The Effect of Laser-Resistant Endotracheal Tube Design on Airflow Dynamics: A Benchtop and Clinical Study.

OBJECTIVE: Compare ventilation pressures of 2 endotracheal tube designs used in laser airway surgery in clinical practice and with a benchtop model to elucidate differences and understand the design elements that impact airflow dynamics. METHODS: Ventilatory and aerodynamic characteristics of the laser resistant stainless-steel endotracheal tube (LRSS-ET) design and the laser resistant aluminum-wrapped silicone endotracheal tube (LRAS-ET) design were compared. Ventilatory parameters were collected for 32 patients undergoing laser-assisted airway surgery through retrospective chart review. An in vitro benchtop simulation measured average resistance and centerline turbulence intensity of both designs at various diameters and physiological frequencies. RESULTS: Baseline patient characteristics did not differ between the 2 groups. Clinically, the median LRAS-ET peak inspiratory pressure (PIP; 21.00 cm H2O) was significantly decreased compared to LRSS-ET PIP (34.67 cm H2O). In benchtop simulation, the average PIP of the LRAS-ET was significantly lower at all sizes and frequencies. The LRSS-ET consistently demonstrated an increased resistance, although no patterns were observed in turbulence intensity data between both designs. CONCLUSION: The benchtop model demonstrated increased resistance in the LRSS-ET compared to the LRAS-ET at all comparable sizes. This finding is supported by retrospective ventilatory pressures during laser airway surgery, which show significantly increased PIPs when comparing identically sized inner diameters. Given the equivocal turbulence intensity data, these differences in resistance and pressures are likely caused by wall roughness and intraluminal presence of tubing, not inlet or outlet geometries. The decreased PIPs of the LRAS-ET should assist in following lung protective ventilator management strategies and reduce risk of pulmonary injury and hemodynamic instability to the patient.

Diagnostic Delay in HPV-Related Oropharyngeal Squamous Cell Carcinoma.

Introduction Human papillomavirus-related (HPV + ) oropharyngeal squamous cell carcinoma (OPSCC) is increasing in incidence and presents diagnostic challenges given its unique clinical presentation. Objective The purpose of the present study is to characterize the impact of the unique clinical presentation of HPV-related OPSCC on delays in diagnosis. Methods Retrospective review of presenting symptoms and clinical characteristics of 284 patients with OPSCC treated from 2002-2014. Delay in diagnosis was defined as the presence of any of the following: multiple non-diagnostic fine needle aspirate (FNA) biopsies; two or more courses of antibiotic therapy; surgery with incorrect preoperative diagnosis; evaluation by an otolaryngologist without further workup; or surgery without definitive postoperative diagnosis. Results p16+ tumors demonstrated a distinct clinical presentation that more commonly involved a neck mass (85.1% versus 57.3% of p16-; p < 0.001) and less frequently included odynophagia (24.6% versus 51.7% of p16-; p < 0.001). Patients who experienced diagnostic delay were more likely to have p16+ tumors (77.7% delayed versus 62.8% not delayed; p = 0.006). p16+ primary tumors were more likely to be undetectable by physical examination of the head and neck including flexible laryngoscopy (19.0% versus 6.7% of p16-; p = 0.007) and more frequently associated with nondiagnostic FNA biopsies of a cervical nodal mass (11.8% versus 3.4% of p16-, p = 0.03). Conclusions Compared with non-HPV related OPSCC, the unique clinical presentation and characteristics of HPV+ OPSCC are associated with an increased incidence of diagnostic delay. Targeted education of appropriate care providers may improve time to diagnosis and treatment.

Voice Improvement After Essential Tremor Treatment via Focused Ultrasound and Deep Brain Stimulation.

