Does Perioperative Radiation Affect Implant Survivorship of Primary Total Hip Arthroplasty in the Setting of Metastatic Bone Disease?

Background: Metastatic bone disease (MBD) commonly affects the hip and surgical intervention including total hip arthroplasty (THA) is often indicated to treat the joint and improve function. Patients with metastatic cancer often receive radiotherapy, and orthopaedic oncologists must consider surgical risks with operating on irradiated bone and soft tissue. We evaluated surgical outcomes and implant survival (IS) of titanium acetabular components and femoral components in patients treated for MBD in the setting of perioperative radiation. Methods: This was a retrospective review of patients who underwent THA for MBD at 3 institutions between 2017 and 2021. Outcomes included rates of reoperation, complications, IS, and overall survival. Results: Forty-six patients who received primary THA for MBD were included in the study. Twenty patients (43.5%) received perioperative radiation for MBD. Six postoperative complications including one superficial wound infection, 2 dislocations, 2 pathologic fractures, and one aseptic acetabular component loosening led to 5 reoperations. There were no significant differences in postoperative outcomes, reoperation after THA, and IS based on radiotherapy status. Conclusions: To our knowledge, this is the first paper evaluating primary THA outcomes and IS between patients who receive perioperative radiation for MBD to the hip and those who do not. As surgical management is a crucial part of the treatment in alleviating pain and disability in patients with MBD, we continue to recommend THA for patients who received radiation at the operative site.

Opiate use after total hip arthroplasty for metastatic bone disease.

OBJECTIVES: To investigate post-operative opioid use following a total hip arthroplasty (THA) in metastatic bone disease (MBD) patients and identify factors associated with post-operative opioid use at 6 weeks and 90 days. BACKGROUND: MBD commonly affects the hip, and surgical intervention including THA may be indicated for pain relief or to improve function. Following THA, patients are often prescribed short courses of opioids for post-operative pain relief. No study has evaluated opiate use following THA in patients for MBD. METHODS: This was a retrospective review of patients using opioids preoperatively who underwent primary THA for MBD at two institutions between 2009 and 2022. Preoperative and post-operative opioid usages, respectively, at 6 weeks and 90 days were quantified through calculating daily morphine milligram equivalents (MMEs) and compared using the sign test. Factors associated with post-operative opioid use at 6 weeks and 90 days were compared using χ2 test or Fisher's exact test as appropriate. RESULTS: Nineteen THA and 11 THA with complex acetabular reconstruction were included. At 6 weeks, 26 (86.7 percent) patients were utilizing opiates, and at 90 days, 23 (76.7 percent) patients were utilizing opiates. There was a statistically significant difference between median daily preoperative MME compared to daily MME at 90 days (p < 0.001). The only statistically significant association with opioid use at 90 days was opioid use at 6 weeks. CONCLUSION: To our knowledge, this is the first paper evaluating post-operative opioid use following primary THA in MBD patients. After THA in the setting of MBD, patients exhibit decreased post-operative opioid use. Future studies with larger cohorts should be conducted to characterize post-operative opioid use following joint arthroplasty in MBD patients.

Building Approachable Surgical Experiences (BASE) in High School Populations.

