Techniques in Otolaryngology: Ultrasound-Guided Transcervical Fine-Needle Aspiration of Laryngeal Masses.

Traditionally, laryngeal masses are diagnosed with direct laryngoscopy with biopsy under general anesthesia. The use of transcervical ultrasound-guided fine-needle aspiration for the diagnosis of base of tongue lesions, thyroid nodules, and cervical lymph node metastases has been well documented, and its use in the diagnosis of laryngeal masses has increased in recent years. We report a technique for office-based transcervical ultrasound-guided fine-needle aspiration for laryngeal masses without cervical metastasis (N0), with outcomes from 6 patients. Benefits of this approach included limited side effects, rapid in-office diagnosis, avoidance of aerosolizing procedures during the COVID-19 pandemic, and avoidance of tracheostomy.

Opioid prescribing practices for pediatric tonsillectomy before and after policy interventions.

Objective: This study's purpose was to investigate opioid prescribing practices after pediatric tonsillectomy in the year before and year after implementation of statewide policy interventions in Vermont. Methods: We reviewed charts of consecutive patients less than 18 years old that underwent tonsillectomy or adenotonsillectomy at a single tertiary academic medical center 1 year before (July 2016-June 2017) and 1 year after (July 2017-June 2018) implementation of policy interventions targeted at opioid prescribing. Data collected included demographics, procedure performed, indication, complications, medical comorbidities, opioid prescribing practices (medication, dose, morphine milliequivalents, and postdischarge opioid prescriptions), and postoperative telephone calls and emergency department (ED) visits. Results: Tonsillectomy or adenotonsillectomy was performed in 360 consecutive patients (185 in the pre-policy year and 175 in the post-policy year). Those receiving an opioid prescription in the pre- compared to post-policy year was 49.7% versus 15.4% (p < .001). Of patients 6 years and older, 95.8% in the pre-policy year compared to 25.2% in the post-policy year received a postoperative opioid (p < .001). There was no difference in pain-related office phone calls, postdischarge opioid prescriptions or ED visits between the two groups. There was no difference in morphine milligram equivalent prescribed in the pre- and post-groups. Conclusion: Implementation of statewide policy interventions can have a substantial impact on opioid prescribing practices in the pediatric tonsillectomy population without an increase in office phone calls, postdischarge opioid prescriptions, and ED visits. Level of Evidence: 4.

Stridor Related to Vagus Nerve Stimulator: A Case Report.

Implantation of a vagus nerve stimulator (VNS) can be an effective treatment for medically refractory seizures. Laryngeal side effects from a VNS can include hoarseness, cough, and shortness of breath. This report highlights a 5-year-old female who presented with stridor in the setting of acquired laryngomalacia, global developmental delay, and a VNS device. The case demonstrates that a VNS can exacerbate the symptoms of acquired laryngomalacia and that close monitoring of laryngeal side effects is crucial to optimizing care in this population. Laryngoscope, 131:E1733-E1734, 2021.

Update on current evaluation and management of pediatric nasal dermoid.

OBJECTIVES/HYPOTHESIS: To review the presentation of congenital pediatric nasal dermoid and present guidelines for its evaluation and management. STUDY DESIGN: Retrospective chart review from 1970 to 2014 at a tertiary referral children's hospital. METHODS: The medical records of all patients diagnosed with a nasal dermoid during the study period were reviewed for demographics, lesion characteristics, imaging, operative details, and outcomes. RESULTS: Ninety-six patients underwent excision of a congenital nasal dermoid during the study period. The mean age at presentation was 3.1 years (range, 0.1-19.3 years). Thirty-four (35%) females and 62 (65%) males were included. The most common presentation was a nasal dorsal mass in 66 (69%) patients. Ninety-two (96%) of the patients underwent preoperative imaging. Seventy-eight (82%) of the patients did not show any clinical or radiographic evidence of intracranial extension preoperatively. Eighty-five (89%) of the patients underwent extracranial excision, and 11 (11%) underwent combined intracranial and extracranial excision. Eight patients (8%) presented with recurrence, on average 3.3 years (range, 1-6 years) after initial excision. Mean follow-up time was 8 years (range, 1-18 years). CONCLUSION: Preoperative imaging of nasal dermoid is crucial to evaluate for intracranial extension, thus facilitating complete removal. Thin section, high-resolution magnetic resonance with contrast provides excellent detail of the extent of the nasal dermoid including intracranial extension. Thin-section high-resolution computed tomography with multiplanar reformatted images provides complimentary information regarding the bone anatomy of the frontonasal region. Surgical strategy is dictated by preoperative imaging and is dependent on the extent of the lesion, but limited facial incisions are preferred. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2151-2160, 2016.

Modulation of bladder function by luminal adenosine turnover and A1 receptor activation.

