Abstract
Analysis of the Laryngeal Morphology and Acoustic Measurement after SCPL
Pei Chen, MD (Presenter); Xiaohui Du
Objectives: To investigate the significance of acoustic data of mobility pattern and tissue texture of neoglottis after different types of supracricoid partial laryngectomy (SCPL).
Methods: Eleven patients who have undergone SCPL, which included cricohyoidoepiglottopexy (CHEP), cricohyoidopexy (CHP), or CEP/Tucker, for the treatment of laryngeal cancers in our hospital were assessed with acoustic analysis and Xion stroboscopic laryngoscope equipment 1 year after operation. Acoustic parameters and the mobility performance of the neoglottis were recorded at the same time and then compared and analyzed.
Results: In patients who underwent CHP-SCPL with unilateral arytenoids spared, neoglottis closure and regular local mucosal vibration were formed and well involved in vibration sound source and speech. In patients who underwent CHP with unilateral arytenoids spared, neoglottis closure and irregular local mucosal vibration could be formed during pronunciation, which were not well involved in vibration sound source and speech. Patients who underwent SCPL-CEP/Tucker with the bilateral arytenoid spared failed to form a good closure of the neoglottis when pronouncing. They were unable to form a regular vibration of local mucosa in the laryngeal cavity, and only breath sound and breath speech could be measured.
Conclusions: Voice and speech in the neoglottis after SCPL can appear as different patterns: effective vibration sources (with small or no breath sounds) that can participate in articulation and speech, ineffective vibration sources (large breath sounds) that are difficult to participate in articulation and speech, and full breath sound.
Assessment of Swallowing in Patients with Cleft Lip and Palate
Emire Aybuke Erdur (Presenter); Osman Gul; Zeliha Muge Baka; Omer Erdur, MD; Kayhan Ozturk, MD
Objectives: With the diagnosis of cleft palate/lip (CLP), swallowing is a major concern for patients and their parents. The aim of this study was to evaluate the swallowing in patients with repaired CLP in the late postoperative period.
Methods: This study consists of 20 repaired CLP patients who applied to the orthodontics clinic for treatment between 2016 and 2018. During orthodontic treatment, patients were referred to the otolaryngology clinic for swallowing evaluation. Patients underwent a modified barium swallowing study (MBSS) and a functional endoscopic evaluation of swallow study (FEES). Patients were also assessed by the pEAT-10 and eating behavior questionnaire.
Results: Eleven patients had no complaints of dysphagia of aspiration. Nasal regurgitation in 6 patients, severe penetration in 1 patient, and oral and laryngeal bolus remnants in 4 patients were present on MBSS. On FEES examination, nasal regurgitation in 6 patients, oral control failure in 2 patients, oral and laryngeal bolus remnants in 4 patients, and partial swallowing in 3 patients were observed. The patients were given appropriate swallowing therapies, and all improved.
Conclusions: Swallowing behavior is normally achieved by harmonious activity of the masticatory muscles, suprahyoid muscles, muscles of the soft palate, infrahyoid muscles, and muscles of the larynx. CLP patients may need this relatively larger physiologic effort for velopharyngeal closure activity during speaking and swallowing. From these findings, it is suggested that the dysfunction of the oropharynx in CLP patients influences the swallowing function in terms of muscle activity. Therefore, a swallowing evaluation in CLP patients is important to prevent possible morbidities.
BTX Injections Improve Work Productivity for Spasmodic Dysphonia Patients
Tanya K. Meyer, MD (Presenter); Rachel Kaye, MD; Charles Spiekerman; Andrew Blitzer, MD, DDS; Edward M. Weaver, MD, MPH
Objectives: A disordered voice can adversely affect performance in the workplace. Spasmodic dysphonia (SD) profoundly impairs vocal function, and botulinum toxin (BTX) injections into the intrinsic laryngeal musculature improves vocal function. There are no prospective studies testing the impact of SD or its treatment on work productivity. We hypothesized that BTX treatment in SD patients would improve work productivity as measured with the Work Productivity & Activity Impairment (WPAI) instrument. We also hypothesized that the WPAI would demonstrate good test-retest reliability.
Methods: This prospective case series included employed patients diagnosed with SD treated by BTX injections between July 2016 and July 2018 at a university laryngology clinic. Participants completed the WPAI immediately prior to BTX injection (baseline), again at 4 weeks postinjection (outcome), and again at 5 weeks postinjection (retest). We tested improvement (paired t-test) and test-retest reliability (intraclass correlation).
Results: Participants (N = 58) had a 16.7% improvement in voice-related work productivity impairment (95% confidence interval [CI] 9.5-23.9, P < .001) and 13.8% improvement in nonwork activity impairment (95% CI 7.8%-19.7%, P < .001). The WPAI showed good test-retest reliability with an intraclass correlation of 0.72 (P < .001).
Conclusion: Patients with SD report that BTX treatment significantly improves their work productivity and activity impairment. The WPAI is a reliable instrument for measuring work productivity and activity impairment.
