The utility of office-based biopsy for laryngopharyngeal lesions: comparison with surgical evaluation.

OBJECTIVES/HYPOTHESIS: Advances in flexible endoscopy with working-channel biopsy forceps have led to excellent visualization of laryngopharyngeal lesions with capability for in-office awake biopsy. Potential benefits include prompt diagnosis without risk of general anesthesia, preoperative counseling, and avoiding an anesthetic should the lesion return benign. We evaluate the accuracy of these biopsies in order to determine their role and diagnostic value. STUDY DESIGN: Retrospective chart review. METHODS: Medical records were reviewed from January 1, 2010, through July 31, 2013, of patients who underwent office-based current procedural terminology code 31576 and were taken to the operating room for direct microlaryngoscopy with biopsy/excision. Clinical diagnoses and pathology reports were reviewed. For statistical analysis, we considered three groups: 1) malignant and premalignant, 2) lesions of uncertain significance, and 3) benign lesions. RESULTS: In the study period, 76 patients with an office biopsy had a clinical picture to warrant direct microlaryngoscopy and biopsy/excision. Kendall's coefficient for each group indicated moderate correlation only. When groups 1 and 2 were considered together, there was a substantial and statistically significant correlation. For malignant and premalignant lesions, the office biopsy analysis was as follows: sensitivity = 60%, specificity = 87%, positive predictive value = 78%, and negative predictive value = 74%. CONCLUSION: Office biopsy may offer early direction and avoid operative intervention in some cases; however, for suspected dysplastic or malignant lesions, direct microlaryngoscopy should be the standard of care to ensure adequate full-thickness sampling and staging. For benign pathology, office biopsy is a safe and viable alternative to direct microlaryngoscopy and biopsy/excision.

Laryngeal sensory deficits in patients with chronic cough and paradoxical vocal fold movement disorder.

OBJECTIVES/HYPOTHESIS: Although the diagnostic accuracy of paradoxical vocal fold movement disorder and chronic cough has improved, the underlying pathophysiology remains relatively unknown. We hypothesize that one potential etiological factor in these patients is an aberrant laryngeal sensory response and sought to determine if respiratory retraining in addition to antireflux therapy alters this aberrant response. STUDY DESIGN: Retrospective, outcomes. METHODS: Sixteen patients who had been on at least 3 months of twice-daily proton pump inhibitors with no subjective improvement in their primary complaint of cough, self-reported symptoms of gastroesophageal and laryngopharyngeal reflux, and concurrent paradoxical vocal fold movement (PVFM) were included in the current study. In addition to continuing twice daily pharmacological therapy, subjects underwent a course of respiratory retraining. Outcome measures including the Reflux Symptom Index (RSI), transnasal flexible laryngoscopy, and laryngopharyngeal sensory discrimination thresholds were obtained prior to and following a course of respiratory retraining. RESULTS: Mean bilateral laryngeal sensory response improved significantly after combined respiratory retraining and aggressive proton pump inhibitor therapy (P = .01). In addition, mean RSI score decreased significantly following treatment (P = .02). Specifically, 13 of 16 patients experienced improved sensory response, corresponding with patient reports of improved PVFM symptoms following treatment. CONCLUSIONS: Aberrant laryngeal sensation was identified in patients with PVFM and chronic cough. This response, however, normalized following a limited course of respiratory retraining, corresponding with improved patient symptoms.

A prospective, randomized trial of nerve monitoring of the external branch of the superior laryngeal nerve during thyroidectomy under local/regional anesthesia and IV sedation.

BACKGROUND: The aim of this study was to assess the impact of the neuromonitoring of the external branch of the superior laryngeal nerve (EBSLN) on the voice quality after mini-incision thyroidectomy under local/regional anesthesia and intravenous sedation. METHODS: Patients undergoing mini-incision thyroidectomy under local anesthesia were prospectively randomized for either nerve monitoring of the EBSLN (group 1) or no nerve monitoring (group 2). Voice and swallowing assessment were obtained by using the Voice Handicap Index-10 (VHI-10) and the Reflux Symptom Index questionnaires (RSI) before surgery and at 3 weeks and 3 months after surgery. RESULTS: Recruitment led to 22 patients in group 1 and 25 patients in group 2. The rate of visualized EBSLN was higher in group 1 (66% vs 21%; P = .003). Contrary to group 1, in group 2, the median total VHI-10 score was significantly higher 3 months after surgery (P = .034) compared with preoperatively, indicating a subjective voice handicap. In both groups, there was no difference in median total RSI score before surgery or at 3 weeks and 3 months after surgery. CONCLUSION: Nerve monitoring aids in the visualization of the EBSLN during mini-incision thyroidectomy under local/regional anesthesia and leads to an improvement in patient-assessed voice quality after surgery but does not impact swallowing.

