Surgical Nonresponders in Zenker Diverticulum and Lower Esophageal Pathology (POUCH Collaborative).

OBJECTIVE: To identify characteristics of patients who have poor improvement in symptoms following surgical management of Zenker Diverticulum (ZD). METHODS: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgical repair of ZD between August 2017 and January 2024. Patient demographics, esophagrams, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were obtained from a REDCap database. t-tests, Wilcoxon rank sum tests, Chi-square or Fisher's exact tests were used to compare the characteristics. Patients with <50% improvement in their EAT-10 scores were deemed surgical nonresponders (SNRs). Those with ≥50% improvement in their EAT-10 scores were deemed surgical responders (SRs). RESULTS: A total of 184 patients were prospectively followed after undergoing either open or endoscopic surgical management. Twenty-two patients (12%) were deemed SNRs. Preoperative presence of a hiatal hernia was statistically significant characteristic between the SNRs (63.6%) and SRs (32.1%) (p = 0.004). Size of the ZD and history of previous ZD surgery was not a significant characteristic. The length of stay and complication rate were not statistically different between the groups. CONCLUSION: Coexistent esophageal pathology may lead to poor symptomatic improvement following ZD surgery. Preoperative workup of other esophageal disorders is recommended to detect likely SNRs. For SNRs, further esophageal workup may be necessary to evaluate for other esophageal causes related to poor symptomatic improvement following ZD surgery. LEVEL OF EVIDENCE: Level 3 Laryngoscope, 2024.

Neisseria meningitidis on Sinonasal Culture for Sinusitis: A Case Series and Literature Review.

Neisseria meningitidis is carried asymptomatically in the nasopharynx and is most known for causing septicemia and meningitis; however, the pathogenesis and incidence rates of N. meningitidis sinusitis are not well described. This case series describes four patients from a tertiary medical center who presented with culture-positive N. meningitidis sinusitis within a nine-month period. Three patients had complete resolution of symptoms after treatment with the appropriate antibiotic regimen, with one patient requiring functional endoscopic sinus surgery. We encourge providers to advocate for vaccination in their young adult unvaccinated patients, as each patient here was not appropriately vaccinated according to CDC guidelines. Laryngoscope, 134:1603-1605, 2024.

Surgical Outcomes in Zenker Diverticula: A Multicenter, Prospective, Longitudinal Study.

OBJECTIVE: To compare improvement in patient-reported outcomes (PROM) in persons undergoing endoscopic and open surgical management of Zenker diverticula (ZD). METHODOLOGY: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgery for ZD. Patient survey, radiography reports, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were abstracted from a REDCap database, which summarized means, medians, percentages, and frequencies of. Outcome based on operative intervention (endoscopic vs. open) was compared using t-test, Wilcoxon rank sum test or chi-square test, as appropriate. RESULTS: One hundred and forty-seven persons were prospectively followed. The mean age (SD) of the cohort was 68.7 (11.0). Overall, 66% of patients reported 100% improvement in EAT-10; 81% of patients had greater than 75% improvement; and 88% had greater than 50% improvement. Endoscopic was used for n = 109 patients, and open surgical intervention was used for n = 38. The median [interquartile range, IQR] EAT-10 percent improvement for endoscopic treatment was 93.3% [72, 100], and open was 100% [92.3, 100] (p = 0.05). The incidence of intraoperative complications was 3.7% for endoscopic and 7.9% for open surgical management. The median [IQR] in follow-up was 86 and 97.5 days, respectively. CONCLUSION: Both endoscopic and open surgical management of ZD provide significant improvement in patient-reported outcomes. The data suggest that open diverticulectomy may provide a modest advantage in symptomatic improvement compared to endoscopic management. The data suggest that the postoperative complication rate is higher in the open surgical group. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:97-102, 2024.

Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative.

OBJECTIVES: The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication. METHODS: Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management. RESULTS: There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26). CONCLUSIONS: Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction. LEVEL OF EVIDENCE: Level III Laryngoscope, 134:2678-2683, 2024.

Recurrent respiratory papillomatosis disease course in immunosuppressed populations.

