Annals of Otology,Rhinology & Laryngology

CO₂ laser medial transverse cordotomy is a permanent static procedure performed to achieve adequate functional airway in cases of posterior glottic stenosis and bilateral vocal fold paralysis. Although it is the preferred method to manage long-term bilateral vocal fold immobility, it is widely believed that cordotomy has the potential to cause aspiration. The minimal existing data on the effect surgical enlargement of the glottic airway on swallowing function is heterogeneous. Through investigation of dysphagia after cordotomy, we hope to better understand the influence of glottic function and its role in dysphagia. The Eating Assessment Tool (EAT-10), is a validated dysphagia symptom-specific outcome measure. We hypothesized that EAT-10 scores would not change after CO₂ laser cordotomy despite causing glottic insufficiency.

Retrospective review was performed on sequential patients having undergone unilateral CO₂ laser cordotomy with complete pre- and postoperative EAT-10 questionnaire data available for evaluation.

Fifteen patients were available for analysis; 10 patients underwent primary unilateral medial transverse cordotomy, 5 patients underwent revision cordotomy, and 20 unique procedures were included in the dataset. The median EAT-10 score during the visit prior to surgery was 3.5, whereas the post-surgery median score was 2. Furthermore, the median difference of 0 was statistically non-significant (P = .91).

CO₂ laser cordotomy does not contribute to patient-reported dysphagia despite creating glottic incompetence. This suggests vocal fold apposition may play a less significant role in normal swallowing function than widely believed.

This study investigated whether the biomarkers present in nasal fluid reflect the severity of symptoms in patients with persistent allergic rhinitis (PAR).

We enrolled 29 PAR patients complaining of nasal symptoms and testing positive to skin prick test. Patients’ total nasal symptom score (TNSS) was measured and their nasal lavage fluid (NALF) was collected. The levels of biomarkers including Clara cell protein 16 (CC16), tryptase, and interleukin 5 (IL-5) in NALF were determined via enzyme-linked immunosorbent assay (ELISA).

PAR patients were classified into persistent mild and persistent moderate-to-severe groups according to the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. The CC16 alone was significantly negatively correlated with TNSS (P < .05). Further, the CC16 level was significantly lower in persistent moderate-to-severe group than persistent mild group of patients (P < .05).

The levels of CC16 alone among several NALF biomarkers showed an inverse correlation with symptoms of PAR patients.

To describe results of image guided sclerotherapy of venous malformations (VM) localized in the masseter muscle.

Retrospective review of prospectively maintained data was done to include consecutive cases treated over 5-year period, with minimum 6 months follow-up. Sclerotherapy was done using ultrasound (US) guided needle puncture(s) of the lesions percutaneously, and 3% polidocanol foam injected under image guidance.

Seventeen cases (10 male, 7 female) with mean age 15.6 years (range 6-28 years) were identified. Clinical presentation was with facial asymmetry, becoming pronounced on jaw clenching, and three cases had mild local pain. On US, the lesions appeared as partially compressible masses with anechoic spaces, showing color filling on releasing probe pressure. Fourteen had phleboliths. Eight patients had undergone magnetic resonance imaging, lesions appearing as oval, homogenous, lobulated, T2 hyperintense masses, with heterogeneous contrast enhancement. Number of sclerotherapy sessions were—single in four cases, two in eight cases and three in five cases, for total of 35 sessions (average 2.05 session per patient). The mean dose of drug injected per session was 1.85 mL and total mean dose per patient was 2.79 mL. Post-procedure vomiting occurred in one patient while all had local swelling and mild pain, lasting between 3 to 7 days. No facial nerve palsy or sloughing/ulceration/skin necrosis was noted. On US follow-up (6-26 months, mean 15.9 months), 12 patients had small echogenic masses without any vascularity, and five had small anechoic areas <25%. All patients had complete resolution of swelling and pain.

For VMs localized to the masseter muscle, image guided sclerotherapy is highly effective and safe, and recommended as first line treatment.