Chronic Syndromes and Their Laryngeal Manifestations
Krzysztof Piersiala, MD (Presenter); Lee M. Akst, MD; Alexander T. Hillel, MD; Simon R. Best, MD
Objectives: Chronic syndromes of an unknown etiology such as fibromyalgia, irritable bowel syndrome (IBS), and chronic fatigue syndrome are traditionally considered distinct entities. However, some believe that these disorders exist on a spectrum with shared pathophysiology. We therefore hypothesized that the clinical manifestation of these syndromes would be similar in a population presenting with voice and laryngeal disorders (VLD).
Methods: Case-control, retrospective, chart review of 4251 patients seen between January 2016 and December 2017 at the Johns Hopkins Voice Center. Diagnoses related to VLD were subdivided into 5 main categories (laryngeal pathology, functional voice disorders [FVD], airway, swallowing, other). Diagnoses, demographic data, and comorbidities were collected.
Results: A total of 227 patients suffering from at least 1 chronic syndrome were identified in the total clinic population (5.3%). There was a strong female predominance (81%). FVDs were common in patients with fibromyalgia (64%), IBS (48%), and chronic fatigue (36%) vs 29% in the control population (P < .00001, .0004, .25). In particular, the prevalence of muscle tension dysphonia was higher in all chronic syndromes (50.6%, 36.0%, 31.0%, respectively) vs 18% in the control group (all P values <.01). The prevalence of objective clinical findings such as airway problems (2.2% vs 11.75%; P < .0001) or cancer (0.9% vs 3.7%; P < .05) was significantly lower in the cases compared with controls.
Conclusion: The clinical manifestations of different chronic syndromes are indistinguishable from each other in their voice and airway presentation. This finding lends support to the theory that they are different manifestations of a shared pathophysiology.
Clinical Evolution of Acid, Nonacid, and Mixed Laryngopharyngeal Reflux
Jerome R. Lechien, MD, PhD (Presenter); Francois Bobin, MD; Vinciane Muls, MD; Didier Dequanter, MD, PhD; Mihaela Horoi, MD; Marie-Paule Thill, MD; Alexandra Rodriguez Ruiz, MD; Sven Saussez, MD, PhD
Objectives: To assess the evolution of symptoms and findings of laryngopharyngeal reflux (LPR) patients according to the type of reflux (acid, nonacid, mixed, and gastroesophageal [GERD]).
Methods: A total of 113 patients with LPR were recruited from 3 European hospitals. According to the reflux characteristics at the impedance-pH monitoring (acid, nonacid, mixed), patients received a personalized treatment based on the association of diet, pantoprazole, Gaviscon, and magaldrate for 3 months. Reflux Symptom Score (RSS) was assessed at baseline, 6 weeks, and 12 weeks after treatment. Reflux Sign Assessment (RSA) was used to rate laryngeal and extralaryngeal findings at baseline and 12 weeks after treatment. Overall success rate and the evolution of symptoms and findings were evaluated according to the LPR groups.
Results: Eighty-two LPR patients (35 acid, 20 nonacid, 27 mixed, including 33 with LPR and GERD) completed the study. RSS and RSA total scores significantly improved from baseline to posttreatment in the acid and nonacid groups (P < .02). The 3-month RSS improvement of patients with mixed LPR was not significant (P = .09), whereas the improvement of patients with GERD and LPR did not differ from those without GERD (P = .07). The mean success rates of treatment ranged from 68.6% to 75.7%, and there was no significant difference between groups. Many extralaryngeal findings, which are not described in the reflux finding score, were significantly associated with LPR and improved throughout treatment.
Conclusions: LPR laryngeal and extralaryngeal symptoms and findings significantly improved throughout treatment in LPR patients. The symptom evolution of patients with mixed reflux could be less favorable than those with acid and nonacid LPR.
Decreased Tongue Volume after Radiation
David Garber, MD (Presenter); Janine M. Rotsides; Sara Abu Ghanem, MD; Mari Hagiwara; Aaron Johnson, PhD; Milan R. Amin, MD
Objectives: To evaluate volume changes within the tongue after radiation therapy (RT) and improve our understanding of causes of post-RT tongue dysfunction.
Methods: A retrospective study was conducted to evaluate tongue volume changes in 20 patients who received RT as part of the primary treatment for tonsillar squamous cell carcinoma. Tongue volumes were calculated from thin-slice computed tomography images collected before RT and up to 29 months after RT. Tongue volumes were calculated by 3 separate imaging technicians using 3-dimensional visualization software (Vital Images). Linear mixed-effects models were used to examine the relationships between time postradiation (months), body mass index (BMI), and tongue volume (cm3).
Results: Interrater reliability was high, with an intraclass correlation coefficient of 0.857 (95% confidence interval = 0.787-0.909). The linear mixed-effects model showed a significant (P < .001) relationship between tongue volume and BMI, with a 1.9 cm3 decrease in tongue volume per unit decrease in BMI. In addition, BMI significantly (P < .001) decreased by 0.12 units per month after radiation.