OBJECTIVE: Recurrent respiratory papillomatosis is a benign manifestation of human papillomavirus types 6 and 11 in the respiratory tract. Disease is recurrent, and factors predicting these recurrences and severity of disease are incompletely characterised. This retrospective cohort study examined the relationship of immunosuppression with recurrent respiratory papillomatosis morbidity. METHODS: A retrospective cohort of 97 adult patients with recurrent respiratory papillomatosis treated at a tertiary referral centre from 2005 to 2020 was conducted. Measures assessed included inter-surgical interval, Voice Handicap Index ('VHI-10') and anatomical Derkay scores. RESULTS: Bivariate analyses comparing average inter-surgical interval, Voice Handicap Index and Derkay scores in immunosuppressed and healthy patients were insignificant. When controlling for diabetes mellitus and comparing immunosuppressed to healthy patients, inter-surgical interval and Voice Handicap Index change were insignificant (p = 0.458 and p = 0.465, respectively). CONCLUSION: Recurrent respiratory papillomatosis morbidity for immunosuppressed patients did not significantly differ from that of immunocompetent patients.

Smoking and Carcinoma Trends in Recurrent Respiratory Papillomatosis Patients.

INTRODUCTION: Recurrent respiratory papillomatosis (RRP) is a chronic disease of the upper respiratory tract caused by human papillomavirus types 6 and 11. The disease course is characteristically unpredictable, ranging from spontaneous remission to aggressive, recurrent disease. Thus, management is often challenging and requires unique approaches tailored to each individual patient. While recent literature has described risk factors for more aggressive disease, few sources have investigated the impact of smoking on RRP disease course and risk for malignant transformation. METHODS: A retrospective chart review was conducted for adult RRP patients evaluated at an academic tertiary care center between 2005 and 2020. A total of 188 patients were identified. Demographic and clinical data were collected, including smoking and alcohol history, HPV subtype, history of dysplasia and/or carcinoma, voice handicap index scores, Derkay scores, debulkings (in office and operating room), and days to papilloma recurrence. RESULTS: Malignant degeneration in RRP occurred in 16.3% of smokers and 3.6% of nonsmokers. Smokers who developed carcinoma had less debulkings per years of evaluation than those not developing carcinoma (0.21 vs 0.92, P = .004). Additionally, patients that either presented with or developed carcinoma during their course had a higher pack-year smoking history (18.0 vs 12.21, P = .0002). No difference in days to recurrence or inter-surgical interval was demonstrated between smokers and nonsmokers. CONCLUSIONS: The report demonstrates that smoking can increase the risk of malignant transformation in RRP patients.

Superior Laryngeal Nerve Block Response Rates in 54 Neurogenic Cough Patients.

OBJECTIVE: Neurogenic cough related to hypersensitivity of the internal branch of the superior laryngeal nerve (SLN) is often treated with neuromodulating medications, which can cause considerable side effects. An alternative therapy is steroid and local anesthetic injection of the SLN ("SLN block"), initially proposed to benefit those with lateralizing symptoms (tenderness over the thyrohyoid membrane or unilateral cough source). Our objectives are to determine if SLN block produces subjective symptomatic improvements and if repeat injections further improve symptoms, and evaluate clinical factors potentially predictive of response. METHODS: Retrospective chart review of 54 patients receiving SLN blocks at a tertiary medical academic center from January 2010 to June 2020. Medical history and anticipated predictors of positive response, including stigmata of laryngeal hypersensitivity, were recorded. Outcomes included symptomatic response, number of injections required, and side effects. Response was defined subjectively by asking patients whether the injection was beneficial and objectively by using CSI scores. RESULTS: Fifty-four patients met the inclusion criteria. Thirty-eight patients (70.4%) endorsed improvement. No variables were identified as positive predictors of response. Thirty-two of the 38 (84.2%) endorsed improvement after one injection. Six of 15 (40%) patients who failed the first injection had positive response to the second. No significant side effects were reported. CONCLUSION: No localizing symptoms, specific cough features, or aspects of the medical history helped predict response, suggesting that a broader range of patients may be offered the intervention. The majority of patients reported symptomatic improvement and repeat injections may benefit patients with initial nonresponse. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2647-2653, 2023.

