Factors Associated With Otolaryngologists Performing Tracheotomy.

Importance: Tracheotomies are frequently performed by nonotolaryngology services. The factors that determine which specialty performs the procedure are not defined in the literature but may be influenced by tracheotomy approach (open vs percutaneous) and other clinicodemographic factors. Objective: To evaluate demographic and clinical characteristics associated with tracheotomies performed by otolaryngologists compared with other specialists and to differentiate those factors from factors associated with use of open vs percutaneous tracheotomy. Design, Setting, and Participants: This multicenter, retrospective cohort study included patients aged 18 years or older who underwent a tracheotomy for cardiopulmonary failure at 1 of 8 US academic institutions between January 1, 2013, and December 31, 2016. Data were analyzed from September 2022 to July 2023. Exposure: Tracheotomy. Main Outcomes and Measures: The primary outcome was factors associated with an otolaryngologist performing tracheotomy. The secondary outcome was factors associated with use of the open tracheotomy technique. Results: A total of 2929 patients (mean [SD] age, 57.2 [17.2] years; 1751 [59.8%] male) who received a tracheotomy for cardiopulmonary failure (652 [22.3%] performed by otolaryngologists and 2277 [77.7%] by another service) were analyzed. Although 1664 of all tracheotomies (56.8%) were performed by an open approach, only 602 open tracheotomies (36.2%) were performed by otolaryngologists. Most tracheotomies performed by otolaryngologists (602 of 652 [92.3%]) used the open technique. Multivariable regression analysis revealed that self-reported Black race (odds ratio [OR], 1.89; 95% CI, 1.52-2.35), history of neck surgery (OR, 2.71; 95% CI, 2.06-3.57), antiplatelet and/or anticoagulation therapy (OR, 1.74; 95% CI, 1.29-2.36), and morbid obesity (OR, 1.54; 95% CI, 1.24-1.92) were associated with greater odds of an otolaryngologist performing tracheotomy. In contrast, history of neck surgery (OR, 1.36; 95% CI, 0.96-1.92), antiplatelet and/or anticoagulation therapy (OR, 0.80; 95% CI, 0.56-1.14), and morbid obesity (OR, 0.94; 95% CI, 0.74-1.19) were not associated with undergoing open tracheotomy when performed by any service, and Black race (OR, 0.56; 95% CI, 0.44-0.71) was associated with lesser odds of an open approach being used. Age-adjusted Charlson Comorbidity Index score greater than 4 was associated with greater odds of both an otolaryngologist performing tracheotomy (OR, 1.26; 95% CI, 1.03-1.53) and use of the open tracheotomy technique (OR, 1.48, 95% CI, 1.21-1.82). Conclusions and Relevance: In this study, otolaryngologists were significantly more likely than other specialists to perform a tracheotomy for patients with history of neck surgery, morbid obesity, and ongoing anticoagulation therapy. These findings suggest that patients undergoing tracheotomy performed by an otolaryngologist are more likely to present with complex and challenging clinical characteristics.

Variability in P2X receptor composition in human taste nerves: implications for treatment of chronic cough.

Background: Antagonists to the P2X purinergic receptors on airway sensory nerves relieve refractory or unexplained chronic cough (RCC/UCC) but can evoke unwanted dysgeusias because the gustatory nerves innervating taste buds express this same family of receptors. However, the subunit composition of the P2X receptors in these systems may differ, with implications for pharmacological intervention of RCC/UCC. In most species, the extrapulmonary airway nerves involved in cough predominantly express P2X3 subunits that form homotrimeric P2X3 receptors. In contrast, most sensory nerves innervating taste buds in mice express both P2X2 and P2X3 subunits, so the majority of receptors in that system are likely P2X2/P2X3 heteromers. Methods: Since neural P2X subunit composition can differ across species, we used immunohistochemistry to test whether taste nerves in humans and rhesus macaque monkeys express both P2X2 and P2X3 as in mice. Results: In taste bud samples of fungiform papillae and larynx from humans and monkeys, all taste bud samples exhibited P2X3+ nerve fibres, but the majority lacked substantial P2X2+. Of the 35 human subjects, only four (one laryngeal and three fungiform) showed strong P2X2 immunoreactivity in taste nerves; none of the rhesus monkey samples showed immunoreactivity for P2X2. Conclusions: These findings suggest that for most humans, unlike mice, taste buds are innervated by nerve fibres predominantly expressing only P2X3 homomeric receptors and not P2X2/P2X3 heteromers. Thus, antagonists specific for P2X3 homomeric receptors might not be spared from affecting taste function in RCC/UCC patients.

