Laryngeal Manifestations of Ehlers-Danlos Syndrome.

OBJECTIVES: The identification of voice and airway manifestations of Ehlers-Danlos Syndrome (EDS), diagnoses, and potential treatment modalities. STUDY DESIGN: Single institution retrospective case series. METHODS: We examined all patients presenting to our institution over a span of 10 years with a history of EDS or who were subsequently diagnosed with EDS after their evaluation. Demographic and clinical data were collected. RESULTS: Four patients were identified with an underlying diagnosis of EDS. All four patients were heavy voice users. All four patients had history and/or stroboscopy findings suggesting vocal hyperfunction, which we suspect is due to EDS-related hypermobility of the cricoarytenoid joint or fragility of the superficial lamina propria. Two patients also had respiratory symptoms - one with respiratory muscle weakness and sensation loss and one with inducible laryngeal obstruction. All patients were treated with voice therapy with subsequent improvement in their symptoms. CONCLUSIONS: Patients with EDS may present to laryngology clinics with symptoms of dysphonia or dyspnea secondary to their underlying condition. Voice therapy is a low-risk and potentially beneficial treatment in this patient population.

Correlating Perceptual Voice Quality in Adductor Spasmodic Dysphonia With Computer Vision Assessment of Glottal Geometry Dynamics.

PURPOSE: This study examined the relationship between voice quality and glottal geometry dynamics in patients with adductor spasmodic dysphonia (ADSD). METHOD: An objective computer vision and machine learning system was developed to extract glottal geometry dynamics from nasolaryngoscopic video recordings for 78 patients with ADSD. General regression models were used to examine the relationship between overall voice quality and 15 variables that capture glottal geometry dynamics derived from the computer vision system. Two experts in ADSD independently rated voice quality for two separate voice tasks for every patient, yielding four different voice quality rating models. RESULTS: All four of the regression models exhibited positive correlations with clinical assessments of voice quality (R 2s = .30-.34, Spearman rho = .55-.61, all with p < .001). Seven to 10 variables were included in each model. There was high overlap in the variables included between the four models, and the sign of the correlation with voice quality was consistent for each variable across all four regression models. CONCLUSION: We found specific glottal geometry dynamics that correspond to voice quality in ADSD.

An updated review of the epidemiological factors associated with recurrent respiratory papillomatosis.

OBJECTIVES: To identify studies evaluating the epidemiology of recurrent respiratory papillomatosis (RRP), including patient demographics, human papillomavirus (HPV) immunology, clinical course, surgical and medical treatments, and psychosocial factors. METHODS: A systematic literature search through PubMed was performed to identify studies evaluating the epidemiological factors associated with RRP. All studies were screened through a priori selection criteria using the titles and abstracts. RESULTS: A total of 208 studies were identified, of which 54 met eligibility criteria and were included in the review. CONCLUSIONS: RRP is a rare disease most commonly caused by HPV 6 and 11. It is characterized by recurring benign papillomatous lesions in the respiratory tract, particularly the larynx. Existing evidence about disease risk factors is limited but includes both maternal HPV infection and patient smoking and sexual behaviors. Disease management involves a combination of routine surgical and medical treatment. Surgical techniques include CO2-laser, sharp dissection, coblation, microdebridement, and photoangiolytic laser. Medical treatments which have been found to facilitate disease control off-label include interferon-alpha (IFN-α), indole-3-carbinol, acyclovir, bevacizumab, retinoids, and the Gardasil and mumps vaccines. Many patients suffer from additional psychosocial challenges related to their diagnosis. Current disease knowledge remains limited, and more robust controlled trials about risk factors, medical therapies, and surgical options are needed. LEVEL OF EVIDENCE: 5.

Transoral Robotic Surgical Proficiency Via Real-Time Tactile Collision Awareness System.

