Dana M. Thompson

Clinical practice guideline: Hoarseness (Dysphonia)

Objective: This guideline provides evidence-based recommendations on managing hoarseness (dysphonia), defined as a disorder characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life (QOL). Hoarseness affects nearly one-third of the population at some point in their lives. This guideline applies to all age groups evaluated in a setting where hoarseness would be identified or managed. It is intended for all clinicians who are likely to diagnose and manage patients with hoarseness. Purpose: The primary purpose of this guideline is to improve diagnostic accuracy for hoarseness (dysphonia), reduce inappropriate antibiotic use, reduce inappropriate steroid use, reduce inappropriate use of anti-reflux medications, reduce inappropriate use of radiographic imaging, and promote appropriate use of laryngoscopy, voice therapy, and surgery. In creating this guideline the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of neurology, speech-language pathology, professional voice teaching, family medicine, pulmonology, geriatric medicine, nursing, internal medicine, otolaryngology–head and neck surgery, pediatrics, and consumers. Results The panel made strong recommendations that 1) the clinician should not routinely prescribe antibiotics to treat hoarseness and 2) the clinician should advocate voice therapy for patients diagnosed with hoarseness that reduces voice-related QOL. The panel made recommendations that 1) the clinician should diagnose hoarseness (dysphonia) in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related QOL; 2) the clinician should assess the patient with hoarseness by history and/or physical examination for factors that modify management, such as one or more of the following: recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve, recent endotracheal intubation, radiation treatment to the neck, a history of tobacco abuse, and occupation as a singer or vocal performer; 3) the clinician should visualize the patients larynx, or refer the patient to a clinician who can visualize the larynx, when hoarseness fails to resolve by a maximum of three months after onset, or irrespective of duration if a serious underlying cause is suspected; 4) the clinician should not obtain computed tomography or magnetic resonance imaging of the patient with a primary complaint of hoarseness prior to visualizing the larynx; 5) the clinician should not prescribe anti-reflux medications for patients with hoarseness without signs or symptoms of gastroesophageal reflux disease; 6) the clinician should not routinely prescribe oral corticosteroids to treat hoarseness; 7) the clinician should visualize the larynx before prescribing voice therapy and document/communicate the results to the speech-language pathologist; and 8) the clinician should prescribe, or refer the patient to a clinician who can prescribe, botulinum toxin injections for the treatment of hoarseness caused by adductor spasmodic dysphonia. The panel offered as options that 1) the clinician may perform laryngoscopy at any time in a patient with hoarseness, or may refer the patient to a clinician who can visualize the larynx; 2) the clinician may prescribe anti-reflux medication for patients with hoarseness and signs of chronic laryngitis; and 3) the clinician may educate/counsel patients with hoarseness about control/preventive measures. Disclaimer: This clinical practice guideline is not intended as a sole source of guidance in managing hoarseness (dysphonia). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Abnormal sensorimotor integrative function of the larynx in congenital laryngomalacia: A new theory of etiology

Objectives/Hypothesis: Laryngomalacia is an enigmatic disease in which laryngeal tone is weak, resulting in dynamic prolapse of tissue into the larynx. Sensorimotor integrative function of the brainstem and peripheral reflexes are responsible for laryngeal tone and airway patency. The goal of this study was to elucidate the etiology of decreased laryngeal tone through evaluating the sensorimotor integrative function of the larynx. The secondary goal was to evaluate factors and medical comorbidities that contribute to the wide spectrum of symptoms and outcomes.

Congenital Dacryocystocele Associated With Intranasal Cysts: Diagnosis and Management†

Objective To improve the diagnostic and therapeutic database for congenital dacryocystoceles.

Laryngomalacia: factors that influence disease severity and outcomes of management.