Paradoxical vocal fold motion: a sensory-motor laryngeal disorder.

OBJECTIVES: The purpose of this study is to determine the laryngeal sensitivity (LS) thresholds and the ratings of laryngopharyngeal reflux symptoms in patients with paradoxical vocal fold motion (PVFM). METHODS: This is a chart review following Institutional Review Board approval of 75 patients from January 2006 to June 2007. The patients were diagnosed with PVFM following case history, transnasal flexible laryngoscopy and spirometric testing. The data analyzed consisted of the reflux symptom index (RSI) and laryngopharyngeal sensitivity (LS). Laryngeal sensitivity and RSI were graded according to mild, moderate, or severe. RESULTS: There were 12 (16%) patients with normal RSI scores, 37 patients (49.3%) with moderate RSI (RSI 11-22), and 26 patients (34.7%) with severe RSI (RSI >22). The right LS was normal in 11 patients (14.7%), moderately impaired in 16 patients (21.3%), and severely impaired in 48 (64%) patients. The left LS showed normal sensation in 11 patients (14.7%), moderately impaired LS in 13 patients (17.3%), and severe impairment in 51 patients (68%). Only one patient had both normal sensation and normal RSI, and 70.4% of patients had abnormal RSI and sensation thresholds. CONCLUSIONS: Patients diagnosed with PVFM had a high prevalence of symptoms related to LPR and markedly reduced LS. These findings suggest that PVFM may be triggered by reduced peripheral sensation or laryngeal inflammation.

Respiratory retraining therapy and management of laryngopharyngeal reflux in the treatment of patients with cough and paradoxical vocal fold movement disorder.

OBJECTIVES: We describe the outcome of patients with cough and paradoxical vocal fold movement disorder (PVFMD) treated with respiratory retraining therapy and management of laryngopharyngeal reflux (LPR). METHODS: Twenty patients with the complaint of cough were given a diagnosis of PVFMD and treated with proton pump inhibitors for a minimum of 6 months followed by 3 to 5 sessions of respiratory retraining therapy. Pulmonary function testing (PFT) and subjective rating of cough and reflux (reflux symptom index; RSI) were performed. Also, PFT and rating of cough were performed on a group of 10 healthy volunteers with no complaint of cough. RESULTS: The study group comprised 13 women and 7 men. The baseline cough rating and ratio of forced inspiratory volume at 0.5 second to forced inspiratory vital capacity (FIV0.5/FIVC) on PFT were significantly worse in the treatment group than in the control group. After therapy, 20 patients (100%) experienced improvement in cough, 19 patients (95%) experienced improvement on PFT, and 17 patients (85%) experienced improvement in the RSI score. The differences were statistically significant. CONCLUSIONS: Respiratory retraining therapy combined with management of LPR is an effective treatment for patients with cough and PVFMD when a single-modality treatment is not sufficient.

Flexible endoscopic evaluation of swallowing with sensory testing: patient characteristics and analysis of safety in 1,340 consecutive examinations.

Flexible endoscopic evaluation of swallowing with sensory testing (FEESST) is a comprehensive endoscopic assessment of the sensory and motor components of a swallow. Previous studies addressing patient safety issues with respect to FEESST included relatively small numbers of patients and paid almost no attention to patient characteristics. The purpose of this study was to determine the incidence of FEESST-related complications in the outpatient and inpatient settings and to analyze patient diagnoses that led to the performance of FEESST. We performed a prospective study of FEESST complications in 1,340 consecutive evaluations performed over a 4 1/2-year period. The primary outcome variables were incidence of epistaxis and airway compromise. The secondary outcome variable was underlying patient diagnoses. The incidence of epistaxis was 1 in 1,340 (0.07%). There were no instances of airway compromise. Stroke was the most common reason for the performance of FEESST (343; 25.6%), followed by cardiac-related dysphagia (298; 22.2%) following open heart surgery (169/298; 56.7%), heart attack, congestive heart failure, or new arrhythmia. The remaining causes were head and neck cancer (207; 15.4%), pulmonary disease (141; 10.5%), chronic neurologic disease (124; 9.3%), and acid reflux disease (80; 6.0%). We conclude that FEESST is a relatively safe procedure for the sensory and motor assessment of dysphagia in a cohort of patients with a wide variety of underlying diagnoses. The emergence of cardiac surgery as a common cause of dysphagia warrants further study.