OBJECTIVES: In 2009, the Food and Drug Administration approved the use of the surgical robotic system for removal of benign and malignant conditions of the upper aerodigestive tract. This novel application of robotic-assisted surgery, termed transoral robotic surgery (TORS), places robotic instruments and camera system through the mouth to reach recessed areas of the pharynx and larynx. Over the successive decade, there was a rapid adoption of TORS with a surgical growth rate that continues to increase. Despite the rapid clinical acceptance, the field of TORS has not yet seen substantive changes or advances in the technical shortcomings, the lack of which has restricted objective TORS-specific surgical skills assessment as well as subsequent skills improvement efforts. One of the primary technical challenges of TORS is operating in a confined space, where the robotic system is maneuvered within the restrictive boundaries of the mouth and throat. Due to these confined boundaries of the pharynx, instruments can frequently collide with anatomic structures such as teeth and bone, producing anatomic collisions. Therefore, we hypothesized that anatomic collisions negatively impact TORS surgical performance. Secondarily, we hypothesized that avoidance of unwanted anatomic collisions could improve TORS surgical proficiency. METHODS: Design and fidelity testing for a custom TORS training platform with an integrated anatomic collision-sensing system providing real-time tactile feedback is described. Following successful platform assembly and testing, validation study using the platform was carried through prospective surgical training with trial randomization. Twenty otolaryngology-head and neck surgery residents, each trainee performing three discrete mock surgical trials (n = 60), performed the initial system validation. Ten of the 20 residents were randomized to perform the surgical trials utilizing the real-time feedback system. The remaining 10 residents were randomized to perform the surgical trials without the feedback system, although the system still could record collision data. Surgical proficiency was measured by Global Evaluative Assessment of Robotic Skills (GEARS) score, time to completion, and tumor resection scores (categorical scale ranging 0-3, describing the adequacy of resection). RESULTS: Major anatomic collisions (greater than 5N of force) negatively affected GEARS robotic skills. A mixed model analysis demonstrated that for every additional occurrence of a major collision, GEARS robotic skills assessment score would decrease by 0.29 points (P = .04). Real-time collision awareness created significantly fewer major (> 5 N) anatomic collisions with the tactile feedback system active (n = 30, mean collisions = 2.9 ± 4.2) as compared with trials without tactile feedback (n = 30, mean collisions = 12.53 ± 23.23) (P < .001). The second assessment measure of time to completion was unaffected by the presence of collisions or by the use of tactile feedback system. The third proficiency assessment was measured with tumor resection grading. Tumor resection scores was significantly (P = .02) improved with collision awareness system activated than trials without collision awareness. CONCLUSION: In order to test our primary hypothesis, a novel TORS training platform was successfully developed that provides collision force measurements including frequency, severity, and duration of anatomic collisions. Additionally, the platform was modulated to provide real-time tactile feedback of the occurrence of out-of-field collisions. Utilizing this custom platform, our hypothesis that anatomic collisions during TORS diminishes surgical performance was supported. Additionally, our secondary hypothesis that subsequent reduction of anatomic collisions improves TORS proficiency was supported by the surgical trial. Dedicated investigation to characterize the effect size and clinical impact is required in order to translate this finding into training curriculums and into clinical utilization. LEVEL OF EVIDENCE: II (Randomized trial) Laryngoscope, 130:S1-S17, 2020.

Lessons learned from open laryngotracheal airway resection and primary anastomosis in high risk patients.

OBJECTIVE: Laryngotracheal stenosis is one of the most difficult conditions treated by the Otolaryngologist. Open resection of stenosis with primary airway anastomosis is the definitive treatment for this condition. However, some patients are considered high risk candidates for open airway surgery and management and outcomes in this group have not been reported. The purpose of this investigation is to identify a series of high risk patients who underwent open laryngotracheal surgery and detail the lessons learned in regards to their post-operative course and outcomes. METHODS: A retrospective cohort study of all patients that underwent airway resection and primary anastomosis over a fifteen-year period was performed. High-risk patients, those with medical comorbidities that impair wound healing, were identified. Post-operative course, management of complications, and ultimate airway outcomes were noted. RESULTS: Seven patients fitting the high-risk category were identified. Comorbidities were poorly controlled insulin dependent diabetes mellitus (N = 4), poorly controlled hypertension (N = 4), end stage renal disease requiring hemodialysis (N = 3), chronic obstructive pulmonary disease (N = 1), and history of radiation therapy (N = 1). Each patient suffered postoperative complications of varying degrees including postoperative infection (N = 1), formation of granulation tissue at the anastomotic site (N = 3), and postoperative hematoma (N = 1). Management included treatment of infection and complications. Anastomotic dehiscence was managed with tracheostomy and T-tubes. CONCLUSIONS: High-risk medical comorbidities may not be absolute contraindications for open laryngotracheal resection of airway stenosis. However, this experience emphasizes the importance of preoperative medical optimization and comprehensive postoperative care.