OBJECTIVE: Pipeline programs are often set up to bring more diverse candidates to medical schools with the goal of diversifying the physician workforce in the years to come. All too often, these programs begin in college, long after many students of diverse backgrounds have been left behind through a myriad of barriers that exist between entering high school and matriculating to medical school. The Building Approachable Surgical Experiences (BASE) outreach program was designed to showcase healthcare careers, with an emphasis on surgical subspecialties, to historically underserved high school students. This pilot program's goal was to increase high school students' interest and confidence in pursuing future medical and surgical careers and provide a platform to initiate mentorship. DESIGN: Local high school students from underrepresented in medicine (URiM) populations or medically underserved communities were invited to spend the day at an academic medical school campus. These students engaged in hands-on clinical and basic operative skill workshops led by third- and fourth-year medical students. They also engaged in small group conversations centered on mentorship with surgical residents and faculty. SETTING: Program implementation took place at an academic medical center school of medicine in an urban city. PARTICIPANTS: Forty high school students, 16 medical students, and 2 surgery faculty participated in this pilot program. CONCLUSIONS: This event allowed early exposure for high school students to surgical and medical specialties, clinical techniques, and surgical mentorship. From the connections made, students have developed mentorship relationships and have felt comfortable reaching out with questions regarding the steps required to seek entrance to medical school. Mentors are currently resident or attending physicians, which provides students from underrepresented populations an opportunity for direct insight and guidance to and through the path to becoming a physician. Based on qualitative feedback from students, their high school teachers, and administrators, this pilot program succeeded in providing a window into healthcare, using a format that was encouraging to students long beyond their time on the school of medicine campus.

Perioperative allogenic blood transfusions are associated with increased fracture related infection rates, but not nonunion in operatively treated distal femur fractures.

INTRODUCTION: Distal femur fractures are common injuries that remain difficult for orthopedic surgeons to treat. High complication rates, including nonunion rates as high as 24% and infection rates of 8%, can lead to increased morbidity for these patients. Allogenic blood transfusions have previously been identified as risk factors for infection in total joint arthroplasty and spinal fusion surgeries. No studies have explored the relationship between blood transfusions and fracture related infection (FRI) or nonunion in distal femur fractures. METHODS: 418 patients with operatively treated distal femur fractures at two level I trauma centers were retrospectively reviewed. Patient demographics were collected including age, gender, BMI, medical comorbidities, and smoking. Injury and treatment information was also collected including open fracture, polytrauma status, implant, perioperative transfusions, FRI, and nonunion. Patients with less than three months of follow up were excluded. RESULTS: 366 patients were included in final analysis. One hundred thirty-nine (38%) patients received a perioperative blood transfusion. Forty-seven (13%) nonunions and 30 (8%) FRI were identified. Allogenic blood transfusion was not associated with nonunion (13% vs 12%, P = 0.87), but was associated with FRI (15% vs 4%, P<0.001). Binary logistic regression analysis identified a dose dependent relationship between number of perioperative blood transfusions and FRI: total transfusion ≥2 U PRBC RR= 3.47(1.29, 8.10, P = 0.02), ≥3 RR= 6.99 (3.01, 12.40, P<0.001), and ≥4 RR= 8.94 (4.03, 14.42, P<0.001). DISCUSSION: In patients undergoing operative treatment of distal femur fractures, perioperative blood transfusions are associated with increased risk of fracture related infection, but not the development of a nonunion. This risk association increases in a dose-dependent relationship with increasing total blood transfusions received.

The Transoral Alar Batten Graft: A Functional Rhinoplasty Technique for the Orthognathic Jaw Surgery Patient.

SUMMARY: Many patients seeking orthognathic jaw surgery also experience nasal obstruction. Current transoral functional rhinoplasty techniques include septoplasty and inferior turbinate reduction, which are performed through the mouth after maxillary downfracture. Although powerful, these interventions do not treat dynamic nasal sidewall collapse. The authors describe a novel transoral alar batten graft. Using the maxillary vestibular approach, septal cartilage is harvested and delivered from the maxillary vestibule into the nasal alar-sidewall junction through a small tunnel. This procedure is simple and versatile, and carries minimal morbidity, enabling the orthognathic jaw surgeon to support the nasal sidewall through a minimal-access approach and improve the patient's nasal function and airway.

Minimally Invasive Mandibular Microsurgery: A Systematic Review and Meta-analysis.