Killian Jamieson Diverticulum, the Great Mimicker: A Case Series and Contemporary Review.

OBJECTIVE: To assess barium esophagram (BAS) as a diagnostic marker for patients with Killian Jamieson diverticula (KJD). METHODS: Prospective, multicenter cohort study of individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative. Patient demographics, comorbidities, radiographic imaging reports, laryngoscopy findings, patient-reported outcome measures (PROM), and operative reporting were abstracted from a REDCap database and summarized using means, medians, percentages, frequencies. Paired t-tests and Wilcoxon Signed Rank test were used to test pre- to post-operative differences in RSI, EAT-10, and VHI-10 scores. Diagnostic test evaluation including sensitivity, specificity, positive, and negative predictive value with 95% confidence intervals were calculated comparing BAS findings to operative report. RESULTS: A total of 287 persons were enrolled; 13 (4%) patients were identified with confirmed KJD on operative reports. 100% underwent open transcervical excision. BAS has a 46.2% (95% confidence interval [CI]: 23.2, 70.9) sensitivity and 97.8% (95% CI: 95.3, 99.0) specificity in detecting a KJD and 50% (95% CI: 25.4, 74.6) positive predictive value but 97.4% (95%CI: 94.8, 98.7) negative predictive value. Preoperatively, patients reported mean (SD) RSI and EAT-10 of 19.4 (9) and 8.3 (7.5) accordingly. Postoperatively, patients reported mean (SD) RSI and EAT-10 as 5.4 (6.2) and 2.3 (3.3). Both changes in RSI and EAT-10 were statistically significant (p = 0.008, p = 0.03). CONCLUSION: KJD are rare and represent <5% of hypopharyngeal diverticula undergoing surgical intervention. Open transcervical surgery significantly improves symptoms of dysphagia. BAS has high specificity but low sensitivity in detecting KJD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2110-2115, 2023.

Cricopharyngeus Muscle Dysfunction and Hypopharyngeal Diverticula (e.g., Zenker): A Multicenter Study.

OBJECTIVE: To describe demographics and imaging and compare findings and symptoms at presentation in a large cohort of persons with cricopharyngeus muscle dysfunction (CPMD) with and without hypopharyngeal diverticula. METHODOLOGY: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeal Hypertonicity (POUCH) Collaborative. Patient survey, comorbidities, radiography, laryngoscopy findings, and patient-reported outcome measures (e.g., Eating Assessment Tool [EAT-10]) data were abstracted from a REDCap database and summarized using means, medians, percentages, and frequencies. Diagnostic categories were compared using analysis of variance. RESULTS: A total of 250 persons were included. The mean age (standard deviation [SD]) of the cohort was 69.0 (11.2). Forty-two percent identified as female. Zenker diverticula (ZD) was diagnosed in 85.2%, 9.2% with CPMD without diverticula, 4.4% with a Killian Jamieson diverticula (KJD), and 1.2% traction-type diverticula. There were no differences between diagnostic categories in regard to age, gender, and duration of symptoms (p = 0.25, 0.19, 0.45). The mean (SD) EAT-10 score for each group was 17.1 (10.1) for ZD, 20.2 (9.3) for CPMD, and 10.3 (9.4) for KJD. Patients with isolated CPMD had significantly greater EAT-10 scores compared to the other diagnostic groups (p = 0.03). CONCLUSION: ZD is the most common, followed by CPMD without diverticula, KJD, and traction-type. Patients with isolated obstructing CPMD may be more symptomatic than persons with ZD or KJD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1349-1355, 2023.

Reduced Asthma Medication Use after Treatment of Pediatric Paradoxical Vocal Fold Motion Disorder.

