Reproducibility of laryngeal force sensor measurements.

OBJECTIVE: The laryngeal force sensor (LFS) measures force during suspension microlaryngoscopy (SML) procedures, and has been previously shown to predict postoperative complications. Reproducibility of its measurements has not been described. STUDY DESIGN: Prospective cohort study. SETTING: Academic medical center. METHODS: 291 adult patients had force data collected from 2017 to 2021 during various SML procedures. 94 patients had passive LFS monitoring (surgeon blinded to intraoperative recordings) and 197 had active LFS monitoring (surgeon able to see LFS recordings). 27 of these patients had repeat procedures, with unique LFS metrics for each procedure. The 27 patients were divided into three groups. Group 1 had passive use for both procedures, group 2 had passive use for the first procedure and active use for the second, and group 3 had active use for both procedures. Force metrics from the two procedures were compared with a paired samples t-test. RESULTS: For airway dilation procedures and cancer resection procedures, average force variances were significantly lower with active versus passive use of the LFS. Group 1-no significant changes in maximum force (procedure 1 = 163.8 N, procedure 2 = 133.8 N, p = 0.324) or average force (procedure 1 = 93.6 N, procedure 2 = 78.3 N, p = 0.617). Group 2-maximum force dropped by 35 % between procedures 1 (219.2 N) and 2 (142.5 N), p = 0.013. Average force dropped by 42.5 % between procedures 1 (147.2 N) and 2 (84.6 N), p = 0.007. Group 3-no significant changes in maximum force (procedure 1 = 158.6 N, procedure 2 = 158.2 N, p = 0.986) or average force (procedure 1 = 94.2, procedure 2 = 81.8, p = 0.419). CONCLUSIONS: LFS measurements were reproducible for similar procedures in the same patient when the type of LFS monitoring was not a confounder.

Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement.

BACKGROUND: This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking. METHODS: An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements. CONCLUSIONS: This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.

One institution's experience with self-audit of opioid prescribing practices for common cervical procedures.

BACKGROUND: We aim to audit our institution's opioid prescribing practices after common cervical procedures. METHODS: Retrospective cohort study from one medical center. Reviewed records from 2016-2019 for 472 patients who underwent one of several common cervical procedures. Data collected on demographics, perioperative details, in-hospital pain medication use, and opioids prescribed at discharge. Multivariable logistic regression was run. RESULTS: In hospital, median daily milligram morphine equivalents (MME) was 4 (IQR 0-15). Median MME prescribed at discharge was 112.5 MME (IQR 75-150). 3/472 patients received NSAIDs. Predictors of decreased discharge MME were age 70 and older (OR 0.33, p = 0.037) and more recent year (compared to 2016, OR 0.23 [p = 0.031] for 2017, OR 0.13 [p = 0.001] for 2018, and OR 0.070 [p < 0.001] for 2019). CONCLUSIONS: MME prescribed at discharge was 28 times the daily in-hospital MME. Only 3/472 patients received postoperative NSAIDs. Self-auditing of opioid prescribing practices identifies actionable items for change.

Application of a Computer Vision Tool for Automated Glottic Tracking to Vocal Fold Paralysis Patients.

OBJECTIVES: (1) Demonstrate true vocal fold (TVF) tracking software (AGATI [Automated Glottic Action Tracking by artificial Intelligence]) as a quantitative assessment of unilateral vocal fold paralysis (UVFP) in a large patient cohort. (2) Correlate patient-reported metrics with AGATI measurements of TVF anterior glottic angles, before and after procedural intervention. STUDY DESIGN: Retrospective cohort study. SETTING: Academic medical center. METHODS: AGATI was used to analyze videolaryngoscopy from healthy adults (n = 72) and patients with UVFP (n = 70). Minimum, 3rd percentile, 97th percentile, and maximum anterior glottic angles (AGAs) were computed for each patient. In patients with UVFP, patient-reported outcomes (Voice Handicap Index 10, Dyspnea Index, and Eating Assessment Tool 10) were assessed, before and after procedural intervention (injection or medialization laryngoplasty). A receiver operating characteristic curve for the logistic fit of paralysis vs control group was used to determine AGA cutoff values for defining UVFP. RESULTS: Mean (SD) 3rd percentile AGA (in degrees) was 2.67 (3.21) in control and 5.64 (5.42) in patients with UVFP (P < .001); mean (SD) 97th percentile AGA was 57.08 (11.14) in control and 42.59 (12.37) in patients with UVFP (P < .001). For patients with UVFP who underwent procedural intervention, the mean 97th percentile AGA decreased by 5 degrees from pre- to postprocedure (P = .026). The difference between the 97th and 3rd percentile AGA predicted UVFP with 77% sensitivity and 92% specificity (P < .0001). There was no correlation between AGA measurements and patient-reported outcome scores. CONCLUSIONS: AGATI demonstrated a difference in AGA measurements between paralysis and control patients. AGATI can predict UVFP with 77% sensitivity and 92% specificity.