Respiratory retraining of refractory cough and laryngopharyngeal reflux in patients with paradoxical vocal fold movement disorder.

OBJECTIVES/HYPOTHESIS: The objective was to describe a case series of patients with refractory cough and paradoxical vocal fold movement disorder treated with respiratory retraining therapy. STUDY DESIGN: Retrospective review of a case series in a tertiary medical care center. METHODS: Five patients with laryngopharyngeal reflux were identified with refractory cough and paradoxical fold movement disorder on transnasal fiberoptic laryngoscopy by a greater than 50% reduction in airway during inspiration. The were four women and one man (age range, 42-67 y). All patients had normal forced vital capacity and forced expiratory flow but decreased ratio of forced inspiratory volume at 0.5 seconds (FIV(0.5)) to forced inspiratory vital capacity (FIVC) before starting therapy. All patients were treated with more than 6 months of twice-daily proton pump inhibitor therapy with improvement in reflux symptoms but persistent and severe daytime cough. They were subsequently treated with respiratory retraining therapy. Patients were asked to rate subjectively the severity of cough at the onset and conclusion of therapy. All patients underwent pulmonary function testing before and after therapy. Long-term follow-up ranged from 5 to 17 months. RESULTS: Patients received two to seven sessions of respiratory retraining therapy. The mean severity score changed from 9.2 before therapy to 1.3 after therapy. All patients subjectively described an improvement in the severity of their cough. Transnasal flexible laryngoscopy demonstrated improvement in paradoxical vocal fold movement, and pulmonary function testing showed improvement in the FIV(0.5)/FIVC ratio. CONCLUSION: Patients with laryngopharyngeal reflux and refractory cough in the absence of pulmonary disease should be evaluated for paradoxical vocal fold movement disorder. Respiratory retraining therapy may represent an effective therapy for cough in the absence of relief from standard management of laryngopharyngeal reflux.

The relationship between ratings of voice quality and quality of life measures.

In the past several years, a number of scales have been developed that elicit a patient's self-assessment of the severity of his or her voice problem. The Voice Related Quality of Life Measure (V-RQOL) assesses a patient's perception of the impact of the voice problem on quality of life. Although this tool assesses the patient's perception of the voice disorder, it may not reflect the severity of dysphonia as perceived by a clinician. The GRBAS is an auditory-perceptual scale developed in Japan and used by clinicians to categorize the voice using five descriptive perceptual parameters: overall grade or severity (G), roughness of the voice (R), breathiness (B), asthenia (A), and strain (S). The purpose of this research is to determine the relationship between the patient's perception of voice related quality of life using the V-RQOL and the clinician's perception of voice severity using the GRBAS scale. Fifty patients with a complaint of a voice disorder completed the V-RQOL prior to their examination. In addition, 45 patients without voice complaints (controls) also completed the V-RQOL. All patients and control subjects were assessed by one of the voice clinicians using the GRBAS. For 25 of the subjects, both clinicians provided GRBAS perceptual ratings. Each of the two groups, were subsequently divided into subgroups consisting of those age 66 years and under and those over 66 years of age. The results indicate that the two clinicians were highly reliable in rating severity in the normal and voice disordered groups using the GRBAS scale. The results also indicate that perceived voice severity and voice-related quality of life are related; however, the relationship is a moderate one, which suggests that factors other than those directly related to voice quality may contribute to responses on voice assessment scales completed by patients. The relationship was stronger for the subgroup under 66 years old compared with the subgroup 66 years and older.

Hypopharyngeal perforation near-miss during transesophageal echocardiography.