On the Legacy of Genetically Altered Mouse Models to Explore Vestibular Function: Distribution of Vestibular Hair Cell Phenotypes in the Otoferlin-Null Mouse.

OBJECTIVES: Early in his career, David Lim recognized the scientific impact of genetically anomalous mice exhibiting otoconia agenesis as models of drastically compromised vestibular function. While these studies focused on the mutant pallid mouse, contemporary genetic tools have produced other models with engineered functional modifications. Lim and colleagues foresaw the need to analyze vestibular epithelia from pallid mice to verify the absence of downstream consequences that might be secondary to the altered load represented by otoconial agenesis. More generally, however, such comparisons also contribute to an understanding of the susceptibility of labyrinthine sensory epithelia to more widespread cellular changes associated with what may appear as isolated modifications. METHODS: Our laboratory utilizes a model of vestibular hypofunction produced through genetic alteration, the otoferlin-null mouse, which has been shown to exhibit severely compromised stimulus-evoked neurotransmitter release in type I hair cells of the utricular striola. The present study, reminiscent of early investigations of Lim and colleagues that explored the utility of a genetically altered mouse to explore its utility as a model of vestibular hypofunction, endeavored to compare the expression of the hair cell marker oncomodulin in vestibular epithelia from wild-type and otoferlin-null mice. RESULTS: We found that levels of oncomodulin expression were much greater in type I than type II hair cells, though were similar across the 3 genotypes examined (ie, including heterozygotes). CONCLUSION: These findings support the notion that modifications resulting in a specific component of vestibular hypofunction are not accompanied by widespread morphologic and cellular changes in the vestibular sensory epithelia.

Bilateral Vocal Fold Medialization: A Treatment for Abductor Spasmodic Dysphonia.

INTRODUCTION: Abductor spasmodic dysphonia, a difficult-to-treat laryngologic condition, is characterized by spasms causing the vocal folds to remain abducted despite efforts to adduct them during phonation. Traditional treatment for abductor spasmodic dysphonia-botulinum toxin injection into the posterior cricoarytenoid muscle-can be both technically challenging and uncomfortable. Due to the difficulty of needle placement, it is often unsuccessful. The purpose of this investigation is to present a previously undescribed treatment for abductor spasmodic dysphonia-bilateral vocal fold medialization. METHODS: A retrospective case review of all cases of abductor spasmodic dysphonia treated in a tertiary care laryngology practice with bilateral vocal fold medialization over a 10-year period was performed. The Voice Handicap Index and the Voice-Related Quality of Life surveys were utilized to assess patient satisfaction with voice outcome. RESULTS: Six patients with abductor spasmodic dysphonia treated with bilateral vocal fold medialization were identified. Disease severity ranged from mild to severe. All six patients reported statistically significant improvement in nearly all Voice Handicap Index and Voice-Related Quality of Life parameters. They reported fewer voice breaks and greater ease of communication. Results were noted immediately and symptoms continue to be well controlled for many years following medialization. CONCLUSIONS: Bilateral vocal fold medialization is a safe and effective treatment for abductor spasmodic dysphonia. It is performed under local anesthesia and provides phonation improvement in the short and long term.

Consensus-Based Attributes for Identifying Patients With Spasmodic Dysphonia and Other Voice Disorders.

