Assessing the Prevalence and Associated Risk Factors for Presbylarynx in the Elderly Laryngology Population.

OBJECTIVE: The primary objective of this study was to assess the prevalence of presbylarynx and its associated features in an elderly population representative of patients seen in a tertiary care laryngology practice. The secondary objective of this study was to compare laryngeal electromyography (LEMG) findings, coexisting VF conditions, medical history, surgical history, medication use, and other parameters between patients with and without presbylarynx. METHODS: Adult voice patients aged 60 years and older who underwent strobovideolaryngoscopy were included in the study. Patients were assigned to one of two groups based on the majority (≥2/3) agreement of three blinded authors' (GA, KL, and HP) graded examinations of strobovideolaryngoscopy (SVL) videos for findings consistent with presbylarynx (atrophic vocal folds [VFA], vocal fold bowing [VFB], vocal process prominence [VPP] and anterior glottic insufficiency [GI]). Patient demographics, medical history, surgical history, medication use, laboratory results, and SVL videos were compiled. Statistical analysis was performed using SPSS 28.0.0.0 (IBM, Armonk, NY). All tests were performed two-tailed, and a P-value of less than 0.05 was considered statistically significant. RESULTS: One hundred sixty-four patients (84 female/80 male, mean age of 68.397 ± 4.947 years) were included in this study. The prevalence of presbylarynx was 52.4% (n = 86) in the study population. The mean age of patients in the presbylarynx group was significantly higher than the nonpresbylarynx group. Additionally, there were significantly more males than females in the presbylarynx group. The presbylarynx group also was found to have a higher proportion of ACE inhibitor (ACEi) use. Further, laboratory results revealed a significantly higher proportion of patients with elevated thyroid stimulating hormone (TSH) levels in the presbylarynx group. Conversely, patients in the nonpresbylarynx group were found to have a significantly higher rate of levothyroxine use. On SVL, patients in the nonpresbylarynx cohort were found to have a significantly higher proportion of benign vocal fold lesions and vocal fold paresis. However, LEMG testing revealed no statistically significant differences in muscle recruitment between groups. Men with presbylarynx were found to have a significantly higher proportion of VFB and VPP compared to women with presbylarynx. CONCLUSION: This retrospective study investigated the prevalence and risk factors associated with presbylarynx in patients representative of those treated by laryngologists. Signs consistent with presbylarynx are observable even in the presence of coexisting VF conditions. Older age, elevated TSH, the use of ACEi, and male gender was associated with signs of presbylarynx on SVL. Of those diagnosed with presbylarynx, males were identified as having higher proportions of VFB and VPP compared to females. More education regarding presbylarynx and further studies to improve standardization of the criteria for its diagnosis, as well as its relationship with other VF conditions, are encouraged to improve management of the aging voice.

Impact of Giving Patients Your Personal Phone Number in Otolaryngology-Head & Neck Surgery.

OBJECTIVE: Patient-provider communication is a major barrier to care, with some providers giving their personal phone number (PPN) to patients for increased accessibility. We investigated participant utilization of provider's PPN, its effect on participant satisfaction, provider's ability to predict abuse of this practice, and evolving provider perceptions. STUDY DESIGN: Prospective, randomized study. SETTING: Single institution, tertiary referral center. METHODS: During a 2-week period, otolaryngology patients were randomized to either receive their provider's PPN or not. Providers predicted the likelihood of abuse. All calls/texts were documented for 4 weeks. At the study's conclusion, participants were surveyed using Press Ganey metrics. Providers were surveyed before and after to assess their likelihood of providing patients with their PPN and its impact on work demands. RESULTS: Of the 507 participants enrolled, 266 were randomized to the phone number group (+PN). Of 44 calls/texts from 24 participants, 8 were considered inappropriate. Ten participants were predicted to abuse the PPN, but only one was accurately identified. Participants in the +PN group had a greater mean composite satisfaction score than the control group (4.8 vs 4.3; Welch's t-test, P < .0011). At the conclusion of the study, providers were more likely to share their PPN (Wilcoxon signed-rank test, P < .0313), and their perceived impact of this practice on workload was lower (Wilcoxon signed-rank test, P < .0469). CONCLUSION: This study demonstrates low patient utilization of provider PPNs, and poor provider predictive ability of patient abuse. Receipt of provider's PPN was associated with improved patient satisfaction.

Randomized, controlled, double-blinded clinical trial of effect of bevacizumab injection in management of epistaxis in hereditary hemorrhagic telangiectasia patients undergoing surgical cauterization.