Analyze the differences in length of stay, cost, disposition, and demographics between syndromic and non-syndromic children undergoing multi-level sleep surgery.

Children with sleep disordered breathing or obstructive sleep apnea that had undergone sleep surgeries were isolated from the 1997 to 2012 editions of the Kids’ Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Children were then classified as syndromic or non-syndromic and stratified by level of sleep surgery (tonsillectomy & adenoidectomy, tonsillectomy & adenoidectomy plus other site surgery, other site surgery). Length of stay and cost were reported with Kruskal–Wallis one-way analysis of variance, disposition with binomial logistic regression, and demographics with chi-square.

Syndromic children compared to non-syndromic children were more likely to have surgery beyond just tonsillectomy & adenoidectomy and also had a longer length of stay, higher total cost and non-routine disposition (all P < .001). Syndromic children undergoing tonsillectomy and adenoidectomy plus other site surgery had a longer length of stay compared to syndromic children undergoing tonsillectomy & adenoidectomy (6.00 days vs 3.63 days, P < .001). However, no similar statistically significant difference in length of stay was found in non-syndromic children (2.01 days vs 2.87 days, P > .05).

The potential risks/benefits need to be weighed carefully before undertaking sleep surgery in syndromic children. They experience a longer length of stay, higher cost, and non-routine disposition when compared to non-syndromic children. This is especially true when considering the transition from tonsillectomy & adenoidectomy to tonsillectomy & adenoidectomy plus other site surgery, as syndromic children experience a longer length of stay and non-syndromic children do not.

Sensation is an integral component of laryngeal control for breathing, swallowing, and vocalization. Laryngeal sensation is assessed by elicitation of the laryngeal adductor reflex (LAR), a brainstem-mediated adduction of the true vocal folds. During Flexible Endoscopic Evaluations of Swallowing (FEES), the touch method can be used to elicit the LAR to judge laryngeal sensation. Despite the prevalence of this method in clinical practice and research, prior studies have yet to examine inter- and intra-rater reliability.

Four speech-language pathologists rated 125 randomized video clips for the presence, absence, or inability to rate the LAR. Fifty percent of video clips were re-randomized and re-rated 1 week later. Raters then created guidelines and participated in formal consensus training sessions on a separate set of videos. Ratings were repeated post-training.

Overall inter-rater reliability was fair (κ = 0.22) prior to training. Pre-training intra-rater reliability ranged from fair (κ = 0.35) to almost perfect (κ = 0.89). Inter-rater reliability significantly improved after training (κ = 0.42, P < .001), though agreement did not reach prespecified acceptable levels (κ ≥ 0.80). Post-training intra-rater reliability ranged from moderate (κ = 0.49) to almost perfect (κ = 0.85).

Adequate inter-rater reliability was not achieved when rating isolated attempts to elicit the LAR. Acceptable within-rater reliability was observed in some raters 1 week after initial ratings, suggesting that ratings may remain consistent within raters over a short period of time. Limitations and considerations for future research using the touch method are discussed.

Taste disturbances are often seen in patients after middle ear surgery due to the stress received by an unprotected chorda tympani. It has also been reported that loss in tactile sensitivity may accompany this issue. The current study was designed to measure electrical, chemical, and tactile sensitives of several senses involved in oral processing, smell, taste and touch, over time.

Prospective cohort study.

For three time points, one before middle ear surgery and two after operation (about 5 and 23 days), sensitivity thresholds were obtained using electrogustometry (electrical taste), taste strips (chemical taste), Sniffin’ Sticks (smell) and Von Frey Hairs (point-pressure tactile sensitivity).

The results show a decline in both chemical and electrical taste responses. Additionally, the electrical taste response showed more sensitivity to deviations and no sign of recovery unlike the chemical taste response. Mechanosensory function of the anterior tongue and olfactory function was not strongly affected by middle ear surgery.

Taste responses, but not mechanosensory or olfaction function, are altered after middle ear surgery. Due to the effects that taste loss has on quality of life, gustometry is recommended for this group of patients.