Conclusions: In this study, we found lingual atrophy occurred following RT, and that this was significantly correlated with loss of BMI over time. Tongue dysfunction and decreased tongue strength are significant contributors to the dysphagia that patients experience after receiving RT. Furthering our understanding and the characterization of radiation-induced changes of the tongue can potentially help guide future treatments and therapies for these patients.
Does Age Impact Botulinum Neurotoxin Treatment in Adductor Spasmodic Dysphonia?
Richard Heyes, MD (Presenter); Charles Adler, MD, PhD; Nan Zhang; Wenli Chen, MS, CCC-SLP; David G. Lott, MD; Stephen F. Bansberg, MD
Objectives: This study aims to analyze the impact of the age of first treatment on outcomes in adductor spasmodic dysphonia (AdSD).
Methods: A database review of all spasmodic dysphonia patients treated with botulinum neurotoxin (BoNT-A) from 1989 to 2018 at Mayo Clinic Arizona was performed. Patients were diagnosed with primary AdSD after a comprehensive neurological, otolaryngological, and speech evaluation. Only patients who had received ≥4 injections of BoNT-A for AdSD were included. Patients were divided into 2 cohorts, with an age of first treatment cutoff of 60 years.
Results: Final analysis included 398 patients, with 199 receiving their first injection at 60 years or younger (50%) and 199 receiving their first injection after their 61st birthday (50%). Documentation of age of voice onset was present in slightly more than half of patients, with means of 40 and 62 years in the younger and older cohorts, respectively. Younger patients were more likely to be male than in the older cohort (27% vs 12%; P < .01). Length of follow-up was similar (median 6 years; P = .26), but younger patients received a higher median number of treatments (13 vs 9; P < .01). Older patients were more likely to have coexistent vocal tremor (P < .01) or another movement disorder (P = .03). Mean dose was statistically significantly higher in the younger cohort (4.4 vs 3.9 units; P = .048). Mean maximal benefit was similar (72% vs 70%; P = .48); however, mean length of benefit was significantly shorter in younger patients (3.0 vs 3.6 months; P < .01). Length of posttreatment breathiness and dysphagia was not statistically significantly different.
Conclusions: Our analysis suggests that younger patients require higher doses of BoNT-A, with their length of benefit being shorter than in older patients.
Dysphagia in the Geriatric Population
Sina Mehraban-Far (Presenter); James Alrassi; Melissa M. Mortensen, MD
Objectives: To understand the difference in the etiology of dysphagia between early-elderly (65-74 years), middle-elderly (75-84 years), and late-elderly (>84 years) patients.
Methods: A retrospective chart review was undertaken of 5632 patients undergoing a videofluoroscopic swallowing study (VFSS) for a chief compliant of dysphagia at a tertiary care university hospital between January 2010 and June 2018. All patients age 65 years and older were included in the study (n = 732). Chi-squared test was used to compare the patients’ diagnoses between the early-elderly (n = 237), middle-elderly (n = 272), and late-elderly (n = 223).
Results: Patients in the early-elderly group were 7.1 times more likely to have a head and neck cancer (P < .001), whereas patients in the late-elderly group were 5 times more likely to have dementia (P < .001). Head and neck cancers represented 22.4% of early-elderly cases, whereas dementia represented 27.35% of late-elderly cases. Most (45%) of the late-elderly patients did not have any cerebrovascular, neurodegenerative, or musculoskeletal diagnoses. The major cause of dysphagia in this group was presbyphagia, age-related sarcopenia in the swallowing muscles. Presbyphagia was 1.51 times more likely to be the cause of dysphagia in the late-elderly than in the early-elderly (P < .001). Linear regression showed that with each 1-year increase in age, the odds of having presbyphagia increases by 3.7% (odds ratio = 1.037; 95% confidence interval, 1.019-1.056).
Conclusions: There is a significant difference in the etiology of dysphagia as a function of age among the elderly, with presbyphagia accounting for nearly half the cases in patients older than 84 years. This emphasizes the importance of screening our oldest patients for presbyphagia.
The Effect of Adipose-Derived Stem Cells on Sulcus Vocalis
Aysegul Batioglu-Karaaltin (Presenter); Muge Ugurlar; Huseyin Dag; Fatma Eyuboglu; Erol Rustu Bozkurt; Ozcan Ozturk
Objectives: To evaluate the efficiency of stem cell therapy in sulcus vocalis (SV) in the light of regenerative perspectives in vocal fold scarring and atrophy.
Methods: Twenty-one New Zealand white rabbits (3.5 ± 0.5 kg) were included in the study. After performing SV modeling and the evaluation of larynx endoscopically, 17 rabbits with SV formation were divided into 3 groups randomly, and Q-tracker–labeled adipose-derived stem cell (ADSC) and hyaluranic acid (HA) injections were performed. In group 1 (n = 7), the right vocal cords of the rabbits were injected with ADSC. In group 2 (n = 7), the right vocal cords of the rabbits were injected with HA. In group 3 (n = 3), the right vocal cords of the rabbits did not receive any injection after SV formation, and these served as the control group. In the fourth week after the endoscopic visualization of vanishing of SV in groups 1 and 2, all rabbits were killed, and their larynxes were harvested. Histopathological analyses of the larynxes were indicated by hematoxylin and eosin staining and immunofluorescence.