OBJECTIVES: The primary objective of this study was to determine whether two neurosurgical procedures, deep brain stimulation (DBS) and focused ultrasound (FUS), to treat essential tremor (ET) of the upper limb also reduce vocal tremor (VT) in patients with comorbid dysphonia. METHODS: Twelve patients with ET and concomitant VT scheduled for neurosurgical intervention (FUS or DBS) or returning for follow-up after DBS implantation were assessed. FUS patients were assessed pre- and post-intervention and DBS patients were assessed with the electrodes turned on and off post-implantation. Three voice recordings of a sustained /a/ were obtained for each participant condition. Percent fundamental frequency variability (FFV) was calculated for each recorded sustained vowel. Additionally, blinded expert perceptual VT rating (VTR) was performed to assess subjective changes in tremors. RESULTS: Of the 12 patients, seven underwent unilateral FUS, and five underwent bilateral DBS. Mean FFV without neurosurgical intervention was 18.3%, SD = 7.8 and with neurosurgical intervention was 6.3%, SD = 3.0 (t (70) =8.7, p < 0.001). Mean FFV decreased in the FUS cohort from 22.0%, SD = 7.1 pre-ablation to 6.7%, SD = 2.4 post-ablation (t (40) = 7.7, p < 0.001). Mean FFV also decreased in the DBS cohort from 15.7%, SD = 7.0 to 6.0%, SD = 3.3 when stimulation was turned on (t (28)=5.7 p < 0.001). In the FUS group, mean VTR decreased from 4.0 to 1.4 post-ablation (Z = 7.8, p < 0.001). In the DBS group, mean VTR decreased from 3.3 to 2.1 with stimulation (Z = 4.1, p < 0.001). CONCLUSION: Neurosurgical interventions for ET (bilateral DBS and unilateral FUS) demonstrate acoustic and perceptual benefits for VT. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:367-373, 2024.

Vocal Fold Polyps: A Scoping Review.

OBJECTIVE: This review aims to summarize the current understanding of vocal fold polyp etiology, pathophysiology, and prognosis, as well as recent developments in management. STUDY DESIGN: Scoping literature review. REVIEW METHODS: OVID Medline, PubMed, Google Scholar, Conference Papers Index, and Cochrane Library were searched for publications within the last 5 years using terms including "vocal," "cord," "fold," and "polyp." All abstracts were screened. Relevant studies pertaining to the etiology, pathophysiology, diagnosis, management, and prognosis of vocal fold polyps (VFPs) were included for review. RESULTS: Eight-hundred and sixty-five citations resulted from database review. Seven-hundred and thirty citations remained after the exclusion of duplicates. One hundred and ninety-three papers underwent abstract review, with 73 citations undergoing full-text review. Fifty-nine papers were included in the review. CONCLUSIONS: VFPs are one of the most common subtypes of benign vocal fold lesions. Phonotrauma contributes significantly to the development of these lesions, with laryngopharyngeal reflux and smoking also contributing. Correct diagnosis relies on a careful history, stroboscopy, response to voice therapy, and, in some cases, intraoperative findings. Phonosurgery is a definitive means of treatment, though more recently, in-office procedures have demonstrated efficacy and are potentially less costly and less invasive treatment options. Treatment modalities can be tailored based on the type and size of the lesion, the patient's vocal needs, medical comorbidities, and initial response to voice therapy. Voice specialists can anticipate greater emphasis placed on minimally invasive office-based procedures for the management of vocal pathology.

Clinical Characteristics of the Cervical Inlet Patch: A Case Series.

