South of the UES: Improving the ability of speech-language pathologists to detect oesophageal abnormalities during videofluoroscopy swallowing studies.

PURPOSE: With two-thirds of adults presenting for a videofluoroscopy swallow study (VFSS) with oesophageal abnormalities, it seems prudent to include visualisation of the oesophagus, in the context of the entire swallow process, to provide further information to the diagnostic team. This study aims to evaluate the ability of speech-language pathologists (SLPs) to interpret oesophageal sweep on VFSS and the relative improvement in that ability with additional training. METHOD: One hundred SLPs attended training in oesophageal visualisation during VFSS, based on a previous study. Ten oesophageal sweep videos (five normal, five abnormal) with one 20 ml thin fluid barium bolus (19% w/v) were presented at baseline and following training. Raters were blinded to patient information other than age. Binary ratings were collected for oesophageal transit time (OTT), presence of stasis, redirection, and referral to other specialists. RESULT: Inter-rater reliability as measured by Fleiss' kappa improved for all parameters, reaching statistical significance for OTT (pre-test kappa = 0.34, post-test kappa = 0.73; p < 0.01) and redirection (pre-test kappa = 0.38, post-test kappa = 0.49; p < 0.05). Overall agreement improved significantly (p < 0.001) for all parameters except stasis, where improvement was only slight. Interaction between pre-post and type of video (normal/abnormal) was statistically significant (p < 0.001) for redirection, with a large pre-post increase in positive accuracy compared with a slight pre-post decrease in negative accuracy. CONCLUSION: Findings indicate that SLPs require training to accurately interpret an oesophageal sweep on VFSS. This supports the inclusion of education and training on both normal and abnormal oesophageal sweep patterns, and the use of standardised protocols for clinicians using oesophageal visualisation as part of the VFSS protocol.

Demonstration of Accuracy and Feasibility of Remotely Delivered Oximetry: A Blinded, Controlled, Real-World Study of Regional/Rural Children with Obstructive Sleep Apnoea.

Objectives: Evaluate diagnostic accuracy and feasibility of a mail-out home oximetry kit. Design: Patients were referred for both the tertiary/quaternary-centre hospital-delivered oximetry (HDO) and for the mail-out remotely-delivered oximetry (RDO). Quantitative and qualitative data were collected. The COVID-19 pandemic began during this study; therefore, necessary methodological adjustments were implemented. Setting: Patients were first evaluated in Swan Hill, Victoria. RDO kits were sent to home addresses. For the HDO, patients travelled to the Melbourne city area, received the kit, stayed overnight, and returned the kit the following morning. Participants: All consecutive paediatric patients (aged 2−18), diagnosed by a specialist in Swan Hill with obstructive sleep apnoea (OSA) on history/examination, and booked for tonsillectomy +/− adenoidectomy, were recruited. Main outcome measures: Diagnostic accuracy (i.e., comparison of RDO to HDO results) and test delivery time (i.e., days from consent signature to oximetry delivery) were recorded. Patient travel distances for HDO collection were calculated using home/delivery address postcodes and Google® Maps data. Qualitative data were collected with two digital follow-up surveys. Results: All 32 patients that had both the HDO and RDO had identical oximetry results. The HDO mean delivery time was 87.7 days, while the RDO mean delivery time was 23.6 days (p value: <0.001). Qualitatively, 3/28 preferred the HDO, while 25/28 preferred the RDO (n = 28). Conclusions: The remote option is as accurate as the hospital option, strongly preferred by patients, more rapidly completed, and also an ideal investigation delivery method during certain emergencies, such as the COVID-19 pandemic.

Recent Levels of Evidence in Otolaryngology Journals.