BACKGROUND: Given its role in the disease pathophysiology, inhibition of vascular endothelial growth factor (VEGF)-mediated angiogenesis has received attention as a potential strategy to reduce epistaxis associated with hereditary hemorrhagic telangiectasia (HHT). In this study we evaluated the efficacy of a submucosal injection of bevacizumab, a VEGF inhibitor, in reducing the severity of epistaxis and improving quality of life when given at the time of operative electrocautery. METHODS: This randomized, double-blinded, placebo-controlled trial was conducted at a single institution from 2014 to 2019. Patients scheduled to undergo operative bipolar electrocautery of nasal telangiectasias were randomized to receive a submucosal injection of saline or bevacizumab at time of surgery. Surveys to assess epistaxis severity and quality of life (QOL), including the Epistaxis Severity Score (ESS) and the 12-item Short Form (SF-12), were administered preoperatively and at 1, 2, 4, and 6 months postoperatively. The minimal clinically important difference (MCID) of the ESS instrument is reported to be 0.71. RESULTS: Of 39 patients enrolled, 37 (94.9%) completed the study. The saline group demonstrated a reduced ESS vs baseline at 1 (-1.2; p = 0.01) and 4 (-1.2; p = 0.05) months postprocedure. The bevacizumab group demonstrated a reduced ESS score vs baseline at 1 (-2.3; p < 0.001), 2 (-2.3; p < 0.001), 4 (-2.0; p = 0.003), and 6 (-1.3; p = 0.05) months postprocedure. The additive benefit of bevacizumab over saline exceeded the MCID at 1, 2, and 4 months, but the difference was not statistically significant. CONCLUSION: The addition of a single treatment of submucosal bevacizumab may be associated with additional clinically meaningful benefit for up to 4 months when compared with electrocautery alone.

Immediate and Short-term Effects of Straw Phonation in Air or Water on Vocal Fold Vibration and Supraglottic Activity of Adult Patients with Voice Disorders Visualized with Strobovideolaryngoscopy: A Pilot Study.

Purpose The first purpose of this study was to investigate and compare the short-term effects after a semi-occluded vocal tract (SOVT) therapy session consisting of straw phonation (SP) in air or water on vocal fold vibration and supraglottic activity of adult patients with voice disorders, visualized with strobovideolaryngoscopy (SVL). The second purpose of this study was to investigate and compare immediate changes in the patients' vocal fold vibration and supraglottic activity during SP in air or water, visualized with SVL. Methods Twelve adult patients with voice disorders (eight women and four men, mean age 52 years) were assigned randomly to one of two study groups: SP in air or SP in water. Immediately before and after a therapy session of 15 min, participants underwent a rigid SVL to determine the short-term effects of the SP session. At the posttherapy examination, flexible SVL while performing SP was added to determine the effects occurring during SP. The visual-perceptual ratings were performed blindly and in random order by three laryngologists, using the Voice-Vibratory Assessment with Laryngeal Imaging rating form for stroboscopy. ResultsShort-term effects after SP: After the SP-in-air session, the supraglottic mediolateral compression decreased significantly. The SP-in-water session led to significantly increased left vibrational amplitude. Immediate effects during SP: During SP in air, a significantly increased left amplitude and mucosal wave, and significantly decreased mediolateral supraglottic activity, were found. SP in water tended to decrease the vibrational amplitude during performance of the task. A trend toward higher anteroposterior supraglottic compression was observed during both SP in air and water, being more prominent in the latter. Conclusion SP in air led to less false vocal fold adduction and consequently less hyperfunction. The small increment in anteroposterior supraglottic activity during SP in air and water might be related to epilarynx narrowing, an economic phenomenon associated with SOVT exercises. The effects on vibrational amplitude were rather ambiguous. The small reduction in amplitude during SP in water is expected to diminish vocal fold impact stress and therefore creates an ideal basis for voice therapy. The increment in amplitude and mucosal wave during SP in air might indicate insufficient supraglottic pressure to obtain the favorable effects of semi-occlusion. Whether or not the rise in amplitude after the SP-in-water session is due to voice efficiency or voice fatigue remains unknown. Future larger-scale investigation in subgroups of voice patients is needed to explore these hypotheses.

The Utility of Strap Muscle in Complex Type I Thyroplasties.

