Laryngoscope最新文献

Objective: This study sought to compare topical lidocaine delivered through a channeled endoscope versus traditional anesthetic methods for office laryngology procedures.

Methods: A single-institution prospective, crossover study of adult patients undergoing office laryngology procedures from February 2023 to February 2024 was conducted. Patient-reported outcomes for procedural tolerance and anesthetic preference were compared between the investigational method of channel-nebulized lidocaine versus control anesthetic delivery (trans-tracheal or drip catheter), with each patient serving as his/her own control.

Results: Twenty-two subjects were included in the study. Control topical anesthesia included: 13 (59.1%) trans-tracheal and 9 (40.9%) drip catheter. On bivariate analysis, the use of channel-nebulized lidocaine was associated with reduced lidocaine dosage (0.4 vs. 1.7 mL, p < 0.001), increased anesthesia delivery time (335 vs. 119 s, p < 0.001), and increased total procedure time (543 vs. 321 s, p < 0.001). No significant differences in anesthetic delivery time or total procedure time were observed when comparing channel-nebulized delivery with drip catheter. Discomfort during lidocaine administration (p < 0.001) and cough/gag during lidocaine administration (p < 0.001) were significantly lower with channel-nebulized lidocaine. Multiple linear regression revealed these improvements were not significantly influenced by indication for procedure, years undergoing procedures, or control method of anesthesia. A majority (63.6%) of patients preferred channel-nebulized lidocaine.

Conclusion: Topical laryngeal anesthesia for office laryngology procedures can be challenging due to patient tolerance. Nebulized lidocaine delivered through an endoscopic working channel may improve patient tolerance and reduce lidocaine dosage but may be associated with longer procedure time.

Level of evidence: 3:

Background: Sensory and autonomic nerves supply the sinonasal mucosa and contribute to chronic rhinitis, rhinosinusitis, and craniofacial pain. While posterior and posterolateral nasal nerves have been studied anatomically and histologically, nerves supplying the anterolateral nasal wall (ALNW) have been incompletely studied. The purpose of this cadaveric study was to investigate the ALNW's nerve supply.

Methods: Sixteen fresh cadaver heads were dissected. First, six heads underwent unilateral ALNW dissection to harvest nerves coursing through the bony ALNW, and these were termed anterior nasal nerves (ANNs). Specimens were formalin-fixed, sectioned, and stained with hematoxylin and eosin, as well as for sensory or autonomic neuropeptides and enzymes. Nerve biomarker presence/absence was recorded. Next, 10 heads (20 sides) were utilized for ALNW mucosal area measurement and dissections. Bilateral subperiosteal dissections were performed to count nerves coursing from the ALNW and anterior portion of the inferior turbinate (IT).

Results: Of the six ANNs analyzed immunohistochemically, sensory and autonomic nerve markers were identified in each ANN. The other 10 cadavers all had ANNs coursing from the bony ALNW, with significantly more ANNs coursing through the bony ALNW superior to the IT-ALNW mucosal junction (p = 0.001).

Conclusion: ANNs were identified in all cadavers, with more supplying the ALNW than the anterior portion of the IT. Sensory and autonomic nerve markers were identified in the ANNs. Future studies should explore the relative contributions of sensory versus autonomic dysfunction in different rhinologic conditions, and whether these aberrations differentially affect the anterior versus posterior nasal cavities.

Objectives: Oval window atresia (OWA) is a rare otologic condition often associated with a maximal conductive hearing loss, and variable ossicular and facial nerve canal (FNC) anomalies, which have contributed to suboptimal middle ear surgical outcomes. No grading scheme exists to detail the spectrum of associated temporal bone anomalies in OWA; therefore, our objectives were to complete an audiometric and radiographic review to characterize audiometric patterns of hearing loss, and refine the classification system for OWA to determine suitability for middle ear surgery.

Methods: A retrospective audiometric and radiographic review was conducted at a pediatric tertiary care institution. Patients with OWA identified on temporal bone computerized tomography (CT) scans obtained from 01/2010 to 06/2024 were included. Audiological, radiological, and patient factors were analyzed.