OBJECTIVE: The development of evidence-based medicine has contributed to improved patient outcomes. This study aims to identify the trends in levels of evidence in otolaryngology journals over time, as represented by the 4 most widely circulated peer-reviewed otolaryngology journals. METHODS: A review of all articles from 2007, 2010, 2013, 2016, and 2019, in 4 major otolaryngology journals. Data points included journal source, year of publication, country of origin, first author sex, and subspecialty category within otolaryngology. Level of evidence was determined based on the study's primary research question and was graded on a scale of 1 (strongest) to 4 (weakest) based on the Oxford Centre of Evidence-based Medicine - Levels of Evidence guideline. Comparison of levels of evidence was performed using Kruskal-Wallis analysis of variance for ordinal data. RESULTS: About 4297 articles were identified over 12 years. The number of research articles remained consistent over the 12 years of this study. Clinical research increased from 78.6% to 85.1%. Female first authorship increased from 20.3% in 2007 to 31.0% in 2019. Of 3558 articles that constituted clinical research from 2007 to 2019, level 1 studies increased from 0.9% to 3.6%, with level 4 studies remaining stable at an overall rate of 60.3%. Randomized controlled trials remained stable at 4.6% of all studies. Systematic reviews increased from 3.2% to 8.4%. CONCLUSION: This article provides an update on the levels of evidence to allow for an honest self-assessment of otolaryngology as a scientific field.

Cost-minimisation analysis of polysomnography and pulse oximetry in a risk stratification protocol for paediatric adenotonsillectomy.

BACKGROUND: Severe obstructive sleep apnoea (OSA) is associated with increased risk of respiratory compromise in the post-operative period following adenotonsillectomy (AT). This study analyses the economic cost of polysomnography or overnight oximetry as part of pre-operative risk stratification in paediatric AT, supplementing previously published research demonstrating the efficacy of this protocol in predicting respiratory complications. METHODS: This cost-minimisation analysis examines costs associated with pre-operative overnight oximetry and polysomnography in triaging paediatric patients older than 2 years old, with no major comorbidities except for OSA, undergoing AT for OSA (n = 1801) to either a secondary or quaternary Australian hospital. Decision analysis modelling via probability trees were utilized to estimate pre- and peri-operative costs. A third hypothetical 'no investigation' model based upon conducting all AT at a secondary hospital was performed. Costs are derived from the financial year 2020-2021, censored at discharge. RESULTS: The total cost per patient of AT including pre-operative investigations of oximetry and polysomnography, and associated inpatient costs, were AUD4181.34 and 5013.99 respectively. This is more expensive compared to a hypothetical no-investigation model (AUD3958.98). CONCLUSION: Within the scope of this partial economic evaluation, this study finds a small additional cost for a model of care involving overnight oximetry as a pre-operative triage tool, balanced by the reduced cost of care in a lower acuity centre for low-risk patients and potential high cost of complications if all children are treated in a low acuity centre. This supports oximetry in peri-operative risk stratification for paediatric AT from a financial perspective.

Paediatric tonsillectomy and adenotonsillectomy in a rural setting: a retrospective study over a period of 6-years.

BACKGROUND: Swan Hill District Health (SHDH) provides Otolaryngological services to outer regional Victoria. A preoperative checklist determines eligibility for tonsillectomy, and the role of preoperative investigations such as oximetry. Visiting specialists who provide T&A also remain on-site for 24 h post-surgery. Management of post-discharge complications is supported by SHDH's Emergency Department. Unstable patients are transferred to tertiary care hospitals. This study examines the safety outcomes associated with rural Tonsillectomy and adenotonsillectomy (T&A) and the impact of peri-operative protocols on these outcomes. METHODS: This is a retrospective cohort study of all paediatric (2-18 years old) patients undergoing T&A from August 2014 to June 2020 at SHDH. Four external hospital databases which accept patient transfers from SHDH were searched for T&A-related complications. The primary outcome was complication incidence. Secondary outcomes were length of stay, and rates of hospital readmissions, return to theatre and inter-hospital transfer. RESULTS: Two hundred and four patients were included, with median age 6 years old; 68.1% (n = 139/204) had obstructive sleep apnoea, or sleep disordered breathing, wherein 36.0% (n = 50/139) had documented evidence of normal/inconclusive oximetry. The complication rate is 6.9% (n = 14/204), with two intraoperative, five perioperative and seven post-discharge complications. All intra- and peri-operative complications were managed locally. All post-discharge complications presented to outer regional EDs. Two patients required inter-hospital transfer for monitoring of post-tonsillectomy bleeds in a specialist unit. CONCLUSIONS: Patients who pass a preoperative risk checklist can safely undergo T&A in selected rural settings which adhere to strict patient selection criteria and implement safety measures to address complications.