Is Thyrohyoid Space Palpation a Reliable and Useful Clinical Tool Within Diagnostic Protocol for Voice Disorders?

OBJECTIVES: Palpation of the extrinsic laryngeal muscles is a common part of examination performed by otolaryngologists and speech-language pathologists on individuals presenting with voice complaints, thought to aid in diagnosis and treatment planning. While research has identified a significant relationship between thyrohyoid tension and hyperfunctional voice disorders, we are not aware of any studies exploring correlations between thyrohyoid posture during palpation and the full spectrum of voice disorders. This study aims to identify whether patterns in thyrohyoid posture at rest and during phonation can be related to stroboscopic findings and voice disorder diagnoses. METHODS: A multidisciplinary team of three laryngologists and three speech-language pathologists participated in data collection during 47 new patient visits for voice complaints. Each patient underwent neck palpation and evaluation of thyrohyoid space at rest and during phonation by two independent raters. Clinicians then used stroboscopy to rate glottal closure and supraglottic activity as part of determining primary diagnosis. RESULTS: Strong inter-rater agreement was found for ratings of thyrohyoid space posture both at rest (κ = 0.93) and during phonation (κ = 0.80). Findings revealed no significant correlations between patterns of thyrohyoid posture and laryngoscopic findings or primary diagnoses. CONCLUSIONS: Findings suggest that the presented method of laryngeal palpation is a reliable measure for assessing thyrohyoid posture at rest and during phonation. Lack of significant correlation between palpation ratings and other collected measures suggests that this method of palpation is not a useful tool for predicting laryngoscopic findings or voice diagnoses. Laryngeal palpation may still be useful in predicting extrinsic laryngeal muscle tension and guiding treatment planning; however, further research exploring the validity of laryngeal palpation as a measure of extrinsic laryngeal muscle tension is needed, as well as studies that include patient-reported measures and repeated measurements of thyrohyoid posture over time to explore whether thyrohyoid posture is impacted by other factors.

Comparative Treatment Outcomes for Idiopathic Subglottic Stenosis: 5-Year Update.

The North American Airway Collaborative (NoAAC) previously published a 3-year multi-institutional prospective cohort study showing variation in treatment effectiveness between 3 primary surgical techniques for idiopathic subglottic stenosis (iSGS). In this report, we update these findings to include 5 years of data evaluating treatment effectiveness. Patients in the NoAAC cohort were re-enrolled for 2 additional years and followed using the prespecified published protocol. Consistent with prior data, prospective observation of 487 iSGS patients for 5 years showed treatment effectiveness differed by modality. Cricotracheal resection maintained the lowest rate of recurrent operation (5%), followed by endoscopic resection with adjuvant medical therapy (30%) and endoscopic dilation (50%). These data support the initial observations and continue to provide value to providers and patients navigating longitudinal decision-making. Level of evidence: 2-prospective cohort study.

Clinicodemographic Predictors of Tracheotomy Tube Size and Decannulation: A Multiinstitutional Retrospective Cohort Study on Tracheotomy.

