Adult Laryngomalacia: A Scoping Review.

OBJECTIVE: This review sought to determine the characteristics of adults diagnosed with new onset laryngomalacia including airway symptoms, laryngoscopic findings, treatments, and outcomes. Moreover, we wanted to highlight suspected limitations in the literature. DATA SOURCES: Studies were identified through CINAHL, Cochrane Review, PubMed, and Scopus published between 1966 and 2023. REVIEW METHODS: The search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews checklist by 2 independent investigators. A meta-analysis of proportions and continuous measures was conducted. RESULTS: Of the 1121 abstracts identified, 33 articles pertaining to laryngomalacia in the adult population were included. The most common presenting symptoms were stridor at rest (78.3%, 65.1-88.3) and dyspnea with exertion (83.8%, 64.8-96.3). The most suspected etiology was exercise-induced (86.0%, 69.4-95.5), and the most common description of laryngomalacia on visualization was collapse of supraglottic structures during exercise (93.3%, 79.0-99.1). Nonsurgical options were attempted in 87.0% (54.0-99.1), which included oral appliances, respiratory retraining, breathing techniques, and working with a speech pathologist. Surgical options were ultimately performed in 84.2% (75.0-91.0). Complete resolution of symptoms following therapy was seen in 61.9% (48.0-74.6). CONCLUSION: Adult onset laryngomalacia is difficult to characterize. It typically presents in patients during exercise, with neurological injury, or idiopathically. Surgical management can lead to improvement or complete resolution of symptoms. The need for a universal nomenclature is highlighted in this review, as it is inconsistently classified.

Work-related musculoskeletal disorders among otolaryngology-head and neck surgery residents.

PURPOSE: Surgical residents are at high risk for work-related musculoskeletal disorders which can impact surgical training and overall quality of life. We sought to assess musculoskeletal symptoms among current United States otolaryngology-head and neck surgery residents. We focused on the upper extremity given fine motor control for microsurgical procedures and increased keyboarding requirements. This study builds on previous research by evaluating setting attribution and attitudes toward ergonomics among otolaryngology residents. MATERIALS AND METHODS: A web-based, cross-sectional survey incorporating Nordic Musculoskeletal Questionnaire and ergonomics-related questions was sent to otolaryngology residency program directors in September of 2021. Descriptive statistics, Spearman's correlation, logistic regression, and comparison of proportions were utilized. RESULTS: Overall, 148 otolaryngology residents completed the survey; 70 were female (45 %), 83 male (54 %), and 1 non-binary (0.6 %). MSK symptoms were reported in the neck (77.0 %), lower back (45.5 %), and upper back (31.8 %) most frequently. Symptoms were work-related for 80 % of residents, with 84.7 % deemed operating-room-related. Some required treatment (14.5 %) or formal evaluation (11.0 %) of their injury. Injuries prevented residents from working (7.4 %), operating (9.5 %), and performing activities of daily living (27.0 %). Many reported they would use ergonomic equipment (94.2 %), dictation software (74.1 %), and scribes (81.3 %) if available. CONCLUSIONS: Despite increased surgical ergonomic awareness, musculoskeletal symptoms are still prevalent among otolaryngology residents. Nearly 1 in 9 residents required evaluation and treatment of their musculoskeletal symptoms, and one third reported lacking various ergonomic measures. Given the high prevalence of work-related musculoskeletal disorders, ergonomic practices for O-HNS trainees should be emphasized by residency programs.

Laryngeal manifestations of cranial nerve IX/X compression at the brainstem.