The Use of Vocal Fold Injection Augmentation in a Transmasculine Patient Unsatisfied With Voice Following Testosterone Therapy and Voice Training.

INTRODUCTION: There exist a cohort of transmasculine patients who remain dissatisfied with vocal function following testosterone therapy and voice training. AIM: The objective of this case report was to describe the use of injection laryngoplasty in this cohort as an alternative to laryngeal framework surgery. METHOD: A case report and literature review was undertaken. RESULTS: Our case describes a 45-year-old transmasculine patient who remained unsatisfied with vocal pitch despite testosterone therapy and voice training. On initial presentation, the patient had fundamental frequency (fo) ranging from 70-344 Hz with a mean of approximately 135 Hz on reading, and 146 Hz in monologue. Injection augmentation of the vocal folds under local anesthesia with an injectable carboxymethylcellulose gel (prolaryn) was trialed. Following re-absorption of this, further injection was performed using autologous fat and subsequently a longer acting Calcium Hydroxyapatite injectable (Prolaryn Plus). This was followed by re-injection 1 year later. Patient satisfaction has been sustained throughout this period. Repeat acoustic evaluation in 2019 revealed a mean fo of 108 Hz on reading, 100 Hz in monologue, and a fo range of 85-134 Hz across these tasks. CONCLUSION: This case report presents an alternative surgical intervention to supplement testosterone and voice training in transmasculine patients unsatisfied with vocal function.

Detecting Aspiration During FEES with Narrow Band Imaging in a Clinical Setting.

The use of narrow band imaging (NBI) during flexible endoscopic evaluation of swallowing (FEES) is recognised as an emerging technology to improve the contrast of the test fluid during endoscopic dysphagia evaluation. This study tested the hypothesis that the use of NBI in FEES would improve the detection of laryngeal penetration and aspiration in patients with unilateral vocal fold paralysis/paresis (UVFP), a typically difficult population in which to detect the presence of aspiration with FEES. Twenty-one consecutive outpatients with UVFP were evaluated with FEES using white light (WL) and NBI under 150 test conditions (75 WL & 75 NBI). Three speech pathologists, highly experienced in FEES using WL but novices to using NBI, rated laryngeal penetration and aspiration for green dyed thin fluid (5 ml and 90 ml) and mildly thick fluid (5 ml) milk, and were compared to two raters more experienced in using NBI during FEES. Laryngeal penetration and aspiration were significantly higher for larger volumes (90 ml) (p < 0.05). With NBI-naïve raters, there was a trend towards lower intra-rater and inter-rater reliability compared to WL on all bolus trials reaching significance on mildly thick fluid (p < 0.01). There was lower rater confidence when using NBI compared to WL in NBI-naïve raters to detect aspiration (p < 0.01). Sensitivity was lower regardless of NBI experience; 80.77-84.21% with WL compared to 46.15-50.00% with NBI. Findings indicate that the improved contrast of a dyed opaque milk trial under WL may negate the potential benefits of using NBI to increase the contrast of the test fluid and supports the use of an opaque test fluid such as milk. NBI may also not be as useful to clinicians with no experience with the altered light condition, and can result in lower sensitivity in even the experienced user.

Tubeless Anesthesia in Subglottic Stenosis: Comparative Review of Apneic Low-Flow Oxygenation With THRIVE.