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There is a lack of hearing health care globally, and tele-audiology and mobile technologies have been proposed as important strategies to reduce the shortfall.

To investigate the accuracy and reliability of smartphone self-test audiometry in adults, in community clinics in low-income settings.

A prospective, intra-individual, repeated measurements design was used. Sixty-three adult participants (mean age 52 years, range 20-88 years) were recruited from ENT and primary health care clinics in a low-income community in Tshwane, South Africa. Air conduction hearing thresholds for octave frequencies 0.5 to 8 kHz collected with the smartphone self-test in non-sound treated environments were compared to those obtained by reference audiometry.

The overall mean difference between threshold seeking methods (ie, smartphone thresholds subtracted from reference) was −2.2 dB HL (n = 467 thresholds, P = 0.00). Agreement was within 10 dB HL for 80.1% (n = 467 thresholds) of all threshold comparisons. Sensitivity for detection hearing loss >40 dB HL in one ear was 90.6% (n = 84 ears), and specificity 94.2% (n = 84 ears).

Smartphone self-test audiometry can provide accurate and reliable air conduction hearing thresholds for adults in community clinics in low-income settings.

Despite studies reporting a possible association between malignant otitis externa (MOE) and diabetes, there are no large-scale population-based empirical studies. This nationwide, population-based case-control study explored the association of MOE occurrence with previously diagnosed diabetes.

Data were retrieved from Taiwan’s National Health Insurance Research Database, 753 patients with MOE (cases) and 2 259 propensity score-matched patients without MOE (controls). Multiple logistic regressions were conducted to examine the association of MOE with previously diagnosed diabetes.

In total, 728 (24.2%) out of 3 012 sample patients had diabetes prior to the index date. Chi-square test revealed a significant difference in diabetes prevalence among cases and controls (54.8% vs 13.9%, p < 0.001). Simple logistic regression showed the odds ratio for prior diabetes among cases versus controls was 7.50 (95% CI, 6.22~9.03). The adjusted odds ratio of prior diabetes for cases versus controls was 10.07 (95% CI, 8.15~12.44) after adjusting for patient demographics and medical co-morbidities.

This study found an association between MOE and diabetes. One clinical practice implication of our study is that when a patient with diabetes complains of otalgia or otorrhea, and physical examination shows swelling of the ear canal or granulation growth, physicians should consider the possibility of MOE.

To determine the quality, content, and readability of patient education materials pertaining to otitis media across several popular online platforms focused on otolaryngology and pediatric primary care education.

Online patient materials related to otitis media and directed toward parents were collected from the American Association for Family Practice (AAFP), ENT-Health section of the American Academy of Otolaryngology—Head and Neck Surgery, Healthychildren.org from the American Academy of Pediatrics, KidsHealth from Nemours, WebMD, and Wikipedia. Materials were analyzed for quality, content, and readability. The DISCERN instrument was used to score quality. A unique content score was generated based on the information provided on each website and on the medical and surgical management of otitis media. Readability scores were calculated using the Flesch-Kincaid Grade Level, Flesch Reading Ease Score, Gunning-Fog Index, Simple Measure of Gobbledygook, Coleman-Liau Index, and Automated Readability Index.

Overall, content was well-balanced. Information from AAFP and Healthychildren.org was focused more on medical management than other sources. The average DISCERN scores showed all sources to be of good quality with minimal shortcomings. The AAFP and KidsHealth websites had some readability scores around the 8th-grade reading level, the National Institute of Health’s upper limit recommended for public health information; however, most websites were above this recommended reading level.

Patient education materials related to otitis media on academic and certain popular internet sites are good sources to obtain high-quality information on the topic. Patient educational background, prior knowledge and understanding of otitis media, and physician-patient partnership goals should be taken into account when referring patients to online materials.

Physicians have high rates of burnout with an Otolaryngology burnout rate of 42%. The most studied burnout correlation is increased work hours. More recently, mindfulness training programs have been shown to decrease burnout and increase self-compassion. Regarding burnout studies specific to Otolaryngology residents, there have been few in the past decade. This study explores correlations between burnout and procedure involvement, non-clinical responsibilities and mindfulness practices along with gathering updated work hours data.