Results: Four weeks after ADSC and HA injections, through evaluation under a light microscope, volumetric expansion, which results in smooth epithelium of vocal fold, was seen in the areas of sulcus in groups 1 and 2 in contrast to group 3. In group 2, foreign-body reaction and granuloma formation against HA were analyzed histopathologically in contrast to group 3, in which no reaction was observed. Moreover, in group 1, injected ADSC exhibited fluorescence, and positive Q-tracker immunostaining on microscopy confirmed the in vivo survival of ADSC.
Conclusions: The regenerative effect of ADSC has been proven by many studies in vocal fold scarring. It is predicted that ADSC might have potential to recover sulcus both by volume expansion and regeneration.
Inhibition of TH2 CD4 T-cell Differentiation Attenuates Laryngotracheal Stenosis
Kevin Motz, MD (Presenter); Michael Murphey; Dacheng Ding, MD, PhD; Alexander Hillel, MD
Objectives: Investigate the effects of inhibiting the differentiation of TH2 CD4+ T cells, via selective deletion of the Rictor gene in CD4 T cells, on the development of airway fibrosis in a murine model of laryngotracheal stenosis (LTS).
Methods: Using an in vivo, in situ bleomycin-induced murine model of LTS, in which subglottic scar is induced by disrupting the tracheal epithelium with a wire brush coated in bleomycin, the development of airway fibrosis was assessed in CD4 Cre-Rictor floxed (TH2-deficient) and CD4 Cre-WT (wild-type [WT]) mice. Primary outcomes included (1) histological assessment of tracheal lamina propria thickness at days 7, 14, and 21; (2) a 21-day Kaplan-Meier survival analyses; and (3) comparison of fibrosis-related gene expression using quantitative real-time polymerase chain reaction.
Results: Wild-type (WT) mice had significantly thickened lamina propria compared with TH2-deficient mice at days 7 (75.2 vs 55.1 µm, P < .05), 14 (85.0 vs 53.4 µm, P < .05), and 21 (88.2 vs 50.8 µm, P < .01), as determined by radial measurements of axial-cut hematoxylin and eosin–stained trachea samples. A 21-day survival analysis demonstrated a 60.9% survival rate in the TH2-deficient group as compared with 26.1% in WT mice (P = .02). Gene expression analysis revealed decreased collagen-1 gene expression in TH2-deficient mice.
Conclusions: Selective inhibition of the TH2 lineage of CD4 T cells in a mouse model of LTS attenuates the development of laryngotracheal scarring and improves overall survival. These data suggest that therapeutics aimed at modulating the CD4 T-cell response, specifically inhibiting TH2 CD4 T cells, represent a potential intervention for disease modulation in patients with LTS.
Machine Learning as a Method to Detect Vocal Fold Immobility
Anthony Law, MD, PhD (Presenter); Albert L. Merati, MD; Tanya K. Meyer, MD; Mark Whipple, MD, MS
Objectives: Diagnosing vocal fold paresis and paralysis often poses a significant clinical challenge. The endoscopic markers of dysfunction are often subtle, and there has been a well-described less-than-optimal interrater reliability for identifying paresis, paralysis, or even the side of dysfunction. We aim to quantify vocal fold motion using a deep neural network on previously recorded endoscopic exams in an attempt to identify objective measures of vocal fold motion abnormalities.
Methods: We use retrospectively collected endoscopic exams of 50 patients with normal motion (20), paresis (15), or paralysis (15) of the true vocal fold (unilateral) to train a deep neural network to identify the borders of the true vocal folds from recorded endoscopic exams. Labeled vocal folds were used to calculate the angle between the medial borders of the true vocal fold as a function of time. The trained model is then applied to 40 independent patients with normal and abnormal vocal fold motion. Clustering of resultant curves were correlated with pathological groups as determined via electromyography (EMG), namely, normal, paresis, or paralysis.
Results: Our model showed good classification of vocal fold paresis and paralysis when compared with the gold standard EMG. No correlation, however, could be determined between studied variables and the side of vocal cord dysfunction.
Conclusions: Computer-aided analysis of vocal fold motion offers a reliable and accurate means of determining normal motion from paresis or from complete paralysis. Further study is necessary to aid with determining the side of dysfunction.
Mental Illness and Voice Disorders
Krzysztof Piersiala, MD (Presenter); Lee M. Akst, MD; Alexander T. Hillel, MD; Simon R. Best, MD
Objectives: Mental illnesses are very common; understanding their clinical manifestations in terms of voice and laryngeal disorders (VLD) is important, as they constitute a significant proportion of all patients seen by otolaryngologists–head and neck surgeons. In this study, we examine different mental illnesses and their presenting symptoms and diagnoses of VLD.