Objective: The goal of this study was to characterize the symptoms and outcomes of patients with a symptomatic cervical inlet patch (CIP). Study Design: Retrospective case series. Setting: Tertiary care laryngology clinic in Charlottesville, Virginia. Methods: A retrospective chart review of the patient's demographics, comorbidities, prior workup, interventions, and response to treatment was performed. All patients received flexible nasolaryngoscopy and barium swallow study. The analysis was descriptive. Results: Eight patients (6 female) were followed for the management of symptoms related to CIP. The mean age at presentation to our clinic was 64.9 (standard deviation = 15.7). Five out of 8 patients presented with a chief complaint of dysphagia, and the remaining 3 with chronic coughs. Five out of 8 patients demonstrated findings of laryngopharyngeal reflux (LPR) including vocal fold edema, mucosal erythema, or postcricoid edema. Swallow study demonstrated hiatal hernia in 3 of 8 patients, and cricopharyngeal (CP) dysfunction (CP hypertrophy, CP bar, and Zenker's diverticulum) in 3 of 8 patients. One patient presented with a history of Barrett's esophagus. Treatment included increased acid suppression therapy and management of coexisting esophageal pathologies. Ablative procedures were performed in 5 out of 8 cases, with 2 patients requiring repeat procedures. All patients experience subjective symptom improvement. Conclusion: CIP tends to present in complex patients with multifactorial dysphagia, with the most common symptoms being dysphagia and cough. Clinical features of CIP overlap with other more common pathologies encountered by otolaryngologists including LPR and CP dysfunction, and future prospective studies in larger populations should seek to clarify these associations.

Vocal Fold Thinning in Transgender Patients.

PURPOSE: Transgender individuals strive to match their voice and gender identity. An increased glottal gap is often noted on stroboscopy without a clear etiology. We hypothesize this gap can be quantified and results from hormone replacement therapy impacting laryngeal tissues. METHODS: Videostroboscopy exams were retrospectively collected for transgender patients from a tertiary care laryngology practice over two years. Data included hormone duration/type and voice therapy duration. Modal pitch videostroboscopy frame counts determined the open quotient in consecutive vocal fold cycles. Glottal opening was measured using the widest still frame gap during stroboscopy with fully adducted arytenoids. RESULTS: Sixteen transgender patients, along with male and female controls, were included, with 15 patients on hormone therapy (mean = 18 months). Voice therapy, employed in 9/16 patients, ranged from 0 to 23 months (mean = 10.67). One-way ANOVA testing revealed a difference between the open quotient in transgender individuals, males, and females.Tukey's post hoc test identified transgender patients as different from both male (P <0.001) and female (P = 0.037) controls. Length of hormone therapy did not correlate to glottal area measurement or open quotient. Conversely, voice therapy length correlated to increased glottal area (Kendall's Tau = 0.03). Mean phonation time, VHI-10, and mean pitch did not correlate to measured glottal area on stroboscopy. CONCLUSIONS: The increased glottal gap noted in many transgender patients, quantified via the open quotient, differs from male and female controls. Results suggest these findings may correlate to duration of voice therapy.

Autoimmune Associated Vocal Fold Lesions: A Systematic Review.

OBJECTIVE: While Autoimmune Associated Vocal Fold Lesions (AaVFLs) have been described in many reports, there is no consensus on best practices in management. The purpose of this systematic review is to clarify the characteristics and treatment of dysphonia in the setting of AaVFLs. STUDY DESIGN: Systematic review METHODS: Pubmed and OVIDMedline and Google Scholar were searched, including terms related to (1) Vocal fold/cord, rheumatoid node/nodule, bamboo nodes/nodules, laryngeal deposits/nodes/nodules and (2) Autoimmune diseases/syndromes, connective tissue disease. RESULTS: Twenty-one studies with 83 patients diagnosed with AaVFLs were included. AaVFLs occurred predominantly in females in the 4th or 5th decade of life, with an overall mean age of 39.8 (SD = 12.8). Autoimmune or connective tissue disease was established prior to presentation to an otolaryngologist in 75.9% (44/58) of patients. Bilateral lesions were present in 83.8% (57/68) of patients. Treatment modalities included medical therapy alone (28.1%), voice therapy alone (17.5%), surgical treatment alone (7.0%), combination of medical and voice therapy (33.3%), and combination of surgical, medical and voice therapy (7.0%). All patients treated with voice therapy had voice improvement; lower rates were seen with solo medical (4/14 improved, 28.6%) or surgical therapy (3/6 improved, 50%). CONCLUSION: AaVFLs occur predominantly in women in their 30's to 50's and are associated with a variety of autoimmune conditions. A significant number of patients (25%) present to the Otolaryngologist without an established autoimmune diagnosis. While treatment outcomes are not robustly reported, a significant number of patients with AAVFLs treated with voice therapy alone or voice therapy in combination with other treatment modalities (medical or surgical) experience subjective improvement in voice quality and function.