OBJECTIVE: We aimed to discern clinico-demographic predictors of large (≥8) tracheostomy tube size placement, and, secondarily, to assess the effect of large tracheostomy tube size and other parameters on odds of decannulation before hospital discharge. SUMMARY OF BACKGROUND DATA: Factors determining choice of tracheostomy tube size are not well-characterized in the current literature, despite evidence linking large tracheostomy tube size with posttracheotomy tracheal stenosis. The effect of tracheostomy tube size on timing of decannulation is also unknown, an important consideration given reported associations between endotracheal tube size and probability of failed extubation. METHODS: We collected information pertaining to patients who underwent tracheotomy at 1 of 10 U.S. health care institutions between 2010 and 2019. Tracheostomy tube size was dichotomized (≥8 and <8). Multivariable logistic regression models were fit to identify predictors of (1) large tracheostomy tube size, and (2) decannulation before hospital discharge. RESULTS: The study included 5307 patients, including 2797 (52.7%) in the large tracheostomy cohort. Patient height (odds ratio [OR] = 1.060 per inch; 95% confidence interval [CI] 1.041-1.070) and obesity (1.37; 95% CI 1.1891.579) were associated with greater odds of large tracheostomy tube; otolaryngology performing the tracheotomy was associated with significantly lower odds of large tracheostomy tube (OR = 0.155; 95% CI 0.131-0.184). Large tracheostomy tube size (OR = 1.036; 95% CI 0.885-1.213) did not affect odds of decannulation. CONCLUSIONS: Obesity was linked with increased likelihood of large tracheostomy tube size, independent of patient height. Probability of decannulation before hospital discharge is influenced by multiple patient-centric factors, but not by size of tracheostomy tube.

Upper Esophageal Sphincter Compression Device as an Adjunct to Proton Pump Inhibition for Laryngopharyngeal Reflux.

BACKGROUND: The Reflux Band, an external upper esophageal sphincter (UES) compression device, reduces esophago-pharyngeal reflux events. This study aimed to assess device efficacy as an adjunct to proton pump inhibitor (PPI) therapy in patients with laryngopharyngeal reflux (LPR). METHODS: This two-phase prospective clinical trial enrolled adults with at least 8 weeks of laryngeal symptoms (sore throat, throat clearing, dysphonia) not using PPI therapy at two tertiary care centers over 26 months. Participants used double dose PPI for 4 weeks in Phase 1 and the external UES compression device nightly along with PPI for 4 weeks in Phase 2. Questionnaire scores and salivary pepsin concentration were measured throughout the study. The primary endpoint of symptom response was defined as reflux symptom index (RSI) score ≤ 13 and/or > 50% reduction in RSI. RESULTS: Thirty-one participants completed the study: 52% male, mean age 47.9 years (SD 14.0), and mean body mass index (BMI) 26.2 kg/m2 (5.1). Primary endpoint was met in 11 (35%) participants after Phase 1 (PPI alone) and 17 (55%) after Phase 2 (Device + PPI). Compared to baseline, mean RSI score (24.1 (10.9)) decreased at end of Phase 1 (PPI alone) (21.9 (9.7); p = 0.06) and significantly decreased at end of Phase 2 (Device + PPI) (15.5 (10.3); p < 0.01). Compared to non-responders, responders to Device + PPI had a significantly lower BMI (p = 0.02) and higher salivary pepsin concentration (p = 0.01). CONCLUSION: This clinical trial highlights the potential efficacy of the external UES compression device (Reflux Band) as an adjunct to PPI for patients with LPR (ClinicalTrials.Gov NCT03619811).

Association of Social Determinants of Health with Time to Diagnosis and Treatment Outcomes in Idiopathic Subglottic Stenosis.

OBJECTIVES: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients. METHODS: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence. RESULTS: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression. CONCLUSIONS: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

Laryngeal Chemoreflex in Health and Disease: A Review.

The larynx plays a key role in airway protection via the laryngeal chemoreflex (LCR). This involuntary reflex can be evoked when hazardous substances activate mucosal receptors, which send signals to be processed within the brainstem. Although the LCR is meant to be protective, the reflex can become hyperstimulated, even to benign stimuli, which can result in pathological disorders, such as chronic cough and inducible laryngeal obstruction. In this review, we will outline the mechanism of the LCR and its associated pathological disorders.

Effect of Unilateral Cordotomy on Perception of Dysphagia.

