Local inflammatory reaction to benign, pre-malignant and malignant glottic lesions: A matched case-control study.

OBJECTIVES: To study the inflammatory infiltrates associated with the different stages of laryngeal carcinogenesis. DESIGN: Observational, matched case-control study of histopathologic specimens. SETTING: An academic referral centre. PARTICIPANTS: A total of 45 patients who underwent removal of glottic lesions between 2008 and 2015. Patients were enrolled and categorised into three matched groups according to lesions' histopathologic diagnoses, 15 patients in each group: benign, pre-malignant and squamous cell carcinoma (SCC). Matching was based on age, gender and pack-years. MAIN OUTCOME MEASURES: Immunohistochemistry staining using monoclonal antibodies against CD4, CD8, CD68, CD20 and S100 representing T-helper cells, cytotoxic T cells, macrophages, B cells and dendritic cells, respectively. Cell counts and distributions were measured and compared between groups. Correlations between the different cells were examined. RESULTS: The predominant cell type was CD8+, followed by CD68+ and CD4+. All inflammatory cells increased significantly in number in SCC (P-value < 0.001), with no significant difference between benign and pre-malignant groups. Strong correlations between the different cells were demonstrated only in the malignant group. S100+ cells correlated with both T-cell subsets, CD4+ (rho = 0.769, P-value = 0.001) and CD8+ (rho = 0.697, P-value = 0.0004). Infiltrates exhibited more extensive distribution in SCC compared to pre-malignant and benign; CD8+ and CD68+ cells were demonstrated in both intraepithelial and stromal regions in 93% of SCC lesions (P-value = 0.0001). CONCLUSIONS: Laryngeal carcinoma demonstrates a unique pattern of inflammatory infiltrates, with significant changes in cell counts and distribution. Leucocyte infiltrates increased significantly in the transition from laryngeal pre-malignant lesion to malignancy while no significant differences were seen between benign and pre-malignant lesions.

Menstrual Cycle, Vocal Performance, and Laryngeal Vascular Appearance: An Observational Study on 17 Subjects.

OBJECTIVE: To assess the anatomical and functional features of the vocal folds during different phases of the female menstrual cycle. METHODS: An observational study of 17 healthy fertile female volunteers not using hormonal contraception was carried out. Each volunteer underwent two examinations: first, during the early days of the menstrual cycle when progesterone levels are low (p-depletion), and second, during premenstruation when progesterone levels are high (p-peak). The workup included blood hormone levels, Voice Handicap Index, acoustic analysis, rigid telescopy, stroboscopy, and narrow band imaging. The videos were evaluated by blinded observers. RESULTS: The participants' mean age was 31.7 ± 5.6 (range 23-43). Progesterone levels were 13- to 45-fold higher in p-peak relative to p-depletion. No significant differences were detected in Voice Handicap Index scores, stroboscopic reports, or acoustic analysis between p-peak and p-depletion examinations. Analyzing the rigid telescopy and narrow band imaging videos, the observers tended to estimate the different laryngeal subsites more vascularized during the p-peak examination. Moreover, this tendency was significantly correlated with blood progesterone levels during the p-depletion examinations; the lower the blood progesterone levels were during p-depletion, the higher the probability for the observers to estimate the p-peak examinations more vascularized (P value = 0.024). CONCLUSIONS: Alterations in laryngeal vascular characteristics are evident throughout the menstrual cycle and may suggest increased congestion during premenstrual days. Variations in progesterone levels during the menstrual cycle correlate with laryngeal vascular changes. Hormone-related alterations in vocal folds' vascularity may have a role in the variability of vocal performance in certain women.

Early and Late Recurrent Epistaxis Admissions: Patterns of Incidence and Risk Factors.