Importance: A roadblock for research on adductor spasmodic dysphonia (ADSD), abductor SD (ABSD), voice tremor (VT), and muscular tension dysphonia (MTD) is the lack of criteria for selecting patients with these disorders. Objective: To determine the agreement among experts not using standard guidelines to classify patients with ABSD, ADSD, VT, and MTD, and develop expert consensus attributes for classifying patients for research. Design, Setting and Participants: From 2011 to 2016, a multicenter observational study examined agreement among blinded experts when classifying patients with ADSD, ABSD, VT or MTD (first study). Subsequently, a 4-stage Delphi method study used reiterative stages of review by an expert panel and 46 community experts to develop consensus on attributes to be used for classifying patients with the 4 disorders (second study). The study used a convenience sample of 178 patients clinically diagnosed with ADSD, ABSD, VT MTD, vocal fold paresis/paralysis, psychogenic voice disorders, or hypophonia secondary to Parkinson disease. Participants were aged 18 years or older, without laryngeal structural disease or surgery for ADSD and underwent speech and nasolaryngoscopy video recordings following a standard protocol. Exposures: Speech and nasolaryngoscopy video recordings following a standard protocol. Main Outcomes and Measures: Specialists at 4 sites classified 178 patients into 11 categories. Four international experts independently classified 75 patients using the same categories without guidelines after viewing speech and nasolaryngoscopy video recordings. Each member from the 4 sites also classified 50 patients from other sites after viewing video clips of voice/laryngeal tasks. Interrater κ less than 0.40 indicated poor classification agreement among rater pairs and across recruiting sites. Consequently, a Delphi panel of 13 experts identified and ranked speech and laryngeal movement attributes for classifying ADSD, ABSD, VT, and MTD, which were reviewed by 46 community specialists. Based on the median attribute rankings, a final attribute list was created for each disorder. Results: When classifying patients without guidelines, raters differed in their classification distributions (likelihood ratio, χ2 = 107.66), had poor interrater agreement, and poor agreement with site categories. For 11 categories, the highest agreement was 34%, with no κ values greater than 0.26. In external rater pairs, the highest κ was 0.23 and the highest agreement was 38.5%. Using 6 categories, the highest percent agreement was 73.3% and the highest κ was 0.40. The Delphi method yielded 18 attributes for classifying disorders from speech and nasolaryngoscopic examinations. Conclusions and Relevance: Specialists without guidelines had poor agreement when classifying patients for research, leading to a Delphi-based development of the Spasmodic Dysphonia Attributes Inventory for classifying patients with ADSD, ABSD, VT, and MTD for research.

Transplanted human multipotent stromal cells reduce acute tongue fibrosis in rats.

BACKGROUND: Tongue fibrosis resulting from head and neck cancer, surgery, radiation, chemotherapy, or a combination thereof devastates one's quality of life. Therapeutic options are limited. Here we investigate human bone marrow-derived multipotent stromal cells (MSC) as a novel injectable treatment for post-injury tongue fibrosis. METHODS: MSCs were grown in culture. Eighteen athymic rats underwent unilateral partial glossectomy. After two weeks for scar formation, a single injection was performed in the tongue scar. Three treatment groups were studied: low and high concentration MSC, and control media injection. Tongues were harvested for evaluation at three weeks post-treatment. RESULTS: Dense fibrosis was achieved in control animals at five weeks. High concentration MSC reduced cross sectional scar burden (P = .007) and pathologic score for inflammation and fibrosis. CONCLUSION: This study establishes the feasibility of a novel rodent tongue fibrosis model, and begins to assess the utility of human MSCs to reduce scar burden. LEVEL OF EVIDENCE: N/a.

Endoscopic Management of Subglottic Stenosis.