OBJECTIVES/HYPOTHESES: The primary objective of this study was to determine whether the diagnosis and treatment of pediatric Paradoxical Vocal Fold Motion Disorder (PVFMD) leads to decreased asthma medication use. Our secondary objective was to determine dyspnea outcomes following diagnosis and treatment for PVFMD. STUDY DESIGN: Prospective observational study. METHODS: Patients with newly diagnosed PVFMD between the ages of 11 and 17 were recruited at a single pediatric institution. A medication questionnaire and Dyspnea Index (DI) were completed at the initial visit, at the first return visit, and at greater than 6 months post-diagnosis and therapy. Laryngeal Control Therapy (LCT) consisted of teaching breathing techniques and identifying emotional, physical, and environmental contributing factors and strategies to reduce them. RESULTS: Twenty-six patients were recruited to the study. There were 19/26 (73%) patients diagnosed with asthma prior to a diagnosis of PVFMD, and 26/26 (100%) patients were using an inhaler prior to the enrollment visit. Twenty-two (85%) patients completed follow-up questionnaires. Five patients participated in no therapy, seven patients in partial therapy, and 14 patients in full therapy. Significant reduction in asthma medication use was seen in the full therapy group (P < .05) and in those with exercise as their only trigger (P < .05). Furthermore, symptoms as scored by the DI decreased overall from 25.5 to 18.8 (P < .001). CONCLUSIONS: Diagnosis and treatment of pediatric PVFMD leads to a decline in asthma medication use in those patients who participate in at least two LCT sessions and in those with exercise-induced PVFMD. LCT for pediatric PVFMD leads to a significant decrease in symptoms as measured by the DI. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1639-1646, 2021.

Yield of Imaging to Evaluate Unilateral Vocal Fold Paralysis of Unknown Etiology.

OBJECTIVES/HYPOTHESIS: To identify the incidence and nature of positive findings on imaging studies ordered for evaluation of unilateral vocal fold paralysis (UVFP) of unknown etiology, to analyze these findings based on laterality, and to examine the use of the expanded-field computed tomography (CT) neck protocol in this evaluation. STUDY DESIGN: Retrospective review. METHODS: A total of 145 patients from 2000 to 2018 with UVFP of unknown etiology were studied. Data on imaging studies ordered, laterality of paralysis, and significant positive results were studied. An expanded-field CT neck protocol that included the entire course of the vagus and recurrent laryngeal nerves was instituted during the study period. RESULTS: A total of 20.7% of patients had an etiology for paralysis identified on imaging. Malignancies comprised the majority of findings overall (19/30), whether in the chest (12/18) or the neck (7/12). Etiology was more often found in the chest for left-sided paralysis (15/21) and in the neck for right-sided paralysis (6/9). In 26 patients who underwent both expanded-field CT neck and CT chest, no findings related to the UVFP were seen on CT chest that were not captured by expanded-field CT neck. CONCLUSIONS: This is one of the largest retrospective studies examining the incidence of positive findings on imaging studies for evaluation of UVFP of unknown etiology. Imaging in one of five patients with UVFP of unknown etiology will reveal a causative lesion, most often malignant. Left-sided paralysis tends to localize to the chest, and right-sided paralysis to the neck. Expanded-field CT neck may allow practitioners to forego dedicated CT chest in evaluation of UVFP. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1840-1844, 2021.

The safety of in-office laryngologic procedures during active antithrombotic therapy.

OBJECTIVES: To determine whether patients undergoing in-office laryngologic procedures on antithrombotic therapy are at increased risk for treatment-related complications. METHODS: Patients were those who underwent at least one in-office laryngologic procedure with any of three fellowship-trained laryngologists. Procedures were identified by current procedural terminology (CPT) code and included biopsies, excisions, laser ablations, and injections (therapeutic and augmentative). Patients were divided into two groups based on the use of antithrombotic therapy at the time of their procedure. Retrospective chart review was performed to identify any complications, with an average follow-up of 186 days. RESULTS: Five hundred-sixty-four unique individuals were identified with ages ranging from 18 to 93 years old and with a relatively even distribution between females (45%) and males (55%). They underwent 647 procedures in total, 310 of which were performed while on some form of antithrombotic therapy. Sixteen procedures were associated with complications either during or after the procedure. In comparing overall complication rates, there was no significant difference between non-antithrombotic (2.4%) and antithrombotic (3.3%) cohorts (OR 1.09, 95% CI [0.46-2.60], P = .8454). CONCLUSIONS: In spite of known risks in other settings, antithrombotic agents do not appear to confer increased risk of treatment-related complications during in-office laryngologic procedures, obviating the need for cessation of therapy prior to these interventions. LEVEL OF EVIDENCE: 4.