INTRODUCTION: Type I thyroplasty is a common procedure used to improve dysphonia secondary to glottic insufficiency caused by vocal fold paralysis, paresis, or bowing. Revision often involves more complex procedures that can be complicated by mucosal violation, hemorrhage, infection, and shifted or extruded implants. Intraoperative challenges can be managed successfully using autologous strap muscle rotation flaps. OBJECTIVES: Review vocal fold medialization with strap muscle as a viable option for thyroplasty, particularly operations with inadvertent mucosal disruption. METHODS: All operative records of the senior author's 30-year experience were queried for modified, complex, or revision type I thyroplasties. Each of these was reviewed, and only those utilizing autologous strap muscle rotation flaps for vocal fold medialization were included. Changes in voice quality were assessed using strobovideolaryngoscopic assessment of glottic closure and Voice Handicap Index-10 (VHI-10) scores when available. RESULTS: Seven patients were found to have undergone eight type I thyroplasty using autologous strap muscle flaps. Improved glottic closure was seen in all patients except one. This patient, complicated by a laryngeal fracture of unknown origin discovered at the time of surgery, had worse voice with strap muscle implantation intraoperatively; therefore, the patient's fracture was reduced, and medialization was postponed. All other patients reported improved voice quality both intra- and postoperatively. Pre- and postoperative VHI-10 scores were available for two of the seven cases with successfully implanted strap muscles. A decrease in VHI-10 was observed in both cases (mean = 11). No postoperative complications occurred in any patient. CONCLUSION: Although revision thyroplasties are relatively rare, they can be challenging. The seven cases presented herein illustrate the successful and safe use of autologous strap muscle rotation flaps for complex, revision type I thyroplasty procedures. They are particularly helpful in cases requiring additional soft tissue between the thyroid cartilage and mucosa in preparation for possible future medialization after Gore-Tex or Silastic implants, and for inadvertent mucosal disruption in which using a foreign implant might pose a risk of infection. Future studies should be performed with larger populations and longer follow-up to confirm the efficacy and safety of this procedure.

Prevalence and Long-term Consequences of Vocal Fold Hemorrhage in Patients who Underwent Microscopic Laryngeal Surgery or Type I Thyroplasty.

OBJECTIVE: Examine incidence of postoperative vocal fold (VF) hemorrhage (PVFH) in patients who underwent microscopic laryngeal surgery and type I thyroplasty and determine the long-term consequences of hemorrhage on the outcome of the surgery. STUDY DESIGN: Retrospective study. PATIENTS AND METHODS: Medical records of patients from a quaternary care laryngology practice who underwent microdirect laryngoscopy (MDL) or type I thyroplasty between November 2015 and December 2018 were reviewed as a consecutive sample. MDL procedures not performed on the VF were excluded. Demographic and medical history data associated with risk of bleeding were collected, and records were reviewed for the incidence of PVFH and long-term consequences of PVFH through Voice Handicap Index-10 (VHI-10) and preoperative and postoperative videostroboscopic findings. We considered each VF surgery as one procedure. Statistical analysis was performed using chi-square analysis for categorical data and a student t test for means. A P value of 0.05 or less was considered significant. RESULT: Total 155 patients were enrolled. The patients underwent 182 MDL surgeries, (122 bilateral and 60 unilateral), and 60 Type 1 thyroplasty surgeries (13 bilateral and 47 unilateral). In the MDL group, 34 of 304 procedures (11%) resulted in VFH. In the thyroplasty group, 10 of 73 procedures (13.7%) were associated with PVFH. Bilateral MDL procedures were associated with a higher incidence of PVFH in comparison with unilateral procedures (P= 0.03), but bilateral thyroplasties were not (P= 0.33). None of the demographic factors significantly increased or decreased risk of PVFH. Comparing the difference between preoperative and 3-6 month postoperative VF mucosal function, and preoperative and 3-6 month postoperative VHI-10 in both MDL and thyroplasty groups, no statistically significant difference was found between patients who had experienced PVFH and those who had not. CONCLUSION: This is the largest investigation into the incidence and long-term consequences of the PVFH. 11% of the patients in the MDL group experienced PVFH; the vibratory margin of the VF was involved in only 1.3%.; and 13.7 % of the procedures in the thyroplasty group resulted in PVFH. However, PVFH was not associated with significant increase in VHI-10 or decrease in VF vibratory function during 3-6 month postoperative follow-up visits. The incidence of PVFH was related significantly to postoperative phonotrauma and upper respiratory infection, but not to gender, age, history of smoking and alcohol consumption, pulmonary and cardiovascular comorbidities, or pre-existing VF varicosities or ectasias.