Laryngeal Force Sensor for Suspension Microlaryngoscopy: A Prospective Controlled Trial.

OBJECTIVES: The laryngeal force sensor (LFS) provides real-time force data for suspension microlaryngoscopy. This study investigates whether active use of the LFS can prevent the development of complications. STUDY DESIGN: Prospective controlled trial. SETTING: Academic tertiary center. METHODS: The LFS and custom software were developed to track intraoperative force metrics. A consecutive series of 100 patients had force data collected with operating surgeons blinded to intraoperative readings. The subsequent 100 patients had surgeons actively use the LFS monitoring system. Patients were prospectively enrolled, completing pre- and postoperative surveys to assess the development of tongue pain, paresthesia, paresis, dysgeusia, or dysphagia. RESULTS: On univariate analysis, the active monitoring group had lower total impulse (P < .001) and fewer extralaryngeal complications (P < .01). On multiple logistic regression, maximum force (odds ratio [OR], 1.08; 95% CI, 1.01-1.16; P = .02) was a significant predictive variable for the development of postoperative complications. Similarly, active LFS monitoring showed a 29.1% (95% CI, 15.7%-42.4%; P < .001) decrease in the likelihood of developing postoperative complications. These effects persisted at the first postoperative visit for maximum force (P = .04) and active LFS monitoring (P = .01). Maximum force (OR, 1.11; 95% CI, 1.04-1.18; P < .01) and active LFS monitoring (16.6%; 95% CI, 2.7%-30.5%; P = .02) were also predictive for the development of an abnormal 10-item Eating Assessment Tool score. These effects also persisted at the first postoperative visit for maximum force (P = .01) and active LFS monitoring (P = .01). CONCLUSION: Maximum force is predictive of the development postoperative complications. Active monitoring with the LFS is able to mitigate these forces and prevent postoperative complications. LEVEL OF EVIDENCE: 2.

Coverage for Gender-Affirming Voice Surgery and Therapy for Transgender Individuals.

OBJECTIVES/HYPOTHESIS: To determine insurance coverage for gender-affirming surgery and voice therapy for individuals who seek to align their voice with their gender identity, and to analyze differences based on state-by-state transgender equality. STUDY DESIGN: Cross-sectional study. METHODS: Policies from the top three commercial insurers per state in 2019 were reviewed. Coverage status was determined by web-based search, telephone interviews, and email inquiries. A state-by-state equality score was calculated based on the number of laws and policies relating to the transgender community. Correlation between number of preauthorized procedures and state equality scores was assessed. RESULTS: Of the 150 insurance companies reviewed, only four (2.7%) held favorable policies, whereas 113 (75.8%) provided no coverage. Endoscopic surgery, open surgery, individual voice therapy, and group voice therapy interventions were equally excluded (n = 93, 62.4%). Coverage was not correlated with laws driving transgender equality (P = .782). CONCLUSIONS: Gender-affirming voice interventions are seldom covered by commercial insurance companies. Despite established medical necessity and years of experience in practice, gender-affirming interventions for voice have not yet been fully considered by third-party payors. Further investigation regarding cost-effectiveness and treatment efficacy is warranted to improve insurance coverage of voice-related gender-affirming care. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E896-E902, 2021.

How Does Smoking Change the Clinicopathological Characteristics of Human Papillomavirus-Positive Oropharyngeal Squamous Cell Carcinoma? One Medical Center Experience.

