would now be more likely to receive the vaccine themselves. There was a significant increase in the average number of HPV vaccines administered at the studied trainee clinic, from 16.83 vaccines/month to 37.6 vaccines/month (percent increase = 123%) in 5 months following the workshop (p = 0.002). CONCLUSION: The present interactive virtual workshop demonstrates efficacy in improving HPV-related knowledge and vaccination practices among trainees. The virtual nature of the course facilitates knowledge transfer and can be used to foster multi-institutional partnerships regarding medical education and vaccination efforts. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.

Cutaneous head and neck angiosarcoma: The 30-year UCLA experience.

Background: Cutaneous angiosarcoma is an aggressive tumor commonly found in the head and neck region. There is no consensus regarding the definitive treatment for angiosarcoma. Methods: This was a retrospective chart review that evaluated 64 patients from 1983 to 2019. Demographic and clinical variables were examined for impact on recurrence using the time to recurrence and the overall survival in Kaplan-Meier curves. Results: Average age at diagnosis was 71 (32-95) years, with a 2.8 male: female ratio. Surgery was utilized in 62% of patients, with mean defect size of 11.4 ± 8.1 cm. Recurrence was found in 70% of patients, and mean time to recurrence was 15.3 ± 12.3 months. Decreased recurrence was associated with use of intraoperative frozen section analysis (p = .036) and negative margins (p = .086). Two-year overall survival was 80%, and recurrence free survival was 30%. Conclusions: Negative margins are associated with decreased recurrence, and intraoperative frozen section analysis may be considered to obtain preliminary surgical margins.Level of Evidence: 4.

HPV Knowledge Retention and Concurrent Increase in Vaccination Rates 1.5 Years After a Novel HPV Workshop in Medical School.

Comprehensive education regarding human papillomavirus (HPV) pathogenesis, vaccination, and patient counseling are not routinely included in the medical school curriculum; consequently, student and provider knowledge, especially concerning head and neck pathology, remains low. The objective of this study was to demonstrate long-term retention of HPV knowledge and positive attitudes towards HPV vaccination after attending our novel HPV workshop, with a focus on knowledge of oropharyngeal cancer. A follow-up survey was administered to medical students 1.5 years after the initial completion of the workshop. HPV vaccination records from the student-led clinic were collected from the immunization information system. Awareness that HPV causes oropharyngeal cancer was present in 33% of medical students pre-curriculum; immediate and long-term post-curricular awareness of this association remained at 90% or higher (p < 0.0001). Comfort with HPV counseling, having enough information to recommend the vaccine, and knowledge of HPV malignancies, symptoms, transmission, and vaccination schedule remained persistently elevated over pre-curriculum scores (p < 0.05). Long-term knowledge scores were also higher than a control group of medical students at the same stage of training who had never participated in the workshop (p < 0.05). HPV vaccination rates at the medical school's student-run clinic also increased after the curriculum, from an average of 1.89 HPV vaccines given per clinic to 3.55 (p = 0.001). This study demonstrates that knowledge and positive attitudes were maintained 1.5 years after participating in this HPV curriculum during students' preclinical years of medical school. Additionally, an increase in HPV vaccination rates occurred at a student-led clinic, indicating a positive clinical impact on the curriculum.

Delayed Tracheal Perforation After Partial Thyroidectomy: A Case Report and Review of the Literature.

Tracheal perforation is an extremely rare and potentially dangerous complication of a partial thyroidectomy. The current case represents a unique presentation of delayed tracheal perforation following an uncomplicated thyroid isthmusectomy for tissue diagnosis of an aggressive appearing thyroid mass in the setting of high-dose steroid administration and recent intubation and self-extubation. While conservative management of tracheal perforation can sometimes be appropriate, our patient was successfully managed via primary closure and infrahyoid muscle transposition flap to cover a 5 mm right lateral tracheal wall defect. We recommend caution be exercised following thyroid surgery in the setting of intubation and high-dose steroids.

COVID-19 Drive-Through Point of Screening and Testing (POST) System: A Safe, Efficient, and Adaptable Model for Nasopharyngeal Swab Collection.

OBJECTIVE: The authors aim to demonstrate that the current drive-through testing model at a health district was improved in certain parameters compared with a previous testing protocol, and to provide the methodology of the current model for other coronavirus disease (COVID-19) testing sites to potentially emulate. METHODS: Initially, a small drive-through site was constructed at a converted tuberculosis clinic, but due to an increase in testing needs, an expanded point of screening and testing (POST) system was developed in an event center parking lot to administer tests to a higher volume of patients. RESULTS: An average of 51.1 patients was tested each day (2.0 tests per personnel in personal protective equipment [PPE] per hour) at the initial tuberculosis clinic drive-through site, which increased to 217.8 patients tested each day (5.9 tests per personnel in PPE per hour) with the new drive-through POST system (P < 0.001). Mean testing time was 3.4 minutes and the total time on-site averaged 14.4 minutes. CONCLUSIONS: This POST drive-through system serves as an efficient, safe, and adaptable model for high volume COVID-19 nasopharyngeal swabbing that the authors recommend other COVID-19 testing sites nationwide consider adopting for their own use.

Missed Testing Opportunities Among HIV-Positive Adults in a Community Emergency Department.

