The Validity and Reliability of the Reflux Finding Score.

Laryngopharyngeal reflux (LPR) disease is common. The incidence of newly diagnosed cases has increased substantially due to awareness and development of new diagnostic measurements. The reflux finding score (RFS) and reflux symptom index (RSI) are believed to be useful in the assessment process, including after the initiation of therapy. However, many authors have suggested concerns about the reliability and validity of the RFS. OBJECTIVE: To evaluate the validity and reliability of the RFS. METHODS: Ninety-two patients diagnosed with LPR who had undergone 24-hour pH-Impedance tests were included. All patients underwent stroboscopy and 24-Hour pH-Impedance monitoring within thirty days. Fifty-nine patients filled out a RSI prior to stroboscopic exam. The RFS was determined by four blinded observers: one otolaryngology resident, two laryngology fellows, and one laryngologist. Stroboscopic images were reviewed again one year later to assess intrarater reliability. RFS and RSI were correlated with 24-hour pH Impedance testing. RESULTS: The Kappa value between reviewers was 0.479. The percent agreement of the four observers for total RFS was 74.04%.The percent agreement between reviewers for subglottic edema was 78.77%; for ventricular obliteration was 65.55%; for erythema/hyperemia was 69.62%, for vocal fold edema was 68.32%; for diffuse laryngeal edema was 66.86%, for posterior commissure hypertrophy was 73.54%; for granuloma/granulation was 96.80%; for thick endolaryngeal mucus was 72.81%. The intrarater reliability of the four observers for total RFS was 67.5% with an intrarater reliability range of 50%-90%. The intrarater reliability for subglottic edema was 85% with a range of 70%-100%; for ventricular obliteration was 77.50% with a range of 70%-90%; for erythema/hyperemia was 65.00% with a range of 50%-90%; for vocal fold edema was 52.50% with a range of 30%-70%; for diffuse laryngeal edema was 62.50% with a range of 20%-80%; for posterior commissure hypertrophy was 52.50% with a range of 10%-80%; for granuloma/granulation was 100%; for thick endolaryngeal mucus was 55.00% with a range of 10%-90%. There was no correlation between RFS and any parameter of the 24-Hr pH-Impedance Test. RSI had a significant correlation with number of upright events (r value of 0.271, R2 of 0.0733 and P-value of 0.037), total symptoms experienced (r value of 0.0.267, R2 of 0.0715 and P-value of 0.041), and symptom correlation score (r value of -0.297, R2 of 0.0884 and P-value of 0.022). CONCLUSION: Many authors have expressed concerns about the reliability and validity of the RFS. In our study we found a fair/substantial interrater reliability, and a modest intra-rater reliability. We found no correlation between the RFS and 24-Hr pH Impedance testing. This study suggests that the concerns about the validity and reliability of the RFS may be warranted. This widely used clinical score should be interpreted with caution and further research and refinement should be considered.

Prevalence of Body Dysmorphic Disorder in an Otolaryngology-Head and Neck Surgery Clinic.

OBJECTIVE: To analyze the prevalence of body dysmorphic disorder (BDD) in a general otolaryngology population presenting to an outpatient clinic. STUDY DESIGN: Prospective prevalence study. SETTING: Single tertiary academic otolaryngology clinic. SUBJECT AND METHODS: New patients over 18 years of age who presented to an academic otolaryngology clinic between August 2018 and May 2021 completed a questionnaire including demographic questions and the validated Body Dysmorphic Disorder Questionnaire (BDDQ). Data collected from the questionnaires were analyzed to assess demographics and prevalence of BDD in an otolaryngology clinic. RESULTS: Of the 242 patients queried, 15 patients screened positive for BDD. The screened prevalence of BDD was determined to be 6.2%. None of the patients had previously been diagnosed with BDD. The prevalence of prior mental health diagnoses was 34.3%. These patients had initially presented for a variety of otolaryngologic concerns and had pre-existing diagnoses of anxiety, depression, obsessive-compulsive, bipolar and eating disorders. CONCLUSION: The prevalence of BDD in our population of new patients presenting to an academic otolaryngology practice (6.2%) is higher than that of the general population (1.9%).

Detection of Muscle Tension Dysphonia Using Eulerian Video Magnification: A Pilot Study.

