Laryngeal papillomatosis associated dysplasia in the adult population: an update on prevalence and HPV subtyping.

OBJECTIVES: The objectives were to determine the prevalence of laryngeal dysplasia and associated human papilloma virus (HPV) subtypes in adult patients, 18 years or older, suffering from laryngeal papillomatosis at a tertiary care institution. STUDY DESIGN: Retrospective cohort study. METHODS: Patients with biopsy proven laryngeal papillomatosis were identified via chart review. All available pathology specimens were reviewed by a dedicated head and neck pathologist to confirm/refute the diagnosis of laryngeal dysplasia, and grade the level of dysplasia. Interrater agreement was compared using cross-tabulation methods. Specimens identified to be positive for dysplasia underwent further testing via in situ hybridization for low-risk (6/11) or high-risk (16/18) HPV subtypes. RESULTS: Of the 85 subjects identified to have laryngeal papillomatosis, 24(28%) demonstrated laryngeal dysplasia. There was good interrater agreement on the presence of dysplasia; however, there was only fair agreement on the grade of dysplasia. Of the pathology specimens tested for HPV subtype, the majority of patients (62%) were positive for HPV 6/11, including all high-grade dysplasia patients. Three (12%) dysplasia specimens were negative for both high- and low-risk HPV subtypes. CONCLUSIONS: We found a 28% prevalence of dysplasia in our patient population with the majority of patients positive for low-risk HPV subtypes indicating that high-risk HPV subtypes do not predispose laryngeal papilloma patients to dysplasia.

Current dysphonia trends in patients over the age of 65: is vocal atrophy becoming more prevalent?

OBJECTIVES/HYPOTHESIS: The current trends in geriatric voice referrals including the number of patients over the age of 65 years seen per year, the common diagnostic patterns, and specifically the number of patients with vocal atrophy were assessed. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective chart review of all patients seen at the Emory Voice Center for otolaryngologic complaints between the years of 2004 and 2009 was performed. RESULTS: Of the 6,360 patients seen over a 6-year period, 21% were over the age of 65 years. Fifty-eight percent of patients over the age of 65 years had vocal complaints, with the most common diagnoses being vocal atrophy (25%), neurologic vocal dysfunction (23%), and vocal fold immobility (19.2%). Of those patients diagnosed with vocal atrophy, the majority opted for voice therapy (57%), followed by reassurance (39%), and injection laryngoplasty (6%). There was a statistically significant improvement in mean pretherapy and post-therapy voice-related quality of life (VRQOL) score. CONCLUSIONS: As the number of people in the over 65-year-old age bracket increases, so do the number of geriatric referrals. Although diagnostic trends remain the same, vocal atrophy is becoming more prevalent, with a large number of patients seeking intervention. This will likely result in an increased need for health resources in the future.

Soft tissue complications after small incision pediatric cochlear implantation.

OBJECTIVES/HYPOTHESIS: To report and analyze the soft tissue complications of 462 consecutive cochlear implants using a minimal access approach at a single institution. STUDY DESIGN: A retrospective case series analysis was performed. METHODS: A database of all patients implanted at our institution between January 2002 and December 2007 was searched, and 385 consecutive patients were identified. Postcochlear implantation notes and case records were searched for soft tissue complications. Soft tissue complications were divided into minor and major complications. All devices were implanted using a minimal access technique with device fixation in all but five patients. RESULTS: There were 385 consecutive children implanted with 462 cochlear implants. Of these, 322 were primary single-sided implants, 124 bilateral implants, and 16 reimplants for device failure. Median follow up was 2.9 years. There were two minor complications: one minor seroma and one postoperative hematoma, both were managed conservatively. There were five major complications: two soft tissue infections, one extrusion, and two major seromas leading to device migration. Four of the five major complications involved loss of device fixation. Three out of the five major complications required device explantation; the decision not to reimplant was made in two cases. CONCLUSIONS: An overall soft tissue complication rate of 1.51% (7/462) at our institution supports the use of a small incision technique combined with device fixation as a safe method of cochlear implantation. We believe that good fixation is especially important in pediatric implantation, because of the thinner soft tissue envelope and increased frequency of minor head trauma.

Effects of stimulus manipulation on electrophysiological responses in pediatric cochlear implant users. Part I: duration effects.