Strap Muscle Type I Thyroplasty After Gore-Tex Implant Extrusion: Case Report and Literature Review.

OBJECTIVES: To discuss the presentation and management techniques of implant extrusion following type I thyroplasty and to illustrate the potential of strap muscle for augmentation following implant removal. METHODS: We report a unique case of a patient with late Gore-Tex implant extrusion after type I thyroplasty treated with removal and autologous strap muscle graft for augmentation. RESULTS: A 41-year-old female nearly 3.5 years status post Gore-Tex type I thyroplasty for left vocal fold paralysis presented for evaluation of dysphonia. Upon flexible laryngoscopy, erythema, edema, and granulation tissue were identified at the left vocal fold and ventricle. The patient subsequently underwent removal of her implant. Intraoperatively, a free portion of sternothyroid muscle was dissected free and placed into the paraglottic space. One month following surgery, the patient reported an improvement in her Voice Handicap Index (VHI) score from 40 to 0. In addition, no major complications were observed and complete glottic closure was achieved. Nine months postsurgery, she continued to function well with a VHI score of 0. At 50 months postop, the patient still reports a VHI score of 0. CONCLUSIONS: Implant extrusion is a rare complication of type I thyroplasty usually occurring in the first few months after surgery and more commonly presenting in females. Current management options consist of observation or augmentation with autologous fat or vocal fold injection following implant removal. This is the first report of a successful strap muscle free graft revision thyroplasty following implant extrusion. The patient's excellent long-term outcome highlights the potential of strap muscle augmentation as a feasible management option for implant extrusion.

Airway Surgery Communication Protocol: A Quality Initiative for Safe Performance of Jet Ventilation.

OBJECTIVES: To assess whether manual jet ventilation can safely be performed with variable anesthesia and operating room (OR) staff experience levels and communication skills. METHODS: Jet ventilation procedures for airway stenosis at a single institution over 35 months were retrospectively reviewed. OR and anesthesia staff were assigned scores based on experience level and communication skills. Data were analyzed for any association between the experience or communication skills of the staff and the successful use of jet ventilation, complication rate, or ultimate patient outcome, controlling for intraoperative variables and patient and airway complexity. A detailed preoperative surgeon-led communication protocol was followed in all cases. RESULTS: Seventy procedures in 46 patients were performed. Jet ventilation was successful in 69 of 70 cases. No relationship was found between staff experience or communication scores and the successful use of jet ventilation, complication rate, or ultimate patient outcome. The percentage of cases performed with a fully experienced team was low, at 7.1%. The experience level of the certified registered nurse anesthetist was significantly associated with likelihood of using an adequate paralytic dose upfront (P = 0.017), which in turn correlated with shorter anesthesia time by 19.7 minutes (P = 0.0131); however, neither affected complication rate nor ultimate patient outcome. The statements above remained true in cases of medically complex patients, difficult airways with high degrees of stenosis, and multiple shift changes. CONCLUSIONS: Manual jet ventilation can be performed safely even in settings of lower staff experience level or communication skills given a surgeon experienced in the technique and a strict communication protocol. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:S1-S13, 2020.

Vocal fold botulinum toxin injection for refractory paradoxical vocal fold motion disorder.