OBJECTIVE: We report an association between lower cranial nerve (CN IX/X) vascular compression at the brainstem with laryngeal symptoms utilizing a stepwise algorithm that systematically evaluates and eliminates all other common etiologies. Our experiences with retromastoid craniectomy with lower cranial nerve (LCN) decompression versus non-neurosurgical treatments are detailed. STUDY DESIGN: Retrospective chart review at a tertiary care academic medical center with follow-up telephone survey. METHODS: Baseline demographics, clinical characteristics, quality-of-life surveys, and treatment outcomes were recorded for patients with laryngeal symptoms associated with LCN compression at the brainstem. RESULTS: Forty-nine patients demonstrated LCN compression at the brainstem on imaging and presented with chief complaints of dysphonia (25 of 49, 51%), chronic cough (19 of 49, 39%), dysphoric breathing (3 of 49, 6%), and dysphagia (2 of 49, 4%). Poor initial scores were noted for Voice-Related Quality of Life (V-RQOL), Reflux Symptom Index, and Glottal Closure Index. Twenty-four patients underwent LCN decompression, of which 21 of 24 (88%) reported partial, near-complete, or complete improvement. Major perioperative complications occurred in four of 24 patients (17%). Patients who had undergone decompression were more likely to obtain complete/near-complete symptom resolution (10 of 24 patients, 42%) compared to those undergoing conservative treatments (2 of 25 patients, 8%) (P = 0.02). V-RQOL scores improved more in surgical patients [mean change score, 33.0 (standard deviation [SD], 31.2) than nonsurgical patients (mean change score 9.6, SD 20.9) (P = 0.03) (mean follow-up 3.0 years, SD 2.0). CONCLUSION: Lower cranial nerve compression at the brainstem should be considered when all other etiologies are excluded. Retromastoid craniectomy with LCN decompression demonstrates an acceptable safety profile. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2105-2111, 2019.

Pyridostigmine for the Reversal of Severe Adverse Reactions to Botulinum Toxin in Children.

Therapeutic botulinum toxin injections are commonly performed in pediatric otolaryngology. Aerodigestive complications from botulinum toxin injections, although rare, may be serious. Oral pyridostigmine is effective in the symptomatic treatment of these complications. We report 2 cases of aerodigestive complications arising from injection of botulinum toxin that were successfully treated with pyridostigmine.

Prevalence of Hearing Loss in Teachers of Singing and Voice Students.

OBJECTIVES: Singers and voice teachers are exposed to a range of noise levels during a normal working day. This study aimed to assess the hearing thresholds in a large sample of generally healthy professional voice teachers and voice students to determine the prevalence of hearing loss in this population. STUDY DESIGN: A cross-sectional study was carried out. METHODS: Voice teachers and vocal students had the option to volunteer for a hearing screening of six standard frequencies in a quiet room with the Shoebox audiometer (Clearwater Clinical Limited) and to fill out a brief survey. Data were analyzed for the prevalence and severity of hearing loss in teachers and students based on several parameters assessed in the surveys. All data were analyzed using Microsoft Excel (Microsoft Corp.) and SPSS Statistics Software (IBM Corp.). RESULTS: A total of 158 participants were included: 58 self-identified as voice teachers, 106 as voice students, and 6 as both. The 6 participants who identified as both, were included in both categories for statistical purposes. Of the 158 participants, 36 had some level of hearing loss: 51.7% of voice teachers had hearing loss, and 7.5% of voice students had hearing loss. Several parameters of noise exposure were found to positively correlate with hearing loss and tinnitus (P < 0.05). Years as a voice teacher and age were both predictors of hearing loss (P < 0.05). CONCLUSIONS: Hearing loss in a cohort of voice teachers appears to be more prevalent and severe than previously thought. There is a significant association between years teaching and hearing loss. Raising awareness in this population may prompt teachers and students to adopt strategies to protect their hearing.

The use of the quadrivalent human papillomavirus vaccine (gardasil) as adjuvant therapy in the treatment of recurrent respiratory papilloma.