OBJECTIVES: CO2 laser medial transverse cordotomy is a permanent static procedure performed to achieve adequate functional airway in cases of posterior glottic stenosis and bilateral vocal fold paralysis. Although it is the preferred method to manage long-term bilateral vocal fold immobility, it is widely believed that cordotomy has the potential to cause aspiration. The minimal existing data on the effect surgical enlargement of the glottic airway on swallowing function is heterogeneous. Through investigation of dysphagia after cordotomy, we hope to better understand the influence of glottic function and its role in dysphagia. The Eating Assessment Tool (EAT-10), is a validated dysphagia symptom-specific outcome measure. We hypothesized that EAT-10 scores would not change after CO2 laser cordotomy despite causing glottic insufficiency. METHODS: Retrospective review was performed on sequential patients having undergone unilateral CO2 laser cordotomy with complete pre- and postoperative EAT-10 questionnaire data available for evaluation. RESULTS: Fifteen patients were available for analysis; 10 patients underwent primary unilateral medial transverse cordotomy, 5 patients underwent revision cordotomy, and 20 unique procedures were included in the dataset. The median EAT-10 score during the visit prior to surgery was 3.5, whereas the post-surgery median score was 2. Furthermore, the median difference of 0 was statistically non-significant (P = .91). CONCLUSION: CO2 laser cordotomy does not contribute to patient-reported dysphagia despite creating glottic incompetence. This suggests vocal fold apposition may play a less significant role in normal swallowing function than widely believed.

Chemical receptors of the arytenoid: A comparison of human and mouse.

OBJECTIVES/HYPOTHESIS: The larynx is a highly responsive organ exposed to mechanical, thermal, and chemical stimuli. Chemicals elicit responses both in intraepithelial nerve fibers and in specialized chemosensory cells, including scattered solitary cells as well as taste cells organized into taste buds. Activation of both chemosensory cells and taste buds in the larynx elicit cough, swallow, or apnea with exposure to sour or bitter substances, and even by water or sweet-tasting chemicals. In an effort to begin understanding their function, we sought to compare the distribution, density, and types of chemosensory cells and chemoresponsive nerve fibers in laryngeal epithelium of humans and mice. STUDY DESIGN: Animal and human laboratory analysis. METHODS: Using immunohistochemistry, we identified taste cells and polymodal nociceptive nerve fibers in the arytenoid area of the laryngeal epithelium of the following: 1) infants undergoing supraglottoplasty for laryngomalacia, and 2) a cadaveric specimen procured from a 34-year-old donor. We then compared these findings to both preweanling and mature mouse tissue. RESULTS: Arytenoid tissue from both human and mouse contained many taste buds containing type II taste cells-bitter, sweet, or umami sensing-which were innervated by nerve fibers expressing P2X3 type adenosine triphosphate receptors. Type III cells (acid responsive) were also present, but they were fewer in human tissue than in equivalent tissue from mice. In both species, the epithelium was densely innervated by free nerve endings. CONCLUSIONS: Our findings suggest that from a standpoint of chemosensation, human and mouse larynges are biologically similar. This suggests that a murine model can be used effectively in laryngeal chemosensory research. LEVEL OF EVIDENCE: NA Laryngoscope, 130:423-430, 2020.

Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis.

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

Voice therapy associated with a decrease in the reflux symptoms index in patients with voice complaints.

OBJECTIVES/HYPOTHESIS: Patients with muscle tension dysphonia often demonstrate an elevation in Reflux Symptom Index (RSI) and 10-item Voice Handicap Index (VHI-10) scores, and may be erroneously diagnosed with laryngopharyngeal reflux disease. In this study we assessed the effects of voice therapy on RSI and VHI-10 scores in patients with voice complaints not responsive to antireflux medications. STUDY DESIGN: Retrospective cohort study. METHODS: A study of patients was conducted at a single tertiary-care center over 1 year (January 2012-January 2013). Patients were included if they had dysphonia not responsive to proton pump inhibition, did not have neurologic or neoplastic disease, and participated in at least three voice-therapy sessions in the absence of antireflux therapy. Primary analysis assessed change in RSI scores between the initial and follow-up visits with a laryngologist. RESULTS: A total of 18 patients were included (mean age = 49.9 ± 14.5 years, 89% female, 83% with a primary complaint of dysphonia). From initial to follow-up visit, the median RSI score (18.5 [interquartile range {IQR}, 9.5-22.8] vs. 10.5 [IQR, 4.5-14]; P = .02) and median VHI-10 score (25.5 [IQR, 11.3-30.0] vs. 13.5 [IQR, 9.5-20.8]; P = .03) significantly decreased. A significant inverse correlation was found between the number of voice therapy sessions/month and change in RSI score (r = -0.4; P = .05). CONCLUSIONS: In this study of patients with muscle tension dysphonia or vocal hyperfunction not responsive to antireflux therapy, RSI and VHI-10 scores improved following voice therapy. Results suggest that self-reported symptoms typically attributed to laryngopharyngeal reflux disease may actually be secondary to inefficient voice use patterns or anxiety about dysphonia that are responsive to voice therapy. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1169-1173, 2019.

