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.

The Demographics of Patients Presenting for Laryngological Care at an Academic Medical Center.

OBJECTIVES/HYPOTHESIS: Few studies address the demographics/epidemiology/socioeconomic status of patients presenting to a laryngologist at a tertiary care center for treatment. To identify any possible disparities in voice, airway, and swallowing care, we sought to analyze the aforementioned data for new patients presenting to the voice center at an academic medical center. METHODS: This is a retrospective cohort study of prospectively collected data from an institutional database of 4,623 new adult patients presenting for laryngological care at a tertiary care, academic medical center from 2015 to 2020. Demographic data were analyzed. RESULTS: Of 4,623 patients, 62.8% were female and 37.2% were male with ages ranging from 19 to 99 years (Avg 59.51, standard deviation 15.83). Patients were 81.8% white, 13% black, and 5.2% other, compared with 56.3% white, 34.8% black, 20% other in the local municipality from US Census Data. Payer mix included 46.98% Medicare, 42.59% commercial insurance, 3.22% Medicaid, 5.19% other, and 2.01% uninsured/self-insured. Patient demographics based on primary diagnosis codes were also examined. A majority of patients presented with voice-related complaints. CONCLUSIONS: Understanding the demographics of those with laryngological disorders will help to develop targeted interventions and effective outreach programs for underrepresented patient populations. Future multicenter studies could provide further insight into the distribution of healthcare disparities in laryngology. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:626-632, 2022.

Auditory-Perceptual Evaluation of Deep Brain Stimulation on Voice and Speech in Patients With Dystonia.

OBJECTIVE: To determine the effects of globus pallidus interna (GPi) deep brain stimulation (DBS) on speech and voice quality of patients with primary, medically refractory dystonia. METHODS: Voices of 14 patients aged ≥18 years (males = 7 and females = 7) with primary dystonia (DYT1 gene mutation dystonia = 4, cervical dystonia = 6, and generalized dystonia = 4) with bilateral GPi DBS were assessed. Five blinded raters (two fellowship-trained laryngologists and three speech/language pathologists) evaluated audio recordings of each patient pre- and post-DBS. Perceptual voice quality was rated using the Grade, Roughness, Breathiness, Asthenia, and Strain scale and changes in speech intelligibility were assessed with the Clinical Global Impression scale of Severity instrument. Inter-rater and intrarater reliability rates for perceptual voice ratings were assessed using the kappa coefficient. RESULTS: Voice quality parameters showed mean improvements in Grade (P < 0.0001), Roughness (P = 0.0043), and Strain (P < 0.0001) 12 months post-DBS. Asthenia increased from baseline to 6 months (P = 0.0022) and declined significantly from 6 to 12 months (P = 0.0170). Breathiness did not change significantly over time. Speech intelligibility also improved from 6 to 12 months (P = 0.0202) and from pre-DBS to 12 months post-DBS (P = 0.0022). Grade and Strain ratings had nearly perfect and substantial inter-rater agreement (0.84 and 0.71, respectively). CONCLUSIONS: Voice and speech intelligibility improved after bilateral GPi DBS for dystonia. GPi DBS may emerge as a potential treatment option for patients with medically refractory laryngeal dystonia.

Use of topical nasal anesthesia during flexible endoscopic evaluation of swallowing in dysphagic patients.

OBJECTIVE: This study aimed to determine the effect of topical lidocaine on Penetration-Aspiration Scale (PAS) scores and patient comfort and tolerance of flexible endoscopic evaluation of swallowing (FEES) examinations in dysphagic patients. METHODS: Adults with dysphagia referred for swallowing evaluation were recruited to participate in consecutive nonanesthetized and then anesthetized FEES examinations. Under endoscopic visualization, participants consumed 6 swallows consisting of graduated volumes of milk, pudding, and cracker in each condition and recorded their discomfort and tolerance in the 2 conditions. Penetration-Aspiration Scale scores were assigned in blinded fashion for each swallow. RESULTS: Twenty-five adults participated in the study. Although there was no statistically significant effect of anesthesia on PAS scores (P=.065), the odds of a higher PAS score were 33% higher during anesthetized swallows. The anesthetized condition yielded significantly less discomfort and pain during the examination, significantly less pain and discomfort during insertion and removal of the endoscope, and significantly greater overall tolerance than the nonanesthetized condition. CONCLUSION: The use of topical lidocaine during FEES may impair swallowing ability in patients with dysphagia, but this result does not achieve statistical significance. Topical nasal anesthesia significantly reduces subjective pain and discomfort and improves tolerance during FEES.

