Differentiation of Bolus Texture During Deglutition via High-Density Surface Electromyography: A Pilot Study.

OBJECTIVE: Swallowing is a complex neuromuscular task. There is limited spatiotemporal data on normative surface electromyographic signal during swallow, particularly across standard textures. We hypothesize the pattern of electromyographic signal of the anterior neck varies cranio-caudally, that laterality can be evaluated, and categorization of bolus texture can be differentiated by high-density surface electromyography (HDsEMG) through signal analysis. METHODS: An HDsEMG grid of 20 electrodes captured electromyographic activity in eight healthy adult subjects across 240 total swallows. Participants swallowed five standard textures: saliva, thin liquid, puree, mixed consistency, and dry solid. Data were bandpass filtered, underwent functional alignment of signal, and then placed into binary classifier receiver operating characteristic (ROC) curves. Muscular activity was visualized by creating two-dimensional EMG heat maps. RESULTS: Signal analysis results demonstrated a positive correlation between signal amplitude and bolus texture. Greater differences of amplitude in the cranial most region of the array when compared to the caudal most region were noted in all subjects. Lateral comparison of the array revealed symmetric power levels across all subjects and textures. ROC curves demonstrated the ability to correctly classify textures within subjects in 6 of 10 texture comparisons. CONCLUSION: This pilot study suggests that utilizing HDsEMG during deglutition can noninvasively differentiate swallows of varying texture noninvasively. This may prove useful in future diagnostic and behavioral swallow applications. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2695-2703, 2023.

Assessment of Laryngeal Sensory Function using a Tactile Aesthesiometer in Healthy Adults.

INTRODUCTION: Laryngeal sensory function in healthy adults was assessed through the delivery of tactile stimuli using Cheung-Bearelly monofilaments. METHODS: 37 healthy adults were recruited with 340 tactile stimuli analyzed. Four calibrated tactile stimuli were delivered to three laryngeal sites: false vocal fold (FVF), aryepiglottic fold (AEF), and lateral pyriform sinus (LPS). Primary outcome was the elicitation of laryngeal adductor reflex (LAR). Secondary outcomes were gag, patient-reported laryngeal sensation (PRLS), and perceptual strength. Analysis was performed with mixed effects logistic regression modeling. RESULTS: Positive LAR was observed in 35.7%, 70.2%, and 91.2% of stimuli at LPS, AEF, and FVF respectively. LAR rates were significantly associated with laryngopharyngeal subsite (p < 0.001), tactile force (p = 0.001), age (p = 0.022) and sex (p = 0.022). LAR, gag, PRLS, and perceptual strength significantly increased as a more medial laryngeal subsite was stimulated and as stimulus force increased. Each of the ten years of age increase was associated with 19% reduction in odds of LAR (aOR = 0.81, 95% CI [0.68, 0.97]; p = 0.022). Male gender was associated with a 55% reduction in odds of LAR (aOR = 0.45, 95% CI [0.23, 0.89]; p = 0.022). CONCLUSION: LAR elicitation capability decreases in the male gender, aging, and a more lateral subsite. This study provides insight into the pathophysiology of hypo- and hyper-sensitive laryngeal disorders and is paramount to making accurate diagnostic assessments and finding novel treatment options for various laryngological disorders. Laryngoscope, 133:2525-2532, 2023.

Abnormal Laryngopharyngeal Sensation in Adductor Laryngeal Dystonia Compared to Healthy Controls.