Results: Thirty-one patients (48 ears) with OWA were identified. Across frequencies, the air-bone gap decreased significantly as frequency increased (ANOVA with pairwise comparisons, p < 0.001) due to a worsening of bone conduction thresholds and improvement in air conduction thresholds. The FNC was abnormal in 43/48 ears and was determined to overlay the oval window in 6 ears. Additional anomalies included inferiorly displaced, dehiscent, and duplicated canals. Ossicular anomalies were reported in 46/48 ears, and stapedial anomalies were most common.

Conclusions: Our findings indicate OWA may manifest audiometrically with consistent and specific hearing loss characterized by a 60-80 dB ABG at lower frequencies that decreases above 2 kHz. CT findings of OWA show considerable variability. We propose a new classification system for OWA based on facial nerve position as this directly influences middle ear surgical feasibility.

Level of evidence: 4:

Objectives: The impact of velopharyngeal insufficiency (VPI) on patient and caregiver quality of life (QOL) is well documented. The social determinants of health (SDOH) that affect this relationship remain unclear. This study aimed to evaluate these associations to better understand how social context impacts patients and caregivers at risk of VPI due to congenital cleft and craniofacial deformities.

Methods: Retrospective review of caregiver-reported Velopharyngeal Insufficiency Effects on Life Outcome (VELO) questionnaire responses was conducted for patients seen in a multidisciplinary cleft and craniofacial clinic from 2020 to 2023. Scores were matched to census data regarding educational opportunities, health/environmental factors, and socioeconomic factors using the Childhood Opportunity Index (COI). Associations between QOL and SDOH were evaluated via linear regression, with higher scores representing better values.

Results: Among the cohort (N = 161), multiple SDOH categories significantly predicted the QOL impacts of VPI (p < 0.05). Socioeconomic factors were positively correlated with speech limitations, situational difficulty, emotional impact, and caregiver impact (β = 0.23-0.36, p < 0.05). Contrary to our hypothesis, health/environmental factors exhibited a significant negative correlation across the same VELO domains in addition to swallowing problems (β = -0.29 to -0.12, p < 0.05). Educational opportunities showed no significant association with any VELO subcategory (β = -0.11 to -0.03, p > 0.1).

Conclusion: Higher socioeconomic status was associated with better VELO scores, underscoring the protective role of resources in health outcomes and caregiver perceptions. In contrast, caregivers with better health/environmental conditions reported worse outcomes, suggesting that higher health standards may influence perceptions of VPI severity.

Level of evidence: 3:

Objective: To introduce a classification system and corresponding surgical techniques for tympanum reconstruction in patients with lateral skull base lesions, aiming to restore tympanic wall structure, maintain aeration, and preserve air conduction hearing.

Methods: We retrospectively reviewed 17 patients (mean age 38.9 ± 10.1 years) with benign lateral skull base tumors requiring extensive tympanectomy between 2015 and 2023. Based on defect location, tympanum reconstruction could be classified as Type 1 (posterior and inferior walls) or Type 2 (anterior and superior walls), using pedicled sternocleidomastoid or temporalis muscle flaps, respectively. Surgical cavity stability, complications, and audiological outcomes were evaluated.

Results: Ten patients underwent Type 1 reconstruction, four received Type 2, and three required both. The mean follow-up was 16 months. Based on postoperative CT scans, well-aerated tympanic cavities without significant adhesions were observed in all cases. The median postoperative air conduction threshold was 40.0 (IQR = 28.8) dB HL, with a median air-bone gap of 25.0 (IQR = 11.3) dB HL. No statistically significant differences were observed compared to preoperative hearing (p > 0.05). Postoperative air-bone gaps were < 30 dB HL in 82% of patients, and < 20 dB HL in 41%.

Conclusion: This classification-based reconstruction approach enables tailored repair of tympanic defects using autologous pedicled flaps, offering structural stability, resistance to infection, and a well-epithelialized auditory canal. Though consistent hearing gains were not achieved, most patients maintained acceptable postoperative hearing, and profound hearing loss was avoided. This approach provided more options for hearing rehabilitation for these patients.

