The growing geriatric otolaryngology patient population: a study of 131,700 new patient encounters.

OBJECTIVES/HYPOTHESIS: To establish the effects the changing population demographics in the United States are having on the general practice otolaryngologists. STUDY DESIGN: Retrospective analysis of 131,070 consecutive new patient visits at a large private practice otolaryngology group from 2004 to 2010. METHODS: Billing records for new patient visits from 2004 to 2010 were reviewed. Analysis of patient age, diagnosis, and year of presentation was completed to determine changes in patient demographics and frequencies of diagnoses stratified by age groups. Predictive analysis was performed to determine future trends in patient demographics. RESULTS: Geriatric patients showed a statistically significant increase from 14.3% of the patient population in 2004 to 17.9% in 2010. Predictive analysis shows that at the current rate, almost 30% of all patients seen by 2030 would be over the age of 65 years. The most common pathologies seen in geriatric patients were also different than that of other age groups, with the five most common geriatric diagnoses being otologic in nature. Geriatric patients also have an overall increased proportion of otologic diagnoses, with 73% of all geriatric diagnoses being otologic, compared to just 32% of those aged 18 to 45 years. CONCLUSIONS: Our data show that the changing population is causing the frequency and type of disease seen by general otolaryngologists to change. This information may be useful in structuring both residency training curricula as well as licensing and recertification exams to ensure otolaryngologists are properly prepared to care for their future patient population.

Complications of adenotonsillectomy.

PURPOSE OF REVIEW: Tonsillectomy and adenoidectomy are two of the most commonly performed pediatric surgical procedures. As with all surgical intervention, tonsillectomy and adenoidectomy are associated with a host of potential complications. Fortunately, for most children undergoing adenotonsillectomy (T&A), complications are rare. This review is intended to summarize recent reports, which may lead to prevention and treatment of T&A complications. RECENT FINDINGS: The presented reports of complications and risk factors for complications in children undergoing T&A highlight perioperative medical management as a means to decrease perioperative complications. Certain tonsillectomy techniques, such as microdebrider intracapsular tonsillectomy, may lead to decreased posttonsillectomy hemorrhage and dehydration. Despite published recommendations, preoperative assessments for bleeding diatheses vary among practitioners. Conversely, guidelines for evaluation of posttonsillectomy hemorrhage are lacking. Some pediatric populations, such as children with coagulopathy, neurologic disease, and obesity, have increased risk of perioperative complications, and recent reports regarding their care are presented. SUMMARY: We present recent data pertinent to the contemporary management of medical and surgical complications of T&A, with particular focus on specific at-risk pediatric populations. In the patient groups illustrated in this review, anticipation of complications may decrease complications or lead to improved management of complications when they occur.

Isolated laryngeal myokymia: diagnosis and treatment.

Myokymia is an uncommon neuromuscular disorder that rarely affects the human larynx. No previous reports of isolated laryngeal myokymia are present in the literature, and as such, established treatment protocols are lacking. We report the first case of isolated laryngeal myokymia in a 48-year-old woman with no other neurological findings, and our successful results in initial treatment and maintenance therapy with focal intralaryngeal injections of botulinum toxin A.

Mucosal bridge and pitting of the true vocal fold: an unusual complication of cidofovir injection.

We describe a unique complication of intralaryngeal cidofovir injection and present the case of a patient with recurrent respiratory papillomatosis in whom both a mucosal bridge and a pit of the true vocal fold developed after intralaryngeal cidofovir injection. A 40-year-old man presented with laryngeal papillomatosis 19 years after being treated with surgery and adjuvant radiotherapy for leiomyosarcoma of the cervical esophagus. The patient underwent 5 papillomatosis excisions combined with subepithelial injections of cidofovir to the bilateral true vocal folds at a concentration of 5 mg/mL without any complications. He subsequently received 2 higher-dose cidofovir treatments 6 weeks apart because of a poor response to the previous treatments. Two months later, there was evidence of a large mucosal bridge along the free edge of the right vocal fold and a deep pit in the lateral aspect of the same vocal fold. We conclude that repeated high-dose intralesional injection of cidofovir may result in significant morphological changes to the vocal fold, most likely due to mucosal injury.

Electromyographic laryngeal synkinesis alters prognosis in vocal fold paralysis.

OBJECTIVES/HYPOTHESIS: Synkinesis, or misdirected reinnervation, is likely a confounder when predicting return of function of an immobile vocal fold. Currently, no information exists on the incidence of synkinesis in unilateral vocal fold immobility (UVFI) or the effect synkinesis has on prognosis and treatment. Our objective was to examine a vocal fold adductor synkinesis screening protocol using diagnostic laryngeal electromyography (LEMG). We aim to determine the effect of synkinesis on prognosis of recovery of purposeful vocal fold motion. STUDY DESIGN: Retrospective review of LEMG data and patient charts from laryngology practice. METHODS: A standardized LEMG analysis method to diagnose vocal fold adductory synkinesis was performed in 124 consecutive laryngeal electromyographic exams. RESULTS: Synkinesis testing was positive in 12/124 patients (9.7%). Post hoc quantitative analysis of electromyographic recordings to compare motor unit potential amplitude in the thyroarytenoid/lateral cricoarytenoid complex during sustained phonation to those in the same muscle during a "sniff" revealed a significant difference in motor unit potential amplitude ratio for control subjects (0.32), those who recovered purposeful vocal fold motion (0.40), and those with vocal fold paralysis (0.96) (P = .001). The presence of synkinesis in patients with UVFI improved the negative predictive value of LEMG from 53% to 100% and the sensitivity from 56% to 100%. CONCLUSIONS: Presence of laryngeal synkinesis using motor amplitude ratio criteria, in the setting of good voluntary motor unit recruitment and UVFI, downgrades a patient's prognosis to one that is poor for recovery. We propose this screening protocol as an adjunct to diagnostic LEMG.

Vocal process granuloma and glottal insufficiency: an overlooked etiology?

OBJECTIVES/HYPOTHESIS: Vocal process granuloma has been attributed to intubation, laryngopharyngeal reflux, and phonotraumatic/hyperfunctional vocal behaviors. Vocal process granuloma has recurrence rates following surgical excision approaching 92%. We hypothesize that a portion of persistent or idiopathic cases of vocal process granuloma result from underlying glottal insufficiency (GI) caused by paresis, scar, or atrophy. Our goal was to examine our vocal process granuloma population and determine the incidence of GI, treatment interventions, and outcomes. STUDY DESIGN: Retrospective chart review. METHODS: Thirty-four patients with vocal process granuloma were divided into surgically or conservatively managed groups. Patients were identified if they carried a diagnosis of GI. The time to resolution and number of recurrences within the overall treatment period was recorded and compared between subgroups. Pre- and post-treatment Voice Handicap Index-10 (VHI-10) and Reflux Symptom Index (RSI) scores were compared. RESULTS: Eighteen of 34 patients (53%) carried an underlying diagnosis of GI, 13/34 (38%) were treated surgically, and 8/13 (62%) surgical patients had underlying GI. VHI-10 and RSI scores significantly improved after disease resolution (P < .05). CONCLUSIONS: The incidence of GI among patients with vocal process granuloma was 53%. Conservative therapies including treatment of laryngopharyngeal reflux and voice therapy may lead to resolution despite underlying glottal incompetence. If conservative measures fail, recognizing and treating glottal incompetence with true vocal fold augmentation may lead to a shorter surgical treatment course.

Serratia marcescens causing cervical necrotizing oropharyngitis.

Necrotizing fasciitis is a rare, life-threatening infection. We report a case of necrotizing oropharyngitis caused by Serratia marcescens in a previously immunocompetent 6-year-old male. This necrotizing infection led to a near-total defect of the oropharynx. The wound was managed with daily wound debridement of the patient's oropharynx with 3% hydrogen peroxide, carotid artery coverage with Kaltostat, and pharyngeal packing with iodoform ribbon gauze. Our patient's resultant nasopharyngeal and hypopharyngeal stenoses present challenges for restoration of form and function for voicing and deglutition. We present our experience of managing this child's hypopharyngeal stenosis with a minimally invasive double-balloon dilatation technique.