BACKGROUND/OBJECTIVES: Laryngeal sensory abnormality has been implicated as a component of adductor laryngeal dystonia (AdLD). The study objective was to assess laryngopharyngeal sensation in AdLD utilizing a calibrated, tactile aesthesiometer to deliver differential stimuli to lateral pyriform sinus (LPS), aryepiglottic fold (AEF), and false vocal fold (FVF). METHODS: Patients with known Botox-responsive AdLD underwent sensory testing using a previously-validated methodology involving calibrated tactile stimuli (6-0, 5-0, 4.5-0, 4-0 nylon monofilaments). Laryngeal adductor reflex (LAR) and participant-rated perceptual strength of stimulI were evaluated. Responses were compared to normative controls (n = 33). Two-samples, Mann-Whitney and Fisher exact tests compared mean strength ratings and LAR between AdLD and control groups. Mixed-effects logistic regression and linear models assessed association of filament size, stimulus site, age, sex, and LD status on LAR and perceptual strength rating respectively. RESULTS: Thirteen AdLD patients (nine women, mean age 60+/-15 years) completed testing. Average LAR response rates were higher amongst all filament sizes in AdLD versus controls at LPS (56.3% vs. 35.7%) and AEF (96.1% vs. 70.2%) with comparable rates at FVF (90.2% vs. 91.7%). AdLD had 3.3 times the odds of observed LAR compared to controls (p = 0.005), but differences in subjective detection of stimuli, perceptual strength ratings, and cough/gag rates were insignificant on multivariate modeling (p > 0.05). CONCLUSIONS: This is the first study to objectively assess laryngopharyngeal sensation in AdLD. Findings demonstrated increased laryngopharyngeal sensation in AdLD compared to controls. The identification of increased laryngeal hypersensitivity in these patients may improve understanding of AdLD pathophysiology and identify future targets for intervention. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:2271-2278, 2023.

Surgical wound classification in otolaryngology: A state-of-the-art review.

Objective: To describe the issues related to the assignment of surgical wound classification as it pertains to Otolaryngology-Head & Neck surgery, and to present a simple framework by which providers can assign wound classification. Data Sources: Literature review. Conclusion: Surgical wound classification in its current state is limited in its utility. It has recently been disregarded by major risk assessment models, likely due to inaccurate and inconsistent reporting by providers and operative staff. However, if data accuracy is improved, this metric may be useful to inform the risk of surgical site infection. In an era of quality-driven care and reimbursement, surgical wound classification may become an equally important indicator of quality.

Exuberant Intratracheal Granuloma.

BACKGROUND: Upper airway granulomas are commonly encountered benign masses and are a result of pronounced tissue reactivity to localized respiratory mucosal trauma. The mechanism of injury to respiratory epithelium is most commonly iatrogenic and associated with intubation or indwelling tracheostomy. Case Report. A 40-year-old obese female with a history of multiple intubations, poorly controlled diabetes mellitus type II, and history of tracheal stenosis presented with sudden onset respiratory distress requiring intubation at an outside hospital. Direct laryngoscopy revealed a rapidly forming transglottic tissue mass, measuring 5.0 × 2.2 × 0.8 cm. The following case represents an unusual exception to our experience with granulomas given its rapidity of onset and migration of tissue around the endotracheal tube. Discussion. Laryngeal erythema and granulation formation are expected postintubation findings in most patients; however, the large size of granuloma tissue and rapid onset of symptoms in this case make it remarkable. Our patient had multiple risk factors for postintubation stenosis: female sex, poorly controlled diabetes, hypertension, obesity, and multiple prior intubations for periods lasting longer than forty-eight hours. CONCLUSION: Our case highlights a rare laryngeal finding of a large granulation tissue mass causing sudden onset airway obstruction.

High-density surface electromyography: A visualization method of laryngeal muscle activity.

OBJECTIVES/HYPOTHESIS: Laryngeal muscle activation is a complex and dynamic process. Current evaluation methods include needle and surface electromyography (sEMG). Limitations of needle electromyography include patient discomfort, interpretive complexity, and limited duration of recording. sEMG demonstrates interpretive challenges given loss of spatial selectivity. Application of high-density sEMG (HD sEMG) arrays were evaluated for potential to compensate for spatial selectivity loss while retaining benefits of noninvasive monitoring. STUDY DESIGN: Basic science. METHODS: Ten adults performed phonatory tasks while a 20-channel array recorded spatiotemporal data of the anterior neck. Data were processed to provide average spectral power of each electrode. Comparison was made between rest, low-, and high-pitch phonation. Two-dimensional (2D) spectral energy maps were created to evaluate use in gross identification of muscle location. RESULTS: Three phonatory tasks yielded spectral power measures across the HD sEMG array. Each electrode within the array demonstrated unique power values across all subjects (P < .001). Comparison of each electrode to itself across phonatory tasks yielded differences in all subjects during rest versus low versus high, rest versus low, and rest versus high and in 9/10 subjects (P < .001) for low versus high phonation. Symmetry of HD sEMG signal was noted. Review of 2D coronal energy maps allowed for gross identification of cricothyroid muscle amidst anterior strap musculature. CONCLUSIONS: HD sEMG can be used to identify differences in anterior neck muscle activity between rest, low-, and high-pitch phonation. HD sEMG of the anterior neck holds potential to enhance diagnostic and therapeutic monitoring for pathologies of laryngeal function. LEVEL OF EVIDENCE: NA Laryngoscope, 129:2347-2353, 2019.