Methods: Case-control, retrospective, chart review of patients seen between January 2016 and December 2017 at the Johns Hopkins Voice Center. Diagnoses, demographic data, and comorbidities were collected. VLD were grouped into categories (laryngeal pathology, functional voice disorders [FVD], airway, swallowing, other) for statistical analysis.
Results: Of a total of 4521 patients, 801 (17.7%) individuals had at least 1 mental illness diagnosis. The group consisted of 454 patients suffering from depression, 384 with anxiety, 72 with bipolar disorder, 86 with alcohol abuse, 45 with substance dependence, and 76 other diagnoses. There was a strong female predominance (male:female = 1:2). The rates of muscle tension dysphonia (25%) and subjective dysphagia (22%) were significantly higher than in the control group (16.0%; P = .04 and 11.2%; P = .0001). Substance and/or alcohol dependence was highly associated with objective vocal cords disorders compared with controls (cancer, 5%; chronic laryngitis, 13%). Diagnostic heat maps for different mental illnesses show unique patterns of VLD that differ significantly from controls.
Conclusions: Patients suffering from mental illness present more frequently with FVDs and swallowing complaints, and awareness of this can guide appropriate referrals. Objective laryngeal findings are common in patients with substance abuse disorders, and they should be screened with careful diagnostic laryngoscopy.
New Insights Regarding Proprioceptive Innervation of the Rat Larynx
Victoria X. Yu (Presenter); Ignacio Hernandez-Morato, PhD; Susan B. Morton, MS; Michael J. Pitman, MD
Objectives: Controversy remains over whether canonical proprioceptive organs, muscle spindles (MS), and Golgi tendon organs (GTO) exist in the intrinsic laryngeal muscles (ILM). Proprioception likely plays a role in disorders such as spasmodic dysphonia and vocal fold paralysis. We investigate proprioceptive organs in the rat larynx with a novel approach using vesicular glutamate transporter 1 (VGLUT1), a marker of afferent sensory nerve endings that has been used to identify MS and GTO in other muscle groups.
Methods: Larynges of 16 rats distributed across 5 age groups (P3, P8, P11, P14-15, and adult) were sectioned and immunostained for VGLUT1 and beta-tubulin III. All sections were analyzed using fluorescence microscopy to identify colocalization of the 2 markers. These data were used to create a map of VGLUT1 expression in the rat larynx.
Results: No MS or GTO was observed in the ILM of any group. VGLUT1+ intramuscular nerve endings were identified in the posterior cricoarytenoid of all adult rats but not in young pups. In addition, VGLUT1+ nerve endings were observed in the mucosa overlying the base of the arytenoid cartilage and in nerve-associated tissue forming paraganglia.
Conclusions: Rat ILM do not contain traditional proprioceptive organs but do contain intramuscular sensory nerve endings and paraganglia whose functions are unknown. These findings suggest that a modified or perhaps unique proprioceptive apparatus governs the rat larynx. Elucidating this apparatus is essential to understanding laryngeal proprioception and its impact on clinical pathology.
A Novel Surgical Technique for the Management of Drooling
Omer Erdur, MD (Presenter); Kayhan Ozturk, MD
Objectives: Various medical and surgical techniques are used to manage drooling, but none is standardized. We aimed to evaluate the efficiency of a new surgical technique in patients with persistent drooling.
Methods: We selectively denervated the submandibular and sublingual glands via the transoral route. The lingual nerve is skeletonized for identifying branches running to the submandibular and sublingual glands. The parasympathetic postganglionic fibers were followed and cauterized and then cut. The saliva disorder severity-frequency form, Teacher’s drooling scale, drooling impact score, and visual analogue scale were used before and after the procedure to evaluate the technique’s efficiency.
Results: Fourteen patients whose drooling was not controlled with conventional methods were operated on with this technique. Of these patients, only 3 patients did not benefit and needed additional surgical techniques. The drooling evaluation scores of the 11 patients were statistically significantly reduced (P < .05).
Conclusions: This noninvasive surgical technique was found effective for the management of drooling among those who did not benefit from conventional techniques.
Pharyngeal Contractile Integral: An Indicator of Postdeglutitive Bolus Residue
Alexandra Hamberis (Presenter); Elise Zhao; Kate Davidson; Shaun A. Nguyen, MD, MA; Ashli K. O’Rourke, MD
Objectives: To examine the efficacy of pharyngeal contractile integral (PhCI) measurement in predicting the normalized residue ratio scale (NRRS) and to recognize the diagnostic and therapeutic utility of these measurements in predicting a patient’s risk for bolus residual and postdeglutitive airway invasion.
Methods: Adult dysphagic patients were recruited between 2015 and 2016 to undergo simultaneous high-resolution pharyngeal manometry (HRPM) and videofluoroscopy during a standardized swallowing protocol. Two independent reviewers measured PhCI and NRRS for swallows of 5 mL thin liquid, 5 mL nectar-thick liquid, and 5 mL pudding boluses with very good interrater reliability (κ = 0.887).