OBJECTIVE: Managing the shared airway in subglottic stenosis presents a unique challenge. Tubeless anesthesia with apneic oxygenation is increasingly being adopted as it overcomes the limitations of access to and visualization of the narrowed subglottis. Low-flow oxygenation (LFO) and transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) are two delivery techniques. We sought to compare their utility in this patient cohort. STUDY DESIGN: Retrospective cohort study. METHODS: Thirty-five cases of endoscopic debridement of subglottic stenosis were retrospectively studied. Operative technique was consistent among the cases. Oxygen was delivered at low-flow rates at the laryngeal inlet with LFO (n = 23) or high-flow rates at the nares with THRIVE (n = 12). Data regarding apnea time, the need for rescue ventilation, and relevant patient and disease factors were recorded for analysis. RESULTS: Median apnea time for LFO and THRIVE were 34 and 25 minutes, respectively. Rescue with intermittent supraglottic jet ventilation was required more often with LFO than THRIVE (61% vs 33%) and was sufficient for the case to be completed in all but one instance. Elevated BMI was the sole significant predictor of early oxygen desaturation (24.8 vs 37.95 kg/m2 , P = .002) with LFO. Median stenosis diameter was 6 mm (range 2-14). CONCLUSION: Apneic techniques are safe and feasible for the endoscopic management of subglottic stenosis of all severities. Elevated BMI is the only significant predictor for early oxygen desaturation. In the many healthcare settings where THRIVE is not available, LFO is a valid alterative in the nonobese patient. Laryngoscope, 132:1231-1236, 2022.

An evaluation of strategies to achieve greater than 90% coverage of maternal influenza and pertussis vaccines including an economic evaluation.

BACKGROUND: Maternal immunisation is an essential public health intervention aimed at improving the health outcomes for pregnant women and providing protection to the newborn. Despite international recommendations, safety and efficacy data for the intervention, and often a fully funded program, uptake of vaccines in pregnancy remain suboptimal. One possible explanation for this includes limited access to vaccination services at the point of antenatal care. The aim of this study is to evaluate the change in vaccine coverage among pregnant women following implementation of a modified model of delivery aimed at improving access at the point of antenatal care, including an economic evaluation. METHODS: This prospective multi-centre study, using action research design, across six maternity services in Victoria, Australia, evaluated the implementation of a co-designed vaccine delivery model (either a pharmacy led model, midwife led model or primary care led model) supported by provider education. The main outcome measure was influenza and pertussis vaccine uptake during pregnancy and the incremental cost of the new model (compared to existing models) and the cost-effectiveness of the new model at each participating health service. RESULTS: Influenza vaccine coverage in 2019 increased between 50 and 196% from baseline. All services reduced their average cost per immunisation under the new platforms due to efficiencies achieved in the delivery of maternal immunisations. This cost saving ranged from $9 to $71. CONCLUSION: Our study demonstrated that there is no 'one size fits all' model of vaccine delivery. Future successful strategies to improve maternal vaccine coverage at other maternity services should be site specific, multifaceted, targeted at the existing barriers to maternal vaccine uptake, and heavily involve local stakeholders in the design and implementation of these strategies. The cost-effectiveness analysis indicates that an increase in maternal influenza immunisation uptake can be achieved at a relatively modest cost through amendment of maternal immunisation platforms.

Laryngotracheal Stenosis Management: A 16-Year Experience.

In recent years, it has become increasingly apparent that the laryngotracheal stenosis (LTS) cohort comprises distinct etiological subgroups; however, treatment of the disease remains heterogeneous with limited research to date assessing predictors of treatment outcome. We aim to assess clinical and surgical predictors of endoscopic treatment outcome for LTS, as well as to further characterize the disease population. A retrospective chart review of adult patients with LTS presenting over a 16-year period was conducted. Seventy-five patients were identified and subdivided into 4 etiologic subgroups: iatrogenic, idiopathic, autoimmune, and "other" groups. Statistical comparison of iatrogenic and idiopathic groups was performed. Subsequently, stepwise logistic regression was employed to examine the association between clinical/surgical factors and treatment outcome, as measured by tracheostomy incidence and dependence. We demonstrate that patients with iatrogenic LTS were significantly more morbid (P < .001) and had worse disease, with significantly greater percentage stenosis (P = .015) and increased incidence of tracheostomy (P < .001). Analyzing the predictive effect of clinical and surgical variables on endoscopic treatment outcome, we have shown that when adjusted for age, sex, and iatrogenic etiology, patients with an American Society of Anesthesiologist score >2 were significantly more likely to undergo tracheostomy (adjusted odds ratio = 11.23, 95% confidence interval [CI] = 1.47-86.17). Similarly, when compared with their idiopathic counterparts, patients with iatrogenic LTS had higher odds of undergoing tracheostomy (17.33, 95% CI = 1.93-155.66) as were patients with Cotton-Myer grade 3-4 stenosis (9.84, 95% CI = 1.36-71.32). The odds of tracheostomy dependence at time of last follow-up were significantly higher in patients with gastroesophageal reflux disease (15.38, 95% CI = 1.36-174.43) and cerebrovascular accident (9.03, 95% CI = 1.01-81.08), even after adjustment. No surgical techniques were significantly associated with either outcome when adjusted. We present a heterogeneous LTS cohort comprised of homogeneous subgroups with distinct levels of morbidity, disease morphology, and treatment burden. Further our data suggest that the treatment outcome is more dependent on patient factors, rather than surgical technique used.