Malignant Transformation in Glottic Dysplasia Treated With Photoangiolytic LASER - A Systematic Review and Meta-analysis.

OBJECTIVE: This systematic review and meta-analysis seeks to characterize the rate of malignant progression among patients with laryngeal dysplasia treated with photoangiolytic laser and compare to prior systematic reviews of conventional surgical approaches. METHODS: OVIDMedline, Pubmed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar were searched, including terms related to patients with vocal fold dysplasia who were treated by angiolytic laser ablation. Some articles already known to authors or identified through hand searching were included. RESULTS: Six articles with 155 cases were included. Two studies used potassium titanyl phosphate exclusively, one solely used the pulsed dye laser, and three studies utilized both laser types during the study period. The pooled overall mean of malignant progression for patients with laryngeal dysplasia treated with photoangiolytic laser was 12%, as calculated by conducting a meta-analysis of single arm proportion. CONCLUSION: Laryngeal dysplasia is a premalignant lesion which confers a risk of progression to malignancy. After biopsy to establish the diagnosis there are multiple surgical techniques available for treatment with the goal of lesion eradication and voice preservation. In our review, there is a low malignant transformation rate for patients treated via with photoangiolytic laser.

Chronic Laryngotracheal Granulomatous Disease Secondary to Sporothrix schenckii in an Immunocompromised Patient.

OBJECTIVE: To describe a rare presentation of laryngotracheal granulomatous disease secondary to sporotrichosis. METHODS: The authors report a case of laryngeal sporotrichosis in an immunocompromised patient, with accompanying endoscopic images and pathology. RESULTS/CASE: A 72-year-old immunocompromised female with a history of rose-handling presented with a year of hoarseness and breathy voice. Flexible nasolaryngoscopy showed diffuse nodularity; biopsy of the lesions demonstrated granulomatous inflammatory changes, and fungal culture grew Sporothrix schenkii. Long-term itraconazole treatment was initiated, with improvement in dysphonia and few residual granulomas on follow-up examination. CONCLUSION: When evaluating granulomatous disease of the airway, a broad differential including infectious or inflammatory etiologies should be considered, especially in immunocompromised patients. Adequate tissue samples should be collected to facilitate special staining. The current recommendations for laryngeal sporotrichosis include treatment with a prolonged course of itraconazole.

Practice Patterns and Barriers in Botulinum Toxin Injection for the Treatment of Voice Disorders.

Laryngeal botulinum toxin injection is an important treatment modality for spasmodic dysphonia and other laryngeal disorders. We sought to compare usage patterns of laryngeal botulinum toxin injections for voice disorders and to identify and quantify inefficiencies and barriers in providing this treatment. A 26 item survey was written and approved for distribution by the American Academy of Otolaryngology-Head and Neck Surgery and the National Spasmodic Dysphonia Association. It was distributed to Otolaryngologists who perform laryngeal botulinum toxin injections via the e-mail lists of the National Spasmodic Dysphonia Association provider database, American Academy of Otolaryngology-Head and Neck Surgery Voice Committee and the American Laryngological Association Neurolaryngology Study Group. There were 81 survey participants who collectively reported performing >1700 laryngeal botulinum toxin injections for voice disorders monthly (Mean = 21.5 pts/month). Regarding botulinum toxin A (BtxA) vial use, 54% of participants reported using multiple doses per vial for different patients during a single clinic day, while 14% reported using pharmacy predrawn single use aliquots. A combination of usage practices was reported by 7% of participants. Using an individual vial per patient and discarding the unused remainder was reported by 26% of participants with an associated annual cost in wasted BtxA of $84,300 per physician. There is wide variation in injection practices regarding management of BtxA vials and adherence to an individual vial per patient policy is associated with significant waste of health care resources. Alternative approaches to BtxA vial use could positively impact health care resource utilization.