The bladder uroepithelium transmits information to the underlying nervous and musculature systems, is under constant cyclical strain, expresses all four adenosine receptors (A(1), A(2A), A(2B), and A(3)), and is a site of adenosine production. Although adenosine has a well-described protective effect in several organs, there is a lack of information about adenosine turnover in the uroepithelium or whether altering luminal adenosine concentrations impacts bladder function or overactivity. We observed that the concentration of extracellular adenosine at the mucosal surface of the uroepithelium was regulated by ecto-adenosine deaminase and by equilibrative nucleoside transporters, whereas adenosine kinase and equilibrative nucleoside transporters modulated serosal levels. We further observed that enriching endogenous adenosine by blocking its routes of metabolism or direct activation of mucosal A(1) receptors with 2-chloro-N(6)-cyclopentyladenosine (CCPA), a selective agonist, stimulated bladder activity by lowering the threshold pressure for voiding. Finally, CCPA did not quell bladder hyperactivity in animals with acute cyclophosphamide-induced cystitis but instead exacerbated their irritated bladder phenotype. In conclusion, we find that adenosine levels at both surfaces of the uroepithelium are modulated by turnover, that blocking these pathways or stimulating A(1) receptors directly at the luminal surface promotes bladder contractions, and that adenosine further stimulates voiding in animals with cyclophosphamide-induced cystitis.

Dysphagia after endoscopic repair of Zenker's diverticulum.

OBJECTIVES/HYPOTHESIS: To determine whether patient outcomes after endoscopic staple-assisted diverticulectomy(ESD) were correlated with demographic or disease-specific patient characteristics. STUDY DESIGN: Retrospective chart review with followup. METHODS: A survey was sent to all eligible subjects who had undergone ESD from February 1995 to June 2004 to gather information about their postoperative weight, diet, dysphagia symptoms, distress, and overall satisfaction. RESULTS: Thirty-five individuals responded(49% response rate) at a mean of 29 (range,3-83) months postoperative. There was a significant reduction in the following symptoms: food avoidance,regurgitation, dysphagia for pills, choking, coughing,difficulty finishing a meal, heartburn/reflux, and halitosis. There was no significant difference for dysphonia.Swallow-related distress had decreased from a preoperative level of 7.86 to 2.23 at follow-up (P <.001). Overall satisfaction with the surgery was high. There were no significant differences in outcome by any demographic characteristic, duration of preoperative symptoms, presence of gastroesophageal reflux disease, Zenker's diverticulum size, time since surgery,or number of surgeries. Ninety-one percent of subjects reported improvement in their swallowing after surgery, but 22% reported some decline since that time. Symptomatic subjects reported significantly higher swallow-related distress and lower satisfaction(P < .01). Preoperative variables were not correlated with a return of symptoms. Individuals who underwent multiple procedures had similar levels of benefit and satisfaction as those who underwent a single ESD procedure. CONCLUSION: ESD results in high levels of patient satisfaction, significant reduction in postoperative symptoms, low levels of complications,and the opportunity to safely and successfully repeat the procedure if necessary.

Modern management of laryngotracheal stenosis.

OBJECTIVES: Laryngotracheal stenosis is a complex problem resulting most often from intubation, trauma,or autoimmune disease. Management options include dilation or airway reconstruction including laryngotracheoplasty (LTP), cricotracheal resection (CTR), and tracheal resection (TR). We describe our experience with management of this difficult problem. STUDY DESIGN: Retrospective chart review of patients treated for laryngotracheal stenosis between January 1995 and July 2005 at an academic, tertiary referral center. METHODS: A total of 127 patients were treated during the study period. Patients were followed, and hospital records were reviewed. RESULTS: There were 38 male and 89 female patients with an average age of 55.5 years treated for laryngotracheal stenosis resulting from intubation (64), idiopathic (25) or autoimmune disease (18), radiation (9), trauma (5), prior surgery (4), and relapsing polychondritis (2). Thirty-three percent were treated for grade I stenosis, 44% grade II, 19% grade III, and 4% grade IV. Seventy percent of patients undergoing initial dilation required a subsequent procedure. LTP, CTR, or TR was performed in 43%, 48%, 71%, and 100% of patients with grade I through IV stenosis, respectively. Among 76 patients undergoing LTP, CTR, or TR, 24 (32%) required a subsequent intervention. Among 36 patients treated with primary LTP, CTR, or TR, only 10 (28%) required further therapy. Twenty-two of 35 (63%) tracheostomy-dependent patients were ultimately decannulated. Three patients died in the immediate postoperative period. CONCLUSIONS: Patients undergoing dilation for laryngotracheal stenosis require multiple procedures. However, major reconstructive procedures are well tolerated and currently represent a viable primary treatment for laryngotracheal stenosis.