A single survey question was shown to be a reliable substitute for Maslach Burnout Inventory in assessing burnout. A survey was sent to all US Otolaryngology residents to investigate the correlation of burnout to post-graduate year, work hours, procedure involvement, non-clinical responsibilities, and mindfulness practices. Residents were asked to answer questions regarding their previous year of training.

Overall burnout was 50%. PGY-1 and PGY-5 were completed with a low burnout rate compared to other years. Increased work hours were confirmed to increase burnout. Increased involvement in procedures, decreased exercise, and increased time completing paperwork correlated with increased burnout. No other factors including mindfulness correlated with increased or decreased burnout. However, only 20% who practiced mindfulness training had this training offered by their department or university.

Annals of Otology, Rhinology & Laryngology A 50% burnout rate is a concerning rate. Increased work hours and PGY-2 through PGY-4 correlated with increased burnout. Accessibility to mindfulness training was low. As mindfulness training is a proven activity to decrease burnout, more departments could benefit from providing these experiences to their residents.

In order to increase junior resident physician proficiency and improve patient safety, simulation-based procedural training courses, or bootcamps, have been become an emerging educational tool.

To compare pre- and post-course confidence levels and to assess station efficacy after completion of our single day bootcamp.

We developed the University of California (UC) Davis otolaryngology bootcamp, a single day course including six cadaveric task trainer stations and four simulations. The six task trainer stations included (1) Epistaxis, (2) Cricothyrotomy/tracheostomy, (3) Peritonsillar abscess/auricular hematoma, (4) Nasal bone reduction/zygoma reduction/lateral canthotomy/canalicular trauma and probing, (5) Local nerve blocks, and (6) Soft tissue reconstruction. The simulations comprised of airway fire during tracheostomy, pediatric respiratory code during airway evaluation, dislodged pediatric tracheostomy tube in the ICU, and angioedema in the emergency department with inability to intubate or ventilate. Junior residents from multiple locoregional institutions were recruited to participate. Pre- and post-course Likert surveys assessing participant confidence and station efficacy were collected and analyzed.

There was a statistically significant increase in resident confidence levels for all task trainer stations. All stations had a station efficacy Likert score average of 4 “very effective” or 5 “most effective.”

A multi-institutional, locoregional, simulation-based bootcamp can be a valuable adjunct to junior resident training. It can promote camaraderie, pool limited resources, and may be cost-effective.

To study the hypothesis that children scheduled for ventilation tube insertion (VTI), a surrogate procedure reflecting otitis media (OM) presence, are overweight or obese.

Charts of Israeli children aged 0 to 9 years undergoing VTI with or without adenoidectomy between 9/1/17 and 3/31/19 in a secondary level hospital were retrospectively identified. We compared their mean body mass index (BMI, kg/m²) to the mean BMI of a control group comprised of children who underwent surgeries unrelated to OM (fracture fixation/reduction, inguinal/umbilical hernia repair, meatotomy, appendectomy). BMI measurements were plotted on gender- and age-matched curves to determine BMI percentile, and were also compared to the national pediatric overweight/obesity data. Normal weight was defined as BMI percentile <85%, overweight was BMI percentile between 85% and 97%, and obesity was BMI percentile >97%.

The VTI group included 83 children (mean age: 3.5 ± 1.8 years). The control group included 77 children (mean age: 6.3 ± 1.9 years). No statistically significant difference was found in the mean BMI values between both groups (P = .22). When compared to age- and gender-adjusted 50th BMI percentile of the general pediatric population, the mean BMI of the VTI group was significantly higher: for boys, 16.9 versus 15.2 (P < .01), and for girls, 16.6 versus 15.3 (P = .03), but not in the control group: P = .16 (boys) and P = .11 (girls).

Children undergoing VTI were overweight when compared to their age- and gender-matched peers. This observation was more noticeable in boys.