Microsurgical advances have led to minimally invasive approaches for mandibular reconstruction. Currently, no resource compares all minimally invasive microvascular mandibular reconstruction (MIMMR) treatment options. Methods: All known cases of MIMMR were identified following the Preferred Reporting Items for Systematic Reviews, Meta-Analyses guidelines, and our own surgical experience. Patient demographics, MIMMR type [submandibular (SM), modified facelift/retroauricular (MFL/RA), or intraoral (IO)], methodology, and clinical outcomes were analyzed with the Fisher exact and Kruskal-Wallis tests. Results: Forty-seven patients underwent MIMMR. Ameloblastoma was the most common pathology treated using all approaches, and MFL/RA was the only approach used to treat squamous cell carcinoma (P = 0.0103). Reconstruction was reported for large, bilateral defects only via the SM or IO approach (P = 0.0216). The iliac crest or fibula was used as a donor site. The facial artery was the most common recipient vessel using the IO and SM approaches, whereas the superior thyroid and external carotid vessels were the most common in the MFL/RA approach (P < 0.0001). Virtual planning was used in all cases performed via an IO approach, 80.0% of cases using an SM approach, and no MFL/RA cases (P < 0.0001). Good aesthetic and functional outcomes were reported for every patient, and there was no difference in complication rates (P = 0.2880). Conclusions: Minimally invasive approaches are safe and effective treatment options for patients requiring mandibular microsurgery, usually in the setting of benign pathology. The IO and SM approaches usually rely on the facial vessels, whereas the MFL/RA approach permits access to the superior thyroid and external carotid vessels and cervical lymphadenectomy.

COVID-19: Impact on the Musician and Returning to Singing; A Literature Review.

OBJECTIVE: The purpose of this study was to review current literature of the impact of COVID-19 on musicians and returning to singing. METHODS: A comprehensive search of peer-review articles was completed using PubMed, GoogleScholar, Scopus, and Web of Science. The search was completed using many key terms including voice, hoarseness, dysphonia, aphonia, cough, singers, and public speakers. The bibliography from each article found was searched to find additional articles. The search process revealed 56 peer-reviewed articles, 18 primary articles, ranging from the years 2019 to 2020. CONCLUSION: COVID-19 has had a major impact on singers and other musicians worldwide. It can affect the voice and can lead to paresis/paralysis of laryngeal nerves to long-term changes in respiratory function. There is a risk from aerosolization/droplet formation transmission with singing, and with playing wind and brass instruments that can be mitigated by following COVID-19 guidelines. Ways to reduce possible transmission during singing and instrument play include virtual rehearsals or performances, mask-wearing, instrument covers, smaller choirs, performing outside, excellent ventilation being socially distanced, shorter rehearsals, regularly cleaning commonly touched surfaces and washing hands, avoiding contact with others, and temperature screening.

Diagnosing Laryngopharyngeal Reflux: A Comparison between 24-hour pH-Impedance Testing and Pharyngeal Probe (Restech) Testing, with Introduction of the Sataloff Score.