Role of Peri- and Postoperative Antibiotics in Microscopic Laryngeal Surgery.

OBJECTIVES: There are no widely accepted guidelines for the use of peri- and postoperative antibiotics for microdirect laryngoscopy (MDL) to prevent postoperative surgical site infection (SSI). This study examines the incidence of not only SSI, but also respiratory and oropharyngeal infections among patients who underwent MDL. STUDY DESIGN: Retrospective cohort. METHODS: Medical records from a quaternary laryngology practice were reviewed retrospectively for patients who underwent MDL between October 2015 and December 2018. Adults who underwent MDL with excision of nonmalignant masses, vocal fold (VF) reconstruction with buccal graft, superficial VF injection, VF injection augmentation, use of carbon dioxide (CO2) or potassium titanyl phosphate (KTP) laser, and laryngeal dilation were included. Subjects were divided into three groups based on the use of antibiotics during the peri- or postoperative period. Group 1 did not receive peri- or postoperative antibiotics. Group 2 received perioperative antibiotics without postoperative antibiotics. Group 3 received both peri- and postoperative antibiotics. Antibiotic use was determined by surgeon policy, which changed over time, not by patient risk factors. Other data collected include demographics, medical comorbidities, surgical procedure, operative time, American Society of Anesthesiology class, incidence of SSI, respiratory or oropharyngeal infection, and postoperative antibiotic and steroid prescriptions for complications. RESULTS: 190 surgeries met inclusion criteria. Groups 1, 2, and 3 consisted of 113, 57, and 20 subjects, respectively. No SSI were reported. Baseline characteristics of median age, American Society of Anesthesiology, wound class, and gender did not differ between groups. Groups were found to have differed in type of procedure performed, with a predominance of vocal fold excision and superficial injection in Group 1, injection laryngoplasty using autologous fat graft and laryngeal reconstruction in Group 3, and a combination of procedure types in Group 2. Laser treatment with CO2 and/or KTP was utilized in 35% of procedures. The mean operative times (total time in which the laryngoscope remained in the oral cavity) for Groups 1, 2, and 3 were 29 (SD = 13), 42 (SD = 23), and 73 minutes (SD = 78), respectively; this was significantly different among the three groups (P < 0.0001). By logistic regression models, operative time was not significantly associated with the overall use of antibiotics (Χ2 = 1.81, P = 0.18) or corticosteroid (Χ2 = .05, P = .82) prescriptions during follow-up. In Groups 1, 2, and 3, 11%, 14%, and 10% of patients, respectively, required a follow-up antibiotic prescription for non-SSI and 11%, 12%, and 0% of patients, respectively, required a follow-up corticosteroid prescription within 30 days postoperatively. There was no significant difference in patients with diabetes or pulmonary comorbidity and patients without comorbidity in use of postoperative antibiotic (P = .45) or corticosteroid (P > .99) prescription. Within 30 days of follow-up, patients in Group 1 experienced VF hemorrhage (defined as any subepithelial blood in the area of excision) at an incidence of 19%. Complications within 30 days of follow-up showed an incidence of substantial pain ranging between 2%-4% and respiratory or oropharyngeal infection between 10%-12%. Two patients in Group 2 reported emergency department visits for dyspnea. One patient in Group 3 was admitted for tongue and floor of mouth swelling secondary to prolonged suspension. CONCLUSION: There were no incidents of SSI in this cohort. The need for follow-up antibiotic and/or corticosteroid prescription did not differ in relation to use or non-use of perioperative antibiotics, and neither did the incidence of respiratory or oropharyngeal infection. Longer operative time was associated with both peri- and postoperative antibiotic use, but there is no evidence yet that antibiotic use was necessary. These findings suggest that avoidance of routine perioperative and/or postoperative antibiotics may be appropriate; and further research should be encouraged.

Role of Postoperative Antibiotics in Patients Undergoing Type I Thyroplasty with Gore-Tex Implant.

