In-office vs. operating room procedures for recurrent respiratory papillomatosis.

We conducted a study to analyze hospital and patient costs, outcomes, and patient satisfaction among adults undergoing in-office and operating room procedures for the treatment of recurrent respiratory papillomatosis. Our final study population was made up of 17 patients-1 man and 16 women, aged 30 to 86 years (mean: 62). The mean number of in-office laser procedures per patient was 4.2, and the mean interval between procedures was 5.4 months (although 10 patients underwent only 1 office procedure); the mean number of operating room procedures was 13.5, and the mean interval between procedures was 14.3 months. An equal number of patients reported complications or adverse events with the two types of procedures-5 each. The difference in cost between the office procedure (mean: $3,413.00) and the operating room procedure (mean: $12,382.59) was almost $9,000, but these savings were offset by the fact that the office procedures needed to be performed three times as often. Patients reported slightly more anxiety and discomfort during the office procedures and, overall, they appeared to prefer the operating room procedure. We conclude that office procedures are significantly more cost-effective than operating room procedures, but their use may be limited by patient tolerance and the increased frequency of the procedure.

Assessing delays in laryngeal cancer treatment.

OBJECTIVES/HYPOTHESIS: To see if there has been a decrease in patient delay, professional delay, diagnostic delay, and treatment delay in laryngeal cancer. STUDY DESIGN: Institutional review board-approved retrospective chart review of patients diagnosed with laryngeal cancer. METHODS: Nine hundred sixty-six patients with International Classification of Diseases, Ninth Revision code for laryngeal cancer were identified from 1993 to 2013. Two hundred fifty patients met inclusion criteria. Patients were placed into two groups based on time at presentation to primary care physician, 1993 to 2004 and 2005 to 2013. Patient delay, professional delay, diagnostic delay, and treatment delay were calculated. Statistical analysis was applied using the Student t test and generalized linear model. RESULTS: From 1993 to 2004, patient delay was 88.7 days, professional delay was 40.9 days, diagnosis delay was 33.1 days, and treatment delay was 24.7 days. From 2005 to 2013, patient delay was 119.2 days, professional delay was 37.9 days, diagnosis delay was 23.8 days, and treatment delay was 23.2 days. Comparison using the Student t test demonstrated the difference in patient delay (shorter before 2005) was statistically significant (P = .045), whereas professional delay (P = .269), diagnosis delay (P = .289), and treatment delay (P = .328) did not reveal any significant differences. There was no association between stage at initial diagnosis and days prior to ear, nose, and throat visit (P = .402). CONCLUSIONS: Delays in the presentation of patients to primary care physicians and otolaryngologists have significantly increased in the past 9 years. Earlier referral to otolaryngologists from primary care physicians in high-risk patients with voice changes will lead to more prompt diagnosis and treatment of laryngeal cancer. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1612-1615, 2016.

Quantitative Analysis of Voice in Parkinson Disease Compared to Motor Performance: A Pilot Study.

BACKGROUND: Characteristic features of hypokinetic dysarthria develop in Parkinson disease (PD). We hypothesized that quantified acoustic changes of voice might provide a correlate of disease severity. OBJECTIVE: To determine if there are significant differences in acoustic measures of voice between mild and moderate PD; 2) To evaluate correlations between acoustic parameters of voice and subtests of the UPDRS in mild and moderate PD. METHODS: Twenty six participants with PD underwent vocal acoustic testing while off PD medication, for comparison to 22 healthy controls. Participants with PD were divided into two groups based upon UPDRS activities of daily living (ADL) ratings: summed scores were used to define mild and moderate PD. Participants voiced /i/ ("ee") at comfort, high, and low pitch (3 trials/pitch). The CSpeech Waveform Analysis Program was used to analyze cycle-to-cycle frequency ("jitter") and amplitude ("shimmer") irregularities of the vocal signal, signal-to-noise ratio, and maximum phonation frequency range converted to semitones. Sections of UPDRS scores were correlated to acoustic variables of voice. RESULTS: Key findings included a significant difference between the semitone range of the control subjects and the moderate PD group (p = 0.036). Further analyses revealed significant differences in semitone range for males between the controls vs. mild PD (p = 0.014), and controls vs. moderate PD (p = 0.005). Significant correlations were also found between acoustic findings and both the ADL and motor portions of the UPDRS. CONCLUSIONS: Acoustic analysis of voice, particularly frequency range, may provide a quantifiable correlate of disease progression in PD.

Vocal fold vibration after photofrin-mediated photodynamic therapy for treatment of early-stage laryngeal malignancies.