Diagnostic Utility of Salivary Pepsin as Compared With 24-Hour Dual pH/Impedance Probe in Laryngopharyngeal Reflux.

OBJECTIVE: Laryngopharyngeal reflux (LPR) is defined as the retropulsion of gastric contents into the larynx, oropharynx, and/or nasopharynx. The 24-hour combined hypopharyngeal-esophageal multichannel intraluminal impedance with dual pH probe (24h-HEMII-pH) is currently the gold standard in LPR diagnosis; however, it is invasive, user dependent, and not always tolerated. This study assesses the diagnostic utility of salivary pepsin (Peptest) at different thresholds and during symptomatic periods as compared with the 24h-HEMII-pH probe in diagnosing LPR. STUDY DESIGN: Prospective cohort study. SETTING: Private laryngology clinic in Melbourne, Australia. SUBJECTS AND METHODS: Thirty-five patients with a clinical history and endoscopic findings of LPR were recruited and simultaneously evaluated for LPR via 24h-HEMII-pH probe and salivary pepsin analysis at 5 key time points over the same 24-hour period. RESULTS: Salivary pepsin was 76.9% sensitive and had a positive predictive value (PPV) of 87.0% at a threshold of 16 ng/mL when compared with the 24h-HEMII-pH probe. If the pathologic pepsin threshold was raised to 75 ng/mL, salivary pepsin had a sensitivity of 57.7%, a specificity of 75.0%, and a PPV of 93.8%. Symptomatic testing conferred a superior specificity at 16 ng/mL (66.7%) and 75 ng/mL (100.0%) and a superior PPV at 16 ng/mL (92.3%) and 75 ng/mL (100.0%). CONCLUSION: Salivary pepsin detection is a simpler, more cost-effective, and less traumatic universal first-line alternative to 24h-HEMII-pH probe in diagnosing LPR. Superior specificities conferring greater diagnostic value may be achieved with higher thresholds and symptomatic testing. If clinical suspicion remains high following negative salivary pepsin analysis, a 24h-HEMII-pH study could provide further diagnostic information.

What is the truth about proton pump inhibitors?

PURPOSE OF REVIEW: This review explores the recent evidence and established scientific literature surrounding proton pump inhibitors in the context of laryngology. RECENT FINDINGS: Proton pump inhibitors are often associated with gastroenterology; however, they also have a place in laryngology. Several laryngopharyngeal disorders are treated with proton pump inhibitors, though limited evidence regarding effectiveness, dosing and length of treatment exists. With the recent influx of articles reporting possible adverse effects of proton pump inhibitors, the appropriate prescribing of them has come under scrutiny. These reported risks include cancer, stroke, myocardial infarction, kidney disease and cognitive decline. It should be noted though that many of these studies by nature, are fraught with potential confounding. Regardless, clinicians ought to be aware of any risks associated with treatment regimens and prescribe the optimal dosage and duration. SUMMARY: Proton pump inhibitor treatment should be dose-appropriate and for a limited duration. Concerning potential adverse effects, the limitations of retrospective cohort studies must be taken into consideration when reviewing the evidence.

Identifying Type III Sulcus: Patient Characteristics and Endoscopic Findings.