Tracheal reconstruction in a canine model.

OBJECTIVE: Tracheal reconstruction using a stem cell-based engineered trachea has recently shown promise. Our goal is to achieve a single-stage stem cell-based tracheal replacement. STUDY DESIGN: Prospective feasibility study. SETTING: Wake Forest Institute of Regenerative Medicine. SUBJECTS AND METHODS: Five healthy male beagles were implanted with a 2.5-cm segment of decellularized trachea. A sixth animal, planned for the control arm, died of anesthetic complications prior to tracheal implantation. The remaining 5 beagles were divided into 2 study arms: 4 had adipose-derived stem cells coating the lumen of the donor trachea, and a control animal had the trachea implanted cell free. The donor tracheas were obtained from previously sacrificed size-matched canines and decellularized. The adipose tissue was harvested from a recipient animal and the trachea prepared, seeded, and then implanted, all in one operation. Adipose stem cells were labeled fluorescently. RESULTS: Five of 6 planned surgical procedures were completed successfully. All required sacrifice for airway distress at approximately 1 week postoperatively. All tracheal grafts were found to be malacic and compromised. CONCLUSION: In a canine model using a decellularized tracheal scaffold and adipose stem cells, the postoperative inflammatory response and evidence of rejection was minimal. However, all scaffolds exhibited breakdown, compromising the animals' airways, necessitating euthanasia earlier than planned. For future study, a similar animal model using a single-stage approach with a more robust scaffold may allow for greater survival and stem cell differentiation.

The effects of topical anesthetic on swallowing during nasoendoscopy.

OBJECTIVES/HYPOTHESIS: To assess the effects of a typical otolaryngologic dose of 1 mL of 4% lidocaine on penetration aspiration scale scores and participant discomfort during flexible endoscopic evaluation of swallowing. STUDY DESIGN: A prospective pilot study. METHODS: Twenty healthy participants consumed 12 swallows consisting of graduated volumes of milk, water, pudding, and cracker in anesthetized and nonanesthetized conditions. Each participant was randomly selected to begin with the anesthetized or nonanesthetized condition. Each participant returned within 7 days to repeat the study in the other condition. Digital recordings of their evaluations were scored via the penetration-aspiration scale in a blinded fashion. Participants recorded their discomfort and tolerance of each flexible endoscopic evaluation of swallowing. RESULTS: The anesthetized condition yielded significantly worse swallowing function (P = .001) than the nonanesthetized condition. The nonanesthetized condition yielded greater discomfort and pain during the procedure (P = .006, .018), greater pain during insertion and removal of the endoscope (P = .002, .003) and less overall tolerance (P = .016) than the anesthetized condition. CONCLUSIONS: A typical otolaryngologic anesthetic dose of 1 mL of 4% lidocaine during flexible endoscopic evaluation of swallowing predisposed healthy young adults to higher penetration aspiration scale scores (less safe swallowing) than the nonanesthetized condition; however, the anesthetic reduced discomfort and provided better overall tolerance. Future studies need to evaluate the effects of lower doses of lidocaine (0.2 and 0.5 mL) on swallowing function and comfort.

Dysphonia and dermatomyositis: an unusual manifestation.

We report a case of a 39-year-old female with a recent diagnosis of dermatomyositis and dysphonia. Dermatomyositis is a connective tissue disease with multisystem involvement: cardiac, pulmonary, musculoskeletal, gastrointestinal, and dermatologic are the most common. While dermatomyositis affects thousands of individuals in the United States, laryngeal involvement has only been described in a single case report to date.

Adverse effects of long-term proton pump inhibitor use: a review for the otolaryngologist.

