Claudio F. Milstein

Laryngopharyngeal reflux: prospective cohort study evaluating optimal dose of proton-pump inhibitor therapy and pretherapy predictors of response.

Purpose: Laryngopharyngeal reflux (LPR) is frequently treated with empiric proton‐pump inhibitors (PPI), but the optimal dosing and duration is unknown. We performed an open label prospective cohort study to evaluate whether twice‐daily (BID) PPI is more effective than once‐daily (QD) PPI for the treatment of LPR.

Prevalence of laryngeal irritation signs associated with reflux in asymptomatic volunteers: impact of endoscopic technique (rigid vs. flexible laryngoscope).

Objectives: The objectives of this study were to 1) determine the prevalence of ENT findings in the normal asymptomatic population and 2) to compare findings between flexible and rigid laryngoscopes in an attempt to increase specificity of diagnosis of reflux in endoscopic laryngeal examinations.

Correlation between Symptoms and Laryngeal Signs in Laryngopharyngeal Reflux

Objective/Hypothesis: Laryngopharyngeal reflux (LPR) is diagnosed by the presence of laryngeal signs and symptoms. Some studies have noted that signs and symptoms may be nonspecific and may have poor correlation. However, many such studies were either observational or had short‐term follow‐up. Therefore, we conducted subgroup analysis of a prospective concurrent controlled study with a 1 year follow‐up to study the correlation between signs and symptoms.

Chronic Laryngitis Associated with Gastroesophageal Reflux: Prospective Assessment of Differences in Practice Patterns Between Gastroenterologists and ENT Physicians

OBJECTIVES:Ear, nose, and throat (ENT) physicians often diagnose gastroesophageal reflux disease (GERD)-related laryngitis on the basis of symptoms and laryngeal signs; and may refer patients to gastroenterologists who contend that many such patients do not have reflux. Because of this dichotomy we designed this study to assess the practice pattern differences among ENT physicians and gastroenterologists in relation to the diagnosis and treatment of patients with GERD-related laryngitis.METHODS:Separate surveys were specifically designed for ENT physicians and gastroenterologists to assess the following: the percentage of patients diagnosed with GERD-related laryngitis, dose and duration of therapy, treatment response, and other diagnostic options in nonresponders. A total of 2000 surveys were mailed randomly to members of both the American Academy of Otolaryngology Head and Neck Surgery and the American Gastroenterological Association.RESULTS:Of the total 4,000 surveys sent, 782 (39%) ENT physicians and 565 (28%) gastroenterologists responded. Most respondents (both specialties) were private practitioners (82% and 74%, respectively). From the ENT survey, the diagnosis was most commonly suspected based on the following symptoms: globus = throat clearing > cough > hoarseness. The most useful signs were laryngeal erythema and edema reported by 70% of respondents. Seventy-four percent of ENT physicians reported they made the diagnosis more on symptoms than on laryngeal signs, and initiated therapy most often with proton pump inhibitor (PPI) once daily for 2 months. Gastroenterologists were divided on pre-therapy testing, 50% reporting testing with esophagogastro-duodenoscopy followed by pH monitoring (distal > proximal) prior to therapy, while the remaining 50% reported treating empirically with PPI twice daily for 3 months. Seventy percent of gastroenterologists reported treatment response of less than 60%, while 62% of ENT physicians reported response rate of greater than 60% (p < 0.05).CONCLUSIONS:(1) Globus and throat clearing were considered the most useful symptoms in diagnosing GERD-related laryngitis, while laryngeal erythema and edema were considered the most useful signs for diagnosis and treatment of this condition by ENT physicians. However, these symptoms and signs may represent the least specific markers for reflux. (2) Many gastroenterologists perform pre-therapy testing which has low sensitivity in GERD-related laryngitis. (3) There is a dichotomy in treatment dose, duration, and perceived patient response to therapy between the two specialists. (4) Our study highlights a need for cross communication and education between these two disciplines in understanding and treating GERD-related laryngitis better.

Long‐term Effects of Micronized Alloderm Injection for Unilateral Vocal Fold Paralysis

Objectives: Micronized Alloderm (Cymetra) is a relatively new product used for vocal fold augmentation. Previous studies evaluating possible long‐term effectiveness of this product have shown mixed results. The objective of this present study is to reassess possible long‐term results of Cymetra injection laryngoplasty in patients with unilateral true vocal fold paralysis.

Results of ansa to recurrent laryngeal nerve reinnervation

Objective We sought to describe the results of ansa cervicalis to recurrent laryngeal nerve (ansa-RLN) reinnervation for unilateral vocal fold paralysis. Study Design A chart review was performed on patients undergoing ansa-RLN reinnervation for unilateral vocal cord paralysis at a tertiary care center. Patient perceptions of preoperative and postoperative voice quality was surveyed. Acoustic and visual parameters were assessed from videostroboscopy. Results From a total of 25 study patients, 15 patients underwent both preoperative and postoperativ video stroboscopies. In stroboscopies within 6 months, the average improvement in overall severity, roughness, and breathiness was 69, 79, and 100 percent, respectively. In stroboscopies after 6 months, the average improvement in overall severity, roughness, and breathiness was 63, 66, and 100 percent, respectively. Postoperatively, all patients had reinnervation of the vocal fold. Conclusions Voice outcomes were improved in patients with preoperative and postoperative stroboscopies. Significance Ansa-RLN reinnervation should be considered as a treatment for unilateral vocal fold paralysis.