OBJECTIVE: To examine the effect of the quadrivalent human papillomavirus vaccine, Gardasil, on the disease course of patients with recurrent respiratory papillomatosis (RRP). METHODS: A retrospective chart review of patients with RRP was conducted and 20 patients were selected who had received the Gardasil vaccine as part of their treatment. Efficacy was assessed by calculating the intersurgical interval (ISI) before and after receiving the vaccine, as well as number of complete and partial remissions. RESULTS: Analysis of all patients found a significant increase in the ISI of 3.1 months (95% confidence interval [CI]: 1.02-5.19, P=0.0061). Male patients experienced an increase in the ISI of 4.2 months (95% CI: 1.6-6.7, P=0.0048). Female patients had a nonsignificant increase in ISI of 1.2 months (95% CI: 3.1-5.4, P=0.51). Eight patients (40%; six male and two female) experienced complete remission. Five patients (25%) overall (three male and two female) experienced partial remission. In total, complete or partial remission was achieved in a total of 13 (65%) patients (nine male and four female). CONCLUSIONS: The Gardasil vaccine can modulate the severity of RRP and induce remission in some patients. The effect was much greater in males and in females in low estrogen states.

Task-specific singing dystonia: vocal instability that technique cannot fix.

OBJECTIVES: Singer's dystonia is a rare variation of focal laryngeal dystonia presenting only during specific tasks in the singing voice. It is underdiagnosed since it is commonly attributed to technique problems including increased muscle tension, register transition, or wobble. Singer's dystonia differs from technique-related issues in that it is task- and/or pitch-specific, reproducible and occurs independently from the previously mentioned technical issues.This case series compares and contrasts profiles of four patients with singer's dystonia to increase our knowledge of this disorder. METHODS: This retrospective case series includes a detailed case history, results of singing evaluations from individual voice teachers, review of singing voice samples by a singing voice specialist, evaluation by a laryngologist with endoscopy and laryngeal electromyography (LEMG), and spectral analysis of the voice samples by a speech-language pathologist. RESULTS: Results demonstrate the similarities and unique differences of individuals with singer's dystonia. Response to treatment and singing status varied from nearly complete relief of symptoms with botulinum toxin injections to minor relief of symptoms and discontinuation of singing. CONCLUSIONS: The following are the conclusions from this case series: (1) singer's dystonia exists as a separate entity from technique issues, (2) singer's dystonia is consistent with other focal task-specific dystonias found in musicians, (3) correctly diagnosing singer's dystonia allows singer's access to medical treatment of dystonia and an opportunity to modify their singing repertoire to continue singing with the voice they have, and (4) diagnosis of singer's dystonia requires careful sequential multidisciplinary evaluation to isolate the instability and confirm dystonia by LEMG and spectral voice analysis.

Pyridostigmine for reversal of severe sequelae from botulinum toxin injection.

OBJECTIVE: Botulinum toxin is used to treat a wide range of dystonias in the head and neck. Occasionally, patients receiving laryngeal botulinum toxin experience severe dysphagia, dyspnea, or even distant and autonomic symptoms. Rarely, these patients may require hospitalization with possible intubation and placement of nasogastric tubes. Botulinum antitoxin is not readily available and ineffective once symptoms have progressed, so patients must wait until the toxin wears off over weeks to months. Pyridostigmine prevents the breakdown of acetylcholine at the neuromuscular junction, thus making more neurotransmitter available for the muscles. STUDY DESIGN: A retrospective case study of patients receiving botulinum toxin for dystonia in the head and neck from 1998 to 2012 who experienced adverse effects that were successfully treated with pyridostigmine. METHODS: Twenty cases were selected and reviewed to demonstrate how pyridostigmine was used to modulate severe dysphagia, breathiness, dyspnea, and some distant/autonomic symptoms. RESULTS: Pyridostigmine was well tolerated and resulted in significant symptom improvement. Only one significant adverse effect, bradycardia, occurred in a patient with severe cardiac disease. CONCLUSIONS: Given the safety and efficacy of this medication, pyridostigmine should be considered to modulate severe sequelae of botulinum toxin in select patients when conservative management is deemed insufficient. Also, physicians should be aware that patient complaints of symptoms at distant sites and temporally delayed from the injection may be a result of the botulinum toxin and relieved with pyridostigmine.

Relationship of laryngeal botulinum toxin dosage to patient age, vitality, and socioeconomic issues.