Results: A total of 41 patients were included in the initial analysis; 22 were women and 19 were men, with a mean age of 61 years (range, 28-86 years). The clearance of thin, nectar thick, and pudding residue from the vallecular space was associated with PhCI (P < .05), with poorer contractility being associated with higher levels of residue. Thin liquid and pudding residue in the piriform sinuses were also associated with PhCI (P < .05); PhCI for nectar-thick residue clearance in the piriform sinus approached significance (P = .08), but data are underpowered.
Conclusions: PhCI is significantly correlated with residue clearance for liquids of various consistencies and can be used clinically to predict the presence of postswallow residue and thus airway invasion risk. Further analysis will be carried out to determine a threshold PhCI value above which residue clearance is expected.
A Prospective Open Label Trial Using Xeomin for Adductor Spasmodic Dysphonia
Nikita V. Kohli, MD (Presenter); Michael Z. Lerner, MD; Diane N. Kirke; Jamie Rashty; Andrew Blitzer, MD, DDS
Objectives: To demonstrate an understanding of the efficacy of Xeomin (incobotulinum toxin A) in the treatment of adductor spasmodic dysphonia (SD) and to explain that Xeomin can successfully be used as an alternative to onabotulinum toxin A (BoNT-A) and for secondary nonresponders.
Methods: We conducted a prospective open-label trial from 2016 until the present day regarding the use of Xeomin for the treatment of adductor SD. Exclusion criteria included pregnant/nursing women, toxin for other indications, known allergy, neuromuscular or systemic diseases, use of aminoglycoside antibiotics, substance abuse, litigation regarding prior therapy, or other confounding conditions. Fifteen patients were enrolled in the study and underwent electromyography-guided Xeomin injections to the thyroarytenoid muscle using a hollow monopolar Teflon-coated needle via a transcricothyroid membrane approach. Dosages to each thyroarytenoid muscle were recorded, and patients completed the Voice Handicap Index–10 (VHI-10), a validated worksheet regarding their perceived percentage of normal function following treatment, and a side effect profile.
Results: Participants achieved an average of 76% peak benefit (range, 30%-100%) as compared with 59% prior to initiating Xeomin (range, 25%-90%). VHI-10 was available for only 8 participants but decreased from 24 initially to 17 at follow-up. This is likely because VHI-10 was assessed at the time of follow-up when patients required toxin as the toxin had worn off by this time. Transient side effects included breathiness and strained voice.
Conclusions: Our study demonstrates the safe and effective use of Xeomin for adductor SD either as first-line treatment or in secondary nonresponders to BoNT-A that will provide physicians and patients an alternative treatment.
Rheology of Saliva in Health and Disease
Shruthi K. Rereddy (Presenter); Brendan Blackwell, PhD; Paolo Arratia, PhD; Natasha Mirza, MD
Background: The viscoelastic flow behavior of saliva is essential to its many functions in the upper aerodigestive tract. Although xerostomia is often equated with hyposalivation, high-risk patients frequently report oral dryness and associated symptoms in the absence of decreased salivary flow. It is unknown whether changes in salivary rheology in patients with xerostomia may be contributing to this pathology.
Objectives: To determine how volumetric flow rate and rheologic properties of saliva differ in healthy individuals compared with patients with xerostomia.
Methods: The study population was patients with postradiation xerostomia, patients with anticholinergic-induced xerostomia, and age-matched healthy controls. All participants filled out a standardized xerostomia questionnaire and provided a saliva sample. Saliva was tested to determine volumetric flow rate. The steady shear viscosity and viscoelasticity of saliva was measured using a rotational rheometer. The extensional viscosity of saliva was characterized via dripping onto substrate rheometry or quantifying the capillary thinning of a liquid filament.
Results: Preliminary results indicate significant differences in the volumetric flow rate, steady shear viscosity, viscoelasticity, and extensional viscosity of saliva in healthy individuals compared with patients with xerostomia.
Conclusions: Xerostomia is associated not only with decreased salivary flow but also significant changes in the rheologic properties of saliva.
Risk Factors for Vocal Cord Paralysis following Thyroid Surgery
Filipe André Correia, MD (Presenter); Gustavo Antunes De Almeida, MD; Pedro Alberto Escada, MD, PhD; Maria-Clara P. Capucho, MD
Objectives: To revise the voice evaluation protocol in patients undergoing thyroid surgery, study transient and permanent vocal cord paralysis rates after thyroid surgery, and identify perioperative factors associated with an increasing risk of voice changes.
Methods: A retrospective study was conducted at a high-volume thyroid surgery center, including patients under the voice evaluation protocol between 2009 and 2015. Collected data included compliance to protocol; patients, disease, and surgery characteristics; and perioperative vocal evaluation. Univariate and multivariable analyses were performed to search for association of perioperative factors with voice changes.