The purpose of this study was to examine age-related effects on esophageal transit times (ETT) among healthy adult participants.

A total of 175 healthy, non-dysphagic participants underwent a modified barium swallow study (MBSS), and ETT was recorded for two standardized swallowing tasks. Differences across age groups were determined using Kruskal–Wallis test. Relationships between an Esophageal Clearance (Modified Barium Swallow Impairment Profile Component 17) score and ETT were also explored.

No significant differences were observed in ETT across age groups for nectar-thickened liquid (P = .335) or pudding (P = .231) consistencies. No significant differences were observed between males and females in ETT for either the nectar (P = .112) or pudding trial (P = .817). For nectar, the mean ETT for patients with Component 17 scores of 2 or greater were significantly higher than that of participants with a score of 0 (P < .0001). For pudding, participants with a score >0 demonstrated significantly higher mean ETT compared to participants with a score of 0 (with P = .0008 and P < .0001, respectively).

Study findings failed to support age-related or sex-related differences in ETT for two standardized swallowing tasks administered during a MBSS in healthy individuals. The normative values following a standardized protocol in this study provide guidance in clinical interpretation of esophageal function.

To present a unique approach to the treatment of motor and phonic tics.

A 26-year-old male presented with motor and phonic tics including grunting, coughing, and throat clearing.

The patient was treated with 2.5 units of onabotulinum toxin A (BoNT) to the facial mimetic musculature and 2.5 units to each supraglottic musculature via a transthyrohyoid membrane approach under fiberoptic visualization.

The patient experienced reduction in the frequency, intensity, and interference with daily life of motor and phonic tics on the Yale Global Tic Severity Scale (YGTSS).

This patient experienced subjective and objective decreases in tic severity using a unique approach in the treatment of phonic tics. Results suggest a novel approach in the treatment of phonic tics and bolster the data regarding safe and effective use of BoNT for tic disorder.

Level V, case report.

Thyroglossal duct cysts are the most common congenital neck mass. They typically present as a painless midline neck mass in a child or young adult, but may also present later in adulthood when the cyst becomes symptomatic. Thyroglossal duct cysts are most commonly located inferior to the hyoid bone in close relation with the thyrohyoid membrane. Very rarely, they may extend intralaryngeal, occupy the posterior hyoid space, and present with dysphonia and/or dysphagia. To our knowledge, this is the 24th reported case in the literature.

Case report with a comprehensive review of the literature.

The patient was a 43-year-old male experiencing dysphonia and dysphagia following a motor vehicle accident. He was subsequently found to have a large thyroglossal duct cyst with endolaryngeal extension that was previously asymptomatic and undiagnosed. He underwent successful surgical excision which resulted in resolution of symptoms.

This is the first reported case of a thyroglossal duct cyst in the posterior hyoid space with endolaryngeal extension being diagnosed following a traumatic event. This case illustrates the need to consider thyroglossal duct cyst in the differential diagnosis when working up a post-traumatic intralaryngeal neck mass. A secondary educational objective in this case is to be diligent to consider and rule out laryngeal fracture in the case of a neck mass presenting after trauma as they can easily be missed and present with many overlapping symptoms.

A nasal septal abscess after placement of a dental implant is seldom seen and is usually caused by an infection around the implant. A septal haematoma following dental implantation leading to septal abscess formation has never been reported.

We present a case of a patient who developed a septal abscess after dental implantation without accompanying signs of infection around the implant. On the computed tomography scan we found the implant protruding the nasopalatine duct which led to bilateral septal hemorrhage, resulting in abscess formation. The patient underwent reconstructive nasal septum surgery, using an autologous auricular cartilage graft. This resulted in a good nasal function and cosmetic outcome.

Medical health care professionals should be aware of a septal abscess in case of an acute blocked nose even without prior nasal or facial trauma or nasal surgery. Reconstruction of the septal nasal cartilage using autologous conchal cartilage is a good solution to preserve nasal function as well as tip support.