OBJECTIVE: The purpose of this study was to compare the diagnostic utility of pH monitoring using 24-hour esophageal pH-Impedance (HEMII-pH) testing versus pharyngeal pH (Restech) testing (Respiratory Technology Corporation, Houston, Texas) for diagnosing laryngopharyngeal reflux (LPR). METHODS: Retrospectively, patients were reviewed who had completed a Reflux Symptom Index (RSI) survey and stroboscopy within 60 days before or after undergoing simultaneous esophageal pH-Impedance monitoring and Restech testing. Reflux Finding Score (RFS) was determined by 4 blinded observers. 80.45% of patients were on anti-reflux medications at the time of study and had incomplete response to treatment for reflux. Improvement on reflux treatment was determined by evaluating presenting pre-pH monitoring RFS, post treatment RFS, and improvement of symptoms. Pearson correlation coefficients were calculated to assess relationships among RSI, RFS, and test results from HEMII-pH and Restech tests. RESULTS: Eighty-seven patients were included in the analysis. The inter-rater reliability of the RFS determination was 74.57%, and the intra-rater reliability was 67.00%. Subjects who had a positive RYAN Score had a significant correlation with RFS (r of 0.222 and p-value of 0.0492). There was no correlation between RFS and number or percent time of reflux events, longest event, total number of events, or percent of time at alkaline pH for either HEMII-PH or Restech test. RSI correlated better with HEMII-pH test than with Restech for percent time spent in both upright (r of 0.226 and p-value of 0.029) and supine position (r of 0.261 and a p-value of 0.032). Restech correlated better with total patient symptom Scores including cough, heartburn, burping, and throat clearing, with a r of 0.242 and a p-value of 0.048. Restech detected more percent time in reflux for total reflux, supine reflux, and upright reflux (p-value less than 0.0001). Restech also detected longer event times than Impedance (p-value of less than 0.0001). When diagnosis of LPR is based on the definition of CRC, the Sataloff Score test had 70.45% sensitivity and 80.95% specificity. The RYAN Score had a sensitivity of 72%, and a specificity of 56.45%, and the Wu Score had a sensitivity of 62.16%, and specificity of 54.05%. When the Sataloff and Wu Score were used together, the sensitivity was 71.45%, specificity 100%, positive predictive value of 100%, and a negative predictive value of 59.46%. CONCLUSION: The amount of time of reflux events correlates with symptoms better than the number of events. The HEMII-pH test was able to detect more events of pH<4 than Restech, possibly because there might have been more acid events below than above the upper esophageal sphincter, while Restech detected more total events. Restech recorded longer event times than HEMII-pH test. Since length of time correlates with RFS (probably reflecting laryngeal inflammation), and since laryngeal clearance of acid is more similar to pharyngeal than esophageal clearance, this finding might prove valuable clinically. The Sataloff Score has a sensitivity of 70.45%, and a specificity of 80.95% and appears useful clinically to detect mild to moderate that is missed by the RYAN Score. A combination of Sataloff Score and Wu Score may be clinically valuable to identify LPR with an increased sensitivity of 71.45% and increased specificity of 100%. The Wu Score is not yet available for the general clinical use, but the Sataloff Score is.

The Validity and Reliability of the Reflux Finding Score.

Laryngopharyngeal reflux (LPR) disease is common. The incidence of newly diagnosed cases has increased substantially due to awareness and development of new diagnostic measurements. The reflux finding score (RFS) and reflux symptom index (RSI) are believed to be useful in the assessment process, including after the initiation of therapy. However, many authors have suggested concerns about the reliability and validity of the RFS. OBJECTIVE: To evaluate the validity and reliability of the RFS. METHODS: Ninety-two patients diagnosed with LPR who had undergone 24-hour pH-Impedance tests were included. All patients underwent stroboscopy and 24-Hour pH-Impedance monitoring within thirty days. Fifty-nine patients filled out a RSI prior to stroboscopic exam. The RFS was determined by four blinded observers: one otolaryngology resident, two laryngology fellows, and one laryngologist. Stroboscopic images were reviewed again one year later to assess intrarater reliability. RFS and RSI were correlated with 24-hour pH Impedance testing. RESULTS: The Kappa value between reviewers was 0.479. The percent agreement of the four observers for total RFS was 74.04%.The percent agreement between reviewers for subglottic edema was 78.77%; for ventricular obliteration was 65.55%; for erythema/hyperemia was 69.62%, for vocal fold edema was 68.32%; for diffuse laryngeal edema was 66.86%, for posterior commissure hypertrophy was 73.54%; for granuloma/granulation was 96.80%; for thick endolaryngeal mucus was 72.81%. The intrarater reliability of the four observers for total RFS was 67.5% with an intrarater reliability range of 50%-90%. The intrarater reliability for subglottic edema was 85% with a range of 70%-100%; for ventricular obliteration was 77.50% with a range of 70%-90%; for erythema/hyperemia was 65.00% with a range of 50%-90%; for vocal fold edema was 52.50% with a range of 30%-70%; for diffuse laryngeal edema was 62.50% with a range of 20%-80%; for posterior commissure hypertrophy was 52.50% with a range of 10%-80%; for granuloma/granulation was 100%; for thick endolaryngeal mucus was 55.00% with a range of 10%-90%. There was no correlation between RFS and any parameter of the 24-Hr pH-Impedance Test. RSI had a significant correlation with number of upright events (r value of 0.271, R2 of 0.0733 and P-value of 0.037), total symptoms experienced (r value of 0.0.267, R2 of 0.0715 and P-value of 0.041), and symptom correlation score (r value of -0.297, R2 of 0.0884 and P-value of 0.022). CONCLUSION: Many authors have expressed concerns about the reliability and validity of the RFS. In our study we found a fair/substantial interrater reliability, and a modest intra-rater reliability. We found no correlation between the RFS and 24-Hr pH Impedance testing. This study suggests that the concerns about the validity and reliability of the RFS may be warranted. This widely used clinical score should be interpreted with caution and further research and refinement should be considered.