Objective Epistaxis is a common complaint, yet few studies have focused on the incidence and risk factors of recurrent epistaxis. Our objective was to determine the patterns of incidence and risk factors for recurrent epistaxis admission (REA). Study Design Case series with chart review. Settings Single academic center. Subjects and Methods The medical records of patients admitted for epistaxis between 1999 and 2015 were reviewed. The follow-up period was defined as 3 years following initial admission. REAs were categorized as early (30 days) and late (31 days to 3 years) following initial admission. Logistic regression was used to identify potential predictors of REAs. Results A total of 653 patients were included. Eighty-six patients (14%) had REAs: 48 (7.5%) early and 38 (6.5%) late. Nonlinear incidence curve was demonstrated for both early and late REAs. Based on logistic regression, prior nasal surgery and anemia were independent risk factors for early REAs. According to multivariate analysis, thrombocytopenia was significantly associated with late REAs. Conclusion Early and late REAs demonstrate different risk predictors. Knowledge of such risk factors may help in risk stratification for this selected group of patients. All patients at risk should be advised on possible preventive measures. Patients at risk for early REA may benefit from a more proactive approach.

Does narrow band imaging improve preoperative detection of glottic malignancy? A matched comparison study.

OBJECTIVES/HYPOTHESIS: The primary suspicion for glottic malignancy during office laryngoendoscopy is based on lesion appearance. Previous studies investigating laryngeal use of narrow band imaging (NBI) are mostly descriptive. The additive value of NBI relative to white light (WL) requires further investigation. STUDY DESIGN: Observational matched study. METHODS: NBI was compared with WL images of 45 vocal fold lesions suspected for malignancy (21 carcinoma, 22 dysplasia, two benign). All images were presented randomly and evaluated by six independent otolaryngology specialists. The observers were asked to estimate lesion size, location, and pathology. The results for the two imaging modalities were compared with each other and with the final pathology. RESULTS: The observers estimated lesion size to be larger in the NBI images by an average of 9% (2.4 mm2 ; P =.04) compared to WL. In 64.6% of cases, the observers estimated similar pathology for NBI and WL. When there was a discrepancy, the estimated pathology was "malignant" in 24.3% by NBI, compared with 11.1% by WL. Overall, 44.7% of the lesions were estimated to be malignant by NBI, compared with 33.8% by WL (P =.001). The sensitivity and specificity rates for malignancy detection by NBI were 58.6% and 61.2%, respectively, compared to 48.7% and 76.1% by WL. CONCLUSIONS: Observers tend to estimate vocal fold lesions to be larger and more frequently suspect malignancy while assessing NBI images. Compared with WL, NBI demonstrates increased sensitivity and decreased specificity for detection of malignancy. Nevertheless, the specificity and sensitivity of NBI alone are considerably low. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:894-899, 2017.

Cervical Osteophytes Increase the Risk for Foreign Body Impaction: A 171-Patient Case-Control Study.

The aim of this study is to define the relationship between anatomical and pathological cervical structures and the impaction of ingested foreign bodies (FBs). The effects of such structures on deglutition have been previously discussed, however their contribution to FB impaction has not yet been examined. This was a retrospective case-control study of 171 patients who underwent computed tomography (CT) scans over the period 2008-2014: 57 patients with an esophageal or hypopharyngeal FB; the other 114 comprised the control group, selected using the 'neighbor control' method. CT scans were reviewed for measurements of cervical structures. The mean age was 63 ± 13 years and 55 ± 17 years in the case and control groups, respectively (p-value = 0.003). Age was the only demographic or clinical characteristic which demonstrated a significant difference. Overall, 24 patients had cervical osteophytes: 28 %(16) with an impacted FB, compared with 7 %(8) from the control group (p-value < 0.001). Of the patients with osteophytes and impacted FBs, 62.5 % had the FB lodged at a vertebral level corresponding to their osteophytes, while another 18.75 % had the FB within three vertebral levels above the osteophytes. Stepwise logistic regression revealed that osteophytes were a significant factor, independent of older age (p-value = 0.004). Adjusted odds ratio for FB impaction in the presence of osteophytes was 4.04. Ventral cervical osteophytes increase the risk for FB impaction in the upper digestive tract. This risk is independent of older age. These findings can be of value in preventive medicine, and emphasize the importance of looking for spinal changes in patients with recurrent FB impaction.

The role of separate margins sampling in endoscopic laser surgery for early glottic cancer.