Discrepancies between electrophysiological and behavioral thresholds in cochlear implant users might be due to differences in stimuli such as the duration and rate of the electrical pulse train. In the present study, we asked: Is there an effect of stimulus duration on electrophysiological responses of the auditory brainstem, thalamo-cortex, and behavioral thresholds? In 5 pediatric cochlear implant users, behavioral thresholds in response to electrical pulse trains at 500 pulses per second (pps) were significantly lower for 40ms than 2ms duration pulse trains. Clear electrically evoked auditory brainstem responses (EABR) and electrically evoked middle latency responses (EMLR) were generated by single electrical pulses and 2, 6, and 10ms pulse trains (500pps) in 5 children. There was a linear decrease in the inter-wave latency between the eV of the EABR and the Na of the EMLR as duration increased. No significant effect of duration was found on eV latency relative to the last pulse in the train or Na latency relative to the onset of the stimuli. Behavioral threshold data is consistent with temporal integration of auditory activity. Electrophysiological data indicates that: (a) recognizable EABR and EMLR waveforms can be recorded in response to electrical pulse trains of up to 10ms; and (b) pulse train stimuli have unique effects on the auditory brainstem compared to thalamo-cortical areas.

Effects of stimulus manipulation on electrophysiological responses of pediatric cochlear implant users. Part II: rate effects.

Electrophysiological thresholds do not accurately predict behavioral thresholds in pediatric cochlear implant users possibly due to differences in rate and duration of pulse presentation. We asked: (1) Is there an effect of rate of stimulus presentation on the electrophysiological responses of the auditory brainstem and thalamo-cortex? and (2) can the relationship between electrophysiological and behavioral thresholds be improved by using the same rate of pulse presentation? Behavioral and electrophysiological (EABR and EMLR) responses were elicited for 14 children to single electrical pulses and pulse trains of 2ms ranging in rate from 500 to 3600 pulses per second (pps). Low rate (500pps) pulse trains resulted in an increase in EABR wave eIII amplitude and a decrease in wave eV amplitude. Further rate increases resulted in smaller EABR wave amplitudes. EMLR amplitudes were unaffected by increases in rate as were EABR and EMLR latencies. Behavioral thresholds decreased with increasing rate, however, there was no associated reduction in electrophysiological thresholds. Correlation between behavioral and electrophysiological thresholds did not improve by using the same rate of electrical pulse stimulation. Results suggest: (1) Higher rates of electrical pulse presentation increase the potential for neural adaptation in the auditory brainstem and (2) using the same rate of electrical pulse presentation does not improve the ability of EABR and EMLR thresholds to predict behavioral thresholds.

Effect of increasing duration of stimulation on the electrically evoked auditory brainstem and middle latency responses in pediatric cochlear implant users.

OBJECTIVE: Electrophysiologic responses used to predict behavioural stimulation levels in implant users are typically evoked with a single-pulse stimulus versus higher-rate pulse trains of longer duration. Unfortunately, electrophysiologic measures tend to overestimate behavioural responses. It may be possible to improve the predictive ability of evoked potential thresholds by increasing the duration of the stimulus. We asked if auditory brainstem and middle latency responses can be reliably measured using electrical pulse trains of increasing duration. DESIGN: Evoked potential testing was performed in five pediatric N24RE cochlear implant users aged 7.6 to 14.9 years. SETTING: Cochlear Implant Program, Cochlear Implant Laboratory, The Hospital for Sick Children, Toronto. METHODS: Responses were electrically evoked for durations of 2, 6, and 10 milliseconds by single pulses and pulse trains of 500 pulses per second. MAIN OUTCOME MEASURES: Evoked auditory brainstem response (EABR) and evoked middle latency response (EMLR) waveform latencies and amplitudes were compared between durations. RESULTS: Clear and replicable EABRs and EMLRs were recorded for all durations. There was no significant change in EABR wave eV latency relative to the stimulus offset. There was no significant change in EMLR wave latencies relative to the stimulus onset. This was confirmed by a linear decrease in the interwave latency between the EABR wave eV and the EMLR wave eNa. No significant changes in wave amplitude were found as the pulse train duration increased for the EABR or the EMLR. CONCLUSIONS: EABRs are dominated by the stimulus offset, whereas EMLRs appear to be dominated by stimulus onset. Clear, unchanging EABRs and EMLRs indicated that electrophysiologic measures were a valid tool for increasing durations.

Survey of current perspectives on laryngopharyngeal reflux among Canadian otolaryngologists.