OBJECTIVE: Type III sulcus is a pathologic structural deformity of the vocal folds that is challenging to accurately diagnose without endoscopic examination under anesthesia. This study aims to further define the clinical presentation and examination features shared among a patient cohort intraoperatively diagnosed with type III sulcus. STUDY DESIGN: Case series with chart review. SETTING: Tertiary laryngology practice. SUBJECTS AND METHODS: All patients diagnosed intraoperatively with type III sulcus from 2002 to 2014 at a tertiary laryngology practice were included. Clinical history of presenting symptoms, videostroboscopy, and intraoperative and histologic findings were reviewed. RESULTS: Twenty-two patients were included in the study. A majority were female (77%) and had a mean age of 32.4 years. All patients endorsed hoarseness, and 86% were defined as professional voice users. Endoscopic examination revealed bilateral type III sulcus in 23% of patients. The most common preoperative stroboscopic findings included decreased mucosal wave (100%), dilated vessel (95%), phase asymmetry (91%), additional benign lesion (91%), and cyst (82%). Histology revealed epithelial changes of atypia and keratosis. CONCLUSION: Both the severity of dysphonia and the difficulty observing structural malformations of the vocal folds make type III sulcus challenging to preoperatively diagnose. This study reports the clinical and endoscopic features seen within a cohort of patients with type III sulcus.

Chronic non-granulomatous supraglottitis of a male adolescent and its successful management with azathioprine.

Chronic non-granulomatous supraglottitis (CNGS) is a rare disorder of the supraglottic larynx, characterised by chronic supraglottic inflammation in the absence of granulomata, vasculitis, neoplasia, autoimmune disease or infective changes on histology. We present the case of a male adolescentwho attended with progressively worsening exertional dyspnoea, stridor and symptoms of obstructive sleep apnoea. Flexible nasendoscopy revealed marked supraglottic subepithelial thickening sparing the glottis and subglottis, confirmed on microlaryngoscopy. MRI of the head and neck demonstrated diffuse, homogenous supraglottic oedema. At the peak of his symptomology, the patient was admitted for further investigations and intravenous steroid therapy, and switched to prolonged oral steroids on discharge. Tracheostomy was avoided. After 3 months, he was successfully weaned from steroids to azathioprine with gradual symptomatic improvement. This case represents the first successful use of a steroid-sparing agent in the management of CNGS.

Systemic safety of serial intralesional steroid injection for subglottic stenosis.

OBJECTIVES/HYPOTHESIS: Serial intralesional steroid injection (SILSI) has recently been proposed as an effective scar-modifying therapy for subglottic stenosis (SGS). We aimed to explore the systemic absorption of steroid following SILSI and to characterize the magnitude and chronicity of any effect observed. Specifically, we aimed to show that any effect resolves prior to the next intralesional injection. STUDY DESIGN: Prospective, observational pilot study. METHODS: Patients were injected intralesionally with 40 to 200 mg triamcinolone. Serum cortisol, as well as white cell counts and inflammatory markers were measured at day 0 (baseline), 1, 7, and 28. Salivary cortisol was measured at baseline and for 7 consecutive days following injection. RESULTS: Six patients with idiopathic SGS were recruited. At baseline, serum cortisol measured 284.0 ± 61.4 nmol/L and fell significantly to 15.5 ± 4.3 nmol/L 1 day following triamcinolone injection (P = .03). At day 7, serum steroid levels showed significant recovery to 221.8 ± 78.9 nmol/L (P = .03) and further rose to 279.5 ± 29.9 nmol/L at 28 days (P = .07). Salivary cortisol exhibited a similar pattern with significant recovery by day 6 (P = .04) and suggestion of exponential clearance of triamcinolone systemically. White cell counts were also affected by systemic absorption of exogenous steroid. No significant change in inflammatory markers was observed. CONCLUSIONS: Our findings demonstrate systemic absorption of steroid following SILSI, with acute hypothalamic-pituitary-adrenal (HPA) axis suppression. However, normalization of HPA axis function by day 7 suggests that although acute steroid side effects should be discussed with patients, no cumulative systemic steroid side effect would occur with serial injections. LEVEL OF EVIDENCE: 2 Laryngoscope, 129:1634-1639, 2019.

Diagnosis of concomitant inducible laryngeal obstruction and asthma.