OBJECTIVE: Demonstrate efficacy of vocal fold botulinum toxin injection for treatment of refractory paradoxical vocal fold motion disorder (PVFMD). METHODS: A retrospective review was completed of patients diagnosed with PVFMD who underwent vocal fold botulinum toxin injection for dyspnea symptoms that persisted despite laryngeal control therapy, medical management, and biofeedback therapy. Outcomes measured included overall improvement and resolution of dyspnea symptoms, number of botulinum toxin injections and dose range, change in dyspnea severity index (DSI) scores, and adverse effects of injection therapy. RESULTS: Thirteen patients (9 female/4 male) underwent vocal fold botulinum toxin injection for refractory PVFMD. The average dose was 2.55 units per vocal fold (range 1.75-5.5 units). The average number of injections was 3.85 (range 1-12 injections). Eleven of 13 (84.6%) patients experienced improvement in dyspnea symptoms, with two of 11 (18.2%) having complete resolution of symptoms. There was a statistically significant improvement in DSI scores because the mean preinjection DSI was 30.43 and improved to 17.43 postinjection (P = 0.017). Temporary breathy voice quality was experienced by all patients with no other adverse side effects. CONCLUSION: Vocal fold botulinum toxin injection is a safe and effective treatment option for PVFMD and should be considered in patients with refractory dyspnea symptoms following appropriate medical therapy and respiratory retraining protocols. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:808-811, 2019.

Multi-institutional Evaluation of Medialization Laryngoplasty in the Elderly.

OBJECTIVE: To evaluate voice outcomes of medialization laryngoplasty in the elderly population (65 years and older) and to identify swallow outcomes, complication rates, and predictors of voice outcomes. STUDY DESIGN: Case series with chart review. SETTING: Two tertiary academic medical centers. SUBJECTS AND METHODS: We retrospectively reviewed charts of 136 patients age 65 years and older undergoing medialization laryngoplasty between January 2008 and May 2016 at 2 tertiary academic institutions. Primary outcome was assessed using Voice Handicap Index 10 (VHI-10) score and Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) score. Secondary outcomes were assessed using the Eating Assessment Tool 10 (EAT-10) when dysphagia was present, stroboscopic analysis of glottic closure, and complication rates. A logistic regression analysis assessed predictors of voice improvement after medialization laryngoplasty. RESULTS: Total GRBAS and VHI-10 scores showed a significant improvement postoperatively ( P < .05). A ≥20% improvement was seen in 81.6% of patients, and a ≥50% improvement was seen in 53.7%. No patient had major complications. Minor complications occurred in 5.9% of patients. Multivariable logistic regression identified preoperative injection augmentation as an independent predictor of less improvement in VHI-10 score ( P = .015). Voice therapy prior to medialization did not affect voice outcomes ( P = .640). CONCLUSION: Patient- and provider-perceived voice quality are significantly improved after medialization laryngoplasty in the elderly, and the procedure is associated with a low complication rate even in an elderly cohort. Improvement in patient-perceived voice outcomes after medialization laryngoplasty was diminished in patients with preoperative injection augmentation.

Risk Factors for Posttracheostomy Tracheal Stenosis.

Objective To determine the incidence of posttracheostomy tracheal stenosis and to investigate variables related to the patient, hospitalization, or operation that may affect stenosis rates. Study Design A combined retrospective cohort and case-control study. Setting Tertiary care academic medical center. Subjects and Methods A total of 1656 patients who underwent tracheostomy at a tertiary care medical center from January 2011 to November 2016 were reviewed for evidence of subsequent tracheal stenosis on airway endoscopy or computed tomography. Forty-three confirmed cases of posttracheostomy tracheal stenosis (PTTS) were compared with a subgroup of 319 controls. Factors including medical comorbidity, type and setting of tracheostomy, and hospitalization details were analyzed. Results Five-year incidence of PTTS was 2.6%. Obesity was the sole demographic factor associated with stenosis. Hospitalization-related variables associated with stenosis included tracheostomy after 10 days of orotracheal intubation and endotracheal tube cuff pressure ≥30 mm H2O. The surgical variables associated with higher rates of stenosis included percutaneous technique and insertion of an initial tracheostomy tube size >6. Bjork flap creation was negatively associated with stenosis. In multivariable analysis, obesity and insertion of tracheostomy tube size >6 were identified as risk factors. Conclusion Greater than 10 days of orotracheal intubation prior to tracheostomy and endotracheal tube cuff pressure ≥30 mm H2O were associated with greater rates of subsequent tracheal stenosis. The only patient-related factor associated with tracheal stenosis was obesity. Surgical variables associated with increased rates of subsequent stenosis included placement of a tracheostomy tube size >6, use of percutaneous technique, and failure to create a Bjork flap.

Current and future management of recurrent respiratory papillomatosis.