OBJECTIVE: Chemical denervation with botulinum toxin A is the current standard of treatment for spasmodic dysphonia, but dosage is determined individually after a titration period that can take months to years. The objective of this study was to determine if age, body mass index (BMI), overall health, and socioeconomic factors were associated with a patient's optimal dose of botulinum toxin. STUDY DESIGN AND METHODS: This retrospective chart review looked at 32 patients with stabilized doses of botulinum toxin. Age and BMI were obtained from patient charts, and overall health was assessed by the Short-Form 36 survey. RESULTS: Analysis showed that BMI was positively correlated with botulinum toxin dose (r = 0.42, P = 0.02). Overall health showed a positive but nonsignificant association with dose, but subgroup analysis found that adductor spasmodic dysphonia (ADSD) patients without tremor had a significant positive correlation between overall health and dose (r = 0.50, P = 0.04), whereas tremor-only and mixed dystonia showed a negative nonsignificant correlation. Age was found to have no significant association with dose. Although socioeconomic factors were found to impact the number and frequency of injections, they had no significant impact on the ultimate dosage. CONCLUSION: BMI and overall health are positively correlated with higher effective dose and may be useful in guiding clinicians during the titration period.

Recurrent laryngeal nerve paresis postpneumonectomy contralateral to site of surgery.

Recurrent laryngeal nerve (RLN) injury is a serious complication of thoracic surgery that increases morbidity and mortality. It is important to consider the long-term effects of mediastinal shift and the possibility of postpneumonectomy syndrome on RLN function. This report documents a unilateral vocal fold paresis contralateral to the side of pneumonectomy that presents for investigation 6 six years after surgery.

Risk factors for supraglottoplasty failure.

OBJECTIVE: To review outcomes after supraglottoplasty for laryngomalacia and identify risk factors for supraglottoplasty failure. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Retrospective case series evaluating patient outcomes after supraglottoplasty at an academic medical center between 2004 and 2010. Surgical failure was defined as need for revision surgery, tracheostomy tube placement, or gastrostomy tube insertion. Multivariable logistic regression was performed to identify risk factors for failure. RESULTS: The authors identified 95 children who underwent supraglottoplasty. After excluding patients with inadequate follow-up data, 74 patients were included. On the basis of chart review, 12 (16%) of those patients were defined as failures according to the criteria above. Age, history of prematurity (<34 weeks' gestational age), weight, growth curve percentile, neurologic/developmental problems, genetic syndrome, cardiac abnormality, synchronous airway lesions, and surgical technique were considered in risk factor analysis. Multivariable logistic regression was performed, revealing history of prematurity to be the only independent risk factor for failure (odds ratio = 4.85; 95% confidence interval, 1.07-22.1; P = .041). CONCLUSIONS: Outcomes after supraglottoplasty were comparable to previous reports in the literature. History of prematurity should be considered a risk factor for surgical failure.

Sarcoidosis presenting as bilateral vocal cord paralysis from bilateral compression of the recurrent laryngeal nerves from thoracic adenopathy.

Bilateral true vocal fold paralysis is rarely attributable to inflammatory diseases. We describe what appears to be the first case in the medical literature of sarcoidosis presenting as isolated, bilateral true vocal cord paralysis resulting from compressive bilateral mediastinal adenopathy. The presenting symptoms, clinical outcome, radiographs and laryngeal findings are discussed in detail. Sarcoidosis should therefore be added to the differential diagnosis of bilateral vocal fold paralysis.

Clinical course following endoscopic repair of type 1 laryngeal clefts.