BACKGROUND: Inducible laryngeal obstruction, an induced, inappropriate narrowing of the larynx, leading to symptomatic upper airway obstruction, can coexist with asthma. Accurate classification has been challenging because of overlapping symptoms and the absence of sensitive diagnostic criteria for either condition. OBJECTIVE: To evaluate patients with concomitant clinical suspicion for inducible laryngeal obstruction and asthma. We used a multidisciplinary protocol incorporating objective diagnostic criteria to determine whether asthma, inducible laryngeal obstruction, both, or neither diagnosis was present. METHODS: Consecutive patients were prospectively assessed by a laryngologist, speech pathologist and respiratory physician. Inducible laryngeal obstruction was diagnosed by visualizing paradoxical vocal fold motion either at baseline or following mannitol provocation. Asthma was diagnosed by physician assessment with objective variable airflow obstruction. Validated questionnaires for laryngeal dysfunction and relevant comorbidities were administered. RESULTS: Of 69 patients, 15 had asthma alone, 11 had inducible laryngeal obstruction alone and 14 had neither objectively demonstrated. Twenty-nine patients had both diagnoses. In 19 patients, inducible laryngeal obstruction was only seen following provocation. Among patients with inducible laryngeal obstruction, chest tightness was more frequent with concurrent asthma. Among patients with asthma, stridor was more frequent with concurrent inducible laryngeal obstruction. Cough was more frequently found in asthma alone, whereas difficulty with inspiration and symptoms triggered by psychological stress were more frequently found in inducible laryngeal obstruction alone. Patients with asthma alone had greater airflow obstruction. Relevant comorbidities were frequent (rhinitis in 85%, gastro-oesophageal reflux in 65%), and questionnaire scores for laryngeal dysfunction were abnormal. However, neither comorbidities nor questionnaires differentiated patients with or without inducible laryngeal obstruction. CONCLUSIONS AND CLINICAL RELEVANCE: In this cohort with suspected inducible laryngeal obstruction and asthma, 42% had objective evidence of both conditions. Clinical assessment, questionnaire scores and comorbidity burden were not sufficiently discriminatory for diagnosis, highlighting the necessity of objective diagnostic testing.

Quality-of-Life Metrics Correlate With Disease Severity in Idiopathic Subglottic Stenosis.

OBJECTIVES: Idiopathic subglottic stenosis (ISGS) can have significant impacts on quality of life (QOL), but it remains unclear how patients' subjective responses correlate with objective measurement of disease severity. Peak expiratory flow percentage (PEF%) has been shown to be an effective measure of disease severity in subglottic stenosis. This study aims to identify the key QOL questions correlated with PEF% and proposes a statistical model for prediction of disease severity. METHODS: Patients with ISGS presenting to an academic laryngologist were included retrospectively from 2012 to 2016. Peak expiratory flow percentage (age, sex, and height adjusted) was recorded for each visit, along with four validated QOL instruments (European QOL-Five Dimensions; RAND 36-Item Health Survey; Clinical COPD [Chronic Obstructive Pulmonary Disease] Questionnaire; and the Airway, Dyspnea, Voice, and Swallowing Summary Assessment). A stepwise multiple linear regression was used to identify statistically significant independent variables correlated with PEF%, and a model was built with these variables. RESULTS: Thirty-two patients were included, with a total of 271 patient encounters. Overall scores from each of the four QOL instruments were correlated with PEF% values recorded each visit (P < 0.05). Question responses correlating most positively included overall breathlessness, difficulty catching breath, cough within the past week, dyspnea with moderate activity, perception that voice changes are restricting social life, and overall general health (all P < 0.01). A model constructed using six nonoverlapping questions yielded an adjusted R2 of 0.58. CONCLUSION: Quality of life is correlated to PEF% in ISGS. Using a limited number of QOL questions, clinicians can predict objective worsening or improvement of disease severity, as measured by spirometry. LEVEL OF EVIDENCE: 2b. Laryngoscope, 2017.

Awake serial intralesional steroid injections without surgery as a novel targeted treatment for idiopathic subglottic stenosis.

