Endoscopic staple diverticulostomy for Zenker's diverticulum: review of experience in 337 cases.

OBJECTIVE: Surgical treatment of Zenker's diverticulum (ZD) has evolved over the previous 2 decades to a predominantly endoscopic approach. In this study, we review our experience with endoscopic staple-assisted diverticulostomy (ESD) for treatment of ZD from 2002 to 2011. METHODS: Retrospective chart review of 359 primary and revision ESD procedures performed on 337 unique patients between September 2002 and December 2011. Data were tabulated for age, sex, size of diverticulum, time to symptom recurrence, complications, and relief of symptoms. RESULTS: Of 337 attempted primary ESD procedures, 3.9% (N = 13) were aborted due to inadequate exposure. Of 324 patients who underwent primary ESD, 93.8% (N = 304) reported postoperative improvement of dysphagia symptoms. There was a 4.0% (N = 13) major complication rate. Patient-reported recurrence of symptoms occurred in 7.1% (N = 23) of primary ESD patients but was not significantly associated with diverticulum size (P = .9765). Twenty-one patients underwent revision ESD, with 95% (N = 20) of patients reporting improvement and 4.8% (N = 1) developing recurrent symptoms. CONCLUSION: Primary and revision ESD were shown to have similar success at relieving the symptoms of ZD, with low procedure abandonment and perioperative complication rates. Further patient follow-up is needed to determine the durability of symptom improvement and ZD recurrence rate following ESD.

Pain Experience and Tolerance of Awake In-Office Upper Airway Procedures: Influencing Factors.

OBJECTIVES/HYPOTHESIS: Awake, unsedated in-office upper airway procedures are performed frequently and have high completion rates, yet less is known about the patients' pain experience and potentially influencing factors. It is also unclear if patients' pain experiences become worse with repeated procedures. We identified procedure- and patient-related factors that might influence procedural completion and pain scores. STUDY DESIGN: Retrospective chart review. METHODS: Pre-, intra-, and post-procedure pain scores were collected prospectively for awake unsedated upper airway procedures performed at a single institution over a 5-year period. Patient factors reviewed were demographics, body mass index, psychiatric and/or pain diagnosis, and related medications. Procedure factors reviewed were procedure type, route, side, and performance of the same procedure multiple times. Patients reported their pain level before, during, and after the procedure using a standard 0 to 10 scale. Maximum pain score change (PΔmax), or the difference between highest and lowest reported pain levels, was calculated. Descriptive and multivariate analyses were performed. RESULTS: Procedure completion was 98.7% for 609 first time patients and 99.0% in 60 patients undergoing 292 repeat procedures. PΔmax did not covary with age, gender, or BMI. PΔmax covaried with pain and psychiatric conditions and associated medications. PΔmax was highest for injection medialization and lowest for tracheoscopy. PΔmax decreased over time for those undergoing multiple identical procedures. CONCLUSIONS: Procedures were performed with a very high completion rate and low pain scores. Age, sex, and BMI did not affect pain experience. A combination of pain and psychiatric conditions did. Injection medialization had the highest PΔmax and tracheoscopy the lowest. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1580-E1588, 2021.

Proteomic and Genomic Methylation Signatures of Idiopathic Subglottic Stenosis.