Importance: Optimal management of subglottic stenosis has not been established. Endoscopic techniques include balloon dilation, radial incisions with carbon dioxide laser or cold knife, and combinations of techniques. Adjunctive measures include mitomycin application and glucocorticoid injection. Objective: To determine whether surgical technique or adjunctive measures are associated with duration between surgical procedures. Design, Setting, and Participants: Adult patients with subglottic stenosis treated endoscopically between 1995-2015 at a quaternary academic medical center were identified. Patients with isolated subglottic (cricotracheal) stenosis 18 years and older were included. Patients with prior open surgical procedures, prior laryngeal surgical procedures, glottic stenosis, or vocal fold paralysis were excluded. Interventions: Patients underwent endoscopic procedures including laser radial incisions, balloon dilation, or both, with some patients receiving topical mitomycin, glucocorticoid injection, or both. Main Outcomes and Measures: Time interval between endoscopic treatments. Results: A total of 101 patients (mean [SD] age, 52.3 [15.9] years; 77.2% female) were included in the analysis, with etiologies including idiopathic (47 [46.5%]), intubation (31 [30.7%]), granulomatosis with polyangiitis (9 [8.9%]), and other autoimmune diseases (6 [5.9%]). Among the 219 operations, both laser and balloon dilation were used in 117 (53.4%), while balloon dilation alone was used in 96 (43.8%) and laser alone in 6 (2.7%). Mitomycin application and steroid injection were used in 144 (65.8%) and 93 (42.5%) cases, respectively. Mitomycin application was associated with improvement in the mean interval to next procedure from 317 to 474 days (absolute difference, 157 days; 95% CI, 15-299 days). Advanced grade of stenosis, dilation technique, and steroid injection did not significantly alter the surgical intervals. Conclusions and Relevance: Endoscopic surgery for subglottic stenosis is a critical aspect of patient management. Neither surgical technique nor grade of stenosis was seen to alter the surgical intervals. Mitomycin application was associated with an extended time interval between endoscopic treatments.

Idiopathic Subglottic Stenosis: A Comparison of Tracheal Size.

OBJECTIVE: To assess the size of the cervical and thoracic trachea among female patients with idiopathic subglottic stenosis (SGS). METHODS: Computed tomography (CT) scans of neck/chest from female patients with idiopathic SGS (n = 7) and normal controls (n = 30) were analyzed. Only female patients were included. The diameter and cross-sectional area of the trachea were measured at the level of the subglottic larynx, mid-cervical trachea, and mid-thoracic trachea. Measurements of tracheal size were compared between groups. RESULTS: Patients with idiopathic SGS were found to have a significantly smaller cross-sectional area throughout the course of the cervical and thoracic trachea as compared to normal controls. CONCLUSIONS: Idiopathic subglottic stenosis is a rare but distinct subclass of subglottic stenosis characterized by smaller cross-sectional area throughout the course of the subglottic, cervical, and thoracic trachea. LEVEL OF EVIDENCE: 3b: Individual case-control study.

Preliminary Study of the Open Quotient in an Ex Vivo Perfused Human Larynx.

IMPORTANCE: Scientific understanding of human voice production to date is a product of indirect investigations including animal models, cadaveric tissue study, or computational modeling. To our knowledge, direct experimentation of human voice production has previously not been possible owing to its invasive nature. The feasibility of an ex vivo perfused human phonatory model has recently allowed systematic investigation in virtually living human larynges with parametric laryngeal muscle stimulation. OBJECTIVE: To investigate the association between adductor muscle group stimulation and the open quotient (OQ) (the fraction of the cycle during which the glottis remains open) of vocal fold vibration. DESIGN, SETTING, AND PARTICIPANTS: An ex vivo perfused human tissue study was conducted at a physiology laboratory. Human larynx recovered from organ donors within 2 hours of cardiac death was used. The study was performed on May 19, 2014; data analysis took place from June 1, 2014, to December 15, 2014. INTERVENTIONS: Perfusion with donated human blood was reestablished shortly after cardiac death. Ex vivo perfused human phonation was then achieved by providing subglottal airflow under graded neuromuscular electrical stimulation bilaterally to the intrinsic adductor groups and cricothyroid muscles. MAIN OUTCOMES AND MEASURES: Phonation resulting from the graded states of neuromuscular stimulation was evaluated using high-speed vibratory imaging; the OQ was derived through digital kymography and glottal area waveform analysis. RESULTS: During constant glottal flow, a stepwise increase in adductor muscle group stimulation decreased the OQ. Quantitatively, OQ values decreased with increased stimulation levels from 2 V (OQ, 1) to 5 V (OQ, 0.68) and reached a lower limit of 8 V (OQ, 0.42). Increased stimulation above maximal muscle deformation was unable to affect OQ beyond this lower limit. CONCLUSIONS AND RELEVANCE: To our knowledge, a negative association between adductor muscle group stimulation and phonatory OQ has been demonstrated for the first time in a neuromuscularly activated human larynx. Further experience with the ex vivo perfused human phonatory model will aid in systematically defining this causal relationship.