The Prevalence of Esophageal Disorders Among Voice Patients With Laryngopharyngeal Reflux-A Retrospective Study.

OBJECTIVE: The goal of this study was to determine the prevalence of esophageal disorders among voice patients with intractable laryngopharyngeal reflux (LPR) who have undergone 24 pH impedance and esophageal manometry. METHODS: A retrospective chart review was performed of patients with LPR-associated dysphonia in the absence of subjective dysphagia who presented between January 1, 2007 and June 30, 2019 and underwent 24 pH impedance and esophageal manometry studies after inadequate response to lifestyle modifications, high dose of Proton Pump Inhibitor (PPIs), H2 blockers, alkaline water, and Gaviscon (GlaxoSmithKline, Warren, NJ, USA). The comorbidities, medications, Strobovideolaryngoscopy findings, 24 pH impedance, and esophageal manometry results were analyzed. RESULTS: The study included 109 patients ages 19 to 80 years old, with a mean age of 51.5 (SD 16.8). About 24.8% of the 109 subjects were found to have peristaltic wave abnormalities indicating esophageal dysmotility (11% with esophageal stasis). Lower esophageal sphincter pressures were normotensive in 56.9% of patients, hypertensive in 24.8%, and hypotensive in 18.4% of patients. In addition, the upper esophageal sphincter pressures were normotensive in 57.8% of patients, hypertensive in 36.7%, and hypotensive in 2.8% of patients. About 12.6% had both lower esophageal sphincter and upper esophageal sphincter dysfunction (hypertensive or hypotensive). The average total reflux events in patients exhibiting dysmotility on manometry 101.81, which was significantly higher compared with the mean total of 61.28 in the group of patients without dysmotility (P= 0.0396). In addition, there was a significantly higher prevalence of total events that were weakly acidic in the group with dysmotility compared with the group without (all patients performed the study on reflux medications, mean of total weakly acidic events 70.2 in dysmotility group vs 44.2 in normal motility group, P= 0.0427).Finally, the average number of total supine reflux events and the total acidic supine events were both significantly higher in the dysmotility group compared with the group without motility problems (P = 0.0199 and P = 0.0213, respectively). CONCLUSION: Esophageal dysmotility may be a significant cofactor in voice patients with refractory LPR on appropriate reflux medications and lifestyle modifications. Further research is advised.

Incidence of and Risk Factors Associated With Vocal Fold Hemorrhage Following Type I Thyroplasty With Gore-Tex Implant.