Utility of Routine Spirometry Measures for Surveillance of Idiopathic Subglottic Stenosis.

Importance: Because of the recurrent nature of idiopathic subglottic stenosis, routine follow-up is necessary for monitoring progression of stenosis. However, no easily accessible, standardized objective measure exists to monitor disease progression. Objective: To determine whether peak expiratory flow (PEF) can be used as a reliable and easily accessible biometric indicator of disease progression relative to other validated spirometry measures in patients with idiopathic subglottic stenosis. Design, Setting, and Participants: Prospectively collected data on PEF, expiratory disproportion index (EDI), and total peak flow (TPF) from 42 women with idiopathic subglottic stenosis without comorbid lower airway or parenchymal lung disease who were treated at a single tertiary referral center between 2014 and 2018 were analyzed. The mean follow-up period was 18.2 months (range, 2-40 months). Ten patients initially screened were not included in the analysis owing to comorbid glottic or supraglottic stenosis or nonidiopathic etiology. Main Outcomes and Measures: Measurements of PEF, EDI, and TPF were taken at preoperative visits and at all other visits. Results: Forty-two women (mean age, 51.5 years; 98% white [n = 41]) met the inclusion criteria. The area under the curve for PEF was 0.855 (95% CI, 0.784-0.926). The optimal cutoff value was 4.4 liters per second (264 L/min), with a sensitivity and specificity of 84.4% and 82.0%, respectively. The area under the curve for EDI was 0.853 (95% CI, 0.782-0.925). For TPF, this was 0.836 (95% CI, 0.757-0.916). Conclusions and Relevance: This study provides evidence supporting the use of PEF as a simple, efficient, and accessible way of monitoring progression of idiopathic subglottic stenosis and predicting receipt of surgical intervention. Sensitivity and specificity of PEF were comparable to those of the more complex measures of TPF and EDI.

Are Perioperative Antibiotics Necessary During Direct Microlaryngoscopy?

OBJECTIVES/HYPOTHESIS: There are currently no established recommendations for the use of perioperative antibiotics (PAs) to prevent surgical site infections (SSIs) for direct microlaryngoscopy (DML). This study examined the incidence of SSI in patients undergoing DML with and without PAs. STUDY DESIGN: Retrospective, multi-institutional chart review. METHODS: A retrospective, multi-institutional chart review was performed at four tertiary referral academic medical centers. Patients undergoing DML from 2010 to 2017 were identified using Current Procedural Terminology codes. Medical records of patients undergoing DML with biopsy, microsurgery, laser ablation, or vocal fold injection who had adequate follow-up were reviewed. Procedures with significant cartilage destruction, concurrent open surgery, or esophageal surgery were excluded. Data recorded included age, gender, pacemaker history, American Society of Anesthesiologists class, wound class, indication for surgery, use of laser, complications, emergency room visits, hospitalizations, pain, fever, and postoperative steroid and antibiotic prescriptions. Presence or absence of SSIs was evaluated by a fellowship-trained laryngologist. RESULTS: There were 834 patients who met inclusion criteria. Of those, 698 did not receive PAs and 136 received PAs. The median age of patients was 54 years of age in the PA group and 57.5 years of age in the non-PA group, and all cases were recorded as wound class II. Overall, 58% of surgeries involved use of carbon dioxide or potassium-titanyl-phosphate laser. Only one SSI was reported on follow-up in a patient who did receive PAs. CONCLUSIONS: SSIs are exceedingly rare following DML. PA use is not indicated for routine DML. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2838-2843, 2018.