OBJECTIVE/HYPOTHESIS: To analyze vocal fold vibration after photofrin-mediated photodynamic therapy (PDT) for the treatment of Tis and T1N0M0 squamous cell carcinoma (SqCCa) tumors of the larynx. It was hypothesized that key attributes of vocal fold vibration would return to baseline within 1-6 months of treatment. STUDY DESIGN: Retrospective. METHODS: Laryngovideostroboscopic data were retrospectively analyzed for eight patients with Tis-T1N0M0 SqCCa tumors of the larynx treated with photofrin-mediated PDT. Baseline and posttreatment videostroboscopy images of select vibratory characteristics of the vocal folds were randomized and analyzed by a speech-language pathologist and fellowship-trained laryngologist specializing in voice disorders. RESULTS: Significant improvement in mucosal wave (P=0.003) and amplitude of vibration (P=0.004) occurred at greater than or equal to 20 weeks post-PDT compared with baseline. Comparing results within 5 weeks postprocedure to 10-19-weeks postprocedure revealed significant improvement in amplitude of vibration (P=0.013) and nonvibrating portion of the vocal fold (P=0.020). Comparing results within 5-weeks postprocedure to 20 or more weeks postprocedure revealed significant improvement in amplitude of vibration (P=0.001), mucosal wave (P=0.001), and nonvibrating portion of the effected fold (P=0.001). CONCLUSION: Photofrin-mediated PDT allows for preservation of function and structure of the larynx without systemic toxicity; however, it may take 4-5 months or more for key vibratory characteristics of the vocal folds to recover posttreatment.

Delayed failure after endoscopic staple repair of an anterior spine surgery related pharyngeal diverticulum.

We present a rare complication of endoscopic staple repair of a pharyngeal diverticulum related to prior anterior cervical spine surgery. A 70-year-old male developed a symptomatic pharyngeal diverticulum 2 years after an anterior cervical fusion that was repaired via endoscopic stapler-assisted diverticulectomy. He initially had improvement of his symptoms after the stapler-assisted approach. Three years later, the patient presented with dysphagia and was found to have erosion of the cervical hardware into the pharyngeal lumen at the site of the prior repair. We present the first reported case of late hardware erosion into a pharyngeal diverticulum after endoscopic stapler repair.

Epigenetic events underlie the pathogenesis of sinonasal papillomas.

Benign inverted papillomas have been reported as monoclonal but lacking common genetic alterations identified in squamous cell carcinoma of the head and neck. Epigenetic changes alter the heritable state of gene expression and chromatin organization without change in DNA sequence. We investigated whether epigenetic events of aberrant promoter hypermethylation in genes known to be involved in squamous head and neck cancer underlie the pathogenesis of sinonasal papillomas. Ten formalin-fixed paraffin DNA samples from three inverted papilloma cases, two exophytic (everted) papilloma cases, and two cases with inverted and exophytic components were studied. DNA was obtained from microdissected areas of normal and papilloma areas and examined using a panel of 41 gene probes, designed to interrogate 35 unique genes for aberrant methylation status (22 genes) using the methylation-specific multiplex-ligation-specific polymerase assay. Methylation-specific PCR was employed to confirm aberrant methylation detected by the methylation-specific multiplex-ligation-specific polymerase assay. All seven cases indicated at least one epigenetic event of aberrant promoter hypermethylation. The CDKN2B gene was a consistent target of aberrant methylation in six of seven cases. Methylation-specific PCR confirmed hypermethylation of CDKN2B. Recurrent biopsies from two inverted papilloma cases had common epigenetic events. Promoter hypermethylation of CDKN2B was a consistent epigenetic event. Common epigenetic alterations in recurrent biopsies underscore a monoclonal origin for these lesions. Epigenetic events contribute to the underlying pathogenesis of benign inverted and exophytic papillomas. As a consistent target of aberrant promoter hypermethylation, CDKN2B may serve as an important epigenetic biomarker for gene reactivation studies.

Management of common voice problems: Committee report.

OBJECTIVE: This report provides the reader with a state-of-the-art update on a number of common voice problems that require phonosurgical intervention. STUDY DESIGN AND SETTING: This multiauthor review is not a position statement of the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) and may reflect institutional preference and/or bias. It arose from a panel discussion at the AAOHNS meeting in 2000. RESULTS: We provide a review of the genesis and management of papillomatosis, dysplastic glottal epithelium, arytenoid granulomas, Reinke's edema, and vocal-fold paralysis. CONCLUSIONS AND SIGNIFICANCE: In the past decade, there has been a dramatic expansion of knowledge regarding a variety of voice disorders and associated treatment. There has been a convergence of basic science investigations in anatomy, physiology, and pathology with clinical trials of treatment, both surgical and nonsurgical. This information should provide the reader with current insight into critical management issues of the aforementioned disorders.