OBJECTIVES/HYPOTHESIS: The fibrotic/erythematous appearance of the subglottis in idiopathic subglottic stenosis (iSGS) hints that it might respond to repeated intralesional steroid treatment similar to keloids. STUDY DESIGN: Retrospective cohort study. METHODS: Thirteen iSGS subjects (six treated in-office with serial intralesional steroid injections [SILSI] versus seven treated endoscopically in the operating room [OR] followed by awake SILSI) between October 2011 and April 2017. Forced spirometry was performed before injections and at each follow-up visit (peak expiratory flow [%PEF] and peak inspiratory flow). Steroids were injected via transcricothyroid or transnasal routes. Injections were grouped into rounds of four to six injections separated by 3 to 5 weeks. RESULTS: Thirteen subjects with a mean follow-up of 3 years (3.3 years for SILSI and 2.7 years for OR). Awake-only SILSI subjects had a mean improvement/round of 23.1% %PEF (range, 65.4%-88.6%), whereas the OR-treated subjects had a mean %PEF improvement/round of 25.1% (range, 57.4%-82.5%). Both groups had improved breathing, and the improvements were statistically equal (P = .569). SILSI subjects underwent 5.3 injections/round in 1.3 rounds, whereas OR subjects had 5.9 injections/round over 2.1 rounds. Statistically significant improvement was seen in %PEF for both groups (SILSI P = .007, OR P = .002). Overall, SILSI achieved sustained %PEF above 80% in 83% (5/6) and OR + SILSI 86% (6/7). CONCLUSIONS: SILSI in the awake outpatient setting can improve the airway caliber in iSGS and is equivalent to endoscopic OR treatment. We believe iSGS can be viewed as a chronic scarring/inflammatory condition that can benefit from steroid scar-modification therapy. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:610-617, 2018.

Laryngeal Cryptococcosis Associated With Inhaled Corticosteroid Use: Case Reports and Literature Review.

Laryngeal cryptococcosis is a rare clinical entity. There have been a limited number of case reports in the literature with no consensus regarding optimal management. This review contributes two additional case reports of immunocompetent patients with cryptococcal infection of the larynx in whom exposure to high doses of inhaled corticosteroids is proposed as a significant risk factor. Twenty cases were identified from review of the literature. All patients presented with hoarseness and a spectrum of microlaryngoscopic features, often mimicking laryngeal malignancy. The majority of cases were treated with systemic antifungal therapy, three cases had surgical excision alone, and another three had a combination of medical and surgical management. Risk factor modification, in the form of a reduction in inhaled corticosteroid was employed in the two new cases, and in some previously published cases. Risk factor modification, such as reduction of inhaled corticosteroid dose, in addition to oral antifungal agents can be effective in managing cryptococcal laryngitis.

Long-term Dose Stability of OnabotulinumtoxinA Injection for Adductor Spasmodic Dysphonia: A 19-Year Single Institution Experience.

OBJECTIVES: Adductor spasmodic dysphonia (AdSD) is a focal dystonia predominantly involving the laryngeal adductor muscles. AdSD is reported to be a largely non-progressive neurological disorder, though fluctuations in symptom severity do occur. Repeated laryngeal onabotulinumtoxinA (BTX-A) injections are the primary management for AdSD. A number of studies have demonstrated long-term dose stability as evidence of this long-term disease stability. METHODS: A retrospective review was performed on all patients undergoing BTX-A injections for AdSD from April 1994 to September 2013 by a single laryngologist at a tertiary referral laryngology center. Patient demographics, injection doses, use of diazepam and/or lidocaine, and self-reported vocal function were recorded. Multiple linear regression analyses were performed. RESULTS: 83 patients underwent a total of 1,168 injections over 19 years. The mean starting dose was 2.35 MU (0.79 SD). The mean long-term dose was 2.36 MU (0.79 SD). After adjusting for confounders, the change in the relative dose of BTX-A, with every year elapsed since initial dose was 0.13% (95% confidence interval -0.31 to 0.57%), p = 0.568. CONCLUSION: BTX-A dose is stable over time in our large cohort of patients treated with bilateral thyroarytenoid injections for AdSD.