The effect of vocal fold augmentation on cough symptoms in the presence of glottic insufficiency.

OBJECTIVE: To determine the effect of injection augmentation of the vocal folds on chronic cough symptoms in patients with glottic insufficiency. METHODS: Medical records from 146 consecutive patients who underwent vocal fold injection augmentation by a fellowship-trained laryngologist between 2013 and 2015 were reviewed. Twenty-three patients (12 male) met inclusion criteria of a vocal fold augmentation injection, cough symptoms lasting more than 8 weeks, and glottic insufficiency as determined by shortened closed phase on stroboscopy. Exclusion criteria included lack of cough complaints, diagnosis of vocal fold immobility, previous history of vocal fold augmentation, and incomplete data sets. Data collected included age, gender, pre- and 1-month postinjection Cough Severity Index (CSI) scores, location of injection (unilateral or bilateral), and patient statement of percent change in symptoms that was recorded at 1-month postinjection visit. RESULTS: Paired t test indicated a significant decrease in CSI scores from pre- (m = 18.5) to 1-month postinjection (m = 12.1) (P = 0.004). Eighteen patients (78.2%) reported a 50% or greater improvement in cough symptoms at the 1-month postinjection visit. CONCLUSION: Injection augmentation of the vocal folds in the presence of glottic insufficiency appears to improve cough symptoms, as was reported by CSI in patients who are refractory to other medical and behavioral treatments. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1316-1319, 2018.

A cardiovascular prescreening protocol for unmonitored in-office laryngology procedures.

OBJECTIVES: Currently, there are no cardiovascular (CV) preprocedure screening parameters for patients undergoing in-office laryngeal procedures (IOLP). Studies have shown significant changes in CV measures for IOLP. The aim was to develop and evaluate a pre-IOLP CV screening protocol. METHODS: Review of IOLP literature and consultation with an anesthesiologist and cardiologist led to the development of CV parameters and questions related to four metabolic equivalents (METS) of work as a patient-screening tool before IOLP. A separate cohort was screened with only a modified CV protocol. All patients were screened for heart rate (HR) and blood pressure (BP) elevation prior to the procedure. Need for further CV evaluation was characterized as systolic blood pressure BP >160, diastolic BP >100, and/or HR >110 beats/minute. Patients whose BP/HR exceeded these values were referred to their primary care physician (PCP) before re-screening. If parameters were exceeded again at the second screen, then the procedure was done under monitored anesthesia care. RESULTS: The first study phase included 56 patients. The fail rate was 40% largely related to four METS of work. The second study phase included 440 patients. The screen fail rate was 15 patients of 572 (2.6%). Of these, 12 patients of 132 (9.1%) failed the initial screen and were sent to their PCP for further evaluation, and five of 440 (1.4%) patients failed on the day of the procedure. Overall, five of 440 (1.5%) patients would qualify to have their site of service changed for their laryngology procedure from an unmonitored to a monitored setting due to the prescreening criteria. CONCLUSION: Few patients needed further workup based upon the in-office CV parameters set in this study. Patients with CV risk factors were identified by the screening protocol. Having established hemodynamic parameters in place may improve the safety of IOLP with a very low physician burden. LEVEL OF EVIDENCE: 2b Laryngoscope, 127:1845-1849, 2017.

Factors Associated With Infectious Laryngitis: A Retrospective Review of 15 Cases.

OBJECTIVES: To identify the culturable microbes associated with infectious laryngitis and outline effective treatment strategies. METHODS: This is a retrospective chart review of adult patients with persistent dysphonia plus evidence of laryngeal inflammation who underwent biopsy for culture at a tertiary care medical center. Demographic factors, symptoms as reported on validated patient assessment tools, past medical history, social history, culture results, and treatment duration and response were reviewed. RESULTS: Fifteen patients with infectious laryngitis were included in this study. Culture results demonstrated Methicillin-sensitive Staphylococcus aureus (MSSA), Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Serratia marcescens, and "normal respiratory flora." In most patients, multiple courses of prolonged antibiotics were needed to treat MSSA or MRSA. Infections associated with other microbes resolved with a single course of antibiotics. CONCLUSIONS: In this population, infectious laryngitis is defined as colonization with bacteria not found in the previously characterized laryngeal microbiome of benign vocal fold lesions. In suspected cases of infectious laryngitis, culture is recommended, by biopsy if needed. For MSSA- and MRSA-associated laryngitis, an extended course of antibiotics may be necessary for symptom improvement and resolution of laryngeal inflammation. However, the optimal treatment regimen has yet to be defined and will require larger, prospective studies.