Treatment of Vocal Fold Polyps with In-Office Potassium Titanyl Phosphate (KTP) Laser Ablation in Professional Singers.

Vocal fold polyp (VFP) is an exophytic gelatinous lesion with an atrophic epithelium. After behavioral and conservative management, phonomicrosurgery is the treatment of choice for VFPs with excellent outcomes in terms of lesion resolution and postoperative vocal function. Office-based potassium titanyl phosphate (KTP) laser ablation is a new treatment modality for VFPs but its efficacy for professional singers has yet to be validated. Reported is a consecutive series of six professional singers (with seven episodes of VFP) who, based on patient and provider preference, underwent in-office KTP laser ablation of VFP. Two polyps required two ablation procedures; otherwise, a single treatment was successful in resolution of VFP at a mean resolution time of 44 days. Singing voice handicap index 10 improved from a mean of 30.8 (range 4-40) to 6.0 (range 0-22). All patients resumed their professional singing careers without vocal limitations. Posttreatment videos were reviewed by three blinded fellowship trained laryngologists, who were not able to accurately predict the laterality of the polyp (52% correct, p = 0.99).

Correlation of Glottic Gap and Voice Impairment in Presbyphonia.

OBJECTIVE/HYPOTHESIS: The objective of this study was to investigate the glottic gap area as a significant marker for the severity of presbyphonia as it relates to patient-reported outcome measures (Voice Handicap Index-10 [VHI-10]) and stroboscopic findings. STUDY DESIGN: Retrospective case-control study conducted in an academic tertiary voice center. METHODS: Patients seen at a tertiary voice clinic who were diagnosed with presbyphonia without other organic laryngeal pathology from January 2014 to December 2017 were included. Clinical data and laryngeal videostroboscopy videos were collected. Still images at the point of vocal process approximation during adduction were captured, and the glottic gap area was measured using ImageJ. These were compared to a control cohort. Correlations were made using Wilcoxon rank sum test, Mann-Whitney U test, and Pearson correlation coefficients. RESULTS: Thirty-three patients were included. Inter-rater reliability of glottic area measurement was strong (intraclass correlation coefficient = 0.73, P < .001). Compared to controls, presbyphonia patients had a larger glottic gap area (P < .001) and greater open-phase quotient on laryngeal videostroboscopy (P < .001). Larger glottic gap area did not correlate with patient-reported vocal function as measured by VHI-10 (P = .79) and did not correlate with presence of secondary muscle tension dysphonia (P = .99). In the presbyphonia cohort, the glottic gap area did not correlate with age (P = .29). CONCLUSIONS: Glottic gap area at the point of vocal process approximation during phonation can be reliably measured. Patients with presbyphonia have a larger glottic gap area and greater open-phase quotient on stroboscopy, but these do not correlate with patient-reported voice impairment or the presence of secondary muscle tension dysphonia (MTD). These data suggest that dysphonia severity in presbyphonia is not fully explained by a glottic gap or secondary MTD alone. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1594-1598, 2021.

Voice Change Following Testosterone Supplementation in Women: A Multi-Institutional Case Series.