OBJECTIVE: To determine whether Eulerian Video Magnification software is useful in diagnosis of muscle tension dysphonia (MTD). STUDY DESIGN: Prospective. METHODS: Adult patients scheduled in a tertiary care laryngology practice for evaluation of dysphonia were recruited between November 2016 and March 2017. Demographic and clinical data were extracted from patient charts. Diagnosis of MTD was confirmed with videostroboscopic and physical exam and by a speech-language pathologist. Eighteen MTD patients were video recorded while at rest and with phonation. Five patients without MTD also were analyzed as controls. Videos were analyzed using Eulerian Video Magnification software (Massachusetts Institute of Technology) to assess change in blood flow at the forehead, infrahyoid muscles, and sternocleidomastoid muscles, while using the values of the background wall as a control value. RESULTS: Patients with MTD demonstrated little change in perfusion to the infrahyoid muscles of the neck while phonating (+1% ± 55%). Control subjects demonstrated an increase in perfusion to the infrahyoid muscles while phonating (+102% ± 164%), with this change being significant when comparing the two groups (P = 0.04, t = 2.189, df = 21). A change in perfusion of 0% or less to infrahyoid muscles was 75% sensitive and 70% specific for diagnosis of MTD. No differences in perfusion were found between other regions assessed. Patient age and gender did not correlate with any change in perfusion between rest and phonation. CONCLUSION: Our data suggest that Eulerian Video Magnification can be used in the diagnosis of MTD by focusing on the difference in perfusion to the infrahyoid muscles between rest and phonation.

Detection of Arytenoid Dislocation Using Pixel-valued Cuneiform Movement.

OBJECTIVES: This study aims to assess utility of pixel-valued movement software in detecting arytenoid dislocation preoperatively. STUDY DESIGN: This is a retrospective analysis. METHODS: Twenty-seven patients diagnosed with unilateral arytenoid dislocation were included. Diagnosis of arytenoid dislocation was confirmed by lack of vocal fold paralysis on preoperative laryngeal electromyography and by intraoperative findings of cricoarytenoid dislocation. A region-tracking software algorithm developed by Zhuang et al was used to analyze 27 preoperative endoscopic videos of patients diagnosed with arytenoid dislocation. Vector analysis measuring cuneiform movement during inspiration was used as an indirect measure of arytenoid movement. Values were normalized using vocal fold length. Two raters blinded to diagnosis of arytenoid dislocation measured vocal fold length and cuneiform movement on both the dislocated and the nondislocated sides. RESULTS: A Wilcoxon signed-rank test indicated that the mean pixel-valued cuneiform movement and standard deviation (SD) were greater for nondislocated (159.24, SD = 73.35) than for dislocated (92.49, SD = 72.11) arytenoids (Z = 3.29, P = 0.001). The interrater correlation coefficient was 0.87 for the dislocated side and 0.75 for the nondislocated side. The intrarater correlation coefficient was 0.87 for the dislocated side and 0.91 for the nondislocated side. The receiver operating characteristic curve revealed an area under the curve between 0.76 and 0.83 (95% confidence interval 0.63-0.90). Analysis by the first and second raters revealed misdiagnosis of laterality of arytenoid dislocation in four and six patients, respectively. CONCLUSIONS: The software program developed by Zhuang et al provides a high-degree of precision, with good interrater and intrarater correlation coefficients. However, high rates of misdiagnosis of arytenoid dislocation and the laborious analysis process using this software program make it of limited utility as a clinical diagnostic tool in its present state.

Histoplasmosis of the head and neck in the immunocompetent patient: Report of 2 cases.

Histoplasmosis of the head and neck is rarely seen in immunocompetent patients. We report 2 new cases of histoplasmosis of the head and neck in immunocompetent patients, one an 80-year-old man and the other a 57-year-old man. The older man presented with oral cavity histoplasmosis; his symptoms included pain, dysphagia, and ulcerative lesions. The younger man had laryngeal histoplasmosis, which resulted in hoarseness and dyspnea. We discuss the methods of diagnosis and the classic findings in histoplasmosis, including the microscopic appearance of caseating granulomas, the results of periodic acid-Schiff staining and Gomori staining, and antibody detection of histoplasmosis. We also review the treatment options with antifungals, including amphotericin B and the oral conazole drugs. With an accurate diagnosis and proper treatment, both of our patients recovered well and their symptoms resolved. Because their symptoms overlapped with those of other, more common disease processes, an accurate diagnosis of these patients was essential to treating their infection.