CONCLUSIONS: Sampling surgical margins in trans-oral laser microsurgery for early glottic squamous cell carcinoma (SCC) may allow for increased local control rate, although with no difference in local control by endoscopic treatment alone. OBJECTIVE: To further delineate the role of routinely sampling separate surgical margins, in patients with early glottic SCC undergoing endoscopic laser resection. METHODS: A retrospective case control study. One hundres and two early glottic cancer patients staged Tis-T2 underwent endoscopic laser surgery with curative intent as the primary treatment. Separate margins from the surgical bed were sampled following complete tumor resection in 64 patients; in 38 patients no margins were sampled. RESULTS: Margin sampling showed a tendency towards reduced risk for local recurrence, adjusted HR = 0.439 (p-value = 0.096). However, there was no difference in local control by endoscopic treatment alone. The patients with sampled margins were further divided based on margins' status: 39 (61%) had negative margins, and 25 (39%) had positive margins. Compared with negative margins, patients with positive margins showed increased risk for recurrence, adjusted HR = 8.492 (p = 0.008). When margins were not sampled the risk for local recurrence was increased compared to negative margins (adjusted HR = 7.875, p-value = 0.008), and relatively comparable to what was observed when sampled margins were positive (adjusted HR = 0.927, p-value = 0.88).

Analysis of cigarette smoking mechanism by real time video-endoscopic documentation.

OBJECTIVE: To view, document and analyze the smoking mechanism as seen via video-endoscopic examination during the action of cigarette smoking. STUDY DESIGN: Observational study. METHODS: Twenty-two healthy smoking volunteers were examined with a trans-nasal video-laryngoscope while breathing, sniffing and cigarette smoking. Smoking a whole cigarette was recorded in each participant. The different stages of smoking were defined and their duration was measured. The glottic opening angle was calculated during breathing, sniffing and smoking. RESULTS: A smoking cycle with four distinct stages was recognized. The stages included an oral smoke accumulation, pharyngo-laryngeal jet inhalation, infralaryngeal spread, and finally humidified exhalation stage. The stages' mean duration was 1.93(±1.21), 0.39(±0.31), 2.00(±1.12) and 4.5(±2.70) seconds, respectively. The glottic opening angle during smoke inhalation was wider in 16% (p = 0.02) compared to normal inhalation during breathing. The glottic opening during smoke exhalation was comparable to what was observed during normal exhalation. The reduction in the glottic opening was more significant during the action of smoking compared with normal breathing (p = 0.042). CONCLUSIONS: Smoking follows a consistent sequence of events, defined by specific anatomic configuration and relatively persistent duration. The fast turbulent flow of the smoke over the narrow glottic aperture and at the areas of bifurcation at the trachea and bronchi may have a role in the high relative risk for carcinoma in these areas.

The anatomic distribution of malignant and premalignant glottic lesions and its relations to smoking.

OBJECTIVE: To describe the anatomic location and distribution of glottic dysplasia and early glottic cancer. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care referral center. SUBJECTS AND METHODS: Review of 167 glottic dysplasia or carcinoma patients between 2008 and 2013. Lesions were described in terms of location and size, and a novel grid system was used to map out anatomic distribution. RESULTS: Seventy-eight patients with dysplasia and 89 with early glottic carcinoma were included. One hundred twenty-eight were smokers and 39 nonsmokers. The medial aspect of the vocal fold was more involved than the superior aspect, 95% versus 71%, respectively (P < .001). The superior aspect was more involved in smokers, 77% versus 51% in nonsmokers (P = .0016). Using a grid system, the most involved area was the midpoint of the membranous vocal fold at the transition between the superior and medial aspects. Ninety-seven percent of the lesions occupied this specific area, with no difference between smokers and nonsmokers. The vocal process mucosa was involved in 48 patients. Exclusive vocal process involvement was limited to 2 cases. All other 46 patients demonstrated extensive disease, encompassing more than half of the vocal fold's length. Carcinomatous lesions tended to be larger relative to dysplastic lesions. Otherwise, all lesion types showed a similar pattern of distribution. CONCLUSIONS: Premalignant and malignant glottic lesions tend to involve the medial aspect of the vocal fold and the midpoint of the membranous part in particular. In smokers, lesions tend to be larger on presentation and are more likely to involve the superior aspect.