Development of the ex vivo laryngeal model of phonation.

OBJECTIVES/HYPOTHESIS: The direct study of human phonation is limited by the invasive and painful nature of human laryngeal neuromuscular manipulation. As a platform for the study of human phonation, indirect models have been utilized for decades such as animal, cadaveric, and computational. We sought to develop a research method allowing direct scientific control of virtually living larynges to expand our ability to understand human phonation. STUDY DESIGN: Canine and porcine models. METHODS: Nineteen canine larynges were surgically removed and reperfused with progressively adapting methodologies to create ex vivo phonation. RESULTS: Full neuromuscular stimulation and phonation were ultimately achieved in the ex vivo larynx. As compared with alternative perfusate solutions, heparinized whole blood was found to result in the most robust neuromuscular response. Modification of the reperfusion technique from a continuous flow to a pulsatile pump system resulted in dramatic increases in neuromuscular response and longevity of the organ. The experimental findings were repeated to demonstrate reliability of the ex vivo model. CONCLUSIONS: The ex vivo larynx model is demonstrated to be a repeatable platform for phonatory research. The process of development has been comprehensively described in the present report. Although the described experimental model was designed for phonatory research, this model can be readily adapted for investigations of organ transplant preservation techniques, effects of organ ischemia, and neuromuscular reinnervation capabilities. LEVEL OF EVIDENCE: NA.

A comparative study of cricotracheal resection and staged laryngotracheoplasty for adult subglottic stenosis.

OBJECTIVE: Cricotracheal resection (CTR) and laryngotracheoplasty (LTP) are open surgical treatments for severe subglottic stenosis. This study aims to compare the applications and outcomes of these techniques. METHOD: Patients with subglottic stenosis at a tertiary academic institution from 2000 to 2012 were identified by diagnosis codes. Patients who underwent LTP or CTR were included. Records were reviewed for treatment data and outcomes. Patients with a history of head and neck malignancy or stenosis without cricoid involvement were excluded. RESULT: Sixty-one and 20 patients underwent LTP and CTR, respectively. When comparing patients receiving LTP and CTR, there was a significant difference in stenosis etiology (P=.014). The groups were similar in Cotton-Myer grade (P=.102). At last follow-up, 80.3% of LTP patients and 90.0% of CTR patients were decannulated. On multivariate analysis, there was a significant association between stenosis grade and decannulation in the LTP group (P=.01). Decannulation was not associated with stenosis grade in the CTR group. In both groups, there was no significant association between decannulation and sex, stenosis etiology, or stenosis length. CONCLUSION: Cricotracheal resection and LTP have both shown excellent long-term decannulation rates. Etiology and stenosis grade are likely to be determining factors when recommending specific surgical interventions for subglottic stenosis.

Staged laryngotracheoplasty in adult laryngotracheal stenosis: predictors of long-term decannulation.

IMPORTANCE: This study reviews a single center's experience of performing staged laryngotracheoplasty (LTP) for the treatment of laryngotracheal stenosis with the ultimate goal of attaining long-term airway patency without restenosis. OBJECTIVE: To identify staged LTP as an efficacious surgical treatment option for laryngotracheal stenosis. DESIGN, SETTING, AND PARTICIPANTS: From January 2000 to January 2012, patients at a tertiary care academic institution presenting with diagnoses of laryngeal or laryngotracheal stenosis were retrospectively identified. Medical records from adult patients were inspected, and patient demographics, clinical data, and clinical outcomes were recorded. All patients undergoing staged LTP were initially included. Patients with history of head and neck malignant neoplasm were excluded. INTERVENTIONS: Staged LTP. MAIN OUTCOMES AND MEASURES: The primary outcome was long-term decannulation, defined as decannulation for duration of at least 6 months. RESULTS: Sixty-one patients were included in this study. The mean (SD) patient age was 47.1 (16.7) at the time of first-stage LTP and had a mean (range) follow-up of 5.32 (0.5-17.3) years from the first-stage reconstruction. Etiology of stenosis included prolonged intubation in 27 patients (44%), autoimmune disease in 9 (15%), idiopathic causes in 11 (18%), blunt laryngeal trauma in 10 (16%), and other causes in 4 (7%). Forty-nine patients (80%) were successfully decannulated, while to date 12 (20%) remain tracheostomy or tympanostomy tube dependent. Univariate analyses showed no significant association between decannulation and age (P = .35), sex (P = .52), history of intubation (P = .22), surgeon (P = .20), etiology of stenosis (P = .91), or length of stenosis (P = .31). Multivariate logistic regression analysis showed a significant inverse relationship between grade of stenosis and probability of decannulation (P = .01). CONCLUSIONS AND RELEVANCE: Staged LTP is an option for the reconstruction laryngotracheal stenosis. Our experience shows excellent decannulation rates in the selected patients with stenosis, many of whom have failed treatment with other surgical modalities.