Ancillary medications and outcomes in post-tonsillectomy patients.

To investigate the impact of medications on outcomes after tonsillectomy, a retrospective review using the MarketScan database was performed. A total of 306,536 privately insured children and adolescents (1 to 17 years old) who underwent tonsillectomy/adenoidectomy were identified from 2008 to 2012. Pharmaceutical claims identified patients who received outpatient prescriptions for ibuprofen, steroids, or topical anesthetics until discharge and for medications for the treatment of attention deficit hyperactivity disorder (ADHD) or montelukast up to 14 days postoperatively. Logistic regression compared prescription claims to outcomes, including postoperative bleeding, dehydration, emergency department visits, and readmissions. Ibuprofen was the only medication associated with increased odds of postoperative bleeding (odds ratio [OR]: 1.45, 95% confidence interval [CI]: 1.07 to 1.95). Patients receiving steroids had lower odds of dehydration (OR: 0.74, 95% CI: 0.65 to 0.84) and emergency department visits (OR: 0.82, 95% CI: 0.76 to 0.88). Odds of dehydration were highest in patients taking ADHD medications (OR: 1.38, 95% CI: 1.15 to 1.66) and topical anesthetics (OR: 1.32, 95% CI: 1.10 to 1.59). Although causality cannot be assumed in observational studies, steroids and ibuprofen should be used judiciously.

Diagnosis and treatment of paradoxical vocal fold motion in infants.

IMPORTANCE: Paradoxical vocal fold motion (PVFM) is a disorder often misdiagnosed in children presenting with shortness of breath and stridor. In infants, little is known about the clinical course and best approach for treatment of PVFM. This retrospective study assesses the approach to treatment and outcomes for infants with PVFM. OBJECTIVE: To investigate the clinical course of paradoxical vocal fold motion (PVFM) in infants. DESIGN: Retrospective review. SETTING: Tertiary academic medical center. PARTICIPANTS: Patients less than 2 years of age diagnosed with PVFM were identified and included in the study. MAIN OUTCOMES AND MEASURES: History, physical exam findings, and clinical course of treatment for patients less than 2 years old with PVFM were reviewed. Findings including those on flexible fiberoptic laryngoscopy (FFL) and subjective assessment by parents and clinicians were compiled for review. RESULTS: Seven infants were diagnosed with PVFM. All patients were full term at birth, and average age at diagnosis was 7 months. All patients initially presented with inspiratory stridor, and two patients had stertor. Two of seven patients also had a history of reactive airway disease and one with laryngomalacia. Five had a history of reflux. Two of seven patients had weight percentiles at diagnosis lower than the 25th percentile, while the remainder were between 37th and 75th percentiles. Initial voice evaluation revealed stridor in all patients, as well as finding of PVFM on FFL. All patients were started on anti-reflux medication. Average time to resolution of PVFM was 5.9 months after treatment. CONCLUSIONS: PVFM can be challenging to diagnose in the infant population. PVFM resolves uneventfully with reflux treatment, however, it is unknown whether reflux treatment is essential or if PVFM would spontaneously resolve. The rarity of infantile PVFM mandates formal evaluation and monitoring by a pediatric otolaryngologist.

Socioeconomic Variables of Patients with Spasmodic Dysphonia: A Preliminary Study.