Mouse models for human head and neck squamous cell carcinomas.

Mouse models of human cancer play an important role in understanding the mechanisms of carcinogenesis and have accelerated the search for finding new molecular targets for cancer therapy. However, genetically engineered mouse models for head and neck squamous cell carcinoma (HNSCC) have only recently overcome major technical obstacles and begun to be explored. Here we review the current progress in the development of mouse models for human HNSCC, with emphasis on conditional transgenic and knockout mouse models. These new models faithfully recapitulate human HNSCC at both the pathologic and molecular levels. These animal models will not only be useful to define the roles of specific genes in HNSCC development and progression but will also provide a unique tool for developing and testing new therapeutic approaches.

Loss of transforming growth factor-beta type II receptor promotes metastatic head-and-neck squamous cell carcinoma.

The prognosis of head-and-neck squamous cell carcinoma (HNSCC) has not been improved in the past 20 years. Validation of HNSCC biomarkers for targeted therapy has been hindered by a lack of animal models mimicking human HNSCC at both the pathological and molecular levels. Here we report that overexpression of K-ras or H-ras and loss of transforming growth factor-beta type II receptor (TGFbetaRII) are common events in human HNSCC. Activation of either K-ras or H-ras in combination with TGFbetaRII deletion from mouse head-and-neck epithelia caused HNSCC with complete penetrance, some of which progressed to metastases. These tumors displayed pathology indistinguishable from human HNSCCs and exhibited multiple molecular alterations commonly found in human HNSCCs. Additionally, elevated endogenous TGFbeta1 in these lesions contributed to inflammation and angiogenesis. Our data suggest that targeting common oncogenic pathways in tumor epithelia together with blocking the effect of TGFbeta1 on tumor stroma may provide a novel therapeutic strategy for HNSCC.

Interaction of bile salts with gastrointestinal mucins.

The properties of three mucins were examined to identify the structural features responsible for their functional difterences. Bovine submaxillary mucin (BSM), porcine gastric mucin (PGM), and rat intestinal mucin (RIM) were each characterized, and high carbohydrate contents were found for RIM and PGM. The amino acid compositions were typical of mucin glycoproteins, with over half comprising small, neutral amino acids. Thereafter, each mucin was equilibrated with three different series of concentrations of the bile salts sodium taurocholate, sodium taurodeoxycholate, and sodium taurochenodeoxycholate. Following multiple centrifugations, the supernatant and mucin pellet concentrations of the bile salts were measured. The bile salt pellet concentration was plotted as a function of supernatant concentration, and from the slopes, the excluded volumes were calculated as 25, 29-44, and 28 55 mL/g for BSM, RIM, and PGM, respectively. The intercepts were 8-10, 2-3, and 1-3 mM for BSM, RIM, and PGM, respectively, which represents an estimate of the bound concentration of bile salt. Differences among the bile salts were observed in the excluded volume and amount bound, but no trends were evident. The bile salts may interact as aggregates with the hydrophobic areas and carbohydrate side chains of the mucins, providing favorable sites for association. The binding at low concentrations with exclusion at high concentrations is significant for modulating the absorption of lipid aggregates from the intestine. Finally, the differences among the mucins reflect the unique structure function relationship of these gastrointestinal mucins.

Excluded volume effect of rat intestinal mucin on taurocholate/phosphatidylcholine mixed micelles.

The interaction of bile salt/phospholipid mixed micelles with an intestinal mucin has been investigated to provide the foundation for the transport of ingested fat and poorly water-soluble drugs through the intestinal mucous layer. Egg phosphatidylcholine (PC) was equilibrated with sodium taurocholate (TC) to generate several series of solutions, which had different intermicellar concentrations of TC. Within each series, each solution had the same IMC and thereby micelle sizes, but varied with respect to micelle concentration. These solutions were combined with isolated rat intestinal mucin, equilibrated, and then separated by centrifugation. The supernatant and mucin pellet were assayed for PC and TC, and the diffusion coefficient of PC was measured in the supernatant by PFG-SE NMR spectroscopy. For each series, four linear relationships were found; TC supernatant concentration plotted as a function of PC supernatant concentration; TC pellet concentration plotted as a function of PC pellet concentration; TC pellet concentration plotted as a function of TC supernatant concentration; and PC pellet concentration plotted as a function of PC supernatant concentration. Theoretical analysis of these results indicated that mucin excludes from 25 to 80% of the bile salt/phospholipid mixed micelles with greater exclusion observed with larger micelle size. There is preferential association of the taurocholate with intestinal mucin, when present in the mixed micelle region of the phase diagram. The association coupled with exclusion would allow mucin to modulate the concentration of bile salt at the epithelial surface.