Just noticeable differences forglottal flow waveform characteristics

This study was primarily motivated by the need to establish the correspondence between auditory abilities and laryngeal function. Just noticeable differences (JNDs) were obtained for the open quotient and speed quotient of the glottal flow waveform. The quotients were synthesized for both the glottal flow alone, and for the output pressure signal after the glottal flow signal was applied to the synthesis vocal tract for the vowel /a/. Six adult men and five adult women, all teachers of singing, participated as listeners. An adaptive auditory listening procedure was used to estimate JNDs for the four types of stimuli. The group average JND values were as follows. For the standard open quotient value of .6000, JND = 0.0264 (SD = .010) for the glottal flow and JND = 0.0344 (SD = .020) for the output pressure. For the open quotient, there was no statistically significant difference between genders or between the types of signals. For the standard speed quotient value of 2.000, JND = 0.154 (SD = .043) for the glottal flow and JND = 0.319 (SD = .167) for the output pressure. For the speed quotient, there was no statistically significant difference between genders, but the difference between types of stimulus (glottal flow versus output pressure) was significant (p < .006). The variance among the JND values was significantly larger for the output pressure stimuli compared to the glottal flow stimuli for both the open quotient and the speed quotient.

Prevalence and Occupation of Patients Presenting With Dysphonia in the United States

OBJECTIVE Voice disorders are common conditions that may have a significant impact on patient quality of life, yet their prevalence and epidemiology are poorly documented. In this study, we estimated the prevalence, demographics, and occupation of patients with dysphonia. METHODS Using the Commercial and Medicare MarketScan databases of 146.7 million lives (2008-2012), the prevalence of dysphonia was estimated. Patient demographics and industry occupation were evaluated. Prevalence estimates overall and by industry were made using Medical Expenditure Panel Survey. Industry estimates were compared with US government employment statistics to assess differences between dysphonia and the general population. RESULTS A gradual increase in the diagnosis of dysphonia was noted from 1.3% to 1.7% of the population from 2008 to 2012, with an associated increase in the diagnosis of acute laryngitis, the largest diagnostic category. A strong correlation was present between diagnosis and age, with acute laryngitis more common in the younger populations and malignancies in older ages. Benign neoplasms were more prevalent in the service industry, with 2.6 times increased likelihood compared with the general population, and malignancies were more prevalent in the manufacturing industry, with 1.4 times increased likelihood. Almost 3 million laryngoscopies and stroboscopies were performed with

Laryngeal reinnervation after vagal paraganglioma resection: a case report.

900 million in costs. CONCLUSION Prevalence rates of the diagnosis of dysphonia are increasing and are associated with large healthcare costs. Prevalence rates also differ somewhat between industries, and there appears to be a higher percentage of malignant neoplasms in the manufacturing industry and benign neoplasms in the service industry.

Paradoxical vocal fold motion (PVFM) in pediatric otolaryngology

1. Case report A 36-year-old man presented to the clinic with a 3-month history of an enlarging right-sided neck mass. He had some associated pain in the region but denied any dysphonia, dysphagia, flushing, palpitations, diarrhea, or previous syncopal episodes. He denied a history of tobacco use, chronic alcohol use, or a family history of paragangliomas. Physical examination demonstrated a right-sided level II neck mass measuring approximately 5 cm in anteriorposterior dimension that was tender to touch. Palpation of the neck did not reveal any additional lymphadenopathy. All cranial nerves were functional with particular attention to cranial nerve X: he had symmetric palatal elevation and normal laryngeal function on fiberoptic nasopharyngolaryngoscopy. The mucosal surface of the entire upper aerodigestive tract was unremarkable. Magnetic resonance imaging (MRI)/magnetic resonance angiography demonstrated a 3.9 × 3.6 × 5.0-cm multilobulated parapharyngeal mass displacing the carotid artery anteromedially and the jugular vein posteromedially with slight compression (Fig. 1), most consistent with a glomus vagale tumor. When compared with a previous MRI performed 3 months earlier, there was interval growth of the mass of approximately 0.5 cm. A whole-body octreotide scan failed to show any additional areas of uptake. The patient was presented at our multidisciplinary tumor board. After extensive discussion of the options in treating vagal paragangliomas along with the functional sequela of surgical resection and the reconstructive options, the patient decided against pursuing a radiation oncology consult but rather opted for a surgical resection. A vascular surgery consult was obtained, and the patient underwent preoperative embolization of the right ascending pharyngeal artery with an Onyx injection (ethylene vinyl alcohol copolymer) less than 24 hours before the procedure. Surgical resection involved a right parapharyngeal space dissection along with a selective neck dissection (levels 2–3) via a modified Blair incision with a cervical extension. External jugular nodes were sent for frozen pathology and were found to be negative. Cranial nerves IX, XI, and XII and the sympathetic chain were identified and preserved, with X being sacrificed. The ansa hypoglossal nerve was significantly attenuated precluding its use for purposes of reinnervation. The stylohyoid and digastric muscles were divided to provide access to the proximal portion of the tumor at the level of the skull base. The tumor was removed en bloc without complication, requiring sacrifice of the superior laryngeal nerve (SLN). Reconstitution of the anticipated defects involved the following: a left ansa cervicalis to right recurrent laryngeal nerve (RLN) neuroplasty; a right greater auricular nerve to right SLN neuroplasty, and a free nerve interposition graft from the left cricothyroid muscle to the right cricothyroid muscle (Fig. 2). The contralateral ansa cervicalis nerve was used because of the attenuation found along the ipsilateral nerve, and a cut branch of the vagus that was found to be histologically normal on frozen section was used for the interposition graft.