OBJECTIVES/HYPOTHESIS: To characterize socioeconomic status (SES) variables of spasmodic dysphonia (SD) patients and determine their impact on voice outcomes after treatment with botulinum toxin. STUDY DESIGN: Retrospective review. MATERIALS AND METHODS: SD patients treated with botulinum toxin for the past 10 years (July 2007-July 2017) for whom sufficient SES and outcome data were available were included. Spearman rho nonparametric correlation coefficients were calculated to determine if SES variables were significantly associated with self-perceived vocal quality. Voice Handicap Index-10 was recorded. Patients were asked at each visit to rate their best voice quality during the period of previous botulinum toxin injection on a scale of 1-10, with 10 being the best. RESULTS: Fifty SD patients were included. Average age was 60.3 ± 11.4 years, with men representing 24% of patients. Ethnicity was 74% Caucasian and 26% non-Caucasian. Median household income was $76,564 ± $24,782. Sixty-six percent of patients were employed. Adductor SD was diagnosed in 82% of patients and abductor SD in 12%. Best voice out of 10 was 7.23 ± 2.0. Mean Voice Handicap Index-10 score was 25.14 ± 9.4. Patients were treated with botulinum toxin for 165.9 ± 101.9 months. Age, gender, median household income, ethnicity, and employment status were not significantly associated with self-perceived vocal quality. Patients with longer disease duration self-reported a better voice (P = 0.02, r = 0.387). CONCLUSIONS: SES variables were not associated with voice outcomes for SD patients treated with botulinum toxin. Patients self-reported improved voice with longer duration of disease.

Perceptions of pain of laryngeal electromyography.

OBJECTIVE: To evaluate pain associated with laryngeal electromyography (LEMG). STUDY DESIGN: A prospective case series. METHODS: Adult patients scheduled for LEMG in a tertiary care laryngology practice were recruited between July 20, 2016, and March 1, 2017. Demographic and clinical data were extracted from the charts. Study participants reported their anticipated pain level using a visual analog scale (VAS) prior to the procedure. VAS was administered again within 10 minutes after the procedure, along with the validated McGill Pain Questionnaire, to gauge patient's pain perception after undergoing LEMG. RESULTS: Results were reviewed for 80 patients (mean age 48.2 ± 16.6 years, 37.5% male). Preprocedure VAS pain scores (4.59 ± 2.3 out of 10) were not significantly different than postprocedure VAS pain scores (4.61 ± 2.4) (P = 0.95). The McGill Pain Questionnaire reported a moderate pain level (32.1 ± 12.7 out of 78). Females anticipated a higher preprocedure VAS pain score (5.04 ± 2.3) than males (3.85 ± 2.2) (P = 0.02); however, postprocedure scores were not significantly different between genders. The following factors did not influence the pain scores: age, professional voice use, history of previous EMG, chronic pain diagnosis, psychiatric diagnosis, or current treatment with pain/psychiatric medications. All LEMGs were completed without any complications. CONCLUSION: Patients appropriately anticipated their pain levels for the LEMG, which may be attributed to proper patient education and counselling before the procedure. Overall pain levels were mild to moderate, and all LEMGs were completed; thus, LEMG was well tolerated. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:896-900, 2018.

Time between First and Second Posttonsillectomy Bleeds.

OBJECTIVE: To determine the time between first and recurrent posttonsillectomy hemorrhages (PTHs) and find factors related to multiple PTHs. METHODS: Retrospective chart review. RESULTS: Of 112 patients, 91 had one PTH, while 21 had recurrent PTHs. Patients with recurrent bleeds had significant differences (P < 0.05) in indication for tonsillectomy (47.6% had recurrent tonsillitis), prior cardiac conditions (28.6%), transfusions (9.5%), and hematology consults during the initial PTH visit (19%). Bleeding occurred at a mean of 6.1 (range 1-13) days for the first episode and 10 (range 9-18) days for the second episode as compared to 6.65 (range 1-18) days for those who bled once. Recurrent PTH patients were less likely to have had surgical control of the initial bleed (P < 0.05). Patients who bled at 7 days or later were more likely to bleed again within one day (OR 23.0, RR 12). Regression analysis showed that age, failure to have operative control of PTH, and surgical indication were most important in predicting recurrent PTH. CONCLUSIONS: Operative control of PTH is associated with a better outcome than monitoring alone. Patients with PTH within 7 days of tonsillectomy are likely safe to discharge soon after treatment; those who bleed after 7 days should be monitored longer.

Women in Otolaryngology.

Advances in gender equality have been sought in the field of medicine for centuries, including the specialty of otolaryngology. Currently, about 14.5% of practicing otolaryngologists are women. Strides have been made to support equality by the American Academy of Otolaryngology-Head and Neck Surgery through the development of the Women in Otolaryngology Section in 2010, among other efforts. This article reviews the literature of women in otolaryngology, as well as current trends toward equality among otolaryngologists of all genders.