Level of evidence: 4:

Objectives: To describe the development of the Laryngology Fellow Online Curriculum (LFOC) for fellowship education and review its impact on standardizing the educational experience for Laryngology fellows.

Methods: Surveys were completed from 2020 to 2024 by Laryngology fellows upon their fellowship graduation and completion of the LFOC. Outcomes measured included overall rating of the curriculum, knowledge gaps filled, degree of engagement with the Laryngology community, and opportunities for collaboration. Laryngologists who completed the LFOC were recruited to complete a separate survey 1-3 years post fellowship graduation on their experiences with the curriculum and academic development. Faculty laryngologists and fellowship directors completed surveys measuring their experiences with teaching within the LFOC, their career academic development, and their insights into knowledge gaps within their own fellowship programs.

Results: One hundred and nine Laryngology fellows and seventy six Laryngology faculty participated in the LFOC from 2020 to 2024. 89.5% of fellow graduates gave the curriculum an excellent rating (8-10/10), while 94.7% of academic laryngologists and 84.6% of fellowship directors felt the LFOC would have improved their training. Graduates (92.9%) reported that the LFOC allowed them to engage more with the Laryngology community. 82.1% of the LFOC graduates responded that the curriculum provided education on topics that were not readily available in their training program. 69.2% of participating fellowship directors identified knowledge gaps in their own training programs.

Conclusions: The LFOC created an interactive learning environment that bridged knowledge gaps, fostered a sense of community among the Laryngology fellows, and allowed for collaboration with peers and academic laryngologists.

Level of evidence: N/A.

Objective: Alcohol hypersensitivity (AH), an exacerbation of respiratory symptoms in response to alcohol consumption, is common in aspirin-exacerbated respiratory disease (AERD) and other forms of chronic rhinosinusitis (CRS). The mechanism of this is unknown. This study investigates the ability of polyphenolic compounds in alcoholic beverages to activate innate immune cells as a means of explaining AH in AERD.

Methods: Data were collected from 478 consecutive adults presenting to a tertiary care sinonasal clinic in whom the presence of AH and their CRS phenotype was determined. A subset of these individuals was invited to provide whole blood samples on which the effects of ethanol, red wine extract (RWE), and individual polyphenolic compounds were explored. Granulocyte activation was quantified by flow cytometry as upregulation of CD63 during the Basophil Activation Test (BAT). Additionally, secretion of lipid metabolites was measured by enzyme immunoassays (EIAs).

Results: Twelve patients with CRSwNP were compared to age and sex-matched healthy controls. A dose-dependent stimulation of basophil degranulation was noted with RWE and epigallocatechin (p < 0.05). No activation was noted in healthy controls or subjects to ethanol. Catechin demonstrated a dose-dependent, but only near-significant difference (p = 0.07) in basophil degranulation compared to controls.

Conclusions: Polyphenolic compounds, and not ethanol, can trigger the activation and degranulation of eosinophils and basophils, and this may explain the sensitivity to alcoholic beverages seen in patients with AERD and CRSwNP.

Level of evidence: NA.

Objectives: Recurrent respiratory papillomatosis (RRP) is characterized by an irregular disease course, with recurrences after long periods of remission. New immunologic strategies are under investigation that aim to eliminate the chronic HPV infection. We evaluated recurrence patterns in RRP patients and sought to identify variables associated with prolonged remission periods.

Methods: Charts of all RRP patients seen since 2003 at our institution were reviewed. Surgical history and disease status in treatment-free intervals were evaluated. Patient and disease characteristics were compared using chi-squared and Fisher's exact tests in an exploratory analysis.

Results: Of 312 RRP patients, 71 (22.8%) experienced a treatment gap (TG) of at least 4 years between treatment and recurrence, with 43 (13.8%) having a TG over 10 years. TG patients did not differ from the remaining cohort in sex, juvenile/adult onset, or other clinical characteristics. To control for the possibility that TG patients resembled the entire cohort because of untreated occult disease, a subset was identified with prolonged (≥ 4 years) definitive remission. Compared to this remission group, TG patients were more likely to undergo surgery rather than office procedures before the gap in treatment (100% vs. 71.4% p = 0.003) and less likely to have supraglottic disease (17.5% vs. 57.1% p = 0.012). Other patient characteristics showed no significant differences.

