Endoscope-assisted approach to excision of branchial cleft cysts.

OBJECTIVES/HYPOTHESIS: The purpose of this study is to describe an endoscope-assisted surgical technique for the excision of branchial cleft cysts and compare it to the standard approach. STUDY DESIGN: Retrospective case series review. METHODS: Twenty-seven cases described as branchial cleft excisions performed by a single surgeon at one academic medical center were identified between 2007 and 2014. Twenty-five cases (8 endoscopic, 17 standard approach) were included in the study. Cases were excluded if final pathology was malignant. Patient charts were reviewed, and two techniques were compared through analysis of incision size, operative time, and surgical outcomes. RESULTS: This study showed that the length of incision required for the endoscopic approach (mean = 2.13 ± 0.23) was significantly less than that of the standard approach (mean = 4.10 ± 1.46, P = 0.008) despite the fact that there was no significant difference in cyst size between the two groups (P = 0.09). The other variables examined, including operative time and surgical outcomes, were not significantly different between the two groups. CONCLUSION: This transcervical endoscope-assisted approach to branchial cleft cyst excision is a viable option for uncomplicated cases. It provides better cosmetic results than the standard approach and does not negatively affect outcomes, increase operative time, or result in recurrence. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1339-1342, 2016.

Management of airway compromise following thyroid cyst hemorrhage after thrombolytic therapy.

The risk of hemorrhage after therapeutic administration of tissue plasminogen activator (tPA) is well known. Cases of postadministration hemorrhage have been reported within many organ systems. We present a case of a 62-year-old female with undiagnosed thyroid goiter who received tPA for acute ischemic stroke and developed acute airway compromise. The surgical airway response team was called due to inability to ventilate or intubate. An incision into the mass during attempted tracheotomy released colloid and blood, decompressing the airway and facilitating ventilation and intubation. Hemithyroidectomy for mass removal was delayed for 3 days to allow normalization of post-tPA coagulopathy.

Smad3: an emerging target for vocal fold fibrosis.

OBJECTIVES/HYPOTHESIS: To determine the efficacy of small interfering RNA (siRNA) targeting Smad3 to mediate fibroplasia in vitro, to investigate the temporal regulation of Smad3 following vocal fold (VF) injury, and to determine the local and distal effects of Smad3 siRNA VF injection. STUDY DESIGN: In vitro and in vivo. METHODS: In vitro, Smad3 regulation was examined at both the level of transcription and translation in a human VF cell line in response to Smad3 siRNA ± transforming growth factor ß (TGF-ß). Collagen transcription was also examined. In vivo, Smad3 messenger RNA (mRNA) expression was quantified as a function of time following rabbit VF injury. Also, the effects of injected Smad3 siRNA were assessed at local and distal sites. RESULTS: Smad3 siRNA knocked down Smad3 transcription and translation and limited TGF-ß-mediated collagen mRNA expression with minimal cytotoxicity in vitro. In vivo, Smad3 mRNA increased 1 day following VF injury and remained elevated through day 7. Smad3 siRNA injection into the uninjured vocal fold had no local or distant effect on Smad3 mRNA at multiple organ sites. CONCLUSIONS: These data provide a foundation for further investigation regarding the development of novel RNA-based therapeutics for the VF, specifically locally delivered siRNA for challenging fibrotic conditions of the VF.

Hoarseness and laryngopharyngeal reflux: a survey of primary care physician practice patterns.

IMPORTANCE: Current approaches to the diagnosis and subsequent management of specific voice disorders vary widely among primary care physicians (PCPs). In addition, sparse literature describes current primary care practice patterns concerning empirical treatment for vocal disorders. OBJECTIVE: To examine how PCPs manage patients with dysphonia, especially with regard to laryngopharyngeal reflux. DESIGN, SETTING, AND PARTICIPANTS: Prospective, questionnaire-based study by an academic laryngology practice among academic PCPs from all major US geographic regions. MAIN OUTCOMES AND MEASURES: A 16-question web-based survey, distributed via e-mail, concerning management and possible empirical treatment options for patients with dysphonia. RESULTS: Of 2441 physicians who received the e-mail broadcast, 314 (12.9%) completed the survey. Among those who completed the survey, 46.3% were family practitioners, 46.5% were trained in internal medicine, and 7.2% identified as specialists. Among all respondents, 64.0% preferred to treat rather than immediately refer a patient with chronic hoarseness (symptoms persisting for >6 weeks) of unclear origin. Reflux medication (85.8%) and antihistamines (54.2%) were the most commonly selected choices for empirical treatment. Most physician respondents (79.2%) reported that they would treat chronic hoarseness with reflux medication in a patient without evidence of gastroesophageal reflux disease. CONCLUSIONS AND RELEVANCE: Most PCPs who responded to our survey report empirically treating patients with chronic hoarseness of unknown origin. Many physician respondents were willing to empirically prescribe reflux medication as primary therapy, even when symptoms of gastroesophageal reflux disease were not present. These data suggest that PCPs strongly consider reflux a common cause of dysphonia and may empirically treat patients having dysphonia with reflux medication before referral.

Glucocorticoids for vocal fold disease: a survey of otolaryngologists.

OBJECTIVE/HYPOTHESIS: Glucocorticoids (GCs) are commonly used in the treatment of laryngeal disorders despite the absence of clear guidelines regarding their use. We sought to assess clinical practice patterns regarding GC use for various vocal fold diseases and to ascertain factors underlying the selection of particular GCs for different vocal fold pathology. STUDY DESIGN: Prospective, survey. METHODS: A web-based 20-question survey querying clinical indications for GC use and other factors influencing decision making in GC administration was distributed to 5280 otolaryngologists via e-mail using a commercially available database. RESULTS: The overall response rate for the survey was 4% (212/5280). Of the respondents, 99% reported GCs to be valuable in their practice. Previous experience/results, familiarity, and use in practice (68%, 54%, and 37%, respectively) were the most commonly cited reasons for choosing a particular GC; pharmacokinetic profile and academic literature were infrequently cited reasons. Fifty-four percent of respondents were more likely to prescribe GCs for vocal performers compared with other patients. Additionally, most respondents stated that the potential for side effects only occasionally prevented GC utilization. CONCLUSIONS: GC prescription practices vary greatly among otolaryngologists. Drug choice appears to be driven primarily by clinician preference and personal experience rather than by specific pharmacologic or physiologic rationale. These findings likely reflect the current lack of well-constructed studies in the laryngology literature to guide GC selection and administration for benign disorders of the larynx and highlight an important potential area for future studies.

An algorithm approach to diagnosing bilateral parotid enlargement.

OBJECTIVE: This contemporary review aims to categorize the disease entities that cause bilateral parotid enlargement and to develop a question-based algorithm to improve diagnosis of bilateral parotid masses. DATA SOURCES: A PubMed search for bilateral and parotid showed 818 results. Of these, 68 relevant studies were reviewed to compile a list of disease processes that can cause bilateral parotid enlargement. REVIEW METHODS: A total of 22 diseases entities were reviewed. The disease processes were initially grouped into 6 categories based on etiology: sialadenosis, infection, neoplasm, autoimmune, iatrogenic, and miscellaneous. For each lesion, the incidence, history, and physical examination were compiled in a matrix. CONCLUSION: After reviewing the matrix, it was clear that grouping diseases based on specific history and physical findings limits the differential diagnosis. The most important factors included disease incidence, timing of onset, nodular or diffuse, pain, and overlying skin changes. With this algorithm, the differential diagnosis can be limited from 28 to 7 or fewer likely diagnoses for a given presentation. Implications for Practice Bilateral parotid disease has a wide differential diagnosis with an expanding number of available tests. An algorithm, based solely on data obtained from the history and physical examination in the first patient encounter, may reduce the differential and aid the clinician in deciding on further workup and treatment. Following the algorithm presented here should allow the clinician to arrive at a diagnosis rapidly without ordering unnecessary tests and wasting resources.

Diagnostic accuracy of history, laryngoscopy, and stroboscopy.

OBJECTIVES/HYPOTHESIS: Although clinical dogma suggests the value of laryngeal visualization (flexible laryngoscopy and stroboscopy) in dysphonic patients, recently published clinical guidelines suggest that, in many cases, history and/or physical examination are sufficient to guide clinical decision-making regarding the timing of such examinations. We sought to prospectively quantify the diagnostic accuracy of history, laryngoscopy, and stroboscopy using direct laryngoscopy as the gold standard. STUDY DESIGN: Expert survey. METHODS: Six laryngologists were presented with vignettes including history and physical examination (HPE), laryngosocpy, and stroboscopy. Questions regarding diagnosis, the certainty of diagnosis, and subsequent management plans were posed. Operative findings via direct laryngoscopy were employed as a comparator. RESULTS: The diagnostic accuracy of HPE was quite low (5%). The accuracy of diagnosis increased substantially following laryngeal imaging; 68.3% for both flexible laryngoscopy and stroboscopy. Particular diagnoses were more consistently identified; cancer, for example, was much more accurately identified on laryngoscopy (100%) and stroboscopy (100%) rather than HPE alone (33%). Cancer was selected as the diagnosis in 10 of 60 HPEs, though was only correct once and missed in five cases. In contrast, no diagnoses of cancer were missed following laryngoscopic and/or stroboscopic examinations. CONCLUSION: These findings confirm the value of laryngeal visualization (flexible laryngoscopy and stroboscopy) in dysphonic patients, and the lack of accuracy of history and physical examination in determining the diagnosis in patients with hoarseness.

Morbidity and patient perception of flexible laryngoscopy.

OBJECTIVES: The recently published Clinical Practice Guideline: Hoarseness (Dysphonia) revealed major deficits in the literature regarding relatively routine clinical decision-making. One of the more controversial points in the Guideline regarded the utility and timing of laryngeal visualization via flexible laryngoscopy, potentially because of sparse literature regarding the risks and potential morbidity. We sought to prospectively address this issue in order to optimize evaluation protocols. METHODS: Two-hundred fifty consecutive patients with a variety of complaints completed a survey after undergoing flexible laryngoscopy. The survey queried 1) demographics; 2) discomfort of pretreatment anesthesia and scope placement in the nose and pharynx; 3) fear of future examinations; and 4) patient perception and past experience. Concurrently, the laryngoscopist reported the complications and anatomic variations encountered. RESULTS: The discomfort and pain ratings from both the anesthetic spray and the scope placement were low. No statistically significant differences were observed with regard to sex; however, women reported greater fear associated with examinations (p = 0.0001). Anatomic abnormalities were observed in 14.4% of patients, and these patients reported greater discomfort, pain, and fear regarding the examination. No adverse events were observed. CONCLUSIONS: Flexible laryngoscopy was well tolerated, with little to no risk. The presence of nasal anatomic abnormalities predicted increased discomfort.

Diagnosis and management of new-onset hoarseness: a survey of the American Broncho-Esophagological Association.

OBJECTIVES: The recently published Clinical Practice Guideline raised issues related to the value and timing of laryngoscopy in patients with hoarseness. We sought to determine the extent to which these guidelines concur with clinical practice among members of the American Broncho-Esophagological Association (ABEA). METHODS: A web-based survey was distributed to ABEA members, composed of four sections: 1) background and demographics; 2) information regarding the appropriate length of time that new-onset dysphonia may be managed before laryngeal visualization, given particular comorbidities; 3) the frequency and risks of office-based flexible transnasal laryngoscopy; and 4) the overall value of laryngoscopy and stroboscopy. RESULTS: Seventy-one ABEA members completed the survey; they had a combined 1,468 years of post-residency experience. Approximately 75% of respondents were involved in a fully academic practice. Across all respondents, an average of 11 patients with new voice complaints were seen per week. Overall, 98.6% of respondents believe that laryngoscopy is very valuable. Stridor in a neonate and potential foreign bodies were both conditions necessitating laryngoscopy on the day of presentation. In patients with no serious underlying condition(s), the mean duration until laryngoscopy was 12.96 days (range, 0 to 30 days). CONCLUSIONS: These data suggest that the current practice patterns among experts in the field are divergent from the recently published Guideline.

Abdominal wall reconstruction: lessons learned from 200 "components separation" procedures.

OBJECTIVES: To determine the efficacy and describe the evolution of the "components separation" technique for abdominal wall repair in 200 consecutive patients. DESIGN: Retrospective medical record review. SETTING: Northwestern Memorial Hospital, Chicago, Illinois. PATIENTS: Two hundred consecutive patients who underwent ventral hernia repair using the components separation technique. INTERVENTIONS: Biological and permanent meshes were used in select patients to augment the repair of the midline fascial closure but were not used as "bridging" materials. MAIN OUTCOME MEASURES: Hernia recurrence rates and major and minor complication rates for the overall series and for the different techniques. RESULTS: Primary components separation (n = 158) yielded a 22.8% recurrence rate. Closure of the midline tissues with augmentation of the repair using an acellular cadaveric dermis underlay (n = 18) had a 33.3% recurrence rate requiring a second operation, whereas intra-abdominal soft polypropylene mesh (n = 18) had 0% recurrence (P = .04). Elevated body mass index was a significant risk factor predicting hernia recurrence (P = .003). Contamination (P = .04) and enterocutaneous fistula (P = .02) at the time of surgery were associated with increased major complications, whereas body mass index (P = .01) and diabetes mellitus (P = .04) were associated with increased minor complications. CONCLUSIONS: Large complex hernias can be reliably repaired using the components separation technique despite the presence of open wounds, the need for bowel surgery, and numerous comorbidities. The long-term strength of the hernia repair is not augmented by acellular cadaveric dermis but seems to be improved with soft polypropylene mesh.

Soft polypropylene mesh, but not cadaveric dermis, significantly improves outcomes in midline hernia repairs using the components separation technique.

BACKGROUND: The search continues for the "ideal" repair of the midline ventral hernia, and the components separation technique has a low, but still concerning, hernia recurrence rate. The authors hypothesize that adding prosthetic or bioprosthetic meshes to the midline closure during components separation would reduce recurrence rates with minimal added morbidity. METHODS: Over a 3-year period, patients had a components separation procedure where either acellular cadaveric dermis (n = 26) or soft polypropylene mesh (n = 28) was used as an intraperitoneal underlay for reinforcement of the midline repair, but not as a "bridging material." In 36 operations, the mesh or cadaveric dermis was placed at the time of the components separation, and in the remaining cases (n = 18), the underlay was used to treat a recurrence after components separation. RESULTS: Cadaveric dermis was associated with a 46 percent "true" recurrence rate that required reoperation (mean follow-up, 17.3 months), whereas soft polypropylene mesh had a significantly lower recurrence rate of 11 percent (p = 0.0057) during a follow-up period of 16 months. Because of a higher incidence of concomitant bowel surgery and contamination in the cadaveric dermis group, additional subset analysis of uncontaminated cases was performed, demonstrating a 61 percent recurrence rate for cadaveric dermis compared with 12 percent for soft polypropylene (p = 0.0017). No significant differences in major and minor complications were seen between groups. CONCLUSION: Soft polypropylene mesh, but not acellular dermis, demonstrates acceptably low complication and hernia recurrence rates when used as a reinforcement of the midline ventral hernia closure in conjunction with components separation.