OBJECTIVES/HYPOTHESIS: The traditional blind passage of a transesophageal echocardiography probe transorally through the hypopharynx is considered safe. Yet, severe hypopharyngeal complications during transesophageal echocardiography at several institutions led the authors to investigate whether traditional probe passage results in a greater incidence of hypopharyngeal injuries when compared with probe passage under direct visualization. STUDY DESIGN: Randomized, prospective clinical study. METHODS: In 159 consciously sedated adults referred for transesophageal echocardiography, the authors performed transesophageal echocardiography with concomitant transnasal videoendoscopic monitoring of the hypopharynx. Subjects were randomly assigned to receive traditional (blind) or experimental (optical) transesophageal echocardiography. The primary outcome measure was frequency of hypopharyngeal injuries (hypopharyngeal lacerations or hematomas), and the secondary outcome measure was number of hypopharyngeal contacts. RESULTS: No perforation occurred with either technique. However, hypopharyngeal lacerations or hematomas occurred in 19 of 80 (23.8%) patients with the traditional technique (11 superficial lacerations of pyriform sinus, 1 laceration of pharynx, 12 arytenoid hematomas, 2 vocal fold hematomas, and 1 pyriform hematoma) and in 1 of 79 patients (1.3%) with the optical technique (superficial pyriform laceration) (P =.001). All traumatized patients underwent flexible laryngoscopy, but none required additional intervention. Respectively, hypopharyngeal contacts were more frequent with the traditional than with the optical technique at the pyriform sinus (70.0% vs. 10.1% [P =.001]), arytenoid (55.0% vs. 3.8% [P =.001]), and vocal fold (15.0% vs. 3.86% [P =.016]). CONCLUSION: Optically guided trans-esophageal echocardiography results in significantly fewer hypopharyngeal injuries and fewer contacts than traditional, blind transesophageal echocardiography. The optically guided technique may result in decreased frequency of potentially significant complications and therefore in improved patient safety.

Laryngopharyngeal reflux testing.

Reflux testing is still evolving as new technology. New criteria for determination of clinical and subclinical laryngopharyngeal reflux are surfacing. The technique and interpretation of pH monitoring, the current gold standard, are still somewhat controversial. The authors' experience and opinions are presented herein.

Laryngeal adductor reflex and pharyngeal squeeze as predictors of laryngeal penetration and aspiration.

OBJECTIVES: The contribution of laryngopharyngeal (LP) sensory deficits to the outcome of swallowing and the relationship between sensory and motor deficits in the laryngopharynx is unclear. The study purpose is to determine if patients with LP sensory and motor deficits are at increased risk for laryngeal penetration and aspiration during swallowing, and to determine the relationship between pharyngeal motor weakness and LP sensory deficits. MATERIALS AND METHODS: Endoscopic evaluation of swallowing with sensory testing was performed on 122 dysphagic patients who were prospectively divided into two groups. The control group was 76 patients with normal sensitivity, determined by an intact laryngeal adductor reflex (LAR) on air pulse stimulation of the mucosa innervated by the superior laryngeal nerve. The study group was 46 patients with severe sensory deficits, determined by an absent LAR. Each group was given puree followed by thin liquid, noting presence or absence of laryngeal penetration and aspiration. Pharyngeal muscle strength was assessed by noting presence or absence of pharyngeal contraction during voluntary adduction of the vocal folds (pharyngeal squeeze). RESULTS: In control subjects, with purees, 6 of 76 (7.90%) penetrated and 3 of 76 (3.94%) aspirated; with thins, 26 of 76 (34.2%) penetrated and 13 of 76 (17.1%) aspirated. In the absent LAR group, with purees, 39 of 46 (84.8%) penetrated and 32 and 46 (69.6%) aspirated; with thins, 46 of 46 (100%) penetrated and 43 of 46 (93.5%) aspirated. For both consistencies, the differences in prevalence of penetration and aspiration between groups was significant (P <.0001, chi2). In control subjects, pharyngeal squeeze was impaired in 17 of 76 (22.4%), with penetration of puree in 6 of 17 (35.3%) and aspiration in 3 of 17 (17.6%). In the absent LAR group, squeeze was impaired in 41 of 46 (89.1%), with penetration of puree in 39 of 41 (95.1%) and aspiration in 32 of 41 (78.0%). The difference in the prevalence of pharyngeal weakness between groups was significant (P <.0001). The difference in the prevalence of penetration and aspiration was higher in the absent LAR/impaired contraction cohort than in the normal sensation/impaired contraction cohort (P <.0001). CONCLUSION: Absence of the LAR and impaired pharyngeal squeeze puts patients with dysphagia at high risk for laryngeal penetration and aspiration compared with patients with an intact LAR and intact pharyngeal squeeze. There is a strong association between motor and sensory deficits in the laryngopharynx.