The Impact of Medical Comorbidities on Cough Improvement Following Superior Laryngeal Block.

INTRODUCTION: Chronic refractory cough is defined as cough lasting greater than 8 weeks and with an unclear etiology. Blockade of the internal branch superior laryngeal nerve (iSLN) has been shown to be safe and effective in the treatment of chronic cough. It remains unknown, however, if underlying comorbidities impact patient response to iSLN blockade. METHODS: A total of 44 patients aged 18 years and older were seen at our institution's Laryngology clinics between 2019 and 2022 and treated with iSLN blockade. Patient demographics, comorbidities, and pre- and post-treatment cough severity index (CSI) scores were collected from electronic medical records. Two-tailed independent T tests were used to compare CSI scores between groups with and without 4 underlying comorbidities: GERD, pulmonary history, smoking history, and evidence of vocal fold paresis or asymmetry on stroboscopy. RESULTS: Patients with a history of GERD or smoking and those with evidence of glottic insufficiency had similar improvements in CSI compared to those who did not (22.5 ± 26.4 vs 45.0 ± 47.1, P = .36; 32.7 ± 27.8 vs 29.0 ± 38, P = .85; 41.3 ± 18.8 vs 27.2 ± 37.7, P = .195). Patients with underlying pulmonary conditions had a significantly reduced response to iSLN blockade than did patients without underlying disease (9.85 ± 15.0 vs 47.4 ± 38.1, P = .028). CONCLUSION: Underlying lung pathology may contribute to decreased iSLN blockade efficacy in the treatment of chronic refractory cough from laryngeal hypersensitivity and its treatment is likely necessary for optimal symptom reduction. Characterizing patient comorbidity profiles can help guide patient counseling on expected treatment efficacy.

Laryngeal dystonia: Phenomenology, genetics, and management.

Laryngeal dystonia is a task-specific movement disorder causing abnormal movement of the adductor or abductor muscles of the vocal folds. In 1984, Blitzer pioneered the first use of onabotulinum toxin A to treat this disorder. Over 1400 patients were diagnosed with laryngeal dystonia in the last thirty years. In this paper, we summarize their clinical and endoscopic findings as well as treatment results. We also summarize the underlying genetics of the disorder. 82% of patients were diagnosed with adductor type laryngeal dystonia and 17% of patients manifested an abductor laryngeal dystonia. Patients with adductor dystonia were treated with toxin to the thyroarytenoid muscles and those with abductor dystonia were treated with toxin to the posterior cricoarytenoid muscle. All patient achieved greater than 70% improvement in percent normal function. Laryngeal dystonia is a rare movement disorder of the larynx with an incidence of approximately 35.1 per 100,000 individuals (Simonyan et al., 2021). Presently, there is no cure for laryngeal dystonia, but botulinum toxin has shown significant success in treating the symptoms of the disorder.

Comparing nationally reported adverse events associated with coblation vs. PlasmaBlade for tonsillectomy.

OBJECTIVE(S): Coblation, or radiofrequency ablation, and pulsed-electron avalanche knife (PEAK) plasmablade are newer approaches for tonsillectomy that reduce exposure to thermal heat. This study aims to describe and compare adverse events related to these devices for tonsillectomy. STUDY DESIGN: Retrospective cross-sectional study. SETTING: The US Food and Drug Administration's Manufacture and User Facility Device Experience (MAUDE) database. METHODS: The MAUDE database was queried for reports involving coblation devices and the PEAK plasmablade from 2011 to 2021. Data were extracted from reports pertaining to tonsillectomy with and without adenoidectomy. RESULTS: There were 331 reported adverse events for coblation and 207 for the plasmablade. For coblation, 53 (16.0 %) of these involved patients and 278 (84.0 %) were device malfunctions. Similarly for the plasmablade, 22 (10.6 %) involved patients and 185 (89.4 %) were device malfunctions. The most frequent patient-related adverse event was burn injury, which was significantly more common with the plasmablade compared to coblation (77.3 % vs. 50.9 %, respectively, p = 0.042). For both the coblator and plasmablade, the most common device malfunction was intraoperative tip or wire damage (16.9 % vs. 27.0 %, respectively, p = 0.010). The Plasmablade tip caught fire in five reports (2.7 %) with one causing burn injury. CONCLUSIONS: While coblation devices and the plasmablade have demonstrated utility in tonsillectomy with or without adenoidectomy, they are associated with adverse events. Plasmablade use may require greater caution for intraoperative fires and patient burn injuries compared to coblation use. Interventions to improve physician comfort with these devices may help reduce adverse events and inform preoperative discussions with patients.

Assessing the safety of continued perioperative antithrombotic therapy in endoscopic airway surgery for laryngotracheal stenosis.

PURPOSE: Given the increasing utilization of endoscopic surgery, particularly for airway stenosis management in the era of COVID-19 due to prolonged intubation, it is important to examine whether continuing antithrombotic therapy perioperatively influences bleeding complications. We examined the impact of perioperative antithrombotic use on postoperative bleeding complications following endoscopic airway surgery for laryngotracheal stenosis. MATERIALS AND METHODS: Retrospective study from January 2016 to December 2021 of cases of patients ≥18 years who underwent endoscopic airway surgery for posterior glottic, subglottic, and tracheal stenosis at a single institution. Cases were excluded if they were an open airway surgery. The primary outcome was the occurrence of postoperative bleeding complications across cases of patients naive to and on baseline antithrombotic therapy, and those with preoperative continuation versus cessation of antithrombotic therapy. RESULTS: 258 cases across 96 patients met inclusion criteria. Of these 258 cases, 43.4 % (n = 112) were performed for patients on baseline antithrombotic therapy and 56.6 % (n = 146) for those not on antithrombotic therapy. Likelihood of perioperative continuation of apixaban was 0.052 (odds ratio, 95 % Confidence Interval: 0.002-0.330, p < 0.001). Likelihood of perioperative continuation of aspirin was 9.87 (odds ratio, 95 % Confidence Interval: 2.32-43.0, p < 0.001). Two instances of postoperative bleeding were found: both in patients who were on aspirin without perioperative cessation for COVID-related coagulopathy. CONCLUSIONS: Our findings suggest that perioperative continuation of aspirin is relatively safe in the setting of endoscopic surgery for airway stenosis management. Prospective investigations to increase understanding of perioperative antithrombotics for COVID-related coagulopathy are warranted.

Long-term laryngological sequelae and patient-reported outcomes after COVID-19 infection.

PURPOSE: We examine prevalence, characteristics, quality of life (QOL) assessments, and long-term effects of interventions for laryngeal dysfunction after recovery from COVID-19 infection. MATERIALS AND METHODS: 653 patients presenting to Yale's COVID clinic from April 2020 to August 2021 were identified retrospectively. Patients with PCR-positive COVID-19 who underwent evaluation by fellowship-trained laryngologists were included. Patient demographics, comorbidities, intubation/tracheostomy, strobolaryngoscopy, voice metrics, and management data were collected. Patient-reported QOL indices were Dyspnea Index (DI), Cough Severity Index (CSI), Voice Handicap Index-10 (VHI-10), Eating Assessment Tool-10 (EAT-10), and Reflux Symptom Index (RSI). RESULTS: 57 patients met inclusion criteria: 37 (64.9 %) were hospitalized for COVID-19 infection and 24 (42.1 %) required intubation. Mean duration between COVID-19 diagnosis and presentation to laryngology was significantly shorter for patients who were intubated compared to non-intubated (175 ± 98 days versus 256 ± 150 days, respectively, p = 0.025). Dysphonia was diagnosed in 40 (70.2 %) patients, dysphagia in 14 (25.0 %) patients, COVID-related laryngeal hypersensitivity in 13 (22.8 %), and laryngotracheal stenosis (LTS) in 10 (17.5 %) patients. Of the 17 patients who underwent voice therapy, 11 (64.7 %) reported improvement in their symptoms and 2 (11.8 %) patients reported resolution. VHI scores decreased for patients who reported symptom improvement. 7 (70 %) patients with LTS required >1 procedural intervention before symptom improvement. Improvement across QOL indices was seen in patients with LTS. CONCLUSIONS: Laryngeal dysfunction commonly presents and is persistent for months after recovery from COVID-19 in non-hospitalized and non-intubated patients. Voice therapy and procedural interventions have the potential to address post-COVID laryngeal dysfunction.

IncobotulinimtoxinA (Xeomin) for the treatment of adductor laryngeal dystonia: A prospective, open-label clinical trial.

OBJECTIVES: Demonstrate an understanding of incobotulinumtoxinA efficacy in the treatment of adductor spasmodic dysphonia (SD). Understand that incobotulinumtoxinA can successfully be used as an alternative to onabotulinumtoxinA and for secondary non-responders. METHODS: We conducted a prospective open-label trial from 2016 until 2019 regarding the use of incobotulinimtoxinA for the treatment of adductor spasmodic dysphonia. Exclusion criteria included pregnant/nursing women, botulinum toxin for other indications, known allergy, neuromuscular or systemic diseases, use of aminoglycoside antibiotics, substance abuse, litigation regarding prior therapy, or other confounding conditions. Sixty-four injection sessions with completed with sixteen patients who were enrolled in the study and underwent EMG-guided incobotulinumtoxinA injections to the thyroarytenoid (TA) muscle using a hollow monopolar Teflon-coated needle via a trans-cricothyroid membrane approach. Dosages to each TA muscle were recorded and patients completed a Voice Handicap Index-10 (VHI-10), a validated worksheet regarding their perceived percent of normal function (PNF) following treatment, and a side effect profile. Outcomes were analyzed using the paired t-test. RESULTS: For primary transitioners to incobotulinimtoxinA, VHI-10 scores and best percent normal function did not significantly change. For non-responders, VHI-10 decreased from 32.5 on Botox to 19.5 on incobotulinimtoxinA and best PNF increased from 37.6 to 90 %, which was statistically significant. Transient side effects included breathiness. CONCLUSIONS: Our study demonstrates that incobotulinimtoxinA may be used successfully for adductor SD either as first line treatment or in secondary non-responders to onabotulinumtoxinA.

Extranodal Head and Neck Mantle Cell Lymphoma: Characteristics, Treatment, and Survival.

OBJECTIVES: To describe disease characteristics and treatment and to analyze survival and mortality for extranodal mantle cell lymphoma (MCL) of the head and neck. METHODS: Patients with extranodal MCL-excluding primary sites in the salivary glands, eye, and adnexa-were identified from the Surveillance, Epidemiology, and End Results (SEER) 18 Registries (2000-2015). Overall survival (OS) and cumulative incidence of MCL and non-MCL mortality were calculated. Factors associated with MCL and non-MCL mortality were analyzed with cause-specific hazard models. RESULTS: Five hundred nine patients met criteria for descriptive analysis and 294 patients met criteria for survival analysis, with a median follow-up of 58 months. The most common sites for MCL were the oropharynx (66.0%), nasopharynx (19.1%), and oral cavity (8.4%). The most common treatment received was chemotherapy alone (48.9%), followed by chemoradiation therapy (16.9%), and radiation therapy alone (10.4%). The proportion of cases diagnosed as early-stage disease ranged from 31% of sinonasal MCLs to 83% of laryngeal MCLs. At 5 years, OS was 63% (95% CI: 57%-69%). There was no significant difference in OS (P = .79), cumulative incidence of MCL mortality (P = .76), or cumulative incidence of non-MCL mortality (P = .98) by anatomic site. Comparing early-stage to late-stage disease, there was no significant difference in OS (P = .38), cumulative incidence of MCL mortality (P = .07), or cumulative incidence of non-MCL mortality (P = .14). Multivariate analysis showed increased hazard of MCL mortality for patients that were older or that presented with stage III or stage IV disease. CONCLUSION: The oropharynx is the most common subsite of head and neck MCLs, followed by the nasopharynx. Primary head and neck MCLs appear to present at an earlier stage than MCLs of other regions. In particular, laryngeal and hypopharyngeal MCLs may present as stage I or II disease.

Adequate short- and long-term pain control with non-opiate analgesics after microdirect laryngoscopy.

OBJECTIVE: In otolaryngology, it is important to minimize the use of opioids for post-operative analgesia given the rise in opioid abuse and mortality due to overdose in the United States. We sought to quantitatively determine the efficacy of non-opiate analgesia in postoperative pain management after microdirect laryngoscopy (MDL). METHODS: This is a single institution prospective study monitoring post-operative pain using a visual analog scale (VAS, 1-10). Patients with a history of vocal fold lesions, paralysis, and stenosis who underwent MDL were surveyed for one month following their procedure (daily for the first week and weekly thereafter). Student's t-test was used to determine whether short (1 week) and long term (1 month) pain was controlled by over-the-counter (OTC) medications. We defined adequate pain control as an average daily VAS score below 4 for the first 4 days and below 1 in the following 3 weeks and hypothesized that patients would report adequate pain control without the use of opioids. RESULTS: Post-operative pain after MDL was generally mild. The average daily VAS score was 2.16 (95% CI [0.0-5.2], P = 0.0014) in the first 4 days post-procedure and 0.28 (95% CI [0.0-1.3], P = 0.0007) in the 3 weeks post-procedure confirming our hypothesis. On average, patients used 3.14 (CI: [0.0-12.8]) pills of acetaminophen and 0.57 (CI: [0.0-4.7]) pills of an NSAID per day in the first week. Only three patients required opioid analgesia, all of whom used opioids in the first 48 h. CONCLUSIONS: OTC analgesics provide sufficient pain control after microdirect laryngoscopy for most patients. Given the potential for substance abuse from opioid medications, this study demonstrates that adequate pain control requires, at most, 48 h of opioid medications. Further study is needed to determine factors that contribute to increased pain after laryngoscopy.

Correlations of Radiographic and Endoscopic Observations in Subglottic Stenosis.

OBJECTIVE(S): Subglottic stenosis (SGS) represents a constellation of diverse pathologic processes that ultimately lead to narrowing of the subglottic region and can produce significant morbidity. Existing endoscopic and radiographic assessments may not be consistent in practice. METHODS: Severity of stenosis was evaluated and reported using the Cotton-Myer classification system from 33 endoscopic procedures from 32 unique subjects. Radiographic imaging within the preceding 3 month period was subsequently reviewed and narrowing was measured by a blinded radiologist. Degree of stenosis was reported as a percentage in 30 out of 33 endoscopic evaluations and subsequently compared to radiographically determined percentage of stenosis. Statistical analyzes were conducted to evaluate concordance between endoscopic and radiographic assessments. RESULTS: About 45.5% (15/33) of the evaluations were in agreement using Cotton-Myer scoring, while 27.3% (9/33) were discrepant by 1 grade and 27.3% (9/33) by 2 grades. Correlation of degree of stenosis as a percentage using Spearman (coefficient: 0.233, P-value: .214) and Pearson (coefficient: 0.138, P-value: .466) methods demonstrated very weak relationships. Radiographic scoring did not predict endoscopic classification to a significant degree using mixed effects regression. CONCLUSIONS: Radiographic and endoscopic grading of subglottic stenosis may not be reliably concordant in practice.

Safety considerations for esophageal dilation by anesthetic type: A systematic review.

OBJECTIVES: Esophageal dilation (ED) may be performed in the office under local anesthesia or in a procedure/operating room under general anesthesia or intravenous (IV) sedation. However, indications for type of anesthesia during these procedures have not been established. The purpose of this review is to assess outcomes of esophageal dilation performed using different types of anesthesia to assess the safety of office-based techniques. METHODS: We conducted a systematic review and meta-analysis comparing the outcomes of anesthesia techniques for ED in adults. Exclusion criteria included reviews, small case series, use of stents, diagnoses with high morbidity, and rare diseases. A comprehensive literature search of the PubMed, CINAHL, and EMBASE databases was performed for articles relating to esophageal dilation. RESULTS: 876 papers were identified of which 164 full text studies were assessed and 25 were included in the analysis using the PRISMA guidelines. Data regarding demographics, dilation technique, and adverse events were extracted. The DerSimonian-Laird random-effect models with inverse-variance weighting were fit to estimate the combined effects. There were no statistically significant differences among mortality, perforation, or bleeding based on anesthetic. CONCLUSIONS: With office-based procedures gaining popularity in laryngology, there is a need to profile their safety. Office-based ED appears to have equivalent safety to general and IV sedation, although further research is necessary to define indications favoring office-based techniques.