INTRODUCTION: Human papillomavirus (HPV)-positive and HPV-negative oropharyngeal squamous cell carcinomas (OPSCCs) are 2 distinct cancers, with HPV-positivity conferring a better prognosis. Smoking status is a complicating factor for both patient populations. There have been scattered literature that have reported on incomplete information regarding the profiles of their patient population. Details including age and sex distributions, TNM staging, histology grading, recurrence time and types, death rates, and the direct causes of deaths have been reported incompletely in the literature. Here, based on the experience at our university medical centers, we explored all the details of the important clinical profiles of HPV-negative OPSCC, HPV-positive OPSCC in smokers and nonsmokers. OBJECTIVE: In this article, we compare detailed clinical profiles of HPV-negative OPSCC and HPV-positive OPSCC in both smokers and nonsmokers. The clinical profiles we elucidated here include patients' age and sex distribution, general health conditions, histology grading, TNM staging, perineural invasion (PNI), and lymphovascular invasion (LVI), extracapsular extension (ECE), recurrence rate and types, death rate, and direct causes. Specifically, we divided HPV-positive OPSCC into smokers and nonsmokers and compared the different clinical profiles between these groups to give a better idea of the complicating role of smoking in the development of HPV-positive OPSCC. METHOD: All patients with OPSCC at a tertiary care publicly funded county hospital and a tertiary care university hospital from June 2009-July 2015 were retrospectively reviewed. The attending physicians were the same at both hospitals. The primary outcome measure was posttreatment 2-year follow-up status (locoregional recurrence, distant recurrence, death rate). Other measures included HPV status based on p16 staining, smoking history, age, sex, comorbidities, tumor size, nodal and distant metastasis information, LVI, PNI, ECE, and tumor histology grade. RESULTS: A total of 202 patients with OPSCC were identified. They were categorized into 3 groups: HPV-negative OPSCC group (HPV-), HPV-positive smoker group (HPV+SMK+), and HPV-positive nonsmoker group (HPV+SMK-). Patients of HPV- group are older (61.1 ± 11.6 years) than the other groups on average. The HPV- group has the highest percentage of women (22.7%). The HPV- patients with OPSCC have more comorbidities than the HPV+SMK+ group and the HPV+SMK- group, although there is no statistical difference. Grade 2 tumor is the most common histology grade for HPV- patients with OPSCC, whereas grade 3 is the most common grade for HPV+SMK+ and HPV+SMK- groups. Both PNI and LVI are positive at around 40% for all groups without any significant difference, but ECE is very common for HPV- OPSCC, at 86.7%, which is significantly higher than that of the HPV+SMK+ and HPV+SMK- groups. There was no difference of bilateral neck metastases noticed among different groups. For T staging and N staging, although HPV+SMK- and HPV+SMK+ patients have relatively lower T stages and higher N stages, there is no significant difference. HPV+SMK- group has highest TNM stages. All death rates and recurrence rates increase with time, but the death rate of HPV- group is about 4 times higher than that of the HPV+SMK+ group and 6 times higher than that of the HPV+SMK+ group. The major recurrence type of HPV- OPSCC and HPV+SMK+ is locoregional, and the major recurrence type of HPV+SMK+ is distant metastasis. CONCLUSIONS: Our data confirmed that HPV+ OPSCC normally presents with more advanced stage, however, it has better prognosis. In comparison, HPV- OPSCC presents at an earlier stage, but the prognosis is worse. Based on their clinical profiles, we noted that HPV-positive OPSCC cells are more "mobile"; they metastasize sooner and further. However, HPV-negative OPSCC cells are more locally infiltrative, leading to more locoregional recurrence. The HPV-positive patients usually are younger and healthier at diagnosis. Although HPV-positive OPSCC tend to be histologically higher grades, there was no statistical difference noticed. Metastatic and recurrent patterns are very different between HPV-positive and HPV-negative patients, but the death rate of HPV-negative patients is way higher, and it is mainly due to locoregional recurrences, which is the major recurrence type for HPV-negative patients. Of our note, smoking is a complicating factor for HPV-positive OPSCC, and it makes the death rate, recurrence rate, histology grade, and TNM staging shift toward HPV-negative OPSCC. How smoking makes HPV-positive OPSCC behave more like OPSCC-negative OPSCC deserves more translational research for further elucidation.

Human Induced Pluripotent Stem Cell-Derived Motor Neuron Transplant for Neuromuscular Atrophy in a Mouse Model of Sciatic Nerve Injury.