OBJECTIVES: To describe voice changes as a result of the off-label use of androgen supplementation in women. METHODS: A multi-institutional retrospective consecutive case series identified women taking androgen supplementation who presented to voice clinics at two institutions with a chief complaint of voice change between 2014 and 2019. Age, occupation, hormone therapy, indication, Voice Handicap Index-10, fundamental frequency, semitone pitch range, testosterone blood level, treatment undertaken, and long-term outcome were collected. RESULTS: Nine women presented with voice change after initiation of androgen hormone supplementation. The mean age was 55 and three patients were performers. All patients underwent hormone therapy with testosterone supplementation, most commonly subcutaneous testosterone pellets. Six patients (67%) were being treated for menopause symptoms, one patient for decreased libido, one patient for breast cancer, and one patient who desired additional muscle gain. Time of symptom onset after hormone therapy initiation was highly variable, ranging from 0 to 48 months with a mean of 15 months. Mean Voice Handicap Index-10 was 21, mean fundamental frequency at comfortable speaking level was 155 Hz and mean semitone pitch range was 22 semitones. Two patients had markedly elevated serum total testosterone levels. Hormone therapy discontinuation and voice therapy were recommended in six (67%) patients each. Five patients returned for follow-up after treatment and noted some subjective benefit. CONCLUSIONS: Female patients treated with androgen supplementation may experience unintended voice changes, most prominently reduction in fundamental frequency. Although some benefit may be obtained from voice therapy and cessation of hormone therapy, voice changes may be permanent. Caution should be exercised when prescribing these medications to women.

Antitumor effect of insulin-like growth factor-1 receptor inhibition in head and neck squamous cell carcinoma.

OBJECTIVES: The insulin-like growth factor-1 receptor (IGF1R) has been implicated in therapeutic resistance in head and neck squamous cell carcinoma (HNSCC), and small molecule tyrosine kinase inhibitors (TKIs) of IGF1R activity may have anticancer activity. Therefore, the relationship between survival and IGF1R expression was assessed for oral cavity (OC) cancer, and the antitumor effects of two IGF1R-TKIs, OSI-906 and BMS-754807, were evaluated in HNSCC cell lines in vitro. METHODS: Clinical outcome data and tissue microarray immunohistochemistry were used to generate IGF1R expression-specific survival curves. Immunoblot, alamarBlue proliferation assay, trypan blue exclusion viability test, clonogenic assay, flow cytometry, and reverse phase protein array (RPPA) were used to evaluate in vitro responses to IGF1R-TKIs. RESULTS: For patients with stage III/IV OCSCC, higher IGF1R expression was associated with poorer overall 5-year survival (P = 0.029). Both BMS-754807 and OSI-906 caused dose-dependent inhibition of IGF1R and Akt phosphorylation and inhibited proliferation; BMS-754807 was more potent than OSI-906. Both drugs reduced HNSCC cell viability; only OSI-906 was able to eliminate all viable cells at 10 µM. The two drugs similarly inhibited clonogenic cell survival. At 1 µM, only BMS-754807 caused a fourfold increase in the basal apoptotic rate. RPPA demonstrated broad effects of both drugs on canonical IGF1R signaling pathways and also inhibition of human epidermal growth factor receptor-3 (HER3), Src, paxillin, and ezrin phosphorylation. CONCLUSION: OSI-906 and BMS-754807 inhibit IGF1R activity in HNSCC cell lines with reduction in prosurvival and proliferative signaling and with concomitant antiproliferative and proapoptotic effects. Such antagonists may have utility as adjuvants to existing therapies for HNSCC. LEVEL OF EVIDENCE: NA Laryngoscope, 130:1470-1478, 2020.

Nasopharyngeal angiofibroma in a 32-year-old man.

Nasopharyngeal angiofibroma (NA) is a benign, highly vascularised tumour of the nasopharynx, which typically occurs in young males aged 14-25 years. We report an interesting case of an NA arising de novo in a 32-year-old male. He was referred to our facility for severe nasal haemorrhage after biopsy of a left nasopharyngeal mass. In the operating room, extensive bleeding was noted, and an endoscopic medial maxillectomy was performed, and the left internal maxillary artery was ligated allowing for near total resection of the lesion. The pathological specimen confirmed the diagnosis of NA. To our knowledge, this is one of the oldest patients presenting with a de novo NA, in his fourth decade of life, confirming that this diagnosis must be considered in all those with large nasopharyngeal masses.

Comorbid Dysphagia and Dyspnea in Muscle Tension Dysphonia: A Global Laryngeal Musculoskeletal Problem.