Northern Nevada's most utilized emergency department (ED) could represent a locale of missed opportunity for human immunodeficiency virus (HIV) detection, as the ED serves as a source of primary care for many patients at risk for HIV infection. The authors conducted a retrospective chart review, through the electronic health record, evaluating new diagnoses of HIV between 2012 and 2017 within a single hospital system. An opportunity for prior detection of HIV in the hospital's adult ED, within the past 5 years, was recorded as a missed testing opportunity (MTO). Out of 46 new HIV diagnoses at this hospital for a 5-year period, 19 patients with at least one MTO were identified. Eight of these patients with an MTO were diagnosed with acquired immunodeficiency syndrome (AIDS) concomitant with detection of their HIV status. Encouraging earlier HIV detection in the ED could reduce transmission, mortality, and health care expenditures.

Cancer of the Larynx and Hypopharynx.

The Radiation Therapy Oncology Group 91-11 trial and US Veterans Affairs trial revolutionized the way locally advanced laryngeal cancers are treated. Adjuvant therapies exist aimed toward laryngeal preservation using docetaxel, cisplatin, and fluorouracil. Cetuximab is a cornerstone of treatment due to the large role of epidermal growth factor receptor in laryngeal and hypopharyngeal carcinomas. In addition, the immune system is vital in the prevention of recurrence, and various immunomodulators against programmed cell death receptor 1 are being investigated. Multidisciplinary management of the patient with laryngeal and hypopharyngeal is key, as many vital functions are affected by this devastating disease.

Perceptual Evaluation of Vocal Fold Vibratory Asymmetry.

OBJECTIVES: Laryngeal vibratory asymmetry occurring with paresis may result in a perceptually normal or abnormal voice. The present study aims to determine the relationships between the degree of vibratory asymmetry, acoustic measures, and perception of sound stimuli. STUDY DESIGN: Animal Model of Voice Production, Perceptual Analysis of Voice. METHODS: In an in vivo canine model of phonation, symmetric and asymmetric laryngeal vibration were obtained via graded unilateral recurrent laryngeal nerve (RLN) stimulation simulating near paralysis to full activation. Phonation was performed at various contralateral RLN and bilateral superior laryngeal nerve stimulation levels. Naïve listeners rated the perceptual quality of 182 unique phonatory samples using a visual sort-and-rate task. Cepstral peak prominence (CPP) was calculated for each phonatory condition. The relationships among vibratory symmetry, CPP, and perceptual ratings were evaluated. RESULTS: A significant relationship emerged between RLN stimulation and perceptual rating, such that sound samples from low RLN levels were preferred to those from high RLN levels. When symmetric vibration was achieved at mid-RLN stimulation, listeners preferred samples from symmetric vibration over those from asymmetric vibration. However, when symmetry was achieved at high RLN levels, a strained voice quality resulted that listeners dispreferred over asymmetric conditions at lower RLN levels. CPP did not have a linear relationship with perceptual ratings. CONCLUSIONS: Laryngeal vibratory asymmetry produces variable perceptual differences in phonatory sound quality. Though CPP has been correlated with dysphonia in previous research, its complex relationship with quality limits its usefulness as clinical marker of voice quality perception. LEVEL OF EVIDENCE: NA, basic science Laryngoscope, 131:2740-2746, 2021.

Biofeedback Training Improves Swallowing in a Unique Case of Upper Esophageal Sphincter Hypotonicity.

Hypotonicity of the upper esophageal sphincter (UES) has been reported only two times previously in the literature, with no reports of treatment options for this rarity. We present a third case of hypotonic UES found during high-resolution pharyngeal manometry. Although the patient had nearly absent resting pressures of the UES, pressures during and post-swallow were normal. It was hypothesized that the patient might be able to increase pre-swallow UES pressure using biofeedback. Using a chin up/out maneuver during manometry, the patient was able to achieve a more normal swallow pressure pattern. This case also highlights the need to complete manometry alongside other swallow imaging techniques for effective treatment planning and patient outcomes. Laryngoscope, 131:E1567-E1569, 2021.

A Trigeminal Schwannoma Masked by Solely Vestibulocochlear Symptoms.

BACKGROUND: Intracranial schwannomas are most commonly associated with the vestibulocochlear nerve, often leading to hearing loss, tinnitus, and vestibular dysfunction. Much less often, a schwannoma can arise from the trigeminal nerve which can lead to facial pain, numbness, and weakness. PURPOSE: We explored a case of a patient with an magnetic resonance imaging (MRI)-confirmed trigeminal schwannoma that was mistaken for a vestibulocochlear schwannoma because of a myriad of ipsilateral vestibulocochlear symptoms. RESEARCH DESIGN: This is a retrospective chart review and case study, with no statistics applied. RESULTS: This diagnostic error led to clinical confusion and inaccurate medical record-keeping. Radiologists and radiation oncologists deemed the patient's symptoms to be unrelated to the asymptomatic trigeminal schwannoma, and she was referred to an otolaryngologist following complaints of ear fullness, ear pain, and hearing loss. The patient's audiogram showed ipsilateral, asymmetric sensorineural hearing loss, and she was diagnosed with concurrent Meniere's disease. Alternative explanations, such as an additional schwannoma or external compression of the vestibulocochlear nerve, were considered, but not apparent on MRI. CONCLUSIONS: From this case, we see that symptoms do not always concur with imaging results and that multiple etiologies, especially when one is rare, can confuse a clinical picture.