Incidence and predictive factors for additional opioid prescription after endoscopic sinus surgery.

BACKGROUND: Excessive postoperative opioid prescription is a source of prescription diversion in the United States opioid crisis and may contribute to chronic opioid use. Efficient prescription by the surgeon can mitigate opioid abuse and improve postoperative pain control. In this study we sought to better characterize the incidence and predictive baseline characteristics associated with the need for additional opioid prescription after endoscopic sinus surgery (ESS) for chronic rhinosinusitis. METHODS: A retrospective review was performed on subjects undergoing ambulatory ESS between November 2016 and August 2017. The medical and Controlled Substance Utilization Review and Evaluation System (CURES) records were reviewed. Uni- and multivariable logistic regressions were performed to evaluate factors associated with additional opioid prescription within 60 days of surgery. RESULTS: A total of 121 patients were included. Additional prescriptions were seen in 22 patients (18%). Surgical factors, including sinuses operated, septoplasty, revision, or extended procedure (Draf IIB/III), were not associated with additional prescription. On multivariate logistic regression, preoperative opioid use (odds ratio [OR], 23.45; 95% CI, 1.52-362.63), greater number of prescribed tablets (OR, 1.13; 95% CI, 1.01-1.26), and lower preoperative health status (ASA score) (OR, 11.21; 95% CI, 1.49-84.30) were associated with additional prescription (p < 0.05). CONCLUSION: A need for extension of postoperative opioid pain control is not uncommon after ESS. Patient baseline clinical characteristics are predictive of a need for re-prescription of opioids. Surgical extent is not associated with need for prolonged postoperative opioid pain management.

Predictive value of SNOT-22 on additional opiate prescriptions after endoscopic sinus surgery.

BACKGROUND: Endoscopic sinus surgery (ESS) is generally well tolerated, yet a subset of patients require an additional opiate prescription in the postoperative period. The purpose of this study was to quantify differences in both preoperative and immediate postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores between patients with a single prescription and those requiring additional opiate prescriptions (AOPs). METHODS: Patients undergoing ESS between November 2016 and August 2017 were reviewed retrospectively. The Medical and Controlled Substance Utilization Review and Evaluation System (CURES) records were reviewed; patients requiring AOP within 60 days after surgery were identified. The primary and secondary outcomes of interest were the association of baseline and first postoperative visit SNOT-22 total and domain scores with AOP. RESULTS: A total of 121 patients were reviewed, 22 (18.2%) required AOP. Baseline SNOT-22 scores were higher in aggregate (58.7 ± 16.0 vs 46.1 ± 22.5) and ear/facial domain (11.4 ± 4.8 vs 8.5 ± 5.4) in the AOP group (p < 0.01). AOP patients also demonstrated higher scores across all SNOT-22 domains (p < 0.001) at the immediate preoperative visit. There was no difference in the absolute improvement between groups (15.5 ± 18.30 vs 12.3 ± 23.9, p = 0.54). AOP patients experienced less relative improvement (20.2% vs 34.8%, p < 0.05) and smaller mean effect size (0.57 vs 0.70, p < 0.001) after ESS. CONCLUSION: Patients reporting increased ear and facial symptoms at baseline have an increased risk of additional opiate prescription after surgery; preoperative SNOT-22 scores may provide utility in identifying these patients. Subjects in both cohorts report symptomatic improvement after ESS; however, relative, not absolute, improvement in SNOT-22 scores is more predictive of AOP.