Purpose of reviewLaryngomalacia is a well described cause of newborn stridor. The spectrum of disease presentation, progression, and outcomes is varied. Some infants will have inconsequential stridor where others will develop feeding symptoms or even severe or life-threatening complications of airway obstruction. The purpose of this review is to identify factors that influence disease severity and outcomes. Recent findingsReview of the current literature and a prospectively collected database shows that patient factors that influence disease severity include APGAR scores, resting SAO2 level at time of presentation, and the presence of a secondary airway lesion. Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) contribute to feeding symptoms. Medical co-morbidities of GERD/LPR, neurologic disease, congenital heart disease, a genetic syndrome, or anomaly also contribute to disease severity and additively affect surgical outcomes. Those with severe disease requiring surgery who have GERD/LPR and one additional co-morbidity are more likely to require revision supraglottoplasty. Those with three medical co-morbidities are more likely to require tracheostomy. SummaryMost with laryngomalacia will have mild to moderate symptoms and not require surgical intervention. Those with GERD/LPR have symptoms improvement from acid suppression therapy. Those with severe enough disease to require supraglottoplasty will have minimal complications and good outcomes if multiple medical co-morbidities are not present. Those with multiple medical co-morbidities could be offered supraglottoplasty as the first intervention but counseled that tracheostomy may be required.

Secondary airway lesions in infants with laryngomalacia.

Objectives: We sought to determine the incidence of secondary airway lesions in infants with laryngomalacia and to compare the incidences of these concomitant airway lesions in infants with severe, moderate, and mild laryngomalacia; to determine whether infants with mild or moderate laryngomalacia have a higher incidence of surgical intervention when a secondary airway lesion is present; and to determine whether the incidence of gastroesophageal reflux disease (GERD) is affected by the presence of a secondary airway lesion. Methods: We performed a retrospective review of a database consisting of 201 infants with a diagnosis of laryngomalacia treated at a pediatric tertiary referral center between June 1998 and June 2003. Data pertaining to demographic information, severity of laryngomalacia, presence of secondary airway lesions, and diagnosis of GERD were collected and analyzed. Results: Of the 201 infants, 104 (51.7%) were found to have a secondary airway lesion. Subglottic stenosis was found in 38.8%, and tracheomalacia in 37.8%. Of the infants with severe laryngomalacia, 30 (79%) had a diagnosis of a secondary lesion, compared with 51 (61.5%) of those with moderate and 23 (28.8%) of those with mild disease. Among infants with mild or moderate disease, those with secondary airway lesions were more likely to require surgical intervention than were infants without secondary airway lesions (27% versus 5.6%; p = 0.0002). There was no difference in the rates of secondary airway lesions in infants managed with supraglottoplasty versus tracheotomy. The incidence of GERD in this patient population was 65.6%. Infants with a secondary airway lesion were more likely to have GERD than were those without a secondary airway lesion (84.6% versus 45.4%; p < 0.0001). Conclusions: The incidence of secondary airway lesions in our population of infants with laryngomalacia was higher than those previously reported. The severity of disease correlated with the diagnosis of a secondary airway lesion. Secondary airway lesions lead to an increased incidence of surgical intervention and GERD in infants with laryngomalacia.

Clinical characteristics of eosinophilic esophagitis in children

Objectives: The role of eosinophilic esophagitis (EE) in aerodigestive tract disorders in children is underestimated and overlooked, primarily because of a lack of understanding of this disorder by otolaryngologists. We sought to better characterize the clinical presentation of EE in order to increase awareness among otolaryngologists. Methods: We retrospectively reviewed 71 children with biopsy-proven EE to determine the most common symptoms and laboratory findings that should increase the clinical suspicion of EE. Results: Dysphagia, food impaction, and emesis were the most common symptoms in children with EE. Asthma was the most common airway diagnosis. Rhinosinusitis was the most common otolaryngological diagnosis. Food allergy was present in 60% of the children tested. Eighty-three percent of the children with elevated immunoglobulin E levels had thick linear streaking or patchy white exudate of the esophagus seen on esophagoscopy. Other major medical comorbidities existed in more than half of the children with EE, of which psychiatric disorders and other disorders of the aerodigestive tract were the most common. Conclusions: Eosinophilic esophagitis may contribute to treatment failure in patients with common and complicated aerodigestive tract disorders. To encourage clinicians to avoid overlooking the diagnosis, we present an evaluative algorithm to increase the suspicion of this entity.