OBJECTIVE: Idiopathic subglottic stenosis (iSGS) is a chronic inflammatory condition that causes dyspnea and affects middle-aged women of White race and non-Latino or Hispanic ethnicity. To better characterize its phenotype and pathogenesis, we assessed the proteomic and genomic methylation signatures of subglottic tissue collected from iSGS patients compared to controls. STUDY DESIGN: Molecular analysis of clinical biospecimens. METHODS: We collected subglottic tissue biopsies from 12 patients during direct laryngoscopy, immediately prior to surgical treatment of iSGS; as well as from 4 age-, sex-, and race/ethnicity-matched control patients undergoing other direct laryngoscopic procedures. We isolated protein and genomic DNA, acquired proteomic data using label-free quantitative mass spectrometry techniques, and acquired genome-wide methylation data using bisulfite conversion and a microarray platform. We compared molecular profiles across the iSGS and control groups, and with respect to clinical course in the iSGS group. Eight of the 12 iSGS patients underwent subsequent blood collection and plasma isolation for further assessment. RESULTS: Proteomic analysis revealed 42 differentially abundant proteins in the iSGS biopsies compared to controls, inferring enrichment of biological pathways associated with early wound healing, innate immunity, matrix remodeling, and metabolism. Proteome-based hierarchical clustering organized patients into two iSGS and one control subgroups. Methylation analysis revealed five hypermethylated genes in the iSGS biopsies compared to controls, including the biotin recycling enzyme biotinidase (BTD). Follow-up analysis showed elevated plasma BTD activity in iSGS patients compared to both controls and published normative data. CONCLUSION: iSGS exhibits distinct proteomic and genomic methylation signatures. These signatures expand current understanding of the iSGS phenotype, support the possibility of disease subgroups, and should inform the direction of future experimental studies. LEVEL OF EVIDENCE: Not applicable Laryngoscope, 131:E540-E546, 2021.

Voice Outcomes following a Single Office-Based Steroid Injection for Vocal Fold Scar.

OBJECTIVE: Persistent dysphonia from vocal fold scar remains a clinical challenge, with current therapies providing inconsistent outcomes. We evaluated voice outcomes after a single office-based steroid injection. STUDY DESIGN: Case series with chart review. SETTING: Academic medical center. SUBJECTS AND METHODS: This study was based on pre- and postoperative analysis of patient-reported, perceptual, acoustic, aerodynamic, and videostroboscopic parameters. The sample comprised 25 patients undergoing office-based dexamethasone injection into the superficial lamina propria for mild/moderate vocal fold scar. Average follow-up was 13.7 ± 4.4 weeks; patients completed 3.5 ± 2.3 sessions of voice therapy between assessments. Complete data sets were not available for each parameter; sample size is noted with results. RESULTS: Voice handicap index (n = 24; P < .001) and glottal function index (n = 22; P < .001) decreased after injection. Total GRBAS score (grade, roughness, breathiness, asthenia, strain) decreased (n = 25; P < .001). Fundamental frequency range increased (n = 24; P = .024). Phonation threshold pressure decreased (n = 14; P = .017). Videostroboscopic parameters of vocal fold edge (P = .004), glottic closure (P = .003), and right mucosal wave (P = .016) improved after injection. CONCLUSIONS: Office-based steroid injection combined with voice therapy for mild/moderate vocal fold scar is associated with improved patient-reported and functional voice measures. These findings provide preliminary support for this approach. Importantly, the procedure is low risk and can be performed in the office, thus offering a simple treatment alternative to patients with a disorder that has traditionally been difficult to manage. Prospective studies evaluating the effects of multiple injections are warranted.

Evaluation of the Dysphonic Patient (in: Function Preservation in Laryngeal Cancer).

The evaluation of the dysphonic patient begins with a complete understanding of the laryngeal anatomy and physiology of voice production. A thorough history must be taken regarding the dysphonia qualities, alarming symptoms, and confounding factors. The complete head and neck examination culminates in a detailed visualization of the vocal folds using image-capturing laryngoscopy as well as stroboscopy or high-speed digital imaging to fully evaluate the viscoelastic properties of the vocal fold cover-body structure and function. Finally, the evaluation leads to the biopsy of any concerning lesions either under magnification in the operating room or topical anesthesia in the office.

Evaluation of preoperative hearing-in-noise protocol for osseointegrated hearing implants.

