The Impact of Hypoglossal Nerve Stimulation on Secondary Health Outcomes.

Objectives: Obstructive sleep apnea (OSA) is a prevalent sleep disorder that can increase the risk of hypertension, diabetes, obesity, and cardiovascular diseases. Hypoglossal nerve stimulation (HGNS) is an alternative therapy for OSA in patients who cannot tolerate continuous positive airway pressure. Understanding the impact of HGNS on blood pressure, hemoglobin A1C (A1C), and body mass index (BMI) currently remains limited. Methods: A retrospective review study of HGNS outcomes at a single practice from January 2020 to November 2022 was conducted. Inclusion/exclusion criteria were based on HGNS eligibility and postoperative titration study. Statistical analysis and data management were performed using statistical software, R (v.4.2.1; R Core Team). Paired Student's T test, Fisher's exact test, and McNemar's exact test were utilized for statistical analysis. P values less than .05 were considered statistically significant. Results: Sixty-three patients were included in this study. A significant decrease in mean apnea-hypopnea index was noted following HGNS (mean change -28; P < .0001). Similar significant decreases were also seen in mean arterial pressures (mean change -8.4, P < .0001). There was a significant change in overall antihypertensive medication requirements and in requirements ≥3 medications (P < .0005, P = .03). There was a trend toward reduction in A1C; however, there was no change in BMI or number of diabetes medications taken. Conclusions: Our results reinforce previous findings that HGNS is an effective treatment option for carefully selected patients with OSA. In addition, our findings suggest that HGNS may improve patients' quality of life while minimizing OSA associated morbidity.

Gluten Sensitivity Underlying Resistant "Laryngopharyngeal Reflux" Symptoms and Signs.

INTRODUCTION: Laryngopharyngeal reflux (LPR) is one of the most common conditions encountered in otolaryngology. Gluten sensitivity may mimic the signs and symptoms of LPR or act as an aggravating cofactor with LPR. Gluten sensitivity and food intolerance also have been implicated as conditions that may be associated specifically with LPR symptoms and signs resistant to traditional medical treatment. Medical management of LPR may be insufficient to control symptoms and laryngeal signs of reflux, constituting resistant LPR. Eliminating gluten from the diet could provide symptomatic relief to patients with gluten sensitivity and LPR that is not controlled adequately by current regimens. The purpose of our study was to investigate the relationship between gluten sensitivity and LPR. We aimed to evaluate reflux finding score (RFS) improvement following elimination of gluten from the diet in patients with resistant LPR who had positive blood tests associated with gluten sensitivity. Symptom improvement was also assessed following dietary gluten elimination. Lastly, we aimed to identify predictors for a positive response to a gluten-free diet. METHODS: Adult patients who underwent gluten sensitivity testing for treatment-resistant LPR symptoms and/or signs were included. Patients with ≥1 positive test were advised to begin a therapeutic trial of a gluten-free diet. Subjects who chose not to trial a gluten-free diet or tested negative for gluten sensitivity markers served as controls. RFS was the primary outcome measure. RESULTS: One hundred ninety-seven patients were included; 81 trialed a gluten-free diet. Subjects who trialed the gluten-free diet were significantly more likely to demonstrate objective improvement in RFS (77.14% vs 43.88%), and report subjective improvement (55.41% vs 25.77%) than those who did not. RFS had decreased significantly from baseline at 1-3, 3-6, 6-12, and >12-month interval follow-up examinations in subjects who trialed a gluten-free diet. Comparison between subjects who trialed the gluten-free diet, tested positive for a gluten sensitivity marker but did not trial the gluten-free diet, and subjects who were negative for all gluten sensitivity markers revealed that a gluten-free diet was associated with a significantly greater percent improvement in RFS compared to controls at 1-3, 6-12, and >12-months. CONCLUSION: Gluten sensitivity can mimic or aggravate LPR. A gluten-free diet should be considered for patients with resistant LPR, especially if blood test abnormalities that suggest gluten sensitivity are identified. The diet should be maintained for a minimum of three months to demonstrate objective improvement using RFS.

Surgical Outcome of Potassium-Titanyl-Phosphate (KTP) Laser Photocoagulation for Vocal Fold Vascular Lesions.

INTRODUCTION: Laser technology is used in microscopic direct laryngeal surgery for a variety of indications. Lasers are categorized broadly as photoangiolytic or cutting/ablating lasers, based on the chromophores that absorb their energy. Photoangiolytic lasers such as the 532 nm Potassium-Titanyl-Phosphate (KTP) laser are absorbed selectively by the chromophore hemoglobin, facilitating controlled intravascular coagulation, with preservation of the overlying epithelium and adjacent tissue. Efficacy of the KTP laser has been demonstrated for incision, coagulation, and ablation in vocal fold (VF) surgery. OBJECTIVE: The purpose of the present study was to examine surgical outcomes following KTP laser photocoagulation for the management of VF vascular lesions. METHODS: Adult patients with sufficient data who had undergone KTP laser photocoagulation in the operating room for the treatment of VF vascular lesions were included in this retrospective study. Strobovideolaryngoscopy (SVL) video footage from all preoperative visits and all available postoperative visits was compiled and de-identified. Patients were followed up at days 1-7, 8-14, 30-60, and greater than 60 days after surgery. Three blinded physician evaluators reviewed and evaluated the SVL footage independently for postoperative outcome parameters. Postoperative SVL video footage was evaluated on a 5-point scale for surgical success (surgical objective score; 1 = failure and 5 = complete success). The average surgical objective score was 4.36, 4.04, 4.25, and 4.46 (out of 5) at postoperative visits 1-4, respectively. RESULTS: There were 60 cases (19 male and 41 female) included in the retrospective cohort. The average age was 42.42 ± 15.51 (range = 18-74). Fifty-one-point six seven percent of subjects were professional voice users (singers, teachers, public speakers, and others). All subjects were diagnosed preoperatively with VF vascular malformations and had undergone pulsed KTP laser photocoagulation. There were 40 bilateral cases and 20 unilateral cases, for a total of 100 VFs included in the study. Vascular malformation recurrence was identified in 3.00% and 10.00% of subjects at the third and fourth postoperative visits, retrospectively. The formation of new vascular malformations was identified in 0.00%, 1.00%, 6.00%, and 7.00% of subjects at postoperative visits 1-4, respectively. CONCLUSION: KTP laser photocoagulation is highly effective for the management of vocal fold vascular lesions. Presence of hemorrhage or edema does not affect the long-term surgical outcome. In relatively few cases, vascular lesion recurrence or formation of new vascular lesions may occur.

The Relationship Between Chronic Cough and Laryngopharyngeal Reflux.

Chronic cough is multifactorial in origin, may affect quality of life adversely, and often poses a diagnostic challenge for physicians. Laryngopharyngeal reflux (LPR) is one common contributing factor for chronic cough, but the mechanism by which reflux causes cough remains unclear. Research investigating the relationship between chronic cough and LPR has focused largely on reflux from the perspective of gastroenterology, rather than otolaryngology. OBJECTIVE: The purpose of our study was to investigate the relationship between chronic cough and LPR by using the objective results of 24-hour pH impedance studies. METHODS: We conducted a retrospective chart review of all patients who presented to the voice center of the senior author (RTS) with a chief complaint of chronic cough and no previous diagnosis of reflux. Patient demographics, past medical history, laboratory data, and exam findings during the initial visit from 2015 to 2020 and at follow-up were analyzed. RESULTS: We identified 28 patients who presented with a chief complaint of chronic cough and who had not been diagnosed with or treated for reflux previously. Twenty-three had additional risk factors for chronic cough (asthma, chronic sinusitis, and bronchial schwannoma). All 28 had findings consistent with LPR upon exam. Treatment with reflux medications and lifestyle modification decreased the reflux finding score significantly from 11.39 to 9.21 (P= 0.005). Of all, 60.7% of patients reported subjective improvement in cough symptoms. The cough had improved in 50.0% and had resolved completely in 10.7%. Patients with VF paresis were less likely to report improvement in their cough. Further workup was performed for the 11 patients who had cough that did not resolve completely after reflux treatment. Detectable levels of antimycoplasma antibodies were found in nine patients, and antipertussis antibodies were found in two patients. Six patients followed up after a course of clarithromycin, three of whom had experienced improvement in their cough. CONCLUSIONS: Our findings suggest that LPR may be a prevalent contributing or etiologic factor for chronic cough. The expected improvement after initiating reflux treatment is 60% at 3 months. Cough resolved completely in 10% of patients at 4 months. Nonresponders may have other contributing causes of cough, including esophageal dysmotility, mycoplasma, pertussis, and other contributors. Further studies are needed to confirm or refute these findings.

Role of Famotidine and Other Acid Reflux Medications for SARS-CoV-2: A Pilot Study.

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the coronavirus-19 disease (COVID-19) pandemic. The H-2 blocker famotidine has been suggested as an FDA-approved drug that could potentially be repurposed for treatment of COVID-19. Famotidine has since been shown to improve patient outcomes and reduce symptom severity in patients acutely ill with COVID-19. Other studies have suggested that proton pump inhibitors (PPIs) might have an association with COVID-19. OBJECTIVE: The purpose of the present study was to determine whether famotidine or any other antireflux medications have a prophylactic or detrimental effect for SARS-CoV-2 infection when taken regularly for the management of acid reflux. METHODS: An anonymous, web-based survey was distributed via email to adult otolaryngology patients to collect demographic data, past medical history, medication history, incidence of symptoms associated with COVID-19, potential exposure to SARS-CoV-2, and results of any PCR or serological testing. Associations between reflux medications and incidence of COVID-19 cases were analyzed. Statistical analysis was performed using SPSS. Chi-square with Fisher's exact test, Point-Biserial correlation, Kendall's-tau-b, independent samples t test, and the Mann-Whitney U test were used as appropriate. A binary logistic regression model was fit to determine probability of COVID-19 cases after adjustment for other risk factors. RESULTS: There were 307 patients who responded to the survey. The average age of respondents was 52.63 ± 17.03. Famotidine use was not associated with incidence of laboratory-confirmed (P= 0.717) or symptomatically suspected (P= 0.876) COVID-19. No other reflux medications were found to be significant predictors for laboratory-confirmed or suspected COVID-19 (P> 0.05). Younger age (odds ratio [OR] = 1.043, 95% CI: 1.020-1.065, P< 0.001), high risk obesity (OR = 4.005, 95% CI: 1.449-11.069, P= 0.007), and use of a corticosteroid nasal spray (OR = 3.529, 95% CI: 1.352-9.211, P= 0.010) were significant predictors for symptomatically suspected COVID-19 cases. CONCLUSIONS: There was no association between incidence of COVID-19 and use of reflux medications, including famotidine at doses used orally to manage reflux and high dose PPIs. Reflux medications did not protect against or increase the risk of COVID-19.

Sex Bias in Laryngology Research and Publishing.

OBJECTIVE: To investigate sex bias in laryngology research and publishing. MATERIALS AND METHODS: Articles published in 2019 in seven mainstream otolaryngology journals were reviewed. Original manuscripts were included. Study type (medical, speech-language pathology, basic science, or pedagogy), subject sex, ≥50% sex-matching (SM≥50), sex-based analysis, and bibliometric data including author sex were recorded. RESULTS: Of 1619 publications reviewed, 259 patient-centered original laryngology studies were included, totaling 7,130,991 subjects (3,411,741 [47.8%] male; 3,718,694 [52.1%] female; 556 [0.0%] unreported). 29 studies included subjects of a single sex and 14 did not report sex. 114 (44%) studies met SM≥50, and 95 (37%) used sex-based analysis; no differences were found among study types or location. Sex-based analysis was used less in single-institution (33%) than database studies (62%, P = 0.01). No difference in SM≥50 was found among single or multi-institution, or database. There were 1340 total authors (578 [43%] female). First, corresponding, and senior authors were 47%, 39%, and 35% female, respectively. Studies that had female first and/or senior authors did not differ in rates of SM≥50 or sex-based analysis or mean enrollment of females compared to studies with male first and senior authors. The proportion of female physician first and senior authors did not differ from the proportion of female Association of American Medical Colleges otolaryngology faculty, but was non-significantly smaller than the proportion of female laryngology fellows at four academic institutions. CONCLUSION: Laryngology research exhibits sex bias in subject enrollment and sex-based analysis. Female authorship was representative of national demographics and author sex did not influence the rate of sex bias.

Gender Differences in Vocal Fold Mass Treatment.

OBJECTIVE: The purpose of the study was to examine gender-related differences in benign vocal fold mass treatment. METHODS: Adult patient with vocal fold mass diagnosed on strobovideolaryngoscopy examination were reviewed retrospectively. Patient demographics, past medical history, laboratory data, and examination findings during the initial visit and at follow-up were collected. The duration of voice therapy and the prevalence of surgery were analyzed for males and females. RESULTS: One hundred and fifty-eight patients (76 male and 82 female) were included. The percentage of professional voice users differed significantly between males and females. Vocal folds of females had a higher percent of reactive masses present. Females were also more likely to have a pseudocyst. Vocal folds of males showed a higher percent of masses of unspecified category on strobovideolaryngoscopy examination. A significantly greater proportion of females had abnormal high shimmer values, and abnormal low maximum phonation time; and a significantly greater proportion of females compared to males chose to participate in voice therapy. The average number of voice therapy sessions for males did not differ, nor did duration of voice therapy. A similar proportion of males and females underwent surgical mass excision. The treatment plan completed differed significantly between males and females with a higher percentage of males choosing to receive no treatment. For 45.54% of males and 59.70% of females the treatment plan consisted of voice therapy only. For 33.33% of males and 37.31% of females, the treatment plan included both voice therapy and surgery. Although gender was the strongest predictor for participation in voice therapy, professional voice uses also predicted participation in voice therapy in both men and women significantly. Professional singing in particular was not a significant predictor for participation in voice therapy. Males were significantly more likely than females to be lost to follow-up before treatment outcome could be assessed CONCLUSION: More females than males were found to have pseudocysts while more males than females had unspecified masses. Females and professional voice users were more willing than males to utilize voice therapy. No difference was found between males and females who decided to have surgery. The best treatment regimen for vocal fold mass is a combination of voice therapy and surgery, when necessary, but gender-specific differences merit further research as well as reconsideration of therapy approaches and strategies to optimize patient compliance.

Cost-effectiveness of Inpatient Tympanostomy Prophylaxis.

OBJECTIVE: Tympanostomy is the most common pediatric ambulatory surgery. Post-tympanostomy otorrhea is a prevalent complication leading to high costs to patients for treatment. The cost-effectiveness of intraoperative prophylaxis for both patient and institution has not been examined. STUDY DESIGN: An analytical observational study of data collected from the literature and purchasing records. METHODS: A break-even analysis was performed to determine the required absolute risk reduction (ARR) and final infection rate in post-tympanostomy otorrhea to make intraoperative prophylaxis using ofloxacin and ciprofloxacin dexamethasone otic version cost effective with the following outpatient treatments: ofloxacin, ciprofloxacin-dexamethasone ophthalmic version, and ciprofloxacin-dexamethasone otic version. Absolute risk reduction is a statistic used to express the difference in risk between a treatment and control. The conservative initial infection rate used was 10%. RESULTS: Ofloxacin intraoperative prophylaxis was not cost effective when prescribing ofloxacin outpatient treatment with an ARR of 0.20. Ofloxacin intraoperative prophylaxis was cost-effective with an ARR of 0.08 for ciprofloxacin-dexamethasone ophthalmic version outpatient treatment. Ofloxacin intraoperative prophylaxis was cost-effective for ciprofloxacin-dexamethasone otic version outpatient treatment with an ARR of 0.01.Ciprofloxacin-dexamethasone intraoperative prophylaxis was not cost-effective when prescribing ofloxacin outpatient treatment with an ARR of 1.52. Ciprofloxacin-dexamethasone intraoperative prophylaxis was not cost-effective when prescribing ciprofloxacin-dexamethasone ophthalmic version outpatient treatment with an ARR of 0.60. Ciprofloxacin-dexamethasone intraoperative prophylaxis was cost effective when prescribing ciprofloxacin-dexamethasone otic version outpatient treatment with an ARR of 0.09. CONCLUSION: Intraoperative prophylaxis can be cost effective for preventing post-tympanostomy otorrhea. Physicians can use this economic model to determine the cost-effectiveness of these interventions for their patients and institutions.