Airway manifestations of pediatric eosinophilic esophagitis: A clinical and histopathologic report of an emerging association

Objectives: Pediatric eosinophilic esophagitis (EE) typically presents with dysphagia, vomiting, dyspepsia, or food impaction. The purpose of this study was to highlight the emerging association of pediatric EE and airway disease. An additional goal of this study was to describe the unique histopathologic findings found in EE and specifically explore the potential role of the cytotoxic protein called eosinophil major basic protein (MBP) in the pathophysiology of the disease. Methods: A retrospective review of 3 children with EE and airway symptoms included symptom presentation, aerodigestive tract endoscopic findings, ambulatory 24-hour dual pH-metry, allergy tests, treatment modalities, and treatment response. Esophageal tissue obtained from biopsies of each patient was evaluated by hematoxylin and eosin to determine the number of eosinophils per high-power field, by immunofluorescent anti-MBP staining to determine the presence of MBP, and by standard light and transmission electron microscopy to evaluate eosinophil migration patterns. Results: All patients had airway inflammation that included nonspecific laryngeal edema and grade I or II subglottic stenosis. Allergy testing was positive in the 2 patients who were tested. All patients had symptoms refractory to standard reflux therapy. Ambulatory pH-metry findings were normal in 2 patients and abnormal in 1 patient despite maximum treatment. Two patients had visual abnormalities seen during esophageal examination. The number of eosinophils ranged from 20 to 45 per high-power field. Intracellular and extracellular MBP deposition was found in all esophageal biopsy specimens. All patients were treated with swallowed fluticasone, and 2 had symptom relapses that required repeat treatment. Conclusions: The spectrum of pediatric EE can include upper airway disease. Intracellular and extracellular MBP deposition is present in EE, which potentially releases cytotoxic mediators that explain the esophageal and airway clinical symptoms seen in those with the disease. Eosinophilic esophagitis should be considered in patients with a history of atopic diseases and unexplained upper airway findings refractory to reflux treatment. Treatment with swallowed fluticasone is successful; however, relapses are common and require repeat treatment and close follow-up.

The study of vocal fold vibratory patterns in patients with unilateral vocal fold paralysis before and after type I thyroplasty with or without arytenoid adduction

Type I thyroplasty and arytenoid adduction have been used for the treatment of symptomatic unilateral vocal fold paralysis since the mid‐1970s. To this date, the vibratory patterns of the vocal folds in patients with unilateral vocal fold paralysis undergoing thyroplasty have not been studied in depth. Abnormal vibration of the vocal fold mucosa often contributes to voice problems in persons diagnosed with vocal diseases or disorders. The preoperative and postoperative videostroboscopic vibratory patterns including mucosal wave, amplitude, glottic closure, and symmetry were studied in 12 patients who underwent unilateral type I thyroplasty separately or in combination with an arytenoid adduction. The observed changes and clinical implications are discussed.

Impact of supraglottoplasty on aspiration in severe laryngomalacia

Objectives: We examined the incidence and significance of aspiration in infants with severe laryngomalacia (LM) who undergo supraglottoplasty. Methods: We performed a 5-year retrospective review of a prospective database from 2 tertiary care pediatric institutions. The studied patients were 50 consecutive infants with severe LM who underwent supraglottoplasty (median age, 4.5 months) and functional endoscopic evaluation of swallowing (FEES) with or without laryngopharyngeal stimulation testing. The intervention was cold-knife microlaryngeal supraglottoplasty and reflux management. The main outcome measure was aspiration resolution. Results: Preoperative FEES identified laryngeal penetration in 44 infants (88%) with severe LM. Laryngeal penetration with aspiration beyond the vocal folds was noted in 36 infants (72%). Postoperative FEES (median follow-up, 3.8 months) indicated resolution of laryngeal penetration and aspiration in 36 (81.8%) and 31 (86.1%) of these patients, respectively. The 14 patients without preoperative aspiration showed no evidence of aspiration after supraglottoplasty. In patients with aspiration, the mean preoperative laryngopharyngeal stimulation test threshold was 8.45 mm Hg. This improved on average by 4.0 mm Hg after supraglottoplasty (paired t-test, p < 0.0001). Multiple medical comorbidities were present in the 5 patients who had persistent aspiration after supraglottoplasty, including congenital heart disease (all 5 patients), congenital syndromes (4 patients), neurologic disorders (2 patients), and a need for tracheostomy (2 patients). Conclusions: Laryngeal penetration and aspiration improve after cold-knife supraglottoplasty. Supraglottoplasty does not cause aspiration in patients who do not have preoperative aspiration. Supraglottoplasty may not improve aspiration in patients with multiple medical comorbidities.

Improved infant swallowing after gastroesophageal reflux disease treatment: A function of improved laryngeal sensation?

Objective: The objective of this study was to describe improvements in pediatric swallowing after gastroesophageal reflux treatment.