Continuous laryngoscopy quantitates laryngeal behaviour in exercise and recovery.

Exercise-induced laryngeal obstruction (E-ILO) causes exertional dyspnoea. There is no standardised methodology which characterises laryngeal obstruction in relation to exercise or links laryngeal obstruction and dyspnoea severity. Continuous laryngoscopy during exercise (CLE) may improve diagnostic sensitivity by enabling laryngeal visualisation at peak work capacity in patients with rapidly resolving obstruction. The time course of laryngeal obstruction across exercise and recovery has not been quantitated until this report.Adolescents and young adults referred for CLE were laryngoscopically monitored across rest, maximal cycle ergometry exercise, and recovery. Three reviewers, blinded to time sequencing, rated inspiratory glottic and supraglottic obstruction during 10 windows of 15-s corresponding to rest, 25%, 50%, 75%, 90% and 100% of individual symptom-limited peak work capacity (expressed in Watts), and four consecutive recovery windows.85 patients were screened and 71 included. Over 96% of time windows were interpretable. Laryngeal obstruction severity reached observed maximal levels at peak work capacity, and rapidly resolved. A spectrum of observed maximal obstruction was measured.CLE provides interpretable data demonstrating laryngeal obstruction in patients with suspected E-ILO that is more severe at peak work capacity than during rest, submaximal exercise, or recovery. Observed maximal obstruction was infrequently severe and rapidly resolved.

A low-cost transcervical laryngeal injection trainer.

OBJECTIVES/HYPOTHESIS: To develop a low-cost, easy-to-construct model for education in transcervical laryngeal injection techniques. To validate the simulator among both fellowship-trained laryngologists and otolaryngology resident learners. STUDY DESIGN: Survey. METHODS: A transcervical laryngeal injection model was constructed. Fourteen otolaryngology residents used the model to practice vocal fold injection techniques. Survey feedback was obtained from all residents. RESULTS: Most learners agreed or strongly agreed that the simulator was easy to use (93%), was a good method to learn transcervical laryngeal injection technique (79%), improved their confidence with the procedure (78%), and could be applied to patients (72%). One hundred percent of the learners agreed or strongly agreed that they would recommend the simulator to other learners. CONCLUSION: Residents can be taught transcervical laryngeal injection techniques with a low-cost, easily constructed simulator prior to treating patients. This allows for a low-stress environment in which the learner can practice injection techniques. Resident feedback about the transcervical laryngeal injection simulator was very positive, including unanimous recommendation for use in other learners. LEVEL OF EVIDENCE: N/A.

Immunohistochemical Analysis of Human Vallate Taste Buds.

The morphology of the vallate papillae from postmortem human samples was investigated with immunohistochemistry. Microscopically, taste buds were present along the inner wall of the papilla, and in some cases in the outer wall as well. The typical taste cell markers PLCß2, GNAT3 (gustducin) and the T1R3 receptor stain elongated cells in human taste buds consistent with the Type II cells in rodents. In the human tissue, taste bud cells that stain with Type II cell markers, PLCß2 and GNAT3, also stain with villin antibody. Two typical immunochemical markers for Type III taste cells in rodents, PGP9.5 and SNAP25, fail to stain any taste bud cells in the human postmortem tissue, although these antibodies do stain numerous nerve fibers throughout the specimen. Car4, another Type III cell marker, reacted with only a few taste cells in our samples. Finally, human vallate papillae have a general network of innervation similar to rodents and antibodies directed against SNAP25, PGP9.5, acetylated tubulin and P2X3 all stain free perigemmal nerve endings as well as intragemmal taste fibers. We conclude that with the exception of certain molecular features of Type III cells, human vallate papillae share the structural, morphological, and molecular features observed in rodents.