OBJECTIVES: The objectives of this study were to determine the rate of hemorrhage following type I thyroplasty performed exclusively with Gore-Tex implant and to define whether age, comorbidities, anticoagulation therapy, presence of vocal fold ectasia, and operative technique are associated with increased incidence of hemorrhage. METHODS: Medical charts of 86 patients who underwent type I thyroplasty with Gore-Tex implant between the years 2013 and 2019 were reviewed retrospectively and divided into two groups based on presence or absence of postoperative vocal fold hemorrhage. Patients were examined on the day following surgery. Hemorrhage was defined as any submucosal erythema on the vocal fold even when isolated to the superior surface. Age, sex, medical comorbidities, preoperative medications with specific attention to anticoagulation therapy, American Society of Anesthesiology score (all procedures were performed under local anesthesia with sedation), operative notes, and pre- and poststroboscopy exams were compared between groups. Statistical analyses were done using Chi-Square (χ 2) Analysis and Student's t test. P values were considered statistically significant at the P < 0.05 level. RESULTS: The rate of hemorrhage was 22.3%. There was a statistically significant difference in incidence of hemorrhage associated with a vocal fold varix on preoperative stroboscopic exam and history of discontinued anticoagulation therapy (1-week preoperatively). No difference was found for the other parameters studied. CONCLUSION: Presence of vocal fold varix or ectasia and preoperative use of anticoagulation or antiplatelet therapy are associated with an increased risk of hemorrhage following type I Thyroplasty with Gore-Tex implant.

Diagnostic Value of Acoustic and Aerodynamic Measurements in Vocal Fold Movement Disorders and their Correlation with Laryngeal Electromyography and Voice Handicap Index.

OBJECTIVES: Investigate the relationships between the Voice Handicap Index, laryngeal electromyography, and objective acoustic voice testing in order to determine the utility of these measures in the management of vocal fold movement disorders. METHODS: A retrospective review of patients who had completed a Voice Handicap Index-10 (VHI-10) questionnaire, laryngeal electromyography (LEMG), and objective acoustic measurements (including jitter, relative average perturbation, shimmer, noise-to-harmonic ratio, and standard deviation of fundamental frequency). All three tests had been completed within 30 days of the initial evaluation. All patients' results for acoustic measures were recorded as standard deviations from the norm. LEMG results were converted to grade of paresis (mild, moderate, severe) based on the muscle with the lowest recruitment. Spearman correlation coefficients were calculated to determine the relationship between these three parameters. RESULTS: A total of 313 subjects were included in the analysis. VHI-10, LEMG (grade of paresis), and objective acoustic measures were, at best, weakly correlated. VHI-10 was better correlated than LEMG to each acoustic parameter including the average acoustic scores; however, the highest correlation observed only reached ρ = 0.349 (P < 0.001). The acoustic variables that correlated best with VHI-10 and LEMG were the standard deviation of the fundamental frequency (ρ = 0.349, P < 0.001) and shimmer (ρ = 0.207, P < 0.001), respectively. CONCLUSION: This study demonstrates that these measures are, at best, weakly associated. VHI-10 correlated better than LEMG (grade of paresis) to each acoustic voice analysis parameter. However, the maximum correlation coefficient observed was 0.349. Therefore, VHI-10 scores and objective voice acoustic measurements are not useful for predicting the severity of vocal fold movement disorders. Moreover, a given severity of paresis can have different effects on voice handicap and acoustic output in different individuals.

Effects of Particle Size of Inhaled Corticosteroid on the Voice.

OBJECTIVES: The purpose of this study was to determine if inhaled corticosteroid (ICS) particle size influences the development of laryngitis including candida laryngitis, dysphonia, or vocalis muscle atrophy in asthmatic patients. STUDY DESIGN: Retrospective analysis. METHODS: Medical records of patients from a quaternary care laryngology practice who have asthma were reviewed retrospectively. Subjects were divided into two groups determined by the particle size of their ICS, small or standard. Each patient only used one type of inhaler. All subjects had been seen in the office for dysphonia evaluation. Statistical analysis was performed on the collected data using χ2 analysis with Yate's Correction for categorical data and a student t-test for means. A P value of less than 0.05 was considered significant. RESULTS: There was a significant difference in vocal fold atrophy rate between groups. CONCLUSION: Routine use of standard particle size ICS is associated with more atrophy than small size ICS.