IMPORTANCE: Human motor neurons may be reliably derived from induced pluripotent stem cells (iPSCs). In vivo transplant studies of human iPSCs and their cellular derivatives are essential to gauging their clinical utility. OBJECTIVE: To determine whether human iPSC-derived motor neurons can engraft in an immunodeficient mouse model of sciatic nerve injury. DESIGN, SETTING, AND SUBJECTS: This nonblinded interventional study with negative controls was performed at a biomedical research institute using an immunodeficient, transgenic mouse model. Induced pluripotent stem cell-derived motor neurons were cultured and differentiated. Cells were transplanted into 32 immunodeficient mice with sciatic nerve injury aged 6 to 15 weeks. Tissue analysis was performed at predetermined points after the mice were killed humanely. Animal experiments were performed from February 24, 2015, to May 2, 2016, and data were analyzed from April 7, 2015, to May 27, 2016. INTERVENTIONS: Human iPSCs were used to derive motor neurons in vitro before transplant. MAIN OUTCOMES AND MEASURES: Evidence of engraftment based on immunohistochemical analysis (primary outcome measure); evidence of neurite outgrowth and neuromuscular junction formation (secondary outcome measure); therapeutic effect based on wet muscle mass preservation and/or electrophysiological evidence of nerve and muscle function (exploratory end point). RESULTS: In 13 of the 32 mice undergoing the experiment, human iPSC-derived motor neurons successfully engrafted and extended neurites to target denervated muscle. Human iPSC-derived motor neurons reduced denervation-induced muscular atrophy (mean [SD] muscle mass preservation, 54.2% [4.0%]) compared with negative controls (mean [SD] muscle mass preservation, 33.4% [2.3%]) (P = .04). No electrophysiological evidence of muscle recovery was found. CONCLUSIONS AND RELEVANCE: Human iPSC-derived motor neurons may have future use in the treatment of peripheral motor nerve injury, including facial paralysis. LEVEL OF EVIDENCE: NA.

Current state of stem cell-mediated therapies for facial nerve injury.

PURPOSE OF REVIEW: Interest in the application of stem cell therapy to nerve injury has grown exponentially in recent years, as the armamentarium of potential stem cell sources has increased. This article reviews literature on the recent developments in the application of stem cell therapy for facial nerve injury. RECENT FINDINGS: Current stem cell therapy for the treatment of peripheral nerve injury can be generalized into those that either enhance native neural regeneration via an anti-inflammatory effect or growth factor secretion, replace Schwann cells, or replace motor neurons. Animal studies have shown that nerve conduits seeded with stem cells (either undifferentiated or differentiated into Schwann-like cells) in sciatic and facial nerve injury models can promote nerve regeneration with similar efficacy to autologous nerve autografts. In-vivo studies have also shown that induced pluripotent stem cell-derived motor neurons, when transplanted into transected mouse tibial nerves, can form functional neuromuscular junctions with the denervated mouse triceps surae. SUMMARY: The authors believe that induced pluripotent stem cells have significant therapeutic potential. This source of human stem cells can be harvested with little morbidity, is isogenic to the donor, and has fewer ethical concerns compared with embryonic cellular sources. Further research is required to determine stem cell efficacy and safety. Questions of stem cell fate unpredictability and possible tumorigenesis must be addressed prior to human trials.

Blood pressure evaluation in children treated with laser surgery for twin-twin transfusion syndrome at 2-year follow-up.

OBJECTIVE: Twin survivors of twin-twin transfusion syndrome (TTTS) may be at risk for early onset of cardiovascular disease. The aim of this study was to determine prevalence and risk factors for elevated blood pressure (BP) among children treated with selective laser photocoagulation of communicating vessels. STUDY DESIGN: Data were prospectively collected from surviving children treated for TTTS with laser surgery from 2008 through 2010. Systolic BP (SBP) and diastolic BP (DBP) were obtained from 91 child survivors at age 24 months (±6 weeks) and evaluated based on age, sex, and height percentile. BP percentiles were calculated for each patient and categorized as normal (<95%) or abnormal (>95%). Clinical variables were evaluated using multilevel regression models to evaluate risk factors for elevated BP. RESULTS: BP was categorized as normal in 38% and abnormal in 62% of twin survivors based on percentile for sex, age, and height; a comparable distribution was found for DBP elevation. There were no differences between donor and recipient twins for absolute SBP and DBP or BP classification. In a multivariate analysis, significant risk factors for higher SBP included prematurity (ß -0.54; 95% confidence interval [CI], -0.99 to -0.09; P = .02), higher weight percentile (ß 0.24; 95% CI, 0.05-0.42; P = .01), and presence of cardiac disease (ß 0.50; 95% CI, 0.10-0.89; P = .01). Prematurity was also a significant risk for abnormal DBP (odds ratio, 0.89; 95% CI, 0.80-1.00; P = .05). CONCLUSION: Child survivors of TTTS had elevated SBP and DBP measurements at 2 years of age, with no differences seen between former donor and recipient twins. Prematurity may be a risk factor for elevated BP measurements in this population. Future studies are warranted to ascertain whether these cardiovascular findings persist over time.