OBJECTIVE: To characterize the associated symptoms of dysphagia and dyspnea among patients presenting with muscle tension dysphonia (MTD). STUDY DESIGN: Retrospective chart review performed over a 14-month period from October 2014 to December 2015. SETTING: Voice and swallowing center of a tertiary academic medical center. SUBJECTS AND METHODS: Thirty-eight patients with MTD were included for analysis. Clinical data were collected and analyzed, including perceptual voice evaluation and patient-reported outcomes measures. RESULTS: Among patients with a diagnosis of MTD, the incidence of reported dysphagia during clinical history and examination was 44.7%. Among patients with MTD, 60.5% had an EAT-10 (10-item Eating Assessment Tool) score ≥3 (ie, abnormal). Patients who reported dysphagia and/or had abnormal EAT-10 score (≥3) had significantly greater voice impairment than that of patients without dysphagia (P = .02). Patients who reported dysphagia also had significantly higher Clinical COPD Questionnaire scores than those of patients who reported only dysphonia (P = .002). CONCLUSIONS: Patients presenting for dysphonia who are diagnosed with MTD have a high rate of comorbid dysphagia. Patients who reported dysphagia had significantly higher self-reported voice impairment and greater severity of breathing dysfunction as measured by the Clinical COPD Questionnaire. The coincidence of these symptoms in this patient cohort may suggest an underlying pathophysiology that has yet to be elucidated. Further prospective studies are needed to clarify the underlying cause of dysphagia and breathing dysfunction in the setting of MTD and to investigate diagnostic and therapeutic paradigms.

Rigid Esophagoscopy for Head and Neck Cancer Staging and the Incidence of Synchronous Esophageal Malignant Neoplasms.

IMPORTANCE: Rigid esophagoscopy (RE) was once an essential part of the evaluation of patients with head and neck squamous cell carcinoma (HNSCC) due to the high likelihood of identifying a synchronous malignant neoplasm in the esophagus. Given recent advances in imaging and endoscopic techniques and changes in the incidence of esophageal cancer, the current role for RE in HNSCC staging is unclear. OBJECTIVE: To analyze the current role of RE in evaluating patients with HNSCC, and to determine the incidence of synchronous esophageal malignant neoplasms in patients with HNSCC. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective study performed at an academic tertiary care center, 582 patients were studied who had undergone RE for HNSCC staging from July 1, 2004, through October 31, 2012. To assess the incidence of synchronous esophageal malignant neoplasms, a literature review was performed, and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) data set was queried. MAIN OUTCOMES AND MEASURES: The primary outcome measure was the incidence of synchronous esophageal malignant neoplasms, as measured by retrospective review at our institution, SEER data set analysis, and literature review. Secondary outcome measures were RE complications and nonmalignant findings during RE. RESULTS: A total of 601 staging REs were performed in 582 patients. The mean age was 60.2 years and 454 (78.0%) were men. There were 9 complications (1.5%), including 1 esophageal perforation (0.2%). Rigid esophagoscopy was aborted in 50 cases. Of the 551 completed REs, no abnormal findings were noted in 523 patients (94.9%), and nonmalignant pathologic findings were identified in 28 patients (5.1%). No synchronous primary esophageal carcinomas were detected. The incidence of synchronous esophageal malignant neoplasms found on screening endoscopy based on literature review and on SEER data set analysis was very low and has decreased from 1980 to 2010 in North America. The incidence reported in South America and Asia was relatively high. CONCLUSIONS AND RELEVANCE: Rigid esophagoscopy is safe, but the utility is low for cancer staging and for detection of nonmalignant esophageal disease. Review of the literature and analysis of a large national cancer data set indicate that the incidence of synchronous esophageal malignant neoplasms in patients with HNSCC is low and has been decreasing during the past 3 decades. Thus, screening esophagoscopy should be limited to patients with HNSCC who are at high risk for synchronous esophageal malignant neoplasms.