The Utility of Strap Muscle in Complex Type I Thyroplasties.

INTRODUCTION: Type I thyroplasty is a common procedure used to improve dysphonia secondary to glottic insufficiency caused by vocal fold paralysis, paresis, or bowing. Revision often involves more complex procedures that can be complicated by mucosal violation, hemorrhage, infection, and shifted or extruded implants. Intraoperative challenges can be managed successfully using autologous strap muscle rotation flaps. OBJECTIVES: Review vocal fold medialization with strap muscle as a viable option for thyroplasty, particularly operations with inadvertent mucosal disruption. METHODS: All operative records of the senior author's 30-year experience were queried for modified, complex, or revision type I thyroplasties. Each of these was reviewed, and only those utilizing autologous strap muscle rotation flaps for vocal fold medialization were included. Changes in voice quality were assessed using strobovideolaryngoscopic assessment of glottic closure and Voice Handicap Index-10 (VHI-10) scores when available. RESULTS: Seven patients were found to have undergone eight type I thyroplasty using autologous strap muscle flaps. Improved glottic closure was seen in all patients except one. This patient, complicated by a laryngeal fracture of unknown origin discovered at the time of surgery, had worse voice with strap muscle implantation intraoperatively; therefore, the patient's fracture was reduced, and medialization was postponed. All other patients reported improved voice quality both intra- and postoperatively. Pre- and postoperative VHI-10 scores were available for two of the seven cases with successfully implanted strap muscles. A decrease in VHI-10 was observed in both cases (mean = 11). No postoperative complications occurred in any patient. CONCLUSION: Although revision thyroplasties are relatively rare, they can be challenging. The seven cases presented herein illustrate the successful and safe use of autologous strap muscle rotation flaps for complex, revision type I thyroplasty procedures. They are particularly helpful in cases requiring additional soft tissue between the thyroid cartilage and mucosa in preparation for possible future medialization after Gore-Tex or Silastic implants, and for inadvertent mucosal disruption in which using a foreign implant might pose a risk of infection. Future studies should be performed with larger populations and longer follow-up to confirm the efficacy and safety of this procedure.

Paradoxical Vocal Fold Movement: A Retrospective Analysis.

BACKGROUND: Paradoxical vocal fold motion (PVFM) is a disorder in which the vocal folds adduct inappropriately during inspiration resulting in episodic dyspnea and sometimes respiratory distress. Diagnosis is obtained through careful history, physical examination, flexible laryngoscopic examination with provocative maneuvers, and laryngeal electromyography. The pathogenesis and clinical findings of this disorder are not known. OBJECTIVES: To determine characteristics of patients with confirmed PVFM and to evaluate efficacy of current treatments. METHODS: A retrospective chart review of the patients with PVFM who presented at a quaternary care laryngology office between January 1, 2007 and August 31, 2019 was performed. Comorbidities, laboratories tests, imaging, 24-hours pH impedance testing, and laryngeal EMG results were analyzed. Dyspnea Index questionnaire before and after treatment was used to evaluate the efficiency of treatments for PVFM. RESULTS: The average age of the 40 patients was 30.25 years. Forty-five percent of patients were under the age of 18, and 80% were female. Twenty-five percent of patients were serious athletes, and 40% of patients were students. Sixty-five percent had a previous diagnosis of asthma. One third of patients had concurrent psychiatric diagnosis. There was no family history of PVFM in the cohort. There were no other common findings. Treatment for laryngopharyngeal reflux (LPR) was used only when there was evidence of LPR; and 93% of our 40 patients received LPR treatment. Ninety percent of patients who received botulinum toxin, voice therapy (VT), and LPR treatment had subjective improvement. Patients with just VT and LPR treatment had a 43% subjective improvement rate; and the difference was statistically significant at P of 0.021. There was no statistical difference between VT and LPR treatment versus VT or LPR treatment alone. CONCLUSION: Botulinum toxin, VT, and LPR treatment regimen is currently the most effective management for patients with paradoxical vocal fold movement disorder. More research is needed to determine the etiology of this disorder.