Objectives: Recurrent respiratory papillomatosis (RRP) is a chronic disease of the respiratory tract that occurs in both children and adults. It is caused by the human papillomavirus (HPV), in particular low-risk HPV6 and HPV11, and aggressiveness varies among patients. RRP remains a chronic disease that is difficult to manage. This review provides perspectives on current and future management of RRP. Results: The current standard of care is surgical excision, with adjuvant therapies as needed. Surgical management of RRP has evolved with the introduction of microdebriders and photoangiolytic lasers; the latter can now be used in the office setting. Numerous adjuvant pharmacologic therapies have been utilized with some success. Also, exciting preliminary data show that HPV vaccines may prolong the time to recurrence in the RRP population. There is also optimism that wide-spread HPV vaccination could reduce RRP incidence indirectly by preventing vertical HPV transmission to newborns. Conclusion: To date, the biology of RRP is not well understood, although it has been noted to become more aggressive in the setting of immune suppression. Additional research is needed to better understand immune system dysfunction in RRP such that immunomodulatory approaches may be developed for RRP management. Level of Evidence: 4.

Jet ventilation in obese patients undergoing airway surgery for subglottic and tracheal stenosis.

OBJECTIVES/HYPOTHESIS: To assess the feasibility of jet ventilation in obese patients and to compare complications of jet ventilation in obese and nonobese patients. STUDY DESIGN: Retrospective review of medical records. METHODS: We reviewed 46 patient charts (70 procedures) with the diagnosis of tracheal or subglottic stenosis who underwent endoscopic surgery with jet ventilation between March 2014 and January 2017. Adequacy of jet ventilation was assessed by chest rise, avoidance of endotracheal intubation, and length of case and ventilation. Records were reviewed for demographic details, anesthesia records, and complications. RESULTS: In 29/70 (41.4%) of cases, patients were obese; in 9/29 (31.0%) of these cases, patients were morbidly obese. Jet ventilation was successful in 28/29 (97%) of obese cases. In 1/29 (3.4%) of cases, the patient required alternative airway management. There were no significant differences between obese and nonobese patients in chest rise, need for endotracheal intubation, and length of surgery or ventilation (P > .05). There were 2/29 (6.9%) cases of intra- and postoperative complications including laryngospasm (1/29, 3.4%) and tachycardia (1/29, 3.4%). Rate of complications did not differ between obese and nonobese patients (P = .178). CONCLUSIONS: Jet ventilation in obese patients can be done successfully, and complications are similar between obese patients and nonobese patients. LEVEL OF EVIDENCE: 4. Laryngoscope, 1887-1892, 2018.

Rate of new findings in diagnostic office bronchoscopy.

OBJECTIVES: Awake Flexible Tracheobronchoscopy (FTB) is an alternative to rigid bronchoscopy or sedated flexible bronchoscopy and allows an awake examination of the tracheobronchial tree. We hypothesized that the ability to perform office bronchoscopy as the need arises during a clinic visit would lead to a high rate of previously undiagnosed and clinically relevant findings. This study reports the rate and nature of such findings for this procedure at our institution. STUDY DESIGN: Retrospective chart review. METHODS: The records of 127 adult patients evaluated at the voice and swallowing disorders clinic between June of 2012 and January of 2015 were reviewed. New findings were defined as new pathology visualized during FTB exam that was not previously diagnosed by means of other diagnostic modalities. RESULTS: A total of 233 scope procedures (84 transnasal bronchoscopies and 149 tracheoscopies) were reviewed, 232 of which were completed and one of which was incomplete due to severe subglottic stenosis. New, clinically relevant findings were seen in 57% of transnasal bronchoscopies (48 of 84) and 21% of tracheoscopies (32 of 149). All of these findings provided additional information directing workup or resulted in a change in patient management. CONCLUSION: Office-based evaluation of the tracheobronchial tree yields a high rate of new findings. In our study, office bronchoscopy had a 57% rate of new findings and was performed without complications. The utility of tracheoscopy was also apparent in its ability to quickly and safely examine the trachea, with a 21% rate of new findings. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1376-1380, 2017.