Evaluating the quality and readability of Internet information sources regarding the treatment of swallowing disorders.

The Internet has become a popular resource for patient education. The information it provides, however, is rarely peer-reviewed, and its quality may be a concern. Since the average American reads at an 8th grade level, the American Medical Association and the National Institutes of Health have recommended that health information be written at a 4th to 6th grade level. We performed a study to assess the quality and readability of online information regarding the treatment of swallowing disorders. A Google search for "swallowing treatment" was conducted. We studied the first 50 websites that appeared on the search engine's results with the use of the DISCERN quality index tool, the Flesch Ease of Reading Score (FRES), and the Flesch-Kincaid Grade Level (FKGL) readability test. DISCERN is a validated 16-item questionnaire used to assess the quality of written health information; FRES and FKGL are used to assess readability. We classified the websites as either patient-targeted or professional-targeted sites, as well as either major or minor. The overall DISCERN score was 1.61 ± 0.61 (range: 1 to 5), the overall FRES was 39.1 ± 19.0 (range: 1 to 100), and the overall FKGL was 11.8 ± 3.4 (range: 3 to 12). As would be expected, patient-targeted websites had significantly higher FRES and significantly lower FKGL scores than did the professional-targeted websites (p = 0.01 and p = 0.04, respectively); there was no significant difference between the two in DISCERN scores. The major websites had significantly higher DISCERN scores than did the minor sites (p = 0.002); there were no significant differences in FRES and FKGL scores. We conclude that online information sources regarding the treatment of swallowing disorders were of suboptimal quality in that information was written at a level too difficult for the average American to easily understand. Also, the patient-targeted websites were written at a lower reading level, and the major websites contained a higher quality of information.

The clinical manifestations of vestibular migraine: A review.

OBJECTIVES: To provide an overview of vestibular migraines presentation, pathology, and diagnosis, as well as an update on current diagnostic criteria. METHODS: A review of the most recent literature on vestibular migraines was performed. RESULTS: Vestibular migraine is a process with significant impact on the quality of life for those afflicted with the disease, with attacks of spontaneous or positional vertigo and migraine symptoms lasting several minutes to 72h. Inner ear disease can co-exist with migraine and the vestibular symptoms occurring with vestibular migraine can mimic inner ear disorders providing a challenge for clinicians in establishing diagnosis. Recent diagnostic criteria for vestibular migraine proposed by a joint committee of the Bárány Society and the International Headache Society provide an important standard for clinical diagnosis and research endeavor. CONCLUSION: Vestibular migraine is a challenging disease process to both diagnose and treat. Proper diagnosis and treatment requires a thorough understanding of the current literature.

Factors related to persisting perforations after ventilation tube insertion.

OBJECTIVE: Over a million ventilation tubes are placed annually in the United States, making this one of the most commonly performed procedures in the field of medicine. Certain factors increase the risk of persistent tympanic membrane perforation following the extrusion of short term ventilation tubes. Persistent perforations may fail to heal on their own, necessitating surgical closure to avoid conductive hearing loss. It is important to detect factors that may predict children who are at increased risk for persistent perforations. METHODS, OUTCOMES DATA AND STATISTICAL ANALYSIS: This study was a retrospective chart review that involved 757 patients between 2003 and 2008. The patients studied were within the age of 2 months-17 years, and all had short term tubes placed. The chart data also included demographic information, comorbidities, and information related to tube insertion and follow-up care. Chi-square, t-test, and multivariate logistic regression were conducted to compare variables between patients with perforations and those without. RESULTS: Data from 757 patients was analyzed, showing that perforation rate is associated with rhinorrhea, operative tube removal, aural polyps, and otorrhea (OR 1.72, 8.16, 4.69, and 1.72 respectively). The absence of otorrhea decreased the likelihood of TM perforations and no significant differences were found in gender, total number of sets of tubes, type of tube, use of nasal steroids, adenoidectomy, or nasal congestion. CONCLUSION: Our findings suggest that children with rhinorrhea, otorrhea, aural polyps, or prolonged intubation requiring operative tube removal should be identified clinically as children at risk of persisting perforation.