Food Sensitivity and Laryngopharyngeal Reflux: Preliminary Observations.

Reflux is an expensive, high prevalence disease that affects at least half of patients with laryngeal and voice disorders. Approaches to treatment of laryngopharyngeal reflux include medical, lifestyle, dietary, and surgical treatment options.2 We review four patients who had persistent reflux signs and symptoms on appropriate lifestyle including elevating head of bed and dietary modifications, as well as antacid, H2 receptor blockers, and proton pump inhibitor therapy, who improved substantially on specific food avoidance diets. This raises food sensitivity as a possible factor in patients with intractable LPR.

Role of Postoperative Antibiotics in Patients Undergoing Type I Thyroplasty with Gore-Tex Implant.

OBJECTIVES: The purpose of this study was to determine the need for postoperative antibiotic administration in patients undergoing type I thyroplasty performed with Gore-Tex implant. STUDY DESIGN: Retrospective analysis. METHODS: Medical records of patients from a quaternary care laryngology practice who underwent type I thyroplasty for glottic insufficiency using Gore-Tex (W.L. Gore, Newark, Delaware) implant between the years 2013 and 2019 were reviewed retrospectively. Subjects were divided into two groups determined by those who did or did not receive routine postoperative antibiotics. All patients received two grams of cefazolin IV (for the standard 70-kilogram patient), and 10 mg of dexamethasone as a one-time dose given 10 minutes prior to incision. Patients allergic to cefazoline who received a single preoperative dose of 600 mg of clindamycin IV. All subjects were seen in the office at least three times after the procedure: one day, one week, and approximately six weeks following surgery. Statistical analysis was performed on the collected data using χ2 analysis for categorical data and a student t test for means. A P value of less than 0.01 was considered significant. RESULTS: There was no significant difference in infection rate or other complications between groups. CONCLUSION: Routine use of antibiotics following type I thyroplasty with Gore-Tex (W.L. Gore, Newark, Delaware) appears unnecessary.

An in vitro demonstration of overcoming drug resistance in SKOV3 TR and MCF7 ADR with targeted delivery of polymer pro-drug conjugates.

Drug resistance is a common phenomenon that occurs in cancer chemotherapy. Delivery of chemotherapeutic agents as polymer pro-drug conjugates (PPDCs) pretargeted with bispecific antibodies could circumvent drug resistance in cancer cells. To demonstrate this approach to overcome drug resistance, Paclitaxel (Ptxl)-resistant SKOV3 TR human ovarian- and doxorubicin (Dox)-resistant MCF7 ADR human mammary-carcinoma cell lines were used. Pre-targeting over-expressed biotin or HER2/neu receptors on cancer cells was conducted by biotinylated anti-DTPA or anti-HER2/neu affibody - anti-DTPA Fab bispecific antibody complexes. The targeting PPDCs are either D-Dox-PGA or D-Ptxl-PGA. Cytotoxicity studies demonstrate that the pretargeted approach increases cytotoxicity of Ptxl or Dox in SKOV3 TR or MCF7 ADR resistant cell lines by 5.4 and 27 times, respectively. Epifluorescent microscopy - used to track internalization of D-Dox-PGA and Dox in MCF7 ADR cells - shows that the pretargeted delivery of D-Dox-PGA resulted in a 2- to 4-fold increase in intracellular Dox concentration relative to treatment with free Dox. The mechanism of internalization of PPDCs is consistent with endocytosis. Enhanced drug delivery and intracellular retention following pretargeted delivery of PPDCs resulted in greater tumor cell toxicity in the current in vitro studies.