PURPOSE: Laryngopharyngeal reflux (LPR) -- gastroesophageal reflux above the upper esophageal sphincter -- is a common problem encountered by otolaryngologists. Despite consensus guidelines, the presentation, diagnosis, and treatment remain controversial. We surveyed Canadian otolaryngologists to assess current perspectives. METHODS: Web-based questionnaires were e-mailed to 135 otolaryngologists. Respondents were categorized by subspecialty as head and neck (H&N) or non-H&N (rhinology, otology, laryngology, facial plastics, general and pediatric otolaryngology). Data were analyzed to determine differences in proportions between groups. RESULTS: The response rate was 48 of 135 otolaryngologists. Symptoms considered to be strongly or moderately associated with LPR included globus sensation, excessive throat clearing, sore or burning throat, hoarseness, chronic cough, and dysphonia. The laryngoscopic signs considered strongly associated with LPR were edema, intra-arytenoid changes, and granulomata. The majority of otolaryngologists in both the H&N (12 of 15) and non-H&N groups (27 of 32) use flexible laryngoscopy for investigation and diagnosis of LPR. Proton pump inhibitors in addition to lifestyle modifications are recommended by both groups as first- and second-line therapy for an initial course of 6 to 12 weeks, with long-term therapy extended for 4 to 12 months. CONCLUSION: Canadian otolaryngologists do correlate specific signs and symptoms with LPR patients. This is consistent across subspecialties within the field. Flexible fibre-optic laryngoscopy is the preferred diagnostic tool. Although evidence based on randomized controlled trials has yet to demonstrate a reproducible, statistically significant improvement in LPR from medical therapy, first-line pharmacologic treatment (in addition to lifestyle changes) is generally provided as a proton pump inhibitor, with the duration of therapy being somewhat variable and less than that recommended by the current literature.

Bone-anchored hearing aids in infants and children younger than 5 years.

OBJECTIVE: While bone-anchored hearing aids (BAHAs) are currently indicated for rehabilitation in children older than 5 years with bilateral maximal conductive hearing loss, our objective was to capitalize on potentially important stages of auditory and speech-language development by providing BAHAs to children younger than 5 years. DESIGN: A retrospective review of surgical data of children receiving BAHA implants over a 10-year period. SETTING: The Hospital for Sick Children, Toronto, Ontario. PATIENTS: Twenty children 5 years or younger (mean +/- SD age, 3.21 +/- 1.65 years) served as the study group, while 20 older children (mean +/- SD age, 7.63 +/- 1.55 years) served as the comparison group. INTERVENTIONS: All patients received BAHA implants. Children with cortical bone thickness less than 2.5 mm underwent a 2-stage procedure; children with cortical bone thickness greater than 4 mm underwent a single-stage procedure. MAIN OUTCOME MEASURES: Traumatic and skin revision complication rates and implantation interstage intervals were compared between groups. RESULTS: The mean +/- SD interstage interval was 7.72 +/- 3.81 months for the younger children, which was significantly longer than for the older children (4.41 +/- 2.51 months) (P<.003). Two traumatic fixture losses occurred in the younger children, while 4 occurred in the older children. Skin site revision was required in 3 younger children. All children are currently wearing their BAHAs. CONCLUSION: Two-stage BAHA implantation with a prolonged interval between stages yields surgical success in younger children comparable to that routinely observed in older children.

Three-week thyroxine withdrawal: a thyroid-specific quality of life study.

OBJECTIVES/HYPOTHESIS: The purpose of this study is to determine the impact of a 3-week T4 withdrawal test on the quality of life (QOL) of patients undergoing investigation for residual/recurrent well-differentiated thyroid cancer. STUDY DESIGN: Prospective survey study. METHODS: 181 patients with well-differentiated thyroid cancer were surveyed using a thyroid-specific QOL-thyroid survey at three times throughout the study: prior to T4 withdrawal, after the 3-week withdrawal period, and 4 weeks after resuming T3/T4 combination therapy. RESULTS: A very small, though statistically significant, reduction was observed in the four domains of QOL defined by the QOL-thyroid survey from baseline values to 3 weeks after T4 withdrawal. The maximal difference was 2.04 (fatigue), out of a possible 10 point score, in the physical well-being category. CONCLUSIONS: The thyroid-specific QOL questionnaire demonstrates a statistically significant though very small and probably not clinically significant reduction in the QOL of thyroid cancer patients undergoing an induced 3-week hypothyroid state. Three-week T4 withdrawal is a simple, cost-effective, and readily available test.