OBJECTIVES: Treatment of type I laryngeal clefts (T1LCs) remains controversial. We present our experience with 16 endoscopic T1LC repairs to evaluate the effect of patient characteristics and surgical technique on outcomes. METHODS: A retrospective study was performed. Diagnosis of T1LC was made by interarytenoid palpation during operative microlaryngoscopy. Two surgeons performed endoscopic repair using either microflap reconstruction or laser demucosalization and reapproximation. All patients received preoperative and postoperative modified barium swallow (MBS) studies. Improved MBS at 3-5 months determined success of repair. Factors contributing to success of repair were analyzed statistically. RESULTS: No intraoperative complications occurred. One T1LC repair dehisced after 3 months. Overall, 11 of 16 repairs (68.8%) were successful. Mean age at repair was 23.3 months. Length of stay for microflap repair was significantly shorter than for laser reapproximation (0.89 days vs. 4.6 days, p<0.001, two-tail t-test). The difference in patient age between failures and successes (21.3 months vs. 24.2 months) was non-significant (p=0.661, two-tail t-test). Success for the nine patients receiving microflap reconstruction (77.8%) vs. the seven receiving laser reapproximation (57.1%) is comparable (p=0.596, Fisher's exact test). No correlation between comorbidities and failure was found (p>0.05, Fisher's exact test). CONCLUSIONS: This series matches the largest reported series of endoscopic T1LC repairs. Success rates were lower than in previously reported studies, and comorbidities were higher. However, comorbidities did not contribute to surgical failure. No difference in outcome was seen between the two endoscopic techniques. Microflap repair may require a shorter hospital stay.

Laryngopharyngeal dysfunction after the Norwood procedure.

OBJECTIVE: We sought to evaluate the incidence and significance of recurrent laryngeal nerve and swallowing dysfunction after a Norwood procedure compared with that after biventricular aortic arch reconstruction. METHODS: From April 2003 through December 2004, 36 neonates underwent a Norwood procedure; 33 of 36 had postoperative fiberoptic laryngoscopy and modified barium swallow. Study results were used to guide the transition from nasogastric tube to oral feeding and placement of gastrostomy tubes. During the same time period, 18 neonates underwent aortic arch reconstruction as part of a biventricular repair. RESULTS: After a Norwood procedure, laryngoscopy showed left true vocal fold (cord) paralysis in 3 (9%) of 33 patients. The results of a modified barium swallow were abnormal in 16 (48%) of 33 patients, with aspiration in 8 (24%) of 33 patients. Of the 3 patients with vocal fold paralysis, 2 had a normal modified barium swallow result, and 1 had aspiration. Gastrostomy tubes were placed in 6 (18%) of 33 patients, all with an abnormal modified barium swallow result. Hospital stay was longer in patients with an abnormal modified barium swallow result: 34 +/- 13 versus 22 +/- 7 days (P < .01). After biventricular repair with aortic arch reconstruction, left true vocal fold paralysis occurred in 4 (25%) of 16 patients; results of a modified barium swallow were abnormal in 10 (59%) of 17 patients, with aspiration in 6 (35%) of 17 patients (all nonsignificant vs patients undergoing the Norwood procedure). Follow-up laryngoscopy in 4 patients with vocal fold paralysis showed no change in 3 of 4 patients and improvement in 1 patient. Follow-up modified barium swallow showed resolution of aspiration in 11 (85%) of 13 patients. Hospital survival was 32 (89%) of 36 patients for the Norwood procedure and 18 (100%) of 18 patients for biventricular repair. There has been 1 sudden death before second-stage palliation. CONCLUSIONS: After a Norwood procedure, swallowing dysfunction occurs in 48% of patients, with aspiration in 24%, and results in increased length of hospital stay. Left recurrent laryngeal nerve injury, seen in 9% of patients, is an uncommon cause of swallowing dysfunction. Postoperative aspiration generally resolves over time, whereas vocal fold paralysis does not. Systematic evaluation of swallowing function allows appropriate tailoring of feeding regimens and might contribute to decreased hospital and interstage mortality.

Extraesophageal manifestations of GERD: diagnosis and therapy.

Extraesophageal manifestations of gastroesophageal reflux disease (GERD) can include upper airway disorders, asthma and chronic cough. They have a common pathophysiology, involving microaspiration of acid into the larynx and pharynx, and vagally mediated bronchospasm and laryngospasm. The role of extraesophageal reflux (EER) in such disorders is underdiagnosed due to the often silent symptoms and difficult confirmation of diagnosis. Laryngeal examination and quantitative evaluation of findings using the reflux finding score are essential to diagnosis and treatment. Long-term high-dose proton pump inhibitor therapy is the first-line approach to controlling symptoms. Use of treatment algorithms is necessary to manage and accurately diagnose the cause of nonresponse to treatment.