OBJECTIVE: Proton pump inhibitors (PPIs) are the mainstay of current medical management for laryngopharyngeal reflux, and treatment often involves long-term use of this class of medications. The long-term adverse effects of PPI use have not been studied extensively, but several analyses have demonstrated epidemiological links between PPI use and adverse outcomes. These include altered mineral and vitamin absorption, orthopedic injury, acute coronary syndromes (ACS), and infectious risks. STUDY DESIGN: A PubMed search was performed for subject headings, including PPIs and adverse outcomes. Relevant studies were included in this review. Studies were compiled, reviewed, and compared in a narrative form. RESULTS: Several epidemiological links between PPI use and metabolic, infectious, cardiac, and orthopedic adverse outcomes were found. No definite causal effects were identified. CONCLUSION: Given these epidemiological patterns, we recommend that the clinician be aware of these possible unintended consequences. In addition, we recommend consideration of dual-energy X-ray absorptiometry (DEXA) bone density scans in at-risk patients who have not been previously tested. We recommend consideration of vitamin B12 and iron levels in selected patients who are at high risk. We also recommend close communication with our cardiology colleagues, as we attempt to ascertain the relationship between clopidogrel and PPI use. We recommend caution in the use of omeprazole in patients undergoing active treatment for ACS. Finally, we recommend consideration of Helicobacter pylori or serum gastrin level testing in patients with known risk factors for gastric carcinoma.

A novel modification of the ansa to recurrent laryngeal nerve reinnervation procedure for young children.

Vocal ford paralysis is a condition often seen in otolaryngologic adult and pediatric clinics. We report a case we believe to be the youngest child to undergo ansa cervicalis (ansa) to recurrent laryngeal nerve (RLN) reinnervation for unilateral vocal fold paralysis. We have included the preoperative and postoperative videostroboscopic and acoustic findings. The acoustic data shows improvement and is consistent with the patient's improved voice quality. Most notably the patient's voice quality is less raspy and his volume has improved while subjectively requiring less effort.

Metastatic calcification involving the true vocal cord.

Metastatic calcification (MC) commonly results secondary to phosphorus and calcium dysregulation in end-stage renal disease (ESRD). Only once before has MC been reported to involve a true vocal cord. A 35-year-old man with ESRD and secondary hyperparathyroidism was evaluated for hoarseness. Three years ago, he underwent a total parathyroidectomy with parathyroid autograft to the forearm. Simultaneously, he had a left lobe thyroidectomy that displayed a papillary thyroid carcinoma. Since that time, he continued to have hyperphosphatemia and hypocalcemia. Laryngoscopy displayed a small papillomatous lesion on the right true vocal cord. He underwent excision of the vocal cord lesion; histologic examination demonstrated benign squamous epithelium with extensive submucosal calcification. In patients with ESRD with secondary dysregulation of serum phosphorus to calcium level balance, MC may involve variable anatomical locations, including the true vocal cords. Regarding histologic findings, pathologists must consider malignancies associated with calcification, mimicking a benign process.

Office-based laryngeal laser surgery: a review of 443 cases using three wavelengths.

BACKGROUND: Unsedated office-based laser surgery (UOLS) of the larynx and trachea has significantly improved the treatment options for patients with laryngotracheal pathology including recurrent respiratory papillomas, granulomas, leukoplakia, and polypoid degeneration. UOLS delivered by flexible endoscopes has dramatically impacted office-based surgery by reducing the time, costs, and morbidity of surgery. OBJECTIVES: To review our experience with 443 laryngotracheal cases treated by UOLS. METHODS: The laser logbooks at the Center for Voice and Swallowing Disorders were reviewed for UOLS, and the medical and laryngological histories were detailed, as were the treatment modalities, frequencies, and complications. RESULTS: Of the 443 cases, 406 were performed with the pulsed-dye laser, 10 with the carbon-dioxide laser, and 27 with the thulium: yttrium-aluminum-garnet laser. There were no significant complications in this series. A review of indications and wavelength selection criteria is presented. CONCLUSION: Unsedated, office-based, upper aerodigestive tract laser surgery appears to be a safe and effective treatment option for many patients with laryngotracheal pathology.