A unique case of sclerosing polycystic adenosis of the sinonasal tract.

Sclerosing polycystic adenosis is an extremely uncommon, recently described, sclerosing lesion of the salivary glands that appears histologically similar to fibrocystic changes of the breast. The key histopathologic features of sclerosing polycystic adenosis include lobular proliferation of ductal and acinar elements, cystically dilated ducts exhibiting frequent apocrine and sebaceous metaplasia, eosinophilic intracytoplasmic granules within some acinar-type cells, intraductal epithelial hyperplasia, and dense fibrosis. Most described cases have occurred in the major salivary glands, particularly the parotid gland. Although most authorities consider sclerosing polycystic adenosis to be a pseudoneoplastic process, the occurrence of dysplasia and carcinoma in situ of ductal epithelium reported recurrence rates of up to 30%, and recent evidence of clonality suggests a possible neoplastic etiology. However, there have been no cases of metastasis. Herein, we report the first case of sclerosing polycystic adenosis of the sinonasal tract in a 79-year-old woman presenting with a sinonasal mass.

Neuromuscular induced phonation in a human ex vivo perfused larynx preparation.

Considering differences in laryngeal anatomy, degree of control, and range of voice qualities between animals and humans, investigations of the neuromuscular process of voice control are better conducted using a living human larynx in which parametric stimulation of individual laryngeal muscles is possible. Due to difficulties in access and monitoring of laryngeal muscle activities, such investigations are impossible in living human subject experiments. This study reports the recent success in developing an ex vivo perfused human larynx model, which allows parametric muscle stimulation and observation of its influence on phonation of a virtually living human larynx in a well-controlled laboratory environment.

Surgery or botulinum toxin for adductor spasmodic dysphonia: a comparative study.

OBJECTIVES: Currently, botulinum toxin (Botox) injection is the standard of treatment for adductor spasmodic dysphonia (ADSD). We sought to compare the outcome of selective laryngeal adductor denervation-reinnervation (SLAD-R) surgery for ADSD to that of Botox injections. METHODS: Patient-oriented measures (VHI-10) and objective single-blinded gradings of digital voice recordings were utilized as outcome measures. The surgical cohort, recruited by retrospective patient selection, consisted of 77 patients with a mean follow-up time of 7.54 +/- 2.55 years (range, 2.2 to 14.2 years). The injection cohort, recruited prospectively, included 28 patients with a mean follow-up time of 46.37 +/- 5.51 days (range, 36 to 54 days). RESULTS: As measured by the VHI-10, the surgical patients had significantly improved voice handicap outcome scores (mean, 14.4 +/- 13.6) as compared to the patients who had Botox injection (mean, 26.5 +/- 12.1; p = 0.001). Aside from VHI-10 item 2, the surgical group demonstrated significantly improved voice-related function on each VHI-10 component (p = 0.01). Within the injection subgroup, 88% agreed that Botox successfully treats their ADSD, yet only 63% agreed that Botox improves their speech consistently. Within the surgical subgroup, 82% would recommend this surgery to others, and 78% agreed that their voice was actually better after surgery than after Botox. Objective voice ratings demonstrated similar levels of breathiness and overall voice quality in the treatment subgroups. CONCLUSIONS: When indicated, the SLAD-R surgery for ADSD demonstrates outcomes equal to or superior to those of the current standard of Botox injections.