OBJECTIVE: Evaluate the clinical use of a preoperative protocol using hearing-in-noise improvement as measured by Adaptive HINT and Quick SIN in patients undergoing ossseointegrated hearing implantation for single-sided deafness (SSD). STUDY DESIGN: Prospective cohort. SETTING: Tertiary academic hospital and clinic. PATIENTS: All consecutive English-speaking patients with SSD undergoing osseointegrated hearing implantation whom we have preoperative and postoperative Quick SIN and Adaptive HINT measurements. INTERVENTIONS: Measure preoperative unaided and aided (headband simulator) hearing-in-noise ratio improvement and compare with postoperative results. MAIN OUTCOME MEASURES: The improvement in hearing-in-noise in preoperative unaided to aided and then correlate to postoperative hearing-in-noise results. RESULTS: Total of 12 patients participated in the study. There was a statistically significant improvement from preoperative unaided Quick SIN and Adaptive HINT scores to preoperative aided scores (p = 0.001 and p = 0.004). There was statistically significant improvement from preoperative unaided Quick SIN and adaptive HINT to postoperative implant scores (p = 0.002 and p = 0.003). Comparing preoperative aided with postoperative implant aided, there demonstrated a significant improvement in QuickSIN with -2.7 SNR (p = 0.045) and in HINT with -2.35 dB (p = 0.05). CONCLUSION: This is the first study evaluating a preoperative protocol using both Quick SIN and Adaptive HINT testing for osseointegrated hearing implantation. Postoperatively, there was a statistically significant improvement in both of the hearing-in-noise measures. There was significant correlation between the preoperative simulator and postoperative hearing-in-noise measures signifying the benefit of using Quick SIN and HINT as a predictive preoperative tool to evaluate surgical candidacy and improve patient education and expectations.

Evaluation of endoscopic harmonic diverticulostomy.

OBJECTIVES/HYPOTHESIS: The purpose of this study is to review a consecutive series of patients with Zenker's diverticulum who were treated with endoscopic diverticulostomy using either the endoscopic stapler (ENDO GIA 30 Autosuture; Covidien, Dublin, Ireland) or Harmonic Ultrasonic Surgical Instrumentation (Ethicon Endo-Surgery, Cincinnati, OH) to evaluate the safety and optimal application of Harmonic technology to the treatment of patients with Zenker's diverticulum. STUDY DESIGN: This is a retrospective review at a tertiary academic hospital with institutional review board approval. METHODS: All patients undergoing endoscopic repair of Zenker's diverticulum between April 1, 2009 and December 1, 2010 at a single institution were studied. RESULTS: A total of 65 endoscopic diverticulostomies were performed: 24 Harmonic assisted, 41 stapler assisted. Average diverticulum size was 3.46 cm. There were two complications with staple-assisted (pharyngeal leak and recurrence) and six complications with Harmonic-assisted diverticulostomies (two pharyngeal leaks, two chest pains, one recurrence, and one subcutaneous emphysema). There was a statistically significant difference in the complication rates between the staple-assisted (4.88%) and Harmonic-assisted (25%) cohorts (P = .04). There were no complications with diverticula <2 cm. CONCLUSIONS: Endoscopic Harmonic esophagodiverticulostomy has been reported for the treatment of Zenker's diverticula. However, our data demonstrate a significantly higher complication rate with use of the Harmonic technology compared to the staple-assisted method (P = .04). Additional evaluations are warranted to validate these findings and before Harmonic diverticulostomy can be recommended as treatment for the majority of cases.

The effect of dilute baby shampoo on nasal mucociliary clearance in healthy subjects.

BACKGROUND: Biofilm formation has been implicated as an etiologic factor in the development of chronic rhinosinusitis (CRS). Nasal irrigation with surfactants including dilute baby shampoo have been proposed as an antibiofilm treatment for CRS patients. The effect of dilute baby shampoo on normal sinonasal mucosal function is unknown. METHODS: Mucociliary clearance time (MCT), as measured by the time in minutes for a subject to detect a sweet taste after the application of a saccharin granules at the anterior part of the inferior turbinate, was performed before and shortly after nasal irrigation with 50 ml of 1% baby shampoo (Johnson & Johnson, New Brunswick, NJ) in 27 healthy volunteers. RESULTS: Mean MCTs before and after irrigation were 12.09 (±4.83 minutes) and 15.45 (±7.71 minutes) minutes, respectively. The mean difference, 3.37 minutes, was statistically significant (p = 0.031). Pre- and post-MCTs for each subject were not correlated (r = 0.324; p = 0.100). CONCLUSION: Nasal irrigations with dilute baby shampoo increase MCTs in healthy subjects. The impact of such interventions in CRS patients warrants additional investigation.