OBJECTIVES: The purpose of this study was to determine the need for postoperative antibiotic administration in patients undergoing type I thyroplasty performed with Gore-Tex implant. STUDY DESIGN: Retrospective analysis. METHODS: Medical records of patients from a quaternary care laryngology practice who underwent type I thyroplasty for glottic insufficiency using Gore-Tex (W.L. Gore, Newark, Delaware) implant between the years 2013 and 2019 were reviewed retrospectively. Subjects were divided into two groups determined by those who did or did not receive routine postoperative antibiotics. All patients received two grams of cefazolin IV (for the standard 70-kilogram patient), and 10 mg of dexamethasone as a one-time dose given 10 minutes prior to incision. Patients allergic to cefazoline who received a single preoperative dose of 600 mg of clindamycin IV. All subjects were seen in the office at least three times after the procedure: one day, one week, and approximately six weeks following surgery. Statistical analysis was performed on the collected data using χ2 analysis for categorical data and a student t test for means. A P value of less than 0.01 was considered significant. RESULTS: There was no significant difference in infection rate or other complications between groups. CONCLUSION: Routine use of antibiotics following type I thyroplasty with Gore-Tex (W.L. Gore, Newark, Delaware) appears unnecessary.

The Sternocleidomastoid Myocutaneous Flap: A Laryngeal Preservation Option for Total Hypopharyngoesophageal Stenosis.

Complete hypopharyngoesophageal (HPE) stenosis is rare and a challenging condition to treat. When endoscopic therapy fails, total laryngectomy with or without pharyngeal reconstruction is usually performed. We present a retrospective case series involving 3 patients with complete HPE stenosis who failed endoscopic repair and were gastrostomy dependent. All were managed successfully with the sternocleidomastoid myocutaneous (SCM) flap. A temporary fistula occurred in 1 patient. Hospitalization ranged from 5 to 15 days, patients resumed oral intake from 21 to 82 days postoperatively, and their gastrostomy tubes were removed from 28 to 165 days postoperatively. We suggest that the SCM flap is a laryngeal preservation option for reconstruction of complete HPE stenosis when endoscopic techniques fail. This flap allows HPE repair and reconstruction within the same surgical field, imposes no significant donor site morbidity, and affords good functional and cosmetic outcomes.

Evidence for a 'preinvasive' variant of fungal sinusitis: Tissue invasion without angioinvasion.

Clinical experience has suggested the existence of an intermediate form of fungal sinusitis between the categories of non-invasive fungal sinusitis (non-IFS) and invasive fungal sinusitis (IFS). This fungal sinusitis variant demonstrates unhealthy mucosa by endoscopy with fungal invasion, but lacks angioinvasion microscopically, representing what clinically behaves as a 'pre-invasive' subtype of fungal sinusitis. Unlike non-IFS disease, patients with pre-invasive fungal sinusitis were still felt to require anti-fungal medications due to histologic presence of invasive fungus. While sharing some clinical features of IFS, these 'intermediate' patients were successfully spared extended and repeated surgical debridements given the microscopic findings, and have been successfully treated with shorter courses of antifungal therapy. These select patients have had favorable outcomes when managed in a judicious and semi-aggressive manner, in an undefined zone between the treatments for routine fungal ball and aggressive IFS.

Defining surgical criteria for empty nose syndrome: Validation of the office-based cotton test and clinical interpretability of the validated Empty Nose Syndrome 6-Item Questionnaire.

OBJECTIVES/HYPOTHESIS: The validated Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) identifies empty nose syndrome (ENS) patients. The unvalidated cotton test assesses improvement in ENS-related symptoms. By first validating the cotton test using the ENS6Q, we define the minimal clinically important difference (MCID) score for the ENS6Q. STUDY DESIGN: Individual case-control study. METHODS: Fifteen patients diagnosed with ENS and 18 controls with non-ENS sinonasal conditions underwent office cotton placement. Both groups completed ENS6Q testing in three conditions-precotton, cotton in situ, and postcotton-to measure the reproducibility of ENS6Q scoring. Participants also completed a five-item transition scale ranging from "much better" to "much worse" to rate subjective changes in nasal breathing with and without cotton placement. Mean changes for each transition point, and the ENS6Q MCID, were then calculated. RESULTS: In the precotton condition, significant differences (P < .001) in all ENS6Q questions between ENS and controls were noted. With cotton in situ, nearly all prior ENS6Q differences normalized between ENS and control patients. For ENS patients, the changes in the mean differences between the precotton and cotton in situ conditions compared to postcotton versus cotton in situ conditions were insignificant among individuals. Including all 33 participants, the mean change in the ENS6Q between the parameters "a little better" and "about the same" was 4.25 (standard deviation [SD] = 5.79) and -2.00 (SD = 3.70), giving an MCID of 6.25. CONCLUSIONS: Cotton testing is a validated office test to assess for ENS patients. Cotton testing also helped to determine the MCID of the ENS6Q, which is a 7-point change from the baseline ENS6Q score. LEVEL OF EVIDENCE: 3b. Laryngoscope, 127:1746-1752, 2017.