Results: A total of 962 thyroid surgeries were included. One out of 5 skipped preoperative evaluation, and only 5% of asymptomatic patients completed the full protocol with 3 postoperative visits. Eighty-six percent were female, and most were age 50 to 70 years, with benign lesions of the thyroid gland. Thirty-two percent scored higher than 3 on preoperative Bethesda cytology classification. In the first postoperative visit, 16.6% reported voice changes, and vocal cord paralysis was detected in 11.4%. Permanent paralysis was diagnosed in 6.4%. Total thyroidectomy was performed in 52% of cases and had a higher risk of vocal cord paralysis compared with unilateral lobectomy (13.6 vs 6.1%, P < .05). Locally advanced malignant tumors were associated with higher rate of permanent paralysis (P < .05). Second surgery, malignant cytology, histology, or diabetes did not relate to higher rates.
Conclusions: The number of participants lost to follow-up led us to reduce postoperative voice evaluations to 2 in asymptomatic patients. Vocal cord paralysis is more common in patients undergoing total thyroidectomy and with locally advanced tumors. This risk should be discussed with the patient, particularly in benign unilateral disease.
Safety of Ambulatory Type 1 Thyroplasty
Jena Patel (Presenter); Maurits Boon, MD; Colin T. Huntley, MD; Joseph R. Spiegel, MD
Objectives: Type 1 thyroplasty is commonly performed for the treatment of vocal fold weakness and has been shown to reliably improve voice and swallowing function. At our institution, this procedure is routinely performed on an outpatient basis when patients are medically stable. In this study, we assess the safety of outpatient thyroplasty by examining a large cohort of consecutive cases for complication rates, readmission, revision surgery, and predictors of these outcome measures.
Methods: We performed a retrospective review of patients at our institution undergoing primary thyroplasty for vocal fold paresis or paralysis between 2013 and 2018. We documented etiology of paresis/paralysis, comorbidities, and demographic data. Our primary outcome measures were need for hospitalization, hospital length of stay, surgical and postsurgical complications, need for readmission, and need for repeat surgery.
Results: During the study period, 184 patients met our inclusion criteria. This included 90 men and 94 women with (mean ± standard deviation) age and body mass index (BMI) of 63.24 ± 13.97 years and 26.56 ± 5.48, respectively. A total of 157 patients underwent unilateral thyroplasty, and 27 underwent bilateral thyroplasty with a mean ± standard deviation length of stay of 0.24 ± 0.68 days. A total of 152 patients underwent outpatient surgery. Ten patients required readmission for complications. There were no instances of postoperative airway compromise. There were no mortalities. The only demographic or comorbidity we found predictive of our outcome measures was a history of vocal fold surgery (excluding prior thyroplasty) predictive of the need for revision surgery (P = .004).
Conclusions: In patients medically stable for same-day surgery, type 1 thyroplasty can be performed safely on an outpatient basis.
Systematic Review of Randomized Controlled Trials in Laryngology: 30-Year Review
Anne S. Lowery (Presenter); Alexander Gelbard, MD
Objectives: Identify trends in randomized, controlled trials (RCTs) in leading otolaryngology journals in the field of laryngology.
Methods: Using MeSH search terms in PubMed, we reviewed RCTs published in 4 major otolaryngology journals from 1976 to 2018. We subsequently identified RCTs published in the field of laryngology. Data extrapolated from published articles include study quality, authors’ conclusions, pathologies, types of interventions, and study funding and support.
Results: Of a total of 995 articles identified as RCTs in otolaryngology, 40 articles were in the field of laryngology. Nineteen articles were published between 2010 and 2018, 17 between 2000 and 2009, and 4 between 1990 and 1999. The 2 most prevalent pathologies were spasmodic dysphonia (5) and vocal fold paralysis (5). Articles average 4.8 authors, with an average of 48.4 patients. Fifty-five percent used intent-to-treat analysis, 48% were double-blinded, 95% used P values, and 5% used confidence intervals. The vast majority of RCTs had medical (17) and surgical/procedural (16) interventions, with a minority involving physical or voice therapy (5) and alternative medicine (2) interventions. The quality of RCTs was fair, with an average Jadad score of 3 (out of a maximum of 5). Most investigators (80%) concluded that experimental intervention was preferred over control interventions.
Conclusions: RCTs are uncommon in laryngology, making up a small proportion of total RCTs published in otolaryngology. However, there has been an encouraging uptrend in recent years. The quality of published RCTs in laryngology is fair, and researchers designing or interpreting RCTs should remain critical of the study’s methodology.
Unilateral versus Bilateral Botox an Injection in Adductor Spasmodic Dysphonia
Richard Heyes, MD (Presenter); Charles Adler, MD, PhD; Nan Zhang; Wenli Chen, MS, CCC-SLP; David G. Lott, MD; Stephen F. Bansberg, MD
Objectives: This study aims to analyze the efficacy of unilateral dosing of botulinum toxin (BoNT-A) in comparison with bilateral dosing in the treatment of adductor spasmodic dysphonia (AdSD).
Methods: A database review of all spasmodic dysphonia patients treated with BoNT-A from 1989 to 2018 at Mayo Clinic Arizona was performed. Patients were diagnosed with primary AdSD after a comprehensive neurological, otolaryngological, and speech evaluation. Only patients who had received a total of 10 treatments that included both bilateral and unilateral dosing with adequate follow-up were included; therefore, participants acted as their own controls.
Results: Our database search identified 795 patients. The final analysis included 26 patients. These patients were predominately female (73%), had coexistent vocal tremor in 11 cases (42%), and had a mean age at first injection of 50 years. Mean follow-up period was 14 years, and patients received a mean of 36 total treatments. Overall, patients had a mean of 11 unilateral and 25 bilateral injections. Mean dose was statistically significantly higher when injected bilaterally (3.2 vs 2.2 units; P < .01). Mean maximal benefit was higher when patients received bilateral injections (79% vs 69%; P < .01), and mean length of benefit was significantly longer when treated bilaterally (2.7 vs 2.2 months; P < .01). However, bilateral injections were associated with statistically significantly longer periods of posttreatment breathiness (18 vs 11 days; P < .01) and dysphagia (2.5 vs 1.2 weeks; P = .03).
Conclusions: Our analysis suggests that bilateral thyroarytenoid injection of BoNT-A in AdSD provides superior maximal efficacy with longer treatment benefit but at the expense of longer posttreatment breathiness and dysphagia.
Use of Obesity and the I-TRACH Scale to Predict Prolonged Mechanical Ventilation
Diana Shao (Presenter); Jeffrey Straub, MD; Laura A. Matrka, MD
Objectives: Examine the effect of including obesity with parameters of the I-TRACH scale in predicting the need for prolonged mechanical ventilation.
Methods: Consecutive patients were identified retrospectively over a 45-month period based on need for mechanical ventilation in an intensive care unit. Chart review was performed to collect demographic information as well as clinical data, including duration of mechanical ventilation, body mass index (BMI), and I-TRACH parameters (heart rate >110 beats per minute, blood urea nitrogen [BUN] >25, serum pH <7.25, serum creatinine >2, serum bicarbonate <20). Statistical analysis was performed to identify any predictors of prolonged mechanical ventilation, defined as more than 14 days.
Results: A total of 742 patients were identified with an average duration of mechanical ventilation of 8.59 days (range, 0-248 days). On univariate regression analysis, both BMI >30 and serum bicarbonate <20 reached statistical significance with respect to prolonged mechanical ventilation (P < .05); however, only the latter reached significance on multivariable regression analysis. The other I-TRACH parameters—either alone or in combination—were not significantly predictive.
Conclusions: This study challenges previous findings regarding the I-TRACH scale and the relation of its parameters to prolonged mechanical ventilation. More specifically, serum bicarbonate <20 was the only reliably predictive I-TRACH parameter. Furthermore, BMI >30 appears to be independently predictive as well. Use of these 2 variables alone could simplify current decision making when determining the likelihood of prolonged mechanical ventilation going forward
Voice and Swallowing Outcomes following Revision Anterior Cervical Spine Surgery
Madeleine Strohl, MD (Presenter); Patricia A. Loftus, MD; Ivan H. El-Sayed, MD; Aaron J. Clark, MD, PhD; Matthew S. Russell, MD
Objectives: To identify risk factors for acute vocal fold dysfunction (VFD) following revision anterior cervical discectomy and fusion (ACDF) and to highlight the role of otolaryngologists in managing immediate postoperative voice and swallowing outcomes.
Methods: Patients who underwent 2-team reoperative ACDF were retrospectively reviewed. In all cases, the otolaryngologist performed the transcervical exposure, and the spine surgeon then completed the ACDF. Patients were included in the study if they underwent documented pre- and postoperative laryngoscopy. Statistical analysis was performed to look at risk factors for VFD.
Results: Seventy patients underwent 72 revision procedures. The overall incidence of postoperative dysphonia and dysphagia was 26% and 43%, respectively. The incidence of immediate VFD was 20% (15/72). On multivariate analysis, factors significantly associated with an increased risk of VFD included C7/T1 surgery (odds ratio [OR] = 16; 95% confidence interval [CI], 2.1-127) and preoperative infection (OR = 28; 95% CI, 2.01-4.04). Number of prior surgeries, side of approach, and number of levels performed were not significant. Two of 15 patients (13%) with VFD had aspiration on a postoperative swallow study. Three (20%) required temporary vocal fold medialization for aspiration and/or dysphonia. Seven patients with VFD had follow-up greater than 3 months, with 5 of 7 (71%) with complete functional recovery.
Conclusions: Early involvement of an otolaryngologist in the care of a patient undergoing revision ACDF can be helpful to the patient in anticipation of voice and swallowing changes in the postoperative period. This may be particularly important in those being treated at C7/T1 or those with spinal infections.