Conclusion: A substantial portion of RRP patients experience recurrence after prolonged treatment-free intervals, and this cohort cannot be easily predicted from available clinical characteristics. This highlights the need for effective immunologic strategies to eliminate the causative chronic infection.

Level of evidence: 3:

Objectives: During initial comparison of DaxibotulinumtoxinA-lanm (Daxi) to botulinum toxin A (BtxA) in adductor laryngeal dystonia (AdLD) (Phase 1), Daxi administration was found to be safe and efficacious. This study sought to determine the reproducibility of Daxi results (Phase 2) and safety/results for Daxi dose escalation (Phase 3) in patients who previously had been successfully treated with Daxi.

Methods: Thirteen AdLD patients with consistent benefit from BtxA were enrolled in an open-label prospective clinical trial involving repeat administration and/or up-titration of Daxi dose. Duration of voice benefit (DVB) and safety of dose escalation were primary outcomes. PROMs and voice recordings were obtained pre- and post-injection.

Results: Twenty-nine total injections (21 repeat dose, 8 dose escalation) were performed in 13 patients (85% female, mean age = 60.4). No adverse events occurred, and there was no difference in EAT-10 pre- to post-injection (repeated dose p = 0.08, dose escalation p = 0.12). In patients who experienced greater benefit with Daxi, average DVB was 112.75 days, 33.5% longer than their average BtxA duration (mean = 84.2 days, p = 0.003). 54% (7/13) had longer DVB with Daxi, and 46% (6/13) had equivocal DVB compared to BtxA DVB by the end of the study. Daxi DVB was comparable to an earlier study, demonstrating reproducibility of Daxi injection results (p = 0.332, SD = 13.6 days).

Conclusions: Our results were variable but showed reproducible results with Daxi, with overall longer DVB with Daxi in 42.8% of total injections, with an average of 33.5% longer DVB than BtxA in a cohort of known Daxi-responsive patients. Daxi dose escalation did not result in significant dysphagia or adverse events. Further studies are needed to determine the clinical utility of Daxi in the treatment of AdLD.

Level of evidence: 3:

Objective (s): Idiopathic and granulomatosis with polyangiitis (GPA)-related subglottic stenosis (SGS) are considered distinct immune-mediated inflammatory disorders. Limited data exist on serum inflammatory markers, specifically C-Reactive Protein (CRP), for SGS diagnosis, differentiation, and prognostication. The study objective was the characterization of CRP levels in idiopathic (iSGS) and GPA-SGS to assess CRP's ability to distinguish SGS subtypes and predict SGS progression and recurrence.

Methods: Retrospective review of patients with idiopathic or GPA-SGS from 2007 to 2024 at a single institution. Surgery-free interval (SFI) was calculated as the time between surgical interventions. Statistical analysis included independent t-tests, chi-squared, and univariate linear regression.

Results: 59 iSGS and 47 GPA-SGS patients were included. CRP was elevated in 36% of iSGS and 49% of GPA-SGS patients (0.0.6 mg/dL). Mean maximum CRP was 2.7 mg/dL lower in iSGS compared to anti-neutrophil cytoplasmic antibody (ANCA)-positive GPA-SGS (p = 0.035). The maximum CRP in iSGS was 3.6 mg/dL, while 10 (21%) GPA patients had CRPs greater than 3.6 mg/dL (max = 31 mg/dL). ANCA-negative GPA-SGS mean CRP was not significantly different than iSGS or ANCA-positive GPA-SGS. CRP and SFI did not correlate on univariate linear analysis.

Conclusion: Mild elevation of CRP is common in SGS patients. High CRP levels are more frequent in GPA-SGS, potentially aiding clinical differentiation of etiologies. However, CRP at presentation does not appear to correlate with disease recurrence in iSGS or GPA-related SGS, limiting its